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
- Share evidence-based information (education, not prescription)
- Support implementation of their medical team's recommendations
- Help clients build sustainable habits
- Refer when needs exceed your scope

What changes is your vigilance. In complex cases, you:
- Check in more frequently with the client's medical status
- Communicate more proactively with healthcare providers
- Adapt interventions more conservatively
- Watch for red flags more carefully
- Document more thoroughly

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. 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.

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, 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. Learn 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. 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
- Educate about how lifestyle factors (sleep, movement, nutrition) affect both mood and blood sugar
- Support her in implementing the lifestyle changes her medical team recommends
- Help her prepare questions for medical appointments
- Encourage and track follow-up with her medical providers
- Help 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 or interpret her blood sugar numbers
- 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
- 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. 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. Maybe it's eating vegetables at one meal per day. Maybe it's 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. 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. 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 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. Depression makes 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. Depression can make even small tasks feel enormous, and 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? 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. He underwent 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, has persistent fatigue, and lives with low-level anxiety about recurrence. His wife describes him as "a shell of who he was."

Client Profile¶

Key Coaching Challenges¶

James's case illustrates post-treatment recovery challenges:

Cancer-related fatigue. This isn't normal tiredness. Cancer-related fatigue is a well-documented phenomenon that can persist months or years after treatment ends. It doesn't respond to rest the same way normal fatigue does, and "pushing through" often backfires.

Significant muscle loss. Chemotherapy and reduced activity during treatment cost James about 30 pounds of muscle. Rebuilding requires progressive resistance training, but doing so safely post-cancer requires oncologist clearance and appropriate pacing.

Recurrence anxiety. Every new symptom triggers fear: Is the cancer back? This anxiety is exhausting and can lead to either hypervigilance about health or complete avoidance of anything health-related.

Identity disruption. Before cancer, James was "the strong one" in his family, the provider, the protector. Now he feels diminished. His wife's supportive behavior ("walking on eggshells") inadvertently reinforces 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¶

Start with medical clearance. Before prescribing any exercise, James needs clearance from his oncologist. This isn't optional. It's required.

"James, before we develop an activity plan, I need you to get clearance from your oncologist. I'll help you prepare questions to ask. Once we know what parameters they recommend, I can help you implement a plan within those guidelines."

Understand fatigue before fighting it. Cancer-related fatigue is different from normal fatigue. Counterintuitively, rest often doesn't help. Gentle activity tends to improve it. But "pushing through" aggressively can cause setbacks.

Help James understand:
- 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

Rebuild gradually. James lost 30 pounds of muscle. He wants it back now. But aggressive training post-cancer treatment can backfire. 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

Address anxiety appropriately. James's recurrence anxiety is understandable and common. You can help with lifestyle factors that support mental health (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.

"James, you mentioned that every new symptom makes you worry the cancer is back. That's incredibly common among survivors, and it's exhausting. Are you talking to anyone about this anxiety, a counselor or therapist? If not, it might help to connect with someone who specializes in supporting cancer survivors."

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). She completed cardiac rehabilitation and was cleared for exercise, but she's terrified of "triggering another event." Her husband, who watched her collapse, has become extremely protective. He discourages her from any exertion. She wants to improve her fitness but doesn't know what's safe.

Client Profile¶

Key Coaching Challenges¶

Patricia's case illustrates cardiac coaching challenges:

Medication effects on exercise response. Patricia takes a beta-blocker, which affects her heart rate response to exercise. Traditional heart rate-based training zones don't work for her. Her heart rate won't rise the same way, even during vigorous exercise. This requires using alternative measures like Rate of Perceived Exertion (RPE).

Fear of exertion. Patricia is terrified of exercise triggering another heart attack. This fear keeps her sedentary, which ironically increases her cardiovascular risk. Her fear is understandable but must be addressed.

Overprotective spouse. Her husband watched her collapse during the heart attack. He's traumatized too. His protective instincts—discouraging activity, doing tasks for her—come from love but keep her inactive and reinforce her helplessness.

Cardiac rehab graduate. The good news: Patricia completed cardiac rehabilitation and was cleared for exercise. This means her cardiologist has already assessed her capacity and provided parameters. Your job is to help her continue 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. Patricia completed cardiac rehab, which means a cardiologist has already assessed her and provided exercise guidelines. Start by confirming what those parameters are:

"Patricia, you mentioned you completed cardiac rehab. That's great. It means your cardiologist has already determined what's safe for you. What exercise parameters did they give you? What intensity did they clear you for?"

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. Patricia can work hard and her heart rate might barely rise. This means heart rate monitors and zone-based training are unreliable for her.

Instead, use Rate of Perceived Exertion (RPE):

"Patricia, because of your beta-blocker, your heart rate isn't a reliable measure of intensity. Instead, we'll use how the exercise feels. For most of your 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 and understandable. Don't dismiss it. Work with it.

"It makes complete sense that you're nervous about exercise after what happened. Your body and your heart went through something traumatic, and so did you. The thing is, your cardiologist cleared you because they've determined exercise is safe. In fact, it's one of the best things you can do for your heart now. Let's start with something that feels low-risk to you and build from there. What would feel safe to try?"

Start where she's comfortable, even if it seems too easy. Build confidence through success experiences. Gradually expand as fear decreases.

Address family dynamics. Patricia's husband means well, but his protectiveness keeps her stuck. This needs gentle addressing, not criticism, but education.

"Patricia, your husband clearly loves you and wants to protect you. It sounds like watching your heart attack was traumatic for him too. Sometimes when loved ones are scared, their way of showing care is to protect us from everything, including things that would actually help us. Would it be useful to involve him in a conversation about how he can support you in a way that helps you get stronger, rather than keeping you from activity?"

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

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. 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, still needs monitoring. But she's no longer paralyzed by fear. She's active, engaged, and building confidence.

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¶

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

Patricia says: "What if I exercise and have another heart attack? I'm so scared."

DON'T say: "You'll be fine, exercise is good for you." (This 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 actually helps protect your heart. But I hear that it's scary. 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: "What if I exercise and have another heart attack? I'm so scared."

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 actually helps protect your heart."

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

Coach: "That makes a lot of sense. What if we start with something that feels very 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 has been on disability for three years. He has chronic low back pain that started 15 years ago after a work injury, and was diagnosed with fibromyalgia five years ago. He's tried "everything"—physical therapy, injections, medications—and is skeptical about "another program." He's gained 40 pounds since his injury, sleeps poorly, and admits to feeling depressed. He takes opioid medication managed by a pain clinic.

Client Profile¶

Key Coaching Challenges¶

Robert's case illustrates chronic pain coaching challenges:

Activity without flares. Robert has learned that activity leads to pain flares. He's caught in a "boom-bust" cycle: on good days, he does too much (boom), then crashes into severe pain and does nothing for days (bust). This pattern makes him increasingly deconditioned and sensitive.

Skepticism from past failures. Robert has tried many treatments with limited success. 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: opioids 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. Now he feels useless, diminished, and unsure who he is.

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¶

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

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
- Push through his pain or encourage "no pain, no gain"
- Promise that lifestyle changes will eliminate his pain
- 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. Don't be.

"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. 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 a bit less stuck. Is that worth trying?"

Teach pacing. The boom-bust cycle keeps Robert trapped. On good days, pain is lower, so he does everything he's been putting off. Then he crashes.

Pacing 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

"Robert, I noticed you mentioned that on good days you try to catch up on things, and then you pay for it. That's the boom-bust cycle, and it's incredibly common with chronic pain. What if we tried something different: doing a moderate amount every day, even on good days when you feel like doing more, and a little bit even on bad days when you don't want to do anything. Consistency, not intensity."

Movement is medicine, but dosing matters. Movement generally helps chronic pain, but only at appropriate doses. Too much triggers flares; too little allows deconditioning. The goal is finding Robert's "just right" activity level and gradually expanding it.

Start with activities he can do on his worst days. If he can walk for 5 minutes on a bad day without a flare, that's his baseline. Build from there, slowly.

Screen for depression. Robert mentions feeling depressed. Use this as an opportunity to check in more deeply:

"Robert, you mentioned feeling depressed. I want to make sure you're getting support for that. Are you currently talking to anyone, a therapist or counselor? Have you mentioned the depression to your pain doctor?"

Chronic pain and depression require treatment. If Robert isn't receiving mental health support, encourage him to discuss this with his PCP or pain management team. Consider using PHQ-2 as a check-in.

Explore identity beyond pain. Robert lost his identity as a capable contractor. He needs help finding new sources of meaning, not replacing what he lost, but expanding who he is.

"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. But I'm curious: what else matters to you? What would you want to be able to do—not work-related, but life-related—that you can't do now?"

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

Red Flags to Watch¶

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¶

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¶

[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. That's a really common pattern with chronic pain. On good days, the pain is low, so you naturally want to catch up. But the problem is that doing too much on good days is 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. On bad days, do a little more than you want to. Keep things 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. 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 affect just physical health. They ripple through every dimension of Deep Health. Let's review how this plays out.

Physical Dimension¶

The medical conditions are the obvious physical concerns. But don't miss:
- 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; plan for it

Emotional Dimension¶

Chronic illness brings 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¶

Don't underestimate cognitive effects:
- "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, internet research

Social/Relational Dimension¶

Illness affects relationships:
- 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 but most important:
- 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:
- 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¶

When working with complex clients, do a brief Deep Health check-in regularly:

"Beyond your physical symptoms, how are you doing overall? How's your mood been? Your energy? Your relationships? How are you feeling about life in general?"

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.

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 framework 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¶

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2. The effectiveness of health coaching. Available from: 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. 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. 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. 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