J Health Behav Med Hist 2025-10.
A Functional Metaphor for Understanding Techniques and Transformation in Behavioural Coaching
Robert C. van de Graaf, MD, director
MEDTCC Institute for Health, Behaviour, Medicine and its History, The Netherlands
Abstract
Coaching is often perceived as a supportive conversation, but in its essence, it is a precise behavioural intervention. This article introduces the metaphor of surgery as a conceptual tool to distinguish two categories of coaching techniques: intervention techniques (ITs) and behavioural change techniques (GVTs). Drawing on parallels with surgical practice, the article reframes coaching as a professional act that requires preparation, precise technique, bodily skill, and constant monitoring, assessment and decision making. This surgical metaphor clarifies the nature of coaching and helps improve its identity as an intentional, embodied, and transformative practice.
Introduction
Coaching is frequently described as a dialogue, a supportive encounter, or a safe space for reflection. Yet such descriptions, while partially true, risk obscuring the essential nature of coaching: an active, structured intervention in human behaviour.
Much like surgery, coaching aims to change something within a living system. It involves preparation, precision, timing, tools, and technique. The coach, like the surgeon, is not merely present—they intervene. They act. The purpose of this article is to offer a metaphorical but functionally accurate reframe: that coaching is more like surgery than many professionals and clients currently perceive. This metaphor is not a decorative analogy, but a diagnostic lens. It clarifies the logic behind coaching techniques, the skill involved in using them, and the need to distinguish between two critical dimensions of professional practice: the conditions for change and the mechanisms of change itself.
Why a Surgical Metaphor?
Professional metaphors shape practice. They provide practitioners with mental models that guide attention, language, and skill development. In medicine, surgery stands as a clear example of professional precision: a structured act upon a living body, with real consequences and high stakes.
Coaching, by contrast, often borrows metaphors from talking, teaching, or parenting. While these may highlight the relational side of coaching, they fail to capture its technical depth. A surgical metaphor reclaims this depth. It reminds us that coaching is not merely about listening—it is about knowing when and how to act.
In both coaching and surgery, the practitioner must understand:
- What system they are working in.
- What change is desired.
- What techniques are available.
- What conditions must be established for the intervention to succeed.
Surgery and coaching both operate in high-stakes, adaptive systems. And in both, timing, preparation, and skill make the difference between healing and harm.
Techniques in Two Domains: ITs and BCTs vs. ITs and TCTs
One of the most clarifying insights offered by the surgical metaphor is the distinction between two categories of techniques:
1. Intervention Techniques (ITs)
These are techniques that create the conditions for change.
In surgery, examples include anesthesia, patient positioning, sterility, hemostasis, and real-time monitoring.
In coaching, these include building trust, creating psychological safety, offering structure, regulating attention, and providing containment.
These techniques do not directly alter tissue or behaviour, but they are essential for preparing the system for change. Without skilled application of ITs, any attempt at transformation risks failure, resistance, or harm.
2. Change Techniques
These are techniques that directly initiate change in the system.
In coaching, we refer to these as Behaviour Change Techniques (BCTs). These include: goal setting, behavioural action planning, prompting self-monitoring, providing task-specific feedback and stimulus control (cue management).
In surgery, the analogous category could be called Tissue Change Techniques (TCTs). These include: incision, dissection, excision, suturing and grafting.
These techniques are the tools of transformation. They are specific, targeted, and often irreversible. Their effectiveness depends entirely on the readiness of the system — and on the quality of the preceding intervention techniques.
Table: Coaching and Surgery Compared
| Coach | Surgeon |
| BCTs: e.g., goal setting, action planning, feedback | TCTs: e.g., incision, suturing, dissection |
| ITs: e.g., trust-building, structure, containment | ITs: e.g., anesthesia, positioning, monitoring |
| Primary instrument: body, presence | Primary instrument: hands, eyes, attention |
| Secondary tools: camera, screen | Secondary tools: scalpel, clamp, optics |
Coaching Is Not a Conversation
It is a carefully structured intervention in a dynamic behavioural system. The body, emotions, memory, motivation, and environment are all part of that system. Coaching aims not just to talk about them—but to work within them.
Like surgery, coaching requires:
- Preparation: Who is this person? What system are we entering? What is the indication for intervention?
- Positioning: What is the first step? How do we gain access without harm?
- Technique: What intervention is appropriate? How do we ensure safety?
- Monitoring: What reactions emerge? What must we adjust?
- Closure and recovery: How do we stabilize the change? What follow-up is needed?
Monitoring and Recovery: Coaching as a Live Procedure
Neither coaching nor surgery ends with the application of a technique. Both demand real-time monitoring and adaptive responsiveness. The human system — behavioural or biological — is not static. It reacts. It compensates. It protests. And it sometimes destabilizes.
In surgery, an unexpected bleeding or a shift in blood pressure prompts immediate action. Monitoring isn’t a formality — it’s a safeguard. In coaching, the same principle applies. Coaches must track verbal and non-verbal cues: shifts in affect, changes in tone, hesitation, resistance, or confusion. These are the system’s vital signs.
If the behavioural “field” becomes unsafe — if the client feels overwhelmed, confused, or exposed — the coach intervenes not with a new BCT, but with a renewed intervention technique: slowing down, re-establishing safety, offering containment.
After the core intervention, closure matters. Just as a surgeon does not walk away from an open wound, a coach does not exit abruptly from a deep behavioural shift. Reflection, consolidation, and preparation for integration are essential. Without this recovery phase, even the best-applied technique can collapse under real-world stress.
The Coach as Instrument: Body, Presence, and Perception
In both coaching and surgery, the practitioner’s own body is the primary tool. Precision, attunement, and timing are not purely cognitive functions — they are sensorimotor and relational.
The surgeon’s eyes, hands, and fine motor control are honed through repetition, presence, and bodily intelligence. Likewise, the coach’s tone of voice, posture, facial expression, and gaze communicate far more than content. They co-regulate the system. They modulate readiness.
Coaching is not performed through the body. It is performed with the body. This insight has major implications for training: technique manuals and scripts are not enough. Coaches must train their instrument — not only in theory, but in breath, voice, stillness, and presence.
Technology plays a supporting role. Just as a surgeon may use scalpels, scopes, or robotic arms, coaches may use video calls, reflective forms, or digital tools. But these are always secondary instruments. The primacy of the human instrument — attuned, grounded, and disciplined — remains.
Clinical Implications: Training, Supervision, and Research
The surgical metaphor offers multiple practical benefits for the field of coaching, particularly in advancing its professional maturity and technical precision.
1. Terminological Precision
Many coaching approaches blur the boundaries between supportive conversation, motivational dialogue, and structured behavioural intervention. By applying the surgical metaphor, we can promote a clear and functional taxonomy of techniques:
- Intervention Techniques (ITs) create the necessary conditions for change — safety, containment, structure.
- Behaviour Change Techniques (BCTs) are the instruments of transformation — planning, goal setting, feedback, and stimulus control.
This clarity enhances communication, consistency, and training within the profession.
2. Professional Identity
Reframing coaching as a deliberate behavioural intervention sharpens the coach’s professional self-image. Coaches are not passive listeners or informal helpers — they are skilled behavioural professionals who perform live procedures with measurable effects. Just as surgeons act with intention and precision, so too must coaches, applying their tools with care, timing, and attunement.
3. Structured Training and Supervision
Surgical education is based on rigorous structure: simulation, stepwise protocols, tactile skill development, reflection on errors, and supervised practice. Coaching can follow suit by:
- Training coaches in recognising and applying ITs before any BCT is attempted.
- Practising how to establish a “sterile field” — a psychologically safe and attuned environment.
- Teaching coaches when to pause, how to contain distress (emotional “bleeding”), and how to close a session with clarity and integration.
- Supervision and teaching can include reviewing the sequence and timing of interventions — much like a surgical team would review a procedure.
4. Research and Evidence-Based Development
Inspired by surgical science, coaching can benefit from a stronger empirical foundation. Future research directions include:
- Sequencing Logic: What are the most effective sequences and combinations of ITs and BCTs for specific behavioural goals? Are there universally effective “intervention paths” for common issues such as habit change, burnout recovery, or motivation loss?
- Checklists and Protocols: Can coaching benefit from procedure-style checklists, improving reliability without losing nuance?
- Adaptive Monitoring: How can real-time emotional and behavioural “vital signs” guide in-session decisions?
- Instrument Calibration: How do coaches develop, train, and refine their primary instrument — their body, presence, and perception? What is the effect of coach regulation on client outcomes?
- Indications and Contraindications: When is a particular BCT (e.g., goal-setting) helpful — and when might it backfire? Just as surgeons consider comorbidities and tissue readiness, coaches can consider motivational states, readiness to change, or cognitive overload before intervening.
- Precision Coaching: Just as surgery moved from broad excisions to minimally invasive and robot-assisted techniques, can coaching evolve toward more precise, individualized intervention strategies, using data, pattern recognition, and reflective practice?
- Intervention Efficacy Across Populations: Are some IT–BCT combinations more effective for specific populations (e.g., trauma survivors, adolescents, executives)? What role do cultural, psychological, or neurobiological differences play?
By learning from the surgical discipline — its language, structure, and commitment to continuous improvement — coaching can evolve into a behavioural profession of comparable clarity and respect. The surgical metaphor is not a claim of superiority, but a call to precision. It reframes coaching as a deliberate act of change, grounded in preparation, technique, monitoring, and care.
Discussion
The metaphor of surgery as applied to coaching is not a claim of equivalence — it is a conceptual tool. Coaching is not medical, and its “patients” are not anesthetized. The coaching relationship is collaborative, co-regulated, and conscious. But even in this difference lies the power of the comparison.
Surgery is serious. Structured. Technical. It is done with preparation, skill, and care. By invoking the metaphor, we assert that coaching too deserves this degree of seriousness — not solemnity, but precision. Not rigidity, but intentionality.
Just as surgical teams operate with clarity about roles, steps, and risks, coaching professionals can adopt similar clarity about techniques, timing, and responsibility.
Of course, metaphors are simplifications. Not all coaching requires deep intervention. Some sessions may resemble diagnostics, maintenance, or light touch. Not every coach wants or needs to adopt this framing.
However, for coaches working with deep change — in trauma, addiction, leadership, health behaviour, or burnout — this metaphor offers both a lens and a language: coaching as a behavioural procedure, not just a reflective practice.
Conclusion
Coaching is not a conversation. It is a live, technical intervention in a dynamic behavioural system. Like surgery, it requires preparation, intervention techniques to create safe conditions, behavioural change techniques to enact the shift, and skillful monitoring to support integration and recovery.
By adopting the surgical metaphor, coaches can clarify their professional craft, distinguish their techniques, and train with greater intentionality. The body becomes an instrument, the technique a skill, and the process a procedure. This reframing elevates coaching from informal support to structured transformation.
In a world increasingly overwhelmed by superficial change and quick fixes, coaching with surgical precision offers an alternative: deliberate, embodied, accountable change work — with care at its core.