Unit 4: The Practice of Longevity Coaching¶

Chapter 4.26: Case Studies - Complex Cases¶

[CHONK: 1-minute summary]

What you'll learn in this chapter:
- How to apply the Triangle of Care model when clients have complex medical situations
- Coaching approaches for four different complex scenarios: multiple chronic conditions, post-cancer recovery, cardiovascular disease with medications, and chronic pain/fatigue
- When to pause coaching, proceed with modifications, or refer immediately
- Professional communication with healthcare providers (with a complete template example)
- Red flags specific to each condition type
- How to maintain scope boundaries when coaching feels more complicated

The big idea: Complex cases aren't rare, they're increasingly common as our population ages. Many of your clients will come to you managing multiple conditions, recovering from serious illness, or taking medications that affect how they respond to lifestyle interventions. This chapter teaches you to work confidently with these clients by tightening your scope awareness, enhancing your medical collaboration, and adapting your coaching approach, all while remembering that your role remains fundamentally the same: helping clients implement behavior change within their physician's parameters.

Key phrase to remember: In complex cases, tighter scope boundaries equal better client care.

[CHONK: The Triangle of Care in Complex Cases]

The Triangle of Care in Complex Cases¶

Why Complex Cases Require Enhanced Collaboration¶

In Chapter 1.5, you learned about the Triangle of Care, the three-way partnership between Client (the CEO), Coach (the Project Manager), and Physician (the Medical Expert). Every longevity coaching relationship operates within this triangle.

But complex cases require you to tighten the triangle.

When clients have multiple conditions, are recovering from serious illness, or take medications that affect their responses to lifestyle interventions, the stakes are higher. A recommendation that's perfectly appropriate for a healthy 45-year-old might be dangerous for someone recovering from cardiac surgery. An exercise intensity that builds fitness in most people might trigger a flare in someone with chronic fatigue syndrome.

This isn't about limiting what you can do. It's about recognizing that the more complex the client's situation, the more essential collaboration becomes.

Your Role Doesn't Change, But Your Vigilance Does¶

Your fundamental role as a coach remains the same in complex cases. You still:
- Facilitate client-led behavior change (rather than directing)
- Share evidence-based information (education, not prescription)
- Support implementation of their medical team's recommendations
- Help clients build sustainable habits over time
- Refer out when needs exceed your scope

What changes is your vigilance. In complex cases, you:
- Check in more often on the client's medical status and symptoms
- Communicate more proactively with healthcare providers, with the client's consent
- Adapt interventions more conservatively when anything is unclear
- Watch for red flags more carefully
- Document more thoroughly so everyone stays aligned

The Hierarchy of Safety¶

When coaching complex cases, this hierarchy guides every decision:

1. Safety first. If there's any question about whether an intervention might harm a client, stop, refer, and get medical clearance. The coaching relationship can wait; the client's safety cannot.

2. Medical parameters second. Whatever the client's physician has established (exercise intensity limits, dietary restrictions, medication schedules), those are your guardrails. You work within them, not around them.

3. Client preferences third. Within safety and medical parameters, you still honor client autonomy. They choose their goals, their pace, and their priorities.

4. Optimization last. Only after safety, medical parameters, and client preferences are addressed do you consider optimizing protocols.

Many coaches get this backwards. They focus on optimization first, then try to fit client preferences around it, then check medical parameters as an afterthought, then address safety concerns only when they arise. In complex cases, that approach is dangerous.

Here’s what that can sound like in a session.

What NOT to do

Client: “I read about a protocol that promises faster results. Can we try it?”

Coach: “Sure. Let’s go for it and see how your body responds.”

A better approach

Client: “I read about a protocol that promises faster results. Can we try it?”

Coach: “Maybe, but let’s run it through our safety checklist first. Any chance this could affect your condition or meds?”

Client: “I’m not sure.”

Coach: “Then we’ll pause and get your clinician’s input. Once we’re clear on safety and your parameters, we can choose an option that also fits what you want.”

If holding all of this in your head feels like a lot right now, that's OK. You don't have to recite the hierarchy from memory in every session; using it as a quick mental checklist (or even pausing to glance back at this section) is part of good, safe practice. And when you're unsure, defaulting to safety and referral is always the right call.

What This Chapter Covers¶

The following sections present four different complex scenarios. Each case demonstrates:

• The client profile: Who they are and what they're managing
• The coaching challenges: What makes this case complex
• Scope boundaries: What you CAN and CANNOT do
• The coaching approach: How to adapt your methods
• Medical collaboration: How to work with their healthcare team
• Red flags to watch: Signs requiring immediate referral
• A realistic outcome: Progress, not perfection

These aren't composite ideals; they're the kinds of clients you'll actually encounter, and you can take something useful from each one.

[CHONK: Case 1 - Maria: T2DM + Obesity + Depression]

Case 1: Maria - Type 2 Diabetes + Obesity + Depression¶

Meet Maria¶

Maria is a 52-year-old Latina woman who works as a school counselor. She's seeking coaching because her doctor told her she needs to "make lifestyle changes" to improve her diabetes, but she doesn't know where to start. When you first meet her, she seems exhausted, and she mentions feeling "like I'm failing at everything."

Client Profile¶

Key Coaching Challenges¶

Maria's case illustrates how conditions interconnect:

Depression affects motivation. Maria knows what she "should" do; she's heard the advice a thousand times, but depression robs her of the energy and motivation to act, so some days getting out of bed feels like enough.

Multiple medical providers. Maria has an endocrinologist for diabetes, a psychiatrist for depression, and a PCP. That's three different medical relationships to coordinate. She doesn't always tell one doctor what the others have recommended.

Isolation compounds everything. Since her divorce two years ago, Maria's social support has shrunk. She eats alone, exercises alone (when she exercises at all), and spends most evenings watching television. Loneliness makes both depression and unhealthy eating worse.

Gentle progression required. Maria has tried and failed at multiple aggressive diet and exercise programs. Each failure reinforced her belief that she "can't do this." She needs success experiences, not another ambitious plan that crumbles.

Scope Boundaries¶

What the Coach CAN Do:
- Help Maria identify small, manageable behavior changes she's confident she can sustain, and explain how lifestyle factors (sleep, movement, nutrition) can affect both mood and blood sugar
- Support her in implementing the lifestyle changes her medical team recommends, and help her prepare questions for medical appointments
- Encourage and track follow-up with her medical providers, and help her build social support structures into her plan
- Use motivational interviewing to explore ambivalence and build readiness

What the Coach CANNOT Do:
- Adjust her diabetes management, interpret her blood sugar numbers, or recommend changes to her medications (including supplements that might interact)
- Provide therapy for her depression, diagnose whether her fatigue is from depression, diabetes, or something else, or tell her whether her depression is "managed well enough" to pursue lifestyle changes
- Create a meal plan (refer to registered dietitian if needed)

The Coaching Approach¶

Start with depression screening. Before diving into longevity interventions, acknowledge what Maria is dealing with. Ask directly: "You mentioned feeling like you're failing at everything. On a scale of 1-10, how has your mood been over the past two weeks?"

If Maria's answers suggest her depression may be worsening (persistent low mood, loss of interest in activities, sleep changes, or especially any thoughts of self-harm), pause your coaching agenda. Her first need is to connect with her psychiatrist or mental health provider.

The PHQ-2 as a check-in tool. The PHQ-2 asks two simple questions:
1. Over the past two weeks, how often have you been bothered by little interest or pleasure in doing things?
2. Over the past two weeks, how often have you been bothered by feeling down, depressed, or hopeless?

Scored 0-3 per question (not at all, several days, more than half the days, nearly every day). A score of 3 or higher suggests the need for further assessment by a mental health provider.

You're not diagnosing; you're checking in and knowing when to pause coaching to support a referral.

Choose one thing. Maria is overwhelmed, and the worst thing you can do is add to her to-do list. Instead, help her identify ONE small change that feels manageable even on a bad day.

"Maria, if we were to work on just one thing over the next two weeks, something small enough that you could do it even when you're tired or not feeling great, what might that be?"

Maybe it's a 10-minute walk after dinner, eating vegetables at one meal per day, or going to bed 30 minutes earlier. The intervention matters less than the success experience.

Build social into the plan. Maria's isolation makes everything harder. Look for ways to build connection into her behavior changes: walking with a colleague at lunch, joining a gentle yoga class, calling a friend during her evening walk. Social support isn't a nice addition; for Maria, it's essential.

Medical Collaboration¶

Maria has three providers, but they may not be talking to each other. With Maria's permission, offer to help coordinate:

"Maria, you mentioned you have an endocrinologist, a psychiatrist, and a primary care doctor. Do they communicate with each other about your care? Would it be helpful if I sent a brief note introducing myself and letting them know we're working on lifestyle changes?"

A simple communication to Maria's PCP might read:

"Dear Dr. [Name], I'm working with Maria [Last Name] as her health coach to support lifestyle changes for her metabolic health, and I understand she's managing Type 2 diabetes, obesity, and depression. I wanted to introduce myself and let you know I'm helping Maria work on [specific goals, e.g., increasing daily movement and improving sleep habits]. I stay within my scope as a coach and support implementation of your medical recommendations. If there are any parameters you'd like me to be aware of, or if you have concerns about specific activities, please let me know. I'm happy to provide periodic updates on Maria's progress. Best regards, [Your name, credentials]"

Red Flags to Watch¶

Immediate referral (pause coaching):
- Any mention of suicidal thoughts or self-harm → Refer immediately to mental health crisis resources
- PHQ-2 score ≥3 with worsening symptoms → Recommend she contact psychiatrist before continuing coaching
- Signs of diabetic crisis (extreme thirst, frequent urination, confusion, breath with fruity odor) → Emergency care

Contact medical provider:
- Significant mood changes (much better or much worse) → May indicate medication changes needed
- Hypoglycemic episodes (shakiness, sweating, confusion) → Physician should review
- Significant weight changes (gain or loss) without intentional changes → Medical evaluation
- Medication side effects affecting daily function → Physician should assess

Deep Health Snapshot¶

What Happened (3-Month Check-In)¶

Maria started with one small change: a 10-minute walk after dinner while calling her sister on the phone. The combination of movement and connection felt manageable even on hard days.

At three months:
- She's walking 15-20 minutes most evenings (5 of 7 days typically)
- She's reconnected with two old friends who now join her for Saturday morning walks
- Her mood has improved. She reports "more good days than bad" for the first time in a year
- Her most recent HbA1c dropped from 8.4% to 8.0%, not at goal yet, but trending in the right direction
- She's now ready to work on one nutrition habit

Maria's progress isn't dramatic, and she's not "transformed," but she's moving in the right direction, building confidence, and, perhaps most importantly, she believes she can keep going.

Key Lessons from Maria's Case¶

1. Depression affects everything. Before pushing lifestyle interventions, assess whether mental health support is in place and adequate.
2. One thing at a time. Overwhelmed clients need smaller steps, not bigger plans.
3. Social connection is an intervention. For isolated clients, building support may be more impactful than any specific exercise or nutrition change.
4. Coordinate with the care team. When clients have multiple providers, offer to help communicate.
5. Celebrate trajectory, not perfection. Maria's numbers aren't at goal, but she's moving in the right direction.

Coaching in Practice: When Depression Affects Motivation¶

[CHONK: Coaching in Practice - When Depression Affects Motivation]

Maria says: "I know I should exercise more, but I just can't make myself do it. I feel so lazy."

DON'T say: "You just need to push through it. Once you start, you'll feel better." (This dismisses her experience and adds to her sense of failure.)

DO say: "That sounds really hard, and depression can make even small tasks feel enormous. That's not laziness, that's the illness. I'm curious: are there any moments when you have a little more energy, even briefly?"

Sample dialogue:

Maria: "I know I should exercise more, but I just can't make myself do it. I feel so lazy."

Coach: "That sounds really hard, and depression can make even small tasks feel enormous. That's not laziness, that's the illness."

Maria: "It really does feel that way."

Coach: "I'm curious, are there any moments in your day when you have a little more energy, even briefly? If so, we could start by planning something tiny for that window."

Why this works: You acknowledge the reality of depression, remove the shame language ("lazy"), and gently explore exceptions rather than prescribing solutions. This opens the door to finding small windows where change might be possible. |

[CHONK: Case 2 - James: Post-Cancer Recovery]

Case 2: James - Post-Cancer Recovery¶

Meet James¶

James is a 58-year-old Black man who works as an accountant. Eighteen months ago, he completed treatment for Stage II colon cancer, including surgery followed by chemotherapy. His oncologist has declared him "cancer-free," but James doesn’t feel like himself: He’s lost 30 pounds of muscle, he’s dealing with persistent fatigue, and he lives with low-level anxiety about recurrence. His wife describes him as "a shell of who he was." (This is a hard place to be, and it’s more common than many people realize.)

Client Profile¶

Key Coaching Challenges¶

James's case highlights several common challenges that can show up during post-treatment recovery:

Cancer-related fatigue. Cancer-related fatigue isn’t normal tiredness; it’s a well-documented phenomenon that can persist for months or years after treatment ends, and it doesn’t respond to rest the same way normal fatigue does. When clients try to "push through," it often backfires. (If you’ve ever felt confused by that, you’re not alone.)

Significant muscle loss. Chemotherapy plus reduced activity during treatment cost James about 30 pounds of muscle. Rebuilding does require progressive resistance training, but doing that safely after cancer treatment means getting oncologist clearance and using appropriate pacing. (Slow can feel frustrating here, but slow is often what works.)

Recurrence anxiety. Every new symptom can trigger fear: Is the cancer back? That level of vigilance is exhausting, and it can swing people toward either hypervigilance about health or total avoidance of anything health-related.

Identity disruption. Before cancer, James was "the strong one" in his family, the provider, the protector, and now he feels diminished. His wife’s supportive behavior ("walking on eggshells") may come from love, but it can also unintentionally reinforce his sense that something is wrong with him.

Scope Boundaries¶

What the Coach CAN Do:
- Help James rebuild activity gradually with appropriate pacing
- Educate about cancer-related fatigue and evidence-based management strategies
- Support implementation of exercise within oncologist parameters
- Help manage anxiety through lifestyle approaches (sleep, movement, stress management)
- Encourage follow-up with oncologist for surveillance and clearance
- Support communication with spouse about what helps versus what inadvertently disempowers
- Help James explore new aspects of identity beyond "the strong one"

What the Coach CANNOT Do:
- Clear James for exercise (oncologist must do this)
- Determine whether symptoms are recurrence or normal recovery
- Provide psychological treatment for cancer-related anxiety
- Adjust intensity based on his "cancer status." That's medical judgment
- Promise that lifestyle changes reduce recurrence risk (can share general research, not personalized risk assessment)

The Coaching Approach¶

Medical clearance comes first. Before prescribing any exercise, James needs clearance from his oncologist. This isn’t optional. It’s required.

What NOT to do:
- Start building workouts or progressing intensity before James has clear parameters from his oncology team.

What this can sound like (in real conversation):

Coach: "James, I’m really glad you want to rebuild your strength. Before we map out any exercise plan, can we make sure we have clearance from your oncologist?"

James: "Yeah, I figured you might say that. What should I ask them?"

Coach: "Great question. I’ll help you prepare a short list. Once we know the parameters they recommend, I can help you build and follow a plan that fits inside those guidelines."

Getting clear on fatigue before trying to fight it. Cancer-related fatigue is different from normal fatigue. Counterintuitively, rest often doesn’t help much, while gentle activity tends to improve it; on the other hand, trying to "push through" aggressively can cause setbacks.

What James needs to know:
- Fatigue is a real, recognized effect of cancer treatment
- It's not weakness or laziness
- Gentle movement often helps more than rest
- Pacing (balancing activity and rest) prevents boom-bust cycles

(This is a lot to hold at once, and that’s okay. Many clients need to hear this more than once.)

Rebuilding happens best in stages. James lost 30 pounds of muscle, and he wants it back now. That makes complete sense, but aggressive training after cancer treatment can backfire, so it’s smart to start conservatively:
- Week 1-2: Focus on daily movement (walking, light stretching)
- Weeks 3-4: Add gentle resistance with clearance (bodyweight exercises, resistance bands)
- Months 2-3: Gradually progress within oncologist parameters

Anxiety needs the right kind of support. James’s recurrence anxiety is understandable and common. You can support mental health with lifestyle factors (sleep, movement, stress management), but if his anxiety significantly impairs his functioning, he needs referral to a mental health provider, preferably one experienced with cancer survivors.

What NOT to do:
- Reassure him out of it ("You’re fine, don’t worry") or try to interpret symptoms as normal recovery versus recurrence.

What this can sound like (in real conversation):

James: "Every little symptom makes me think it’s back."

Coach: "That sounds exhausting. And it’s also incredibly common among survivors. Are you talking with anyone about the anxiety, like a counselor or therapist?"

James: "No. I didn’t think it was… serious enough."

Coach: "I hear you. At the same time, you deserve support with this. If you’re open to it, connecting with someone who specializes in supporting cancer survivors could really help, and I can also support you with sleep, movement, and stress management strategies alongside that."

Medical Collaboration¶

James needs oncologist clearance before starting any exercise program. Here's a template for how that communication might look:

Coaching in Practice: Sample Communication to Oncologist¶

[CHONK: Coaching in Practice - Sample Communication to Oncologist]

To: Dr. [Oncologist Name]
From: [Your Name], [Credentials], Health Coach
Re: James [Last Name] - Exercise Clearance Request

Dear Dr. [Name],

I am working with your patient James [Last Name] as his health and wellness coach. James has expressed interest in rebuilding his physical strength and improving his energy levels following his colon cancer treatment (Stage II, completed 18 months ago).

Before developing an activity plan, I am requesting your clearance for exercise. Specifically, I would appreciate guidance on:

1. Exercise clearance: Is James cleared for progressive exercise, including aerobic activity and resistance training?
2. Intensity parameters: Are there heart rate or exertion limits I should be aware of?
3. Any contraindications: Are there specific movements, activities, or intensity levels that should be avoided?
4. Monitoring recommendations: What symptoms should prompt James to stop exercise and contact you?

I understand my role as a coach is to support behavior change and implementation within your medical parameters. I do not diagnose, interpret symptoms, or make medical recommendations. I will work within whatever guidelines you provide.

I'm happy to provide periodic progress updates if that would be helpful for James's care. Thank you for your time and guidance.

Best regards,
[Your Name]
[Credentials]
[Contact Information]

Note: Always get client's written consent before contacting any healthcare provider. |

Red Flags to Watch¶

Contact oncologist immediately:
- Unexplained weight loss (not intentional)
- New or worsening digestive symptoms (especially changes in bowel habits)
- Unexplained pain
- Persistent fatigue that's significantly worse than baseline
- Any symptom James reports as "different from normal"

Mental health referral:
- Anxiety that prevents normal functioning
- Depression symptoms (withdrawal, hopelessness, loss of interest)
- Intrusive thoughts about cancer that won't stop
- Any mention of not wanting to continue or feeling like a burden

Exercise-related warning signs:
- Chest pain or severe shortness of breath → Emergency care
- Unusual fatigue that doesn't improve with rest → Pause exercise, contact oncologist
- Pain in surgical area → Stop activity, follow up with medical team

Deep Health Snapshot¶

What Happened (3-Month Check-In)¶

James received oncologist clearance with the following parameters: cleared for progressive exercise with no heart rate restrictions; avoid heavy lifting (>50 lbs) for another 3 months due to surgical healing; stop if experiencing abdominal pain.

At three months:
- James walks 30 minutes daily (up from 10 minutes at start)
- He's doing resistance band exercises 3x/week, progressing gradually
- His fatigue has improved. He describes it as "manageable" rather than "crushing"
- He gained 6 pounds (likely a mix of muscle and some fat). His oncologist is pleased with the weight gain
- He started seeing a counselor specializing in cancer survivorship for his anxiety
- He and his wife had a conversation about letting him "do more." She's working on stepping back

James isn't back to his pre-cancer self. He may never be exactly the same. But he's rebuilding, and he's finding new aspects of strength beyond physical power.

Key Lessons from James's Case¶

1. Medical clearance is non-negotiable. Post-cancer clients need oncologist approval before exercise programs.
2. Fatigue isn't laziness. Cancer-related fatigue is real and requires specific management approaches.
3. Pacing prevents setbacks. Aggressive progression often backfires; gradual rebuilding works better.
4. Identity extends beyond physical. Help clients find meaning and strength in new ways.
5. Family dynamics matter. Well-meaning support can inadvertently disempower; address this gently.

[CHONK: Case 3 - Patricia: CVD with Multiple Medications]

Case 3: Patricia - Cardiovascular Disease with Multiple Medications¶

Meet Patricia¶

Patricia is a 64-year-old Asian American woman who recently retired from teaching. Two years ago, she had a heart attack (myocardial infarction), completed cardiac rehabilitation, and was medically cleared to exercise, but she’s still terrified of “triggering another event,” which is understandable.

Her husband watched her collapse during the heart attack, and he’s been extremely protective ever since. Out of love, he discourages her from exerting herself, which leaves Patricia stuck: she wants to improve her fitness, but she honestly doesn’t know what’s safe anymore.

Client Profile¶

Key Coaching Challenges¶

Patricia’s case brings up a few classic cardiac coaching challenges. If you’ve ever felt a little intimidated by cardiac cases, you’re not alone.

Medication effects on exercise response. Patricia takes a beta-blocker, which changes how her heart rate responds to exercise. That means traditional heart rate-based training zones won’t work well here: even when she’s working hard, her heart rate might not rise the way you’d expect, so you’ll need other tools, like Rate of Perceived Exertion (RPE).

Fear of exertion. Patricia is scared that exercise could trigger another heart attack, and that fear keeps her sedentary, which can increase cardiovascular risk over time. Her fear makes sense, and it also needs a plan. Both can be true.

Overprotective spouse. Her husband is traumatized too. His protective instincts, like discouraging activity or doing tasks for her, come from love, but they keep her inactive and can reinforce a sense of helplessness.

Cardiac rehab graduate. Here’s the good news: Patricia completed cardiac rehabilitation and was cleared for exercise. That means her cardiologist has already assessed her capacity and set parameters, and your job is to help her keep building on the progress she started in rehab.

Scope Boundaries¶

What the Coach CAN Do:
- Help Patricia continue the exercise program her cardiac rehabilitation established
- Work within parameters set by her cardiologist
- Educate about RPE-based training (since heart rate zones don't apply for her)
- Help address fear through gradual exposure and success experiences
- Support communication with spouse about helpful versus unhelpful support
- Track adherence and help troubleshoot barriers
- Encourage follow-up with cardiologist for any concerns

What the Coach CANNOT Do:
- Set exercise intensity parameters (cardiologist does this)
- Determine what's "safe" for her heart (medical judgment)
- Modify her exercise prescription based on how she "seems"
- Adjust anything related to her medications
- Tell her whether symptoms are concerning (that's for her medical team)
- Promise that exercise won't trigger another cardiac event

The Coaching Approach¶

Confirm cardiac rehab parameters. Because Patricia completed cardiac rehab, her cardiologist has already evaluated her and provided exercise guidelines. Your first step is to find out what those guidelines are so you’re working from the same playbook.

Coach: “Patricia, you mentioned you completed cardiac rehab, which is a big deal. Your cardiologist has already determined what’s safe for you. What exercise parameters did they give you, and what intensity did they clear you for?”

Patricia: “I don’t remember the exact numbers. I just remember being scared.”

Coach: “That makes sense. Before we build a plan, I’d like you to check in with your cardiologist so we’re working from the same guidelines they gave you.”

If Patricia can’t remember or isn’t sure, she needs to follow up with her cardiologist before you proceed.

Teach RPE-based training. Beta-blockers blunt heart rate response to exercise, so Patricia can work hard and still see only a small change in heart rate. That makes heart rate monitors and zone-based training unreliable for her.

Instead, use Rate of Perceived Exertion (RPE):

Coach: “Because of your beta-blocker, heart rate isn’t a reliable way to measure intensity, so we’re going to go by how the exercise feels.”

Patricia: “So… I don’t have to stare at the numbers the whole time?”

Coach: “Exactly. For most sessions, you should be able to talk in sentences but not sing. If you can only manage single words, you’re working too hard.”

Coach through fear. Patricia’s fear is real, so don’t dismiss it or try to logic her out of it. Instead, work with it.

Patricia: “I’m really scared I’ll trigger another heart attack if I push myself.”

Coach: “Of course you are. What you went through was traumatic.”

Coach: “And here’s what also matters: your cardiologist cleared you because they’ve determined exercise is safe for you within specific limits. Exercise is actually one of the best things you can do for your heart now.”

Coach: “We can start with something that feels low-risk to you and build from there. What would feel safe to try this week?”

Start where she’s comfortable, even if it seems “too easy,” and then build confidence through success experiences. As fear decreases, you can gradually expand.

Address family dynamics. Patricia’s husband means well, but his protectiveness is part of what keeps her stuck. This needs gentle addressing, not criticism.

Coach: “Patricia, your husband clearly loves you and wants to protect you. It also sounds like watching your heart attack was traumatic for him.”

Coach: “Sometimes when loved ones are scared, they try to protect us from everything, including the activities that would help us get stronger.”

Coach: “Would it help if we brought him into a conversation about what supportive help looks like now, so you can build confidence without feeling held back?”

Red Flags to Watch¶

Emergency: stop exercise and seek immediate care:
- Chest pain, pressure, or tightness
- Severe shortness of breath disproportionate to exertion
- Dizziness, lightheadedness, or feeling faint
- Irregular heartbeat or palpitations
- Pain radiating to arm, jaw, or back

Contact cardiologist:
- Unusual fatigue during or after exercise
- Swelling in legs or feet
- Difficulty sleeping lying flat (new symptom)
- Exercise tolerance suddenly decreasing
- Any new symptoms Patricia hasn't had before

Reading lists like this can feel a little intense. That’s normal.

Deep Health Snapshot¶

What Happened (3-Month Check-In)¶

At three months:
- Patricia is walking 30-40 minutes daily at RPE 4-5
- She's started light strength training 2x/week with resistance bands (cleared by cardiologist)
- Her fear has decreased, and she describes exercise as "empowering now, not scary"
- Her husband attended one coaching session; he now joins her walks instead of discouraging them
- Her cardiologist is pleased with her progress and maintenance of cardiac rehab gains
- She's lost a few pounds (which pleased her but wasn't the goal)

Patricia hasn’t eliminated her cardiovascular disease. She still has it, still takes medications, and still needs monitoring, but she’s no longer paralyzed by fear, and that’s a huge shift. She’s active, engaged, and building confidence one session at a time.

Key Lessons from Patricia's Case¶

1. Medication effects matter. Know that beta-blockers affect heart rate; use RPE instead.
2. Work within physician parameters. Cardiac clients need cardiologist-set limits; you don't determine safety.
3. Fear is a barrier worth addressing. Coaching through fear requires patience and gradual exposure.
4. Include family systems. Overprotective loved ones can be redirected toward helpful support.
5. Success breeds confidence. Start conservatively; let success experiences reduce fear.

Coaching in Practice: Coaching Through Fear of Exertion¶

What NOT to do (dismiss or over-reassure):

Patricia: “I’m afraid exercise will trigger another heart attack.”

Coach: “You’ll be fine. Just trust me and push through it.”

A better approach (validate, stay in scope, and build confidence):

Patricia: “I’m afraid exercise will trigger another heart attack.”

Coach: “That fear makes a lot of sense after what you went through.”

Coach: “We’ll stay inside the parameters your cardiologist already set, and we’ll use RPE so you can feel in control of the intensity. For today, what would feel like a ‘safe enough’ start?”

Patricia: “Maybe a short walk where I can still talk?”

Coach: “Perfect. If you can talk in sentences, you’re in a good zone for most sessions. We’ll aim for that, and we’ll build up slowly as your confidence grows.”

[CHONK: Coaching in Practice - Coaching Through Fear of Exertion]

Patricia says: "I'm scared that if I exercise, I'll have another heart attack."

DON'T say: "You'll be fine, exercise is good for you," because it dismisses her fear and doesn't address the real concern.

DO say: "That fear makes complete sense after what you went through. Your cardiologist cleared you for exercise because, based on your tests and your recovery, they've determined it's safe for you. In fact, regular exercise helps protect your heart, and I hear how scary that feels. What if we start with something that feels low-risk to you, maybe just a 10-minute walk around your neighborhood? We can build from there as you feel more confident."

Sample dialogue:

Patricia: "I'm scared that if I exercise, I'll have another heart attack."

Coach: "That fear makes complete sense after what you went through. Your cardiologist cleared you for exercise because, based on your tests and your recovery, they've determined it's safe for you. In fact, regular exercise helps protect your heart."

Patricia: "I hear that, but I still feel nervous."

Coach: "I can understand that. What if we start with something that feels low-risk to you, like a 10-minute walk around your neighborhood, and you stop if anything feels off? We can build from there as you feel more confident."

Why this works: You validate the fear, provide reassurance based on medical authority (not your own opinion), and offer a small first step that feels safe.

[CHONK: Case 4 - Robert: Chronic Pain + Chronic Fatigue]

Case 4: Robert - Chronic Pain + Chronic Fatigue¶

Meet Robert¶

Robert is a 49-year-old former contractor who’s been on disability for three years, and he’s been dealing with chronic low back pain since a work injury 15 years ago. Five years ago, he was also diagnosed with fibromyalgia.

He says he’s tried “everything” (physical therapy, injections, medications), so it’s understandable that he’s skeptical about “another program.” Since the injury, he’s gained 40 pounds, sleeps poorly, admits he’s been feeling depressed, and takes opioid medication managed by a pain clinic.

Client Profile¶

Key Coaching Challenges¶

Robert’s case highlights a few common, very real chronic pain coaching challenges. If you’ve coached someone like Robert, you know this can feel heavy.

In a first conversation, it might sound like:

Robert: “Honestly, I’ve tried everything, and I’m not sure coaching is going to help.”

Coach: “That makes sense, and I can hear why you’d feel that way. Before we talk about plans, can you tell me what’s been hardest day to day, and what a ‘good day’ versus a ‘bad day’ looks like for you?”

Activity without flares. Robert has learned that activity leads to pain flares, which has him stuck in a “boom-bust” cycle. On good days, he does too much (boom), then crashes into severe pain and does nothing for days (bust). Over time, that pattern can leave him more deconditioned and more sensitive.

Skepticism from past failures. Robert has tried many treatments with limited success, so he’s skeptical, maybe cynical, about coaching. “I’ve heard it all before” is his default stance.

Opioid medication. Robert takes opioid medication for pain, managed by a pain clinic. This adds complexity because opioids can affect energy, mood, and cognition. They’re part of his current treatment plan, and any changes require his pain management team’s involvement.

Identity loss. Robert built his identity as a contractor: physical, capable, strong. His injury took that away, and now he feels useless, diminished, and unsure who he is. This kind of loss is real, and it deserves to be treated like real grief.

Depression comorbidity. Chronic pain and depression frequently co-occur. Robert admits to feeling depressed, though he hasn’t been formally treated for it. This needs attention and, potentially, referral.

Scope Boundaries¶

Clear boundaries protect Robert, and they protect you. They also help build trust, because you’re not pretending to be the pain clinic or a therapist.

What NOT to do (outside scope):

Coach: “We can adjust your meds so you’re not in so much pain.”

Robert: “Okay… sure.”

Do this instead (clear and supportive):

Coach: “I can’t manage or change your medication. What I can do is help you pace your activity, build routines that work on both good and bad days, and support you in bringing questions back to your pain team.”

Robert: “Got it.”

Robert: “So… what can you help with, and what’s off-limits?”

Coach: “Great question. Here’s what’s in my lane, and what isn’t.”

Coach: “Here’s what I can do:”

What the Coach CAN Do:
- Help Robert understand pacing principles to avoid boom-bust cycles
- Support gradual, consistent movement within his tolerance
- Educate about pain science (what we know about how chronic pain works)
- Help build sustainable routines that account for pain variability
- Support engagement with his pain management team’s recommendations
- Encourage exploration of non-pain aspects of identity
- Recognize depression symptoms and encourage appropriate referral

Coach: “And here’s what I can’t do:”

What the Coach CANNOT Do:
- Manage or modify his pain medication in any way
- Determine what’s “good pain” versus “bad pain” (he needs PT for this)
- Provide treatment for depression or act as his mental health provider
- Push through his pain or encourage “no pain, no gain,” promise that lifestyle changes will eliminate his pain, or override his pain management team’s recommendations

The Coaching Approach¶

Acknowledge his skepticism. Robert expects you to be another person telling him what to do. Your job is to be different: curious, realistic, and on his side.

What NOT to do (unhelpful):

Coach: “If you just follow my plan, your pain will go away.”

Robert: “Sure… that’s what everyone says.”

Do this instead (realistic, collaborative):

Coach: “Robert, I hear that you’ve tried a lot of things and haven’t gotten the relief you hoped for. I’m not going to promise you that coaching will fix your pain. I can’t promise that, and I don’t think you’d believe me if I did.”

Robert: “Yeah. I don’t.”

Coach: “Totally fair. What I can do is help you find ways to be a little more active without crashing, to do things that matter to you despite the pain, and to feel less stuck. Would you be open to trying that for a few weeks and seeing what happens?”

Robert: “I guess I can try.”

Pacing (and why it matters). The boom-bust cycle keeps Robert trapped. When pain is lower, he tries to catch up on everything, and then he crashes.

Robert: “When you say pacing… what do you mean, exactly?”

Coach: “It usually comes down to a few simple rules:”

Coach: “Pacing usually means:”
- Doing less on good days than you think you can
- Doing a little on bad days, even when you don’t want to
- Keeping activity consistent rather than variable
- Stopping before the pain tells you to stop

In practice, it can sound like:

Coach: “On good days, we stop while it still feels like you could do more. On bad days, we keep a tiny thread of consistency.”

Robert: “That feels backward.”

Coach: “It does at first, but it’s one of the best ways to get fewer crashes over time.”

Movement is medicine, but dosing matters.

Robert: “People keep telling me to move more, but if it hurts, how is that supposed to help?”

Coach: “Movement generally helps chronic pain, but only at appropriate doses. Too much can trigger flares, and too little can lead to deconditioning. The goal is finding your ‘just right’ activity level and gradually expanding it.”

Start with activities he can do on his worst days. For example, if he can walk for 5 minutes on a bad day without a flare, that’s his baseline, and you build from there slowly.

Robert: “So if I feel okay one day, can I push it?”

Coach: “We can build, but we’ll do it in small steps, and we’ll let your symptoms tell us when it’s time to level up.”

Depression screening and referral. Robert mentions feeling depressed, which is your cue to slow down and check in.

What NOT to do (unhelpful):

Coach: “We’re all down sometimes. Can we just focus on your steps?”

Robert: “...Okay.”

Do this instead (simple, supportive, within scope):

Coach: “Robert, you mentioned feeling depressed, and I want to make sure you’re getting support for that. Are you currently talking to anyone, like a therapist or counselor?”

Robert: “No.”

Coach: “Have you mentioned the depression to your pain doctor or your PCP?”

Robert: “Not really.”

Coach: “Thanks for telling me. Chronic pain and depression often show up together, and you don’t have to white-knuckle it alone. Would you be willing to bring it up with your PCP or pain management team? If it helps, we can also do a quick PHQ-2 check-in and use that to guide the conversation.”

Identity beyond pain. Robert lost his identity as a capable contractor. The goal isn’t to replace what he lost or pretend it didn’t matter, but to expand who he is alongside the pain, and it can bring up a lot, so go gently.

What NOT to do (unhelpful):

Coach: “You’ll find a new purpose. Try to stay positive.”

Robert: “It doesn’t feel that simple.”

Do this instead (validate, then open a door):

Coach: “Robert, you mentioned that being a contractor was a big part of who you were. That loss is real, and I’m not going to pretend otherwise.”

Robert: “It’s like I don’t know what I’m for anymore.”

Coach: “That makes a lot of sense, and if you’re open to it, can I ask you something? Outside of work, what else matters to you? What would you want to be able to do, life-wise, that feels out of reach right now?”

Maybe it’s playing with grandchildren, fishing with his son, or just being able to sit through a movie. Those become goals to work toward.

Red Flags to Watch¶

This part is serious, and it’s also part of good coaching. If any of the items below show up, you’re not “failing” as a coach. You’re doing your job by escalating appropriately.

In the moment, it might sound like:

Coach: “If you notice new numbness or weakness, bowel or bladder changes, or thoughts about harming yourself, that’s not something we work through in coaching. That’s a ‘contact your care team right now’ situation.”

Immediate referral:
- Any mention of suicidal thoughts or wanting to “end the pain permanently” → Crisis referral
- Signs of severe depression (hopelessness, withdrawal, inability to function) → Mental health referral
- New neurological symptoms (numbness, weakness, bowel/bladder changes) → Emergency/urgent medical care

Contact pain management team:
- Significant change in pain pattern (much better or much worse without clear cause)
- Medication isn’t controlling pain adequately
- Side effects from medications affecting daily function
- Any desire to adjust medication (increase or decrease)

Pause and assess:
- Flares that don’t recover within 24-48 hours
- Activity causing consistent worsening rather than the expected temporary increase
- Psychological deterioration (increased hopelessness, isolation)

Deep Health Snapshot¶

Coach: “When I look at the whole picture, I see pain and sleep on the physical side, and a lot of identity loss and hopelessness on the existential side. Does that fit?”

Robert: “Yeah, that’s pretty much it.”

What Happened (3-Month Check-In)¶

At three months:
- Robert is walking 15 minutes daily, every day, regardless of pain level (up from nothing consistent)
- He’s had fewer severe flares. The boom-bust cycle is improving
- He started seeing a therapist specializing in chronic pain psychology
- He and his son resumed monthly fishing trips. Short ones, with breaks, but meaningful
- His pain hasn’t disappeared (it won’t), but he describes it as “more manageable”
- He lost 8 pounds. Not the goal, but a side effect of increased activity
- His wife reports he seems “more like himself”

Robert isn’t “fixed.” He still has chronic pain, still takes medication, and still has bad days, but he’s not stuck anymore. He’s doing more of what matters to him, within his limitations, without the constant boom-bust crashing.

Key Lessons from Robert's Case¶

1. Pacing is everything. The boom-bust cycle perpetuates chronic pain; consistency breaks it.
2. Don’t promise pain elimination. Be honest that lifestyle changes help but don’t cure chronic pain.
3. Depression requires attention. Chronic pain and depression co-occur; ensure mental health is addressed.
4. Identity extends beyond work. Help clients find meaning in non-work activities and relationships.
5. Small wins matter. Fishing trips with his son, walking consistently: these are victories.

Coaching in Practice: Explaining Pacing to Avoid Boom-Bust Cycles¶

What NOT to do (the “push harder” trap):

Coach: “If you can do 15 minutes today, you should do 30. You’ve got to build grit.”

Robert: “That’s exactly how I end up wrecked for three days.”

Coach: “You’re just being negative.”

A better pacing conversation (same goal, different method):

Coach: “Walk me through a ‘good day.’ What do you do when the pain is lower?”

Robert: “I try to get everything done. Yard, errands, whatever I’ve been putting off.”

Coach: “And then what happens the next day or two?”

Robert: “I pay for it, bad, and I’m on the couch.”

Coach: “That boom-bust pattern is incredibly common with chronic pain. What I’d like us to try is boring on purpose: a moderate amount every day.”

Robert: “Even when I feel good?”

Coach: “Especially when you feel good. On good days, we stop while it still feels like you could do more. On bad days, we keep a tiny thread of consistency, even if it’s just a short walk or gentle movement. Consistency, not intensity.”

Robert: “So how do we pick the number?”

Coach: “We anchor it to your worst days. If 5 minutes is doable on a bad day without a flare, that’s our baseline. We’ll hold it steady, watch what your symptoms do, and only build when your body is showing us it can handle it.”

Robert: “That’s… not what I’m used to. But it makes sense.”

[CHONK: Coaching in Practice - Explaining Pacing to Avoid Boom-Bust Cycles]

Robert says: "On good days I try to get stuff done because I know I'll pay for it later. It's the only way."

DON'T say: "You just need to push through the bad days too." (This misunderstands chronic pain.)

DO say: "I hear you, and that's a really common pattern with chronic pain. On good days, the pain is low, so you naturally want to catch up, but doing too much on those days is often what triggers the crash. It's called the boom-bust cycle, and it keeps you stuck. What if we tried something different: on good days, do less than you think you can, and on bad days, do a little more than you want to, so things stay more consistent. It feels frustrating at first, but it actually leads to fewer crashes and more overall activity."

Sample dialogue:

Robert: "On good days I try to get stuff done because I know I'll pay for it later. It's the only way."

Coach: "I hear you, and that's a really common pattern with chronic pain. On good days the pain is lower, so of course you want to catch up. The tricky part is that doing too much on those days is what sets up the crash afterward."

Robert: "So what am I supposed to do, just sit around on the good days?"

Coach: "Not at all. What if we tried a different approach: on good days, you do a bit less than you think you can, and on bad days, you still do a tiny bit instead of nothing. That consistency usually leads to fewer crashes and more overall activity. Would you be open to experimenting with that?"

Why this works: You explain the mechanism (boom-bust), validate that his current approach makes intuitive sense, and offer an alternative with a clear rationale. |

[CHONK: Universal Principles for Complex Cases]

Universal Principles for Complex Cases¶

Having reviewed four different complex scenarios, let's distill the principles that apply across all of them.

Red Flag Categories¶

Category 1: Safety Red Flags (Immediate Action Required)

These require immediate referral and may require pausing coaching:
- Suicidal ideation or intent to harm self or others → Crisis referral (988, emergency services)
- Acute cardiac symptoms (chest pain, severe shortness of breath, irregular heartbeat)
- Signs of stroke (sudden weakness, confusion, slurred speech)
- Signs of diabetic emergency (confusion, fruity breath, extreme thirst)
- Severe psychological decompensation (psychosis, severe dissociation)
- New neurological symptoms (sudden numbness, weakness, bowel/bladder changes)

Category 2: Medical Referral (Contact Provider)

These require communication with the client's healthcare provider:
- Significant symptom changes (better or worse without clear explanation)
- Medication side effects affecting function
- Exercise intolerance beyond what's expected
- Weight changes without intentional intervention
- New symptoms the client hasn't experienced before
- PHQ-2 score of 3 or higher

Category 3: Proceed with Caution

These don't require immediate referral but warrant increased vigilance:
- Client seems more fatigued than usual
- Mild mood changes
- Temporary flares that resolve within expected timeframe
- Life stressors affecting adherence

If you're worried about remembering every single red flag right now, that's OK. In real life, you'll often pause, check your notes or this chapter, and then decide how to proceed.

Documentation Best Practices¶

As established in Chapter 1.5 (Scope of Practice and Medical Collaboration), proper documentation is essential for professional practice. When coaching complex clients, document more thoroughly:

Every session should note:
- Client's subjective report of how they're doing
- Any symptom changes mentioned
- Activities completed since last session
- Any concerns raised
- Referrals made or recommended
- Plans for next session

Flag and follow up on:
- Any symptoms that seem unusual
- Mentions of mental health concerns
- Medication changes reported
- Medical appointments attended and outcomes

Documentation protects you, protects your client, and enables better collaboration with their healthcare team.

When to Pause, Proceed, or Refer¶

Use this decision tree for complex cases:

Step 1: Is this a safety issue?
- Yes → Refer immediately (emergency services or crisis line). Pause coaching until safe.
- No → Continue to Step 2

Step 2: Is this a medical question or concern?
- Yes → Refer to appropriate medical provider. Don't answer medical questions.
- No → Continue to Step 3

Step 3: Is this within my coaching scope?
- Yes → Proceed with coaching.
- No → Refer to appropriate professional (dietitian, therapist, trainer, etc.)

Step 4: Am I unsure?
- Yes → When in doubt, refer. It's better to refer unnecessarily than to miss something important.
- No → Proceed with appropriate boundaries.

If you find yourself pausing often to think through these steps, that's actually a good sign. You don't need to make instant decisions in complex cases; it's appropriate to slow down, review this decision tree, and err on the side of referral when you're uncertain.

Communication Template Elements¶

When communicating with healthcare providers, include:

1. Your role and credentials: Make clear you're a health coach, not a medical provider
2. The client relationship: How long you've been working together, what you're working on
3. Specific questions or concerns: What do you need from this provider?
4. Your scope acknowledgment: Make clear you understand your boundaries
5. Offer to share information: Progress updates can be valuable for the care team
6. Contact information: Make it easy for them to respond

Knowing Your Limits Checklist¶

Review this before each session with complex clients:

• [ ] Do I understand this client's medical conditions at an educational level?
• [ ] Do I know the parameters their healthcare providers have set?
• [ ] Am I staying within those parameters?
• [ ] Am I helping implement their medical team's recommendations, not creating my own?
• [ ] If I'm uncertain about something, am I referring rather than guessing?
• [ ] Am I documenting appropriately?
• [ ] Am I watching for red flags?
• [ ] Am I communicating with their healthcare team when appropriate (with consent)?

If you answer "no" to any of these, pause and address before continuing.

[CHONK: Deep Health Integration in Complex Cases]

Deep Health Integration in Complex Cases¶

Complex medical situations don’t just affect physical health; they tend to ripple through every dimension of Deep Health. Here’s how that often shows up in real life. If you’re thinking, “That’s a lot,” you’re not wrong.

Physical Dimension¶

The medical conditions themselves are the obvious physical concerns, but it’s easy to miss the downstream effects, like:
- Medication side effects: Fatigue, weight changes, cognitive effects
- Deconditioning: Chronic illness often leads to reduced activity, which creates its own problems
- Sleep disruption: Pain, medications, anxiety, all affect sleep
- Energy fluctuations: Variable energy is common, so plan for it; planning ahead can reduce frustration

Emotional Dimension¶

Chronic illness carries emotional weight:
- Grief: For lost health, lost identity, lost possibilities
- Fear: Of disease progression, of another event, of never getting better
- Frustration: At limitations, at slow progress, at the body that "betrayed" them
- Depression and anxiety: Common comorbidities that require attention

Mental/Cognitive Dimension¶

Cognitive effects can be real and significant, so try not to dismiss them:
- "Chemo brain" or "fibro fog": Real cognitive changes from illness/treatment
- Medication effects: Many medications affect cognition
- Decision fatigue: Managing complex conditions requires constant decisions
- Health information overload: Multiple providers, conflicting advice, and internet research can add up fast

Social/Relational Dimension¶

Illness affects relationships, even when everyone has good intentions:
- Role changes: From provider to dependent, from caretaker to patient
- Relationship strain: Chronic illness stresses partnerships and families
- Isolation: Many complex clients are socially isolated
- Communication challenges: Difficulty explaining invisible symptoms to others

Existential/Purposeful Dimension¶

This is often the most neglected dimension, but it can be one of the most important and the hardest to talk about:
- Identity disruption: Who am I if I can't do what I used to do?
- Meaning questions: Why did this happen? What's the point?
- Purpose redefinition: Finding new sources of meaning when old ones are lost
- Hope and hopelessness: Maintaining hope while being realistic

Environmental Dimension¶

The environment can help or hinder progress, sometimes more than people expect:
- Home setup: Is it conducive to movement? Sleep? Recovery?
- Access to care: Can they get to appointments? Afford medications?
- Workplace: If working, is it supportive of health needs?
- Social environment: Are people around them supportive or sabotaging?

Assessing Deep Health in Complex Cases¶

With complex clients, it helps to do a quick Deep Health check-in regularly, so you can catch problems early instead of waiting until they spill over. It doesn’t need to be a big formal assessment every time.

For example:

What not to do

Coach: "How are you doing overall with your mood, energy, relationships, stress, and outlook?"

Client: "I’m not sure. It’s all kind of a lot."

A better approach

Coach: "Beyond your physical symptoms, how are you doing overall? If we check in on mood, energy, and relationships, which one feels most important to talk about today?"

Client: "Honestly, my energy. I’m wiped out by mid-afternoon."

Coach: "Got it. Would it help to start with your energy today, and then circle back to the other areas over the next couple of sessions?"

If taking in all six dimensions at once feels overwhelming, that’s OK. You don’t have to address every area in every session; focusing on one or two dimensions that seem most pressing and building from there is often the most realistic approach. That’s still progress.

Study Guide Questions¶

These questions help you review key concepts and prepare for the chapter exam.

1. What is the Triangle of Care, and why does it require "tightening" in complex cases?

2. Explain the "hierarchy of safety" when coaching complex clients. What comes first?

3. When coaching a client with depression alongside physical health conditions (like Maria), what should you assess before focusing on lifestyle interventions?

4. Why can't heart rate-based training zones be used reliably for clients on beta-blockers? What alternative measure should be used?

5. What is the "boom-bust cycle" in chronic pain, and how does pacing help break it?

6. What are the three categories of red flags, and what action does each category require?

7. Why is medical clearance required before developing exercise programs for post-cancer clients like James?

8. What elements should be included when communicating with a client's healthcare provider?

9. How does the Deep Health approach apply to complex cases? Give an example of how a medical condition might affect the existential dimension.

10. What does the phrase "referral is appropriate care, not failure" mean? Why is this framing important?

[CHONK: Works Cited]

References¶

These sources support the case study and coaching guidance in this chapter. You don’t need to track down every paper, but if you want to follow a specific point back to the evidence, this list will get you there.

1. Boehmer KR, Álvarez-Villalobos NA, Barakat S, de Leon-Gutierrez H, Ruiz-Hernandez FG, Elizondo-Omaña GG, et al. The impact of health and wellness coaching on patient-important outcomes in chronic illness care: A systematic review and meta-analysis. Patient Education and Counseling, 2023;117:107975. doi:10.1016/j.pec.2023.107975

2. The effectiveness of health coaching. Available at: https://www.ncbi.nlm.nih.gov/books/NBK487697/

3. Fortmann AL, Walker C, Barger K, Robacker M, Morrisey R, Ortwine K, et al. Care Team Integration in Primary Care Improves One-Year Clinical and Financial Outcomes in Diabetes: A Case for Value-Based Care. Population Health Management, 2020;23(6):467-475. doi:10.1089/pop.2019.0103

4. Chow CP, Chesley CF, Ward M, Neergaard R, Prasad TV, Dress EM, et al. Patients’ Perspectives on Life and Recovery 1 Year After COVID-19 Hospitalization. Journal of General Internal Medicine, 2023;38(10):2374-2382. doi:10.1007/s11606-023-08246-9

5. National Board for Health & Wellness Coaching. Health & Wellness Coach Scope of Practice, 2023. Available at: https://nbhwc.org/scope-of-practice/

6. Manzi H, Halling J, Parisio Poldiak N, Perkins S. Burnout and Health Scores Among Residency Programs as an Indicator of Wellness. HCA Healthcare Journal of Medicine, 2024;5(3). doi:10.36518/2689-0216.1839

7. Family-Centered Coaching Toolkit. Referring clients for mental health services, 2011. Available at: https://familycenteredcoaching.com/

8. Roberts K, Baysari M, Ho E, Beckenkamp P, Tian Y, Jennings M, et al. A community health-coaching referral program following discharge from treatment for chronic low back pain – a qualitative study of the patient’s perspective. BMC Health Services Research, 2024;24(1). doi:10.1186/s12913-024-11509-8

9. Lancha AH, Sforzo GA, Pereira-Lancha LO. Improving Nutritional Habits With No Diet Prescription: Details of a Nutritional Coaching Process. American Journal of Lifestyle Medicine, 2016;12(2):160-165. doi:10.1177/1559827616636616

10. Singh HK, Kennedy GA, Stupans I. A pharmacist health coaching trial evaluating behavioural changes in participants with poorly controlled hypertension. BMC Family Practice, 2021;22(1). doi:10.1186/s12875-021-01385-0

11. American College of Sports Medicine. ACSM's Guidelines for Exercise Testing and Prescription, 11th Edition, 2022. Available at: https://www.acsm.org/education-resources/books/guidelines-exercise-testing-prescription

12. Fong DYT, Ho JWC, Hui BPH, Lee AM, Macfarlane DJ, Leung SSK, et al. Physical activity for cancer survivors: meta-analysis of randomised controlled trials. BMJ, 2012;344(jan30 5):e70-e70. doi:10.1136/bmj.e70

13. Bower JE. Cancer-related fatigue: mechanisms, risk factors, and treatments. Nature Reviews Clinical Oncology, 2014;11(10):597-609. doi:10.1038/nrclinonc.2014.127

14. Edwards RR, Dworkin RH, Sullivan MD, Turk DC, Wasan AD. The Role of Psychosocial Processes in the Development and Maintenance of Chronic Pain. The Journal of Pain, 2016;17(9):T70-T92. doi:10.1016/j.jpain.2016.01.001

15. Nicholas M, Asghari A, Corbett M, Smeets R, Wood B, Overton S, et al. Is adherence to pain self‐management strategies associated with improved pain, depression and disability in those with disabling chronic pain? European Journal of Pain, 2012;16(1):93-104. doi:10.1016/j.ejpain.2011.06.005