Abstract
This paper analyzes the ethics of text based coaching over live coaching. Two real world coaching companies are evaluated for their adherence to upholding the highest ethical standards through the lens of Cohen’s ethical model of beneficence, nonmalfecence, justice and autonomy. While it is clear that text based coaching does not uphold the philosophies of the International Coaching Federation, the question of whether text based coaching is ethical is a nuanced conversation that depends on the desired outcome for the patient.
Ethical Dilemma
Digital health companies that offer health coaching to either treat chronic illness, various pathologies, or support overall health are growing in popularity. Currently there are a variety of coaching models that do not require in person coaching such as telephonic, video, and text based coaching. As the industry develops and figures out a sustainable model, the question is whether text coaching, the least personable form, is viable, ethical, and in the patient’s best interest.
The argument in favor of text coaching
Digital health companies are often being paid by an enterprise company which means they need to satisfy the enterprise client and hit specified metrics and KPI’s for billing purposes and ROI. KPI’s often include quantifiable points of contact per week, perceived ease of communication, and immediate measurable success. They are also managing large volumes of people and employing a lot of coaches, which makes the logistics of weekly coaching sessions challenging. Text coaching eliminates the frustration of trying to schedule coaching sessions, deal with people who are cancelling or attempting to reschedule, etc. For people who are busy with work and families, text coaching provides a logistically easier way to access support, especially for those who may think they don’t have time for a live session. Text based coaching is analogous to an online educational program where students learn from professors via digital classrooms. The experience is different than being in person, yet still effective.
The argument against text coaching
Taking into consideration the International Coaching Federation (ICF) standards and ethics of coaching is important in gauging the limitations of text based coaching. The ICF is an organization that sets the competencies for the philosophical and ethical standards as it applies to coaching. Similar to any other well regarded health related organization, the ICF has a thorough and well thought out framework. While text coaching doesn’t violate any of the ethical standards that coaches are expected to uphold, it does conflict with the standards of coaching.
Coaching is defined as a modality that seeks to produce action, accountability and follow-through. When a person does not have to commit to an appointment or is able to hide behind a phone, the principles of action, accountability and follow through comes into question. It is much easier to ignore a text than it is to ignore a person you speak to on the phone or see in person. The ICF philosophy of coaching as written by Williams and Anderson (2006) is as follows:
1. Discover, clarify, and align with what the client wants to achieve
2. Encourage client self-discovery
3. Elicit client generated solutions and strategies
4. Hold the client responsible and accountable (p.259).
These tenants are best met when the coach can witness body language, tone, and other non-verbals that give clues to the coach in how best to bring awareness and ask powerful questions to the client so that they can move forward. All non-verbal communication is lost over text coaching which limits all the philosophies stated above.
Ethical model
Cohen’s (2003) model of Nonmaleficence includes four points and how text coaching relates to each point.
1. Beneficence. To have the welfare of the individual in mind, text coaching does not maximize the potential of the client to self actualize or take action to help themselves. It may be better than nothing but is certainly inferior to live coaching.
2. Nonmaleficence. Text coaching may not directly do any harm to the client, however for the high risk client who may be lying or going through the motions to satisfy an employer or loved one, it is much easier to hide red-flag attitudes and behavior over text than other forms of coaching.
3. Respect for autonomy. Text coaching is the ultimate platform for autonomy. The client gets to engage whenever they feel like it.
4. Justice. Considering the ubiquity of smart phones across all populations, the access to text coaching is equal. For those that have more demands on their time, text coaching allows for something rather than nothing. At the same time, those that are serious about transformation can always find time for live coaching by making it a priority.
Industry Examples
Weight Loss
The question of whether text based coaching is ethical must take into consideration what health issue is it addressing and what are the typical behaviors that people who have that specific illness embody. For example, Kurbo Health is a digital health company that teaches behavior modification to overweight and obese children. Unlike other weight-loss apps, Kurbo factored in the need for children to have face-to-face interaction and that “long-term weight management requires a range of behavioral and lifestyle changes in order to address the multifactorial etiology of obesity” (Rivera et al., 2016, 87). Consequently, the product offers once a week live coaching sessions via videoconference. If Kurbo offered only text based coaching, would the program be as effective? With little data available comparing text coaching to live coaching, it is hard to conclude. Anecdotally, coaches at Kurbo report that text interactions are challenging, less meaningful, and lack the productivity of a live coaching call. Weight loss appears to be less common than when coached live. Spring et al., (2013) points towards Kurbo’s anecdotes to possibly be true in a study that found the inclusion of telephonic coaching sessions improved weight loss outcomes as compared to no coaching sessions.
Measuring the model of once a week live coach sessions to Cohen’s ethical model proves to be a positive exercise in determining Kurbo’s ethical stance. Kurbo is both benevolent and nonmalificent in its approach. The combination of coaching and tracking food in the app supports the user in becoming aware of their own behavior and accountable to new and healthy behaviors. The child has the ability to have autonomy (maybe for the fist time from their parents) because they track their food in the app on their own accord and meet with their personal coach. If they choose to cancel a session, the onus is on them to reschedule and continue with coaching. The principle of justice is addressed in that Kurbo is provided by employers and gives discounts for low-income families. Anyone is able to have their own personal health coach that meets with them live.
Binge Drinking
Annum is a digital health company that is battling binge drinking and alcoholism. The year-long program is a multi-pronged solution centered around an app. After four months of meeting with a licensed therapist and medical doctor, the client receives 9 months of text based coaching from their personal coach. This poses the question of whether it is ethical for someone who has a tendency to be in denial (Benton, 2009) to only have text based coaching while still under treatment? One could argue that after four months of live professional treatment the use of text based coaching provides a support that is easily accessible for the client. It does not violate any of Cohen’s ethical principles, and is better than no coaching at all. On the other hand, studies show that the efficacy of coaching lies in the communication and relationship between the client and the coach (Brivio, Gatti, Galimberti, Gambini, & Binello, 2015). The principle of beneficence, or promoting good, may be accomplished with text coaching, however not to it’s full potential. For a person who is recovering from alcohol addiction, a human relationship and emotional support system is predictive of improved psychological distress (Segrin, McNelis, & Swiatkowski, 2016). So much of what comprises the positive components of human interaction is lost over text. Nonmalfecence is a more complicated principle to analyze in the case of heavy drinking and text based coaching. In the worst case scenario, a client may be texting with the coach and not completely revealing the whole truth about their behavior or emotional state. It is much easier for a coach to pick up on non-verbal cues that may indicate the client is not on track than over text. For the client to justify to him/herself that they are doing well (when in fact they are not) because they have a coach is a far too easy way of denying what may actually be reality. Inherent in the text coaching is the ability for the client to decide when to engage their coach making autonomy an ethical standard that is well accounted for. Given that almost the entire population has a smartphones, anyone with a drinking problem is able to utilize this service.
Conclusion
The ethics of text coaching are debatable. It is in the client’s best interest to have live coaching sessions, however text coaching is better than no coaching. When someone is at the stage of being ready to make change, it takes very little provocation to motivate new behaviors. Arguably, text coaching can be just as effective for these types of people. For those that are in the contemplative stage of behavior change, they may require more quality and depth of exploration with the coach that suffers over text coaching (Prochaska, 2008). It is advised for companies that are addressing more serious disease or illness to consider the principles of beneficence and nonmaleficence over efficiency and KPI’s. For the companies addressing more serious psychological diseases such as heavy drinking or depression where it’s too easy to hide behind a phone, they will want to seriously consider what is best for their clients.
References
Benton, S. (2009) Characteristics of high-functioning alcoholics: What is a high-functioning alcoholic? Psychology Today. https://www.psychologytoday.com/blog/the-high-functioning-alcoholic/200901/characteristics-high-functioning-alcoholics
Brivio, E., Gatti, F., Galimberti, C., Gambini, P., & Binello, M. (2016). Effect of telephone calls and text messages on goal attainment in a ehealth coaching service. Annual Review of Cybertherapy and Telemedicine 2015: Virtual Reality in Healthcare: Medical Simulation and Experiential Interface, 219, 135-138. Retrieved from http://www.arctt.info/volume-13-summer-2015
Cohen, M. H. (2003). Future Medicine: Ethical dilemmas, regulatory challenges, and therapeutic pathways to health care and healing in human transformation. Ann Arbor, MI: University of Michigan Press.
Herbert, L., Owen, V., Pascarella, L., and Streisand, R. (2013). Text Message Interventions for Children and Adolescents with Type 1 Diabetes: A Systematic Review. Diabetes Technology & Therapeutics, 15(5): 362-370.
Prochaska, J. O. (2008). Decision making in the transtheoritical model of behavior change. Medical Decision Making,28(6). https://doi.org/10.1177/0272989X08327068
Rivera, J., McPherson, A., Hamilton, J., Birken, C., Coons, M., Iyer, S., … Stinson, J. (2016). Mobile Apps for Weight Management: A Scoping Review. JMIR mHealth and uHealth, 4(3), e87. http://doi.org/10.2196/mhealth.5115
Spring, B., PhD., Duncan, J. M., PsyD., Janke, E. A., Kozak, A. T., PhD., McFadden, H. G., DeMott, A., B.A., . . . Hedeker, D., PhD. (2013). Integrating technology into standard weight loss treatment: A randomized controlled trial. JAMA Internal Medicine, 173(2), 5. Retrieved from https://tcsedsystem.idm.oclc.org/login?url=https://search-proquest-com.tcsedsystem.idm.oclc.org/docview/1283003213?accountid=34120
Segrin, C., McNelis, M., & Swiatkowski, P. (2016). Social Suport Indriectly Predicts Pronlme Drinking Through Reduced Pshycolgoical Distress. Substance Use & Misuse, 51(5), 608-615. Doi:10.3109/10826084.2015.1126736.
Technology Components as Adjuncts to Family-Based Pediatric Obesity Treatment in Low-Income Minority Youth.Childhood Obesity. https://doi-org.tcsedsystem.idm.oclc.org/10.1089/chi.2017.0021
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