Wellness Coaching Outcomes in a Case Report of a Diabetic Native American Male

Jennifer S. Berna, MS, MS, PhD, MCHES, BCCcorresponding author

Abstract

Medically referred wellness coaching clients may present thinking patterns that generate internal resistance to change, including lack of urgency, inadequate incentives, and uncertainty about what they need to do differently. Applying the Wellcoaches (Wellcoaches Corp, Wellesley, Massachusetts) model interventions within a framework of the four domains of learning (cognitive, affective, behavioral, and conative)2 can enhance wellness coaching outcomes. This case report reviews wellness coaching outcomes with a 44-year-old single male tribal member of a Midwest Native American tribe who recently had been diagnosed with diabetes. Challenges presented by resistance to change and a discussion of the four domains of learning applied to wellness coaching are also reported.

Key Words: Wellness coaching, diabetes, domains of learning, resistance to change

摘要

医学上所指的健康辅导患者可 能会存在思维定势,即对变化 产生内心抗拒,包括缺乏紧迫 感、激励不足以及对其需要做 的不同之事的不确定感。1 在四 个学习领域(认知、情感、行 为和意动) 的框架内应用 Wellcoaches ( Wellcoaches Corp,马萨诸塞州韦尔斯利) 模型干预措施2 可增强健康辅导 的作用。此病例报告载有最近 诊断出患有糖尿病的 44 岁单身 男性(为美国中西部土著部落 的部落成员) 的健康辅导成 果。还报告了面临改变抗拒的 挑战以及将四个学习领域应用 至健康辅导中的讨论。

SINOPSIS

Los clientes que han sido remitidos por su médico para recibir formación de bienestar pueden presentar patrones de pensamiento que generan cierta resistencia interna al cambio, incluida la falta de urgencia, los incentivos inadecuados y la incertidumbre en torno a qué aspectos necesitan realizar de forma diferente. La solicitud de admisión para las intervenciones del modelo Wellcoaches (Wellcoaches Corp, Wellesley, Massachusetts, EE. UU.) en un marco de cuatro dominios de aprendizaje (cognitivo, afectivo, conductual y conativo)2 puede mejorar los resultados de la formación de bienestar. Este caso clínico evalúa los resultados de la formación de bienestar en un varón soltero de 44 años de edad perteneciente a la tribu de nativos americanos del Medio Oeste de Estados Unidos al que recientemente se le había diagnosticado diabetes. También se notifican los problemas planteados como consecuencia de la resistencia al cambio, así como un debate sobre los cuatro dominios de aprendizaje aplicados a la formación de bienestar.

INTRODUCTION

After slipping from pre-diabetic to diabetic range in clinical tests, a 44-year-old single male tribal member of a Midwest Native American tribe was medically referred by the tribal community healthcare center to the tribal Health Promotion and Disease Prevention department for wellness coaching. The client persisted in the coaching protocol for the referral period of 1 year (2011), with only one missed monthly appointment. Insights into the client’s thinking patterns, which were revealed during wellness coaching sessions, provided evidence of resistance to change that limited the outcomes of wellness coaching.

BACKGROUND

The client had been medically referred previously for Wellness Coaching with very limited involvement and coaching success. A 44-year-old single man, the client lived at home with both parents and a younger brother and had never resided on his own outside the family setting. Based on family history of both parents’ and other close relatives’ diagnosis of diabetes, the client had repeatedly undergone clinical testing for diabetes. He also had an early adult diagnosis of being in the pre-diabetes range. In line with a prevalent tribal community view, the client did not perceive himself to be generally at risk for any chronic disease, nor did he perceive himself to be particularly at risk for diabetes despite his prior pre-diabetic diagnosis. The recent shift from being in the pre-diabetic to being in the diabetic range as indicated by the results of his recent clinical blood work testing and a medical referral from a tribal doctor were the client’s external motivation for seeking wellness coaching.

The client’s family history included being the middle son with one older brother and one younger brother. The client perceived his older brother as more successful in life (described as living on his own in a large city and working for a large manufacturing company). The client and his younger brother shared basement living space in their parents’ home. They also shared a personal history of having contentious, argumentative interactions and a conflicting relationship as close-in-age siblings. This family history contributed to the only gap in the client’s wellness coaching involvement: he was incarcerated for family violence after a fight with his brother erupted when they were playing cards while watching a football game.

PRESENTING CONCERNS

The client was aware of his and the family’s pattern of sedentary lifestyle and seasonal sports television (TV) viewing. When the Motivational Inquiry was made regarding which seasonal sports were preferred for viewing, it became clear that, for this client and his extended family, TV sports viewing was a daily and year-round leisure activity. The client also was able to relate awareness of his and his family’s pattern of overeating snack foods high in salt and sugar and/or highly processed foods and consuming beer almost daily while snacking and watching TV.

The client was aware that he was overweight, with the majority of excess weight unevenly distributed in his “beer belly.”The client viewed his weight as a “family build”but admitted to struggling with his weight “all his life.”He joked about these health conditions (“I’m not doing so bad—I’ve only been pre-diabetic all this time”).

Now nearing an age benchmark that bothered him (“Forty-five is old!”) the client expressed frustration at being chronically underemployed or unemployed. While expressing vague interest in obtaining a General Educational Development degree (GED) and aware of time running out before he would need to take all GED requirements, he was unable to identify personal action steps on his own accord.

The client admitted to repeatedly failing at previous attempts to make exercise a regular part of his lifestyle at the tribal fitness center. He admitted to failing at all previous attempts to implement recommended dietary modifications suggested by medical staff or other tribal wellness coaches. He was frustrated that his efforts had been short-lived and unsuccessful. The client acknowledged previously working with two other tribal wellness coaches in the past 2 years, but his current motivation to change any health habits remained externally motivated (“the doctor made me come here”).

CLINICAL FINDINGS

The client had recently moved in his medical diagnosis from pre-diabetic to diabetic. The family medical history, on both sides of his extended family, was rife with chronic disease conditions (including diabetes, cardiovascular disease, stroke, neuropathy, and appendage amputation). The client presented with physical signs of obesity, excessive fat distribution in his midsection, florid and flushed face, excessive sweating, and shortness of breath when climbing stairs.

THERAPEUTIC FOCUS AND ASSESSMENT

Beginning with a 90-minute Wellness Vision intake session, weekly (45 min–60-min) wellness coaching sessions were provided for a 12-week period from mid-January to mid-April 2011. Monthly follow-up (30 min–45-min) wellness coaching sessions were provided during the remaining 9-month period (mid-April to mid-December) of 2011. The client’s participation in aerobic training at the tribal fitness center and his active involvement in monthly wellness coaching sessions decreased as the National Football League playoffs and the winter holidays neared.

OUTCOMES

The client achieved a modest success in weight loss (9 lbs) during the first 3 months of wellness coaching, which included weekly support from a tribal personal fitness trainer. When that exercise-focused period concluded, over the course of the next 6 to 9 months of wellness coaching, the client regained the weight. Though several physical fitness indicators (resting heart rate, blood pressure readings, body mass index [BMI], and several strength indices) shifted in a positive direction, these gains were temporary. The client reported high satisfaction with both the fitness training and wellness coaching protocols. He self-reported satisfaction with his original weight loss as well. However, no medical indicators pertinent to his diabetic diagnosis were impacted in a sustainable manner by either the fitness training (over a 3-mo period) or the (1-y) wellness coaching.

FOLLOW-UP

While this client was diligent in participating in almost all of the initial 12 weekly wellness coaching sessions, he did have an unanticipated gap in the third month of wellness coaching due to short-term incarceration. Upon his release, the client contacted his wellness coach to resume coaching and successfully complete the culminating activities (post-fitness test; post-wellness survey; and 3-mo wellness goal setting). The client then completed the expected wellness coaching protocol of 9 monthly sessions but with varying success. The client achieved reduced weight, reduced BMI, and increased physical energy and mood over the course of the initial 12-week phase of combined fitness training and wellness coaching. His pleasantness in wellness coaching sessions never wavered, and he continued meeting baseline requirements of exercising twice weekly at the tribal fitness center and also completing monthly follow-up sessions with his wellness coach. Near the concluding sessions of the 9-month follow-up period, it became evident the client had lost motivation for full investment in his wellness goals and weekly action plans. When observed informally while exercising in the fitness center, he was seen to be maintaining a moderate pace on the treadmill and completing a basic routine of upper-body weightlifting. His joking manner about daily beer consumption became a tip-off to his slipping into previous eating and drinking habits that were offsetting any physical activity efforts in the tribal fitness center. Over the course of several months of follow-up sessions, the client’s facial appearance became markedly ruddy; profuse sweating was reported for only mild physical exertion; and the client’s midsection became very rotund in appearance. The client reverted to wearing baggy sweatpants and oversized t-shirts as his preferred attire. When further explored in wellness coaching sessions, it became clear by the client’s self-reported behaviors that he had slipped into a mild depression about his unemployment, was unmotivated to take recommended steps to complete his GED, and had increased emotional tension about his living arrangement and interactions with his parents and younger adult brother in their home. The client deflected with humor and self-depreciating joking when asked to rank (1 low to 10 high) the importance he placed on his weekly wellness goals. The client was unable to report a self-rating (1-10) of his own success in achieving health-related behavior changes connected to his wellness goals. Having worked with this population myself over a 2-year period, I wondered about developmental delays or some type of limitation of the client due to drug- or alcohol-related habits in the family.

DISCUSSION

In her book, Progress Not Perfection, Kate Larsen emphasizes that “Thinking patterns and unwanted behaviors are often the driving factor behind unachieved goals and a dissatisfied life.”4(p13) Larsen further identified common challenges to setting goals in order to improve upon or change health-related behavior. Several of those challenges seem to apply in the lack of sustained success in achieving wellness goals by this client. Challenges to change that are evident in this case include

  • lack of focus or discipline related to exercise, nutrition, sleep/rest needs;

  • lack of belief that efforts are good enough;

  • fear of rejection preventing individual risk-taking or dreaming beyond one’s current reality;

  • general lack of contentment;

  • lack of clarity about what is really needed and wanted in life;

  • lack of permission from oneself to make one’s own health a consistent priority; and

  • self-sabotage including a variety of avoidance behaviors and poor self-talk.

Wellness coaches who are aware of and apply the four domains of learning (cognitive, affective, behavioral, and conative) in their coaching work with resistant clients may better facilitate the client achieving success as the client strives to attain his or her wellness vision and personal-change goals. The following concluding points summarize contributing factors in this case report of a middle-aged tribal male. Several aspects related to each of the four domains of learning are briefly outlined for wellness coaches to consider when coaching clients who exhibit symptoms embedded in Kegan and Lahey’s model of “Immunity to Change” or when coaching clients who repeatedly resist choices of health-related change.

Cognitive Domain (Knowing)

“The greatest power of all is that if you don’t like your thoughts, if they’re not working to make you a healthier, happier person, then you have the power to change them.”

This middle-aged tribal male expressed thinking patterns that were indicative of low self-esteem, low self-responsibility, and a mindset of “stuck”in a yo-yo pattern of weight gain.

  • Much of our basic mental programming comes in our childhood, at a time when humans have not developed filters that allow us to discriminate between helpful and unhelpful beliefs. Core beliefs are the way people orient themselves in life, in such a basic way they often never stop to think about it. Early mental programming often has a pervasive influence on our actions. While for many people actions in the present are determined by the core beliefs taken on at a young age, our core belief structure is continuously being shaped by others in our environment (coworkers, family, media, authority figures, and our particular subcultures). Five core belief aspects are self-responsibility, self-esteem, trust in the universe, positive attitude, and flowing with change.

  • Being fully aware of the impact of personal choices for material comforts (such as active or passive recreation or entertainment) and food and health is an important mental focus, as each one does affect the web of personal existence.

  • Unbinding our thinking by being open to and creating a focused shift from a particular mindset into different modes of thinking can prevent the confusion of feeling “stuck”or trying to do everything at once.

  • Freeing our selves from constricting mindsets or self-imposed limits placed on our health and appreciating the importance of becoming guardians of our own health enhances our well-being.

Affective Domain (Valuing)

“If you want to improve your life and the lives of those around you, you must take action (and) build a strengths-based development plan by exploring how your greatest natural talents interact with your skills, knowledge and experience.”10(pvi)

This client presented himself as having low self-efficacy, a hardened attitude about self-perceived failure to sustain weight loss or a regular routine of aerobic exercise, an unassuming manner, and an inability to recognize personal strengths. While he presented with a positive sense of humor, it was also deemed self-effacing in tone and language. These affective aspects are considered as key contributing factors to this client’s limited success in achieving wellness goals.

  • Three vital elements of success are within the affective domain of learning: (1) Self-efficacy (“I know I CAN be a success”); (2) Will to Change (“I am determined I WILL be a success”); and (3) Mind Map for Change—development of a plan of action based upon an understanding of the obstacles or challenges standing between you and your objective.

  • While many people become hardened by the difficulty of their lives, hiding behind a tough outer shell that protects them, this hardening also blocks them from trusting in the kinds of positive experiences human spirit needs to know in order to grow and flourish. Shifting focus to watching personal efforts bloom can have a “healing, transforming effect on the human spirit, (provide) proof the human heart is resilient, and that beauty and hope and high expectations can work wonders in even the most difficult lives.”12(p137)

  • Appreciating and applying personal strengths can “enable and support people and organizations in using their strengths to strengthen others.”13(p18) In the Realise2 (2010) model, personal strengths are assessed according to three dimensions (energy, performance, and use). The model suggests people can enhance their well-being when they “marshal realized strengths, maximize unrealized strengths, moderate learned behaviors, and minimize personal weaknesses.”13(p19)

  • Creating a mind shift from negativity to positivity can enable a new sense of energy and vitality. Barbara Fredrickson, in her leading-edge book Positivity, shares a dozen tools to attain a “3-to-1 positivity ratio.” These include the following affective domain tools: (1) Be open; (2) Create high-quality connections; (3) Cultivate kindness; (4) Develop distractions; (5) Dispute negative thinking; (6) Find nearby nature; (7) Learn and apply your strengths; (8) Meditate mindfully; (9) Meditate on loving-kindness; (10) Ritualize gratitude; (11) Savor positivity; and (12) Visualize your future.14(pp200-13)

Behavioral Domain (Doing Psychomotor Skills)

“You might be thinking, “my circumstances are too difficult.”Or, “I’m too old.”Or, “It’s too late to make changes.”And while you may have some very legitimate, even tragic, events from your past or current circumstances that affect your present life, with purposeful actions founded on your values, you can still take action to build a much brighter future, the future that you are destined for.”15(p111-12)

The client described in this case report had a historical and current pattern of “start-stop”behavior and dysfunctional adult sibling interactions. He exhibited an inability to sustain effort relative to self-declared dietary or exercise goals.

  • Active, structured, involved learning teaches us more fully how to do a new health-related behavior. A four-step process suggested by Goldstein, Sprafkin, and Gershaw involves describing, rehearsing, getting feedback, and transferring the behavior into our daily lives. In this process, asking others (such as a professional wellness coach) for support, feedback, and responsiveness as small persistent steps are taken can aid in attaining the desired wellness goals.

  • Committing oneself to detachment and allowing oneself and those around us the freedom to be as they are, as suggested by Deepak Chopra in The Seven Spiritual Laws of Success, are behaviors that blend the three other domains of learning (cognitive, affective, and conative) with the behavioral domain of learning. This way of being challenges us to not rigidly impose our own ideas of how things should be and to not force solutions on problems (such as family dynamics or dysfunctional “stuck”patterns of interacting).

  • By participating in everything with detached involvement, accepting uncertainty as an essential ingredient of (life) experience, and showing up with a “willingness to accept uncertainty, solutions will spontaneously emerge out of the problem, out of the confusion, disorder and chaos.”17(p91) By stepping into the field of all possibilities, we can “anticipate the excitement that can occur [as we] remain open to an infinity of choices [and] experience all the fun, adventure, magic, and mystery of life.”17(p92)

  • There is hope for improving our adult sibling relationships, if we are willing to behave in different ways. These behaviors include both an attitude shift and action steps: (1) If you really desire a change, examine yourself first; (2) Prepare yourself to be with your siblings; (3) Take your siblings seriously – in a respectful give-and-take manner; (4) Express genuine interest in their families; (5) Communicate with one another by taking the time to actively listen; (6) Remember you are in control to view your sibling connections as an “adventure in discovery (of) new strengths and deeper insights in your journey toward maturity.”18(p9)

  • Chopra links the physical domain of learning a new behavioral skill as directly to the cognitive domain of our thinking process:

    When we learn a new skill, we are only conscious of thinking and wanting. The brain isn’t accessible (until we) dip into it and start rewiring its connections by hand. The physical level takes care of itself once we start thinking … Every skill (is) a mental process that reverberates through the body and soul at the same time (and involves): 1. Becoming genuinely interested; 2. Pursuing your interest spontaneously; 3. Practicing until you see improvement; and 4. Sticking with your practice until the new skill is mastered.19(p117)

While these related cognitive and behavioral action steps seem simple, the whole process cannot be triggered simply by the brain, as “Step 1 requires inspiration; Step 2 requires turning inward; Step 3 requires discipline; and Step 4 requires patience.”19(pp117-8)

For wellness coaches, one hope is to assist clients in dropping their self-imposed resistance to change. Wellness coaches hope to help clients stretch themselves to achieve their self-selected wellness goals. In these endeavors, it is important to be aware of the four interrelated domains of learning and the inexplicable link of the human body-mind-spirit to strive toward enhanced well-being.

Conative Domain (Striving and Activating)

You must understand yourself enough to know what you want in life and what desires you believe are worthwhile for your future. You need to depend upon yourself and your talents. Appreciate others for their personal skills and abilities, but always continue to focus on your own strengths and energies. Life is too short to spend it worrying about someone else’s accomplishments or expecting someone else to be responsible for making your life better. If you have dreams, then you have purpose. You have something to believe in and work towards obtaining. Dedicate yourself to your self. Promise yourself a life filled with love, and then whatever roads you travel will be the roads you want them to be.20(p4)

The client described in this case report exhibited “spotty”self-regulation and poor internal ability to self-challenge. He maintained denial of any long-term effects of being pre-diabetic and exhibited low personal reference to the possibility of catastrophic health conditions pertaining to his own recent diabetes diagnosis.

  • The conative domain of learning provides a “useful niche for developing self-regulation.” Conation focuses on the brain’s frontal cortex role of executive function associated with ability to engage in purposeful, organized, strategic, goal-directed self-regulation. According to Atman, the conative domain has impact in many areas of human endeavor and skill development including study skills, communication and leadership, organizational planning, managing time/stress, and skills to attain fitness, health and well-being. When humans say they are “trying, striving, endeavoring, paying keen attention, making an effort, exerting or working hard (doing their utmost to concentrate all their energies) they are manifesting conation.”2(p10)

  • Hardiness is both a psychological construct and a concept that aligns with the conative domain of learning. Hardy people ask what action they can take to get them to their goals; ask what choices they have in perceived difficult life situations; and tend to describe a challenge as an opportunity to learn something they otherwise might never have known. Hardy people accept a challenge as an invitation to deepen wisdom and expand inventiveness in taking appropriate steps toward a goal.

  • Appreciative Inquiry (AI) is a tool that enables Wellness Coaches to assist clients through several key action steps: (1) Appreciate and Value (best of what is); (2) Envision (what might be); (3) Dialogue (what should be); and (4) Innovate (what will be). Through the wellness coaching process of AI, a client develops skill in personally identifying a series of positive statements “phrased as if they were already happening.”As positive statements are practiced, they become “amplifications of what has already happened”and become more easily visualized by the client. Gaining a sense of success “doing more of what they have already done”can crowd out prior negativity of feeling health-related concerns are insoluble problems.3(p31) AI is a wellness coaching tool that can help both the coach and client tap into the conative “striving will to change” domain for health-related learning and concomitant behavior change.

Personal attitudes, such as viewing well-being as a journey or seeing personal change as growth to anticipate rather than fear provides a spiritual compass to orient ourselves. Having a spiritual compass enlivens, liberates, and steadies us on our wellness journey. “To grow is to be alive, and to be on the growing edge is to experience life in its most dynamic state, that of becoming.”6(p14)

CONCLUSIONS

Regarding holistic approaches to life changes and reasons for resistance to change, Martin and Jung state,

One reason why we resist making internal changes is an often subconscious awareness of their impact on the structure of our lives. When we choose to be whole and integrated in body-mind-spirit, then it follows that anything in our lives not in support of our wholeness will need to go. When we release our fears and limitations, we are freed to celebrate the truth that all the good of our past remains alive within us, and what is ‘dead’ or no longer serves growth can be allowed to drop away. We cannot fully feel the grace that connects us with our own immortality if we continue to fear and fight (health-related change or) the passage of years.7(p22)

In this case of a middle-aged Native American male, it may have been a sense of being overwhelmed, felt or perceived by him as an inability to address insurmountable family medical history and/or family dynamics that held him back from a breakthrough in his chosen wellness goals. In this case, the following were contributing factors in this client’s low success rate for his wellness goals: low self-esteem and low self-efficacy (cognitive and affective domain of learning); fear of success (affective domain); lack of persistence (behavioral domain); and low internal readiness to change (conative domain). As a wellness coach, I found myself curious as to why the client continued to come for coaching. I wondered what benefits the client experienced that led him to pursue the full year of coaching sessions. I noticed in my work with this tribal population that positive outcomes may be limited but still can be beneficial and worth the effort.

Cultural shifts create new demands on human psychological resources. Specifically, cultural changes challenge humans to develop “greater capacity for innovation, self-management, personal responsibility, and self-direction.”1(p25) Additionally, within many global organizations what is needed now are unprecedentedly higher levels of knowledge and skill and higher levels of “independence, self-reliance, self-trust, and the capacity to exercise initiative.”1(p25) In another regard, this laundry list of qualities, skills, and human capacities enable people, seeking to change their lives through goal-oriented health behavior to achieve higher levels of wellness.

Traditionally, tribal clients experiencing pre-diabetic symptoms or diabetic conditions have been treated by a diabetic care team, including primary physicians, ophthalmologists, podiatrists, and diabetes educators. Through the involvement of a professionally certified wellness coach, a holistic proactive focus is brought to the healthcare team. Within a framework of a multidimensional domain-of-learning approach to wellness coaching, many aspects of human capacity building including self-management, personal responsibility, self-direction, and self-regulation can be brought into a personalized action plan for enhanced well-being.

Notes

Disclosure The author disclosed no competing interests.

REFERENCES

1. Kegan R, Lahey LL.
Immunity to change. Boston, Massachusetts: Harvard Business Press; 2009 []
2. Atman KS.
Highway to success. www.ncef/pdf/Highway_to_Success_28b.ppt
Accessed May 17, 2013
3. Hammon SA.
The thin book of appreciative inquiry. Bend, Oregon: Thin Book Publishing; 2000 []
4. Larsen K.
Progress not perfection: your journey matters. Andover, Minnesota: Expert Publishing, Inc; 2007 []
5. Ward B.
Think yourself well: the amazing power of your mind. Boca Raton, Florida: Globe Communications Corp; 1998 []
6. Gershon D, Straub G.
Empowerment: the art of creating your life as you want it. West Hurley, New York: High Point; 1989 []
7. Martin L, Jung P.
Taking charge of the change. Albany, New York: Delmar Thomson Learning; 2002 []
8. De Bono E.
Six action shoes. New York: HarperCollins; 1991 []
9. Langer EJ.
Counter clockwise: mindful health and the power of possibility. New York: Ballantine Books; 2009 []
10. Rath T.
Strengths finder 2.0. Washington, DC: The Gallup Organization; 2007 []
11. Sweetland B.
I will: a practical guide for utilizing the powerful forces of your subconscious mind. Englewood Cliffs, New Jersey: Prentice-Hall, Inc; 1960 []
12. Strickland B.
Make the impossible possible. New York: Broadway Books; 2007 []
13. Linley A, Willars J, Biswas-Diener R.
The strengths book. Coventry, United Kingdom: CAPP Press; 2010 []
14. Fredrickson BL.
Positivity. New York: Three Rivers Press; 2009 []
15. Duncan T.
Life by design: building the future of your dreams. Nashville, Tennessee: J. Countryman; 2002 []
16. Goldstein AP, Sprafkin RP, Gershaw NJ.
I know what’s wrong—but I don’t know what to do about it. Englewood Cliffs, New Jersey: Prentice-Hall, Inc; 1979 []
17. Chopra D.
The seven spiritual laws of success: a practical guide to the fulfillment of your dreams. San-Rafael, California: Amber-Allen Publishing; 1994 []
18. Tucker RC.
The busy woman’s guide to a balanced life. Wheaton, Illinois: Tyndale House Publishers, Inc; 1997 []
19. Chopra D.
Reinventing the body, resurrecting the soul: how to create a new you. New York: Three Rivers Press; 2009 []
20. Beisser D.
Is it time to make a change? Boulder, Colorado: Blue Mountain Press; 1997 []
21. Gray A, Stephens S, Van Diest J.
Lists to live by: the third collection. Sisters, Oregon: Multnomah Publishers, Inc; 2001 []
22. Centers for Disease Control and Prevention
Take charge of your diabetes. 3rd ed. Atlanta, Georgia: US Department Health and Human Services; 2003 []
23. Griffin J, Tyrrell I.
Human givens: a new approach to emotional health and clear thinking. East Sussex, United Kingdom: HG Publishing; 2004 []

Leave a Reply