Nursing Inquiry 2012 [Epub ahead of print]

Feature

Problematizing health coaching for

chronic illness self-management
Lisa M Howarda and Christine Cecib
aFaculty of Health Sciences, University of Lethbridge, Lethbridge, AB, bUniversity of Alberta, Edmonton, AB, Canada

Accepted for publication 13 July 2012

DOI: 10.1111/nin.12004

HOWARD LM, CECI C. Nursing Inquiry 2012 [Epub ahead of print]

Problematizing health coaching for chronic illness self-management
To address the growing costs associated with chronic illness care, many countries, both developed and developing, identify
increased patient self-management or self-care as a focus of healthcare reform. Health coaching, an implementation strategy to
support the shift to self-management, encourages patients to make lifestyle changes to improve the management of chronic ill-
ness. This practice differs from traditional models of health education because of the interactional dynamics between nurse and
patient, and an orientation to care that ostensibly centres and empowers patients. The theoretical underpinnings of coaching
reflect these differences, however in its application, the practices arranged around health coaching for chronic illness self-man-
agement reveal the social regulation and professional management of everyday life. This becomes especially problematic in con-
texts defined by economic constraint and government withdrawal from activities related to the ‘care’ of citizens. In this paper,
we trace the development of health coaching as part of nursing practice and consider the implications of this practice as an
emerging element of chronic illness self-management. Our purpose is to highlight health coaching as an approach intended to
support patients with chronic illness and at the same time, problematize the tensions contained in (and by) this practice.
Key words: chronic illness, health coaching, problematization, self-management.

NURSING AND HEALTH COACHING FOR
CHRONIC ILLNESS SELF-MANAGEMENT
As policy-makers and healthcare providers around the world
become increasingly preoccupied with managing what is
described as the growing care burden associated with
chronic diseases, patient self-management and other forms
of self-care are becoming more prominent on national
health agendas (cf. Parliament of Canada Standing Commit-
tee on Social Affairs and Technology 2002; World Health
Organization 2009). This preoccupation with orienting
healthcare reform securely around self-care is expressed, cf.
in a recent World Health Organization discussion of Health
for All, which emphasizes self-care as a necessary response to
the high burden of care associated with an increasing preva-
lence of chronic conditions (World Health Organization
Correspondence: Lisa M Howard, Faculty of Health Sciences, University of
Lethbridge, 4401 University Drive, Lethbridge, AB T1K 0N1, Canada.
E-mail: <lisa.howard@uleth.ca>
2009). However, it is important to note that this focus does
not represent an entirely new strategy for achieving health
so much as familiar practices being redeployed (and trans-
formed) in a changed epidemiological landscape that is
complicated by concerns about ageing populations, the sus-
tainability of health systems and significantly, a political con-
text characterized by a changing relationship between
citizens and the state. Of specific relevance is the dismantling
or decline of a state oriented to the welfare of its citizens
(cf. Rose 1999; Ong 2006). As Ong observes, ‘there is a fun-
damental shift… in the ethics of citizenship as governing
becomes concerned less with the social and collective man-
agement of the population (biopolitics) and more with
instilling behaviour of self-management (ethico-
politics)…. The neoliberal ethical regime requires citizens to
be self-responsible, self-governing subjects’ (237).
Chronic illness management takes shape in this chang-
ing political ethos as healthcare organizations, for reasons of
both economic utility and care management, take up and
enact the discourse of ‘active’ citizenship, that is, the citizen

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LM Howard and C Ceci
who is ‘‘no longer dependent on the welfare state,’’ through
policies and practices highlighting notions of choice, respon-
sibility and participation (Newman and Tonkens 2011, 9). In
practice and policy discourses, terms such as self-care or self-
management have become shorthand, as Kendall and col-
leagues argue (2011), for ‘a complex set of beliefs and ideas
about health, the role of people in maintaining their health,
and the responses that should be made by health systems’
(89). Practices of self-management, and those that support it
such as health coaching, arrive underpinned by assumptions
about the nature of ‘responsible’ patients, the availability of
the right knowledge and the capacities of people to apply
this knowledge to achieve right outcomes (Kendall et al.
2011). In this heightened atmosphere, patients’ everyday
activities of taking care of their health are not only an indi-
vidual imperative but also a national industry and a global
cause, and the practices arranged around health coaching
for chronic illness self-management reveal the social regula-
tion and professional management of everyday. In this
paper, we explore these tensions through consideration of
the evolution of the meanings and practices of health coach-
ing, the implications of the current sociopolitical contexts
for this practice and finally, how nurses might disentangle, at
least a little, from a preoccupation with ‘best practices’ and
refocus instead on the nature of best care.
Health coaching, a strategy to support patient self-man-
agement, emerged in the mid-20th century when Anselm
Strauss described coaching as an alternative to an expert-dri-
ven, didactic model of health education (Strauss 1959).
Later, health coaching was seen as an appropriate response
to the patient rights movement of the late 20th century. The
subsequent re-orientation of the patient’s role not only con-
ferred greater autonomy upon patients but also shifted sig-
nificant responsibility for a wide array of illness management
decisions and activities to patients. Yet there is a certain irony
in this professional (and political) conferral of responsibility
to patients in the promotion of ‘self-care’ as sociologist
Carl May (2011) observes: ‘‘of course patients are ‘involved’ in
their care. They and their significant others are enrolled as
unpaid workers in these extended and extending systems of
practice’’ (xii). Patients have always influenced formal health
practices by following or not following professional advice,
and by contributing expert knowledge about their illness
that sometimes supported and other times, contradicted,
expert clinical knowledge (May 2011). That patients are ‘‘of
course ‘involved’ in their care’’ does not mean, however,
that a coaching relationship between patient and nurse may
not be a ‘good thing’, only that, in our current social–political
context, it is a relationship and system strategy that should
be closely examined. While health coaching aims to re-unite
2  2012 Blackwell Publishing Ltd
generalized approaches to chronic illness care with the indi-
vidual particularities of illness, in reality nurses engaged in
health coaching spend a great deal of time reconciling the
needs of patients with the demands of the social institutions
that circumscribe good chronic illness management (Gast-
aldo 1997). In this context, clinical interactions such as
health coaching may not then be best understood as ‘auton-
omous or privatized encounters’ between individual patients
and individual practitioners but rather as infiltrated by (cor-
porate) mechanisms that surveil, regulate and structure the
range of possible actions (May 2010, 317; see also Armstrong
2005). Our purpose with this paper is to highlight some of
the trends in the health coaching literature that alert us to
these tensions in the discourse.
APPROACH TO THE LITERATURE
Chronic illness care practices reach deep into medical and
social history, and the kinds of things nurses do and their
influences on patient care are shaped by this history and also
by current practice circumstances. In this paper, we explore
the present circumstances and the history of health coaching
through a critical review of the health coaching literature,
with particular emphasis on those elements that highlight
the tensions described above. To support a more critical
uptake of the discourses of health coaching, we undertake
this close reading in light of the ideas of social philosophers
Michel Foucault and Annemarie Mol. Foucault’s (1973) per-
spective on medicine and health reminds us of the historic
associations between science, society and healthcare provid-
ers. The manner in which chronic illness is inscribed, nor-
malized, and disciplined in situated contexts has particular
consequences for nurses and patients. Confer, when the
medical gaze privileges the conditions of illness risk over the
circumstances of human flourishing, the body becomes not
only objectified but also the focus of control. Foucault’s work
examined how we organize and control bodies through the
‘expert’ medical governance that produces truths and norms
about the body. Teaching patients to ‘control’ their disease
through identifying deviance from prescribed norms is a
powerful means of controlling disease by controlling the
body, and it is this understanding of the relationship between
health and disease that often underlies practices of health
coaching. Mol (2008) examines the consequences of these
practices through contrasting the logics of care and choice as
they play out in the lives of both clinicians and patients. The
growing capacity for professional and social intervention,
even to the level of the individual’s cells, set us on a trouble-
some road – health takes on new meanings and increasingly
becomes a locus of medical and social manipulation.

WHAT IS HEALTH COACHING?
Throughout history, coaching embodied the concept of an
individual learning by doing alongside a skilled mentor to
the realization of one’s full potential (Frost 1989). Regard-
less of domain – sport, theatre, health – coaching embodied
physical and moral excellence, focused on the psychological
aspects of performance and embedded these features in
a reciprocal relationship (Semotiuk 1982; Adler 1985;
Lombardo 1987). Coaching first appeared in Homer’s Iliad
when Nestor tutored his son Antilochus in chariot racing
and since that time coaching is predominantly associated
with sport. However, coaching is more than training physical
bodies; it is interplay among knowledge, skills, competences
and social relations. In the late 15th and early 16th centuries,
the relational aspect of coaching became visible in the Eng-
lish language and the term referred to a person who con-
veyed another through the performance of a sport or skill
(Adler 1985; Merriam-Webster 2003). From the origins in
Greece to the emergence in English language, the practice
of coaching brought together expert knowledge, experience
and practical wisdom to help people navigate challenging
personal, physical and psychological journeys.
In a contemporary healthcare context, coaching is apply-
ing skills of listening, questioning and reflecting to support
persons with a chronic illness to manage the physical, psy-
chological and social influences of the disease (Benner
1985; Clarke and Spross 1996; Lewis and Zahlis 1997;
Hughes 2003; Rollnick, Miller and Butler 2008). In this
regard, health coaching is often compared with motivational
interviewing, and health coaches frequently use motivational
interviewing techniques to achieve their goals (Rubak
et al. 2005; Houston Miller 2010; Linden, Butterworth and
Prochaska 2010). Health coaching differs from a traditional
education approach because the focus is on ‘empowering’
patients to identify how they can use health information to
achieve their goals to best manage their illness. Patients are
coached in routines of measuring, monitoring and adjusting
as an expression of good chronic illness care and to achieve
good outcomes. An overview of coaching theories in nursing
and health-care reflects the evolving practice of health
coaching, shifting views of the patient and the role of the cli-
nician and increasing corporate influence on the organiza-
tion of health.
Strauss (1959) provided the first conceptual framework
for health coaching comparing the coaching process to
pruning ‘a tree with many branches and twigs, the (patient)
moves along certain branches until reaching alternatives and
the coach channels the (patient’s) movements until the next
set of alternatives arise’ (117). This early conceptualization
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Health coaching for chronic illness self-management
of coaching reflects the privileged role of healthcare provid-
ers in interpreting science and prescribing interventions:
The coach is the expert authority and the patient is the yield-
ing subject, (com)pliant in the face of the coach’s skilled
manoeuverings.
In the late 20th century, an era characterized by cost con-
tainment and role restructuring, the nurse’s role in health
education presented itself as an arena in which the profes-
sion could demonstrate its unique contribution to both
patient care and cost-effectiveness (Smith 1989). Patricia
Benner (1985) identified coaching as a domain of nursing
practice and extended Strauss’ framework to include specific
coaching functions such as teaching clinical monitoring and
treatment protocols, as well as providing relational support.
Differently than Strauss however, Benner emphasized the
need for the nurse coach to understand the patient’s experi-
ence and context of chronic illness. Benner’s framework
encouraged coaches to use uncertainty as a bridge to a new
understanding of the chronic illness experience, an impulse
that was concurrent with a growing interest in nursing to
move beyond the content of education and toward the pro-
cesses of patient education (Clarke and Spross 1996). Unlike
Strauss’ coach’s pruning of options (content) for patient
change, Benner’s coach works to coax the branches of
change (process) from buds of possibility.
Clarke and Spross (1996) continued Benner’s inward
exploration of the nature of coaching, asserting that coach-
ing depends on the intersection of self-reflection with clini-
cal, technical and interpersonal competencies. The repeated
reflection upon the competencies, and the skilled articula-
tion of how these might facilitate or inhibit the coaching
relationship, was seen as central to helping patients adjust to
the transitions of chronic illness. This intense focus on
reflection was extended in the work of Lewis and Zahlis
(1997) and made visible through the identification of six
observable behaviours of health coaching: attending to the
patient’s story, contextualizing the experience, engaging the
patient in work of change, exploring solutions to change,
anchoring skills and positioning the patient for success. This
framework articulated the nurturing work of shaping health
behaviour change in the context of chronic illness and situ-
ated the unique knowledge and practice of this work within
the domain of nursing.
Perhaps in response to a political and societal question-
ing of the nurse’s role, Lewis and Zahlis (1997) work made a
case for the unique value nurses bring to health behaviour
change and described the importance of the nurse’s expert
knowledge in chronic illness care. Schenk and Hartley
(2002) also argued for the need for expert knowledge in ill-
ness pathology, and highlighted the importance of expert
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LM Howard and C Ceci
comportment in coaching. They described health coaching
as a partnering process where nurses motivate patients to
harness personal knowledge and skills and determine the
possibilities for change based on patient-centred goals.
A provocative observation emerges from the introduction
and evolution of coaching in health-care. While the athlete
or artist chooses coaching for success, the chronically ill indi-
vidual is enlisted or motivated – through health coaching –
to take responsibility for illness management activities. This
marks a significant shift from historical understandings of
coaching to a practice of coaching in health-care wherein
the patient’s body becomes both an object of knowledge and
the subject of personal reconstruction through participation
in health-promoting and illness-monitoring behaviours; the
body becomes subject to professional, self and societal disci-
pline (Gastaldo 1997; Rose 2001). The emphasis in the
health coaching literature on interpersonal relationships in
patient encounters, with practical wisdom and patient choice
as guiding values, does not account for the parallel project of
the efficient, cost-effective administration of health resources
to achieve good chronic illness management and outcomes.
As Kendall and colleagues (2011) argue, the self-manage-
ment discourses which health coaching serves have been
‘recontextualized to serve the aims of economic utility that
drive contemporary health systems’ (88). So rather than an
independent, autonomous or even private nurse–patient
relation (May 2011), we see instead a shifting landscape pop-
ulated by professional interests, professional knowledge prac-
tices and administrative imperatives.
MANAGING MULTIPLE AGENDAS:
COACHING, CHRONIC ILLNESS CARE AND
NURSING
In an early overview of the opportunities and challenges for
nurses entering the 21st century milieu, Smith (1989)
emphasized the need to make both public and policy-makers
aware of the unique contributions nurses make through
health education. She identified challenges including secur-
ing a place at the policy-making table, having a voice in rele-
vant programme planning, and ‘linking patient education to
compliance with health and medical care regimens and
quality of life’ (586). In these terms, health coaching figures
as a reasonable approach to link compliance, health, medi-
cal regimens, and quality of life, and nurses appear to be will-
ing to invest themselves in a broader social agenda by
volunteering client self-management approaches such as
health coaching as a resource to reduce costs, and improve
outcomes, while demonstrating to those managing corpo-
4  2012 Blackwell Publishing Ltd
rate budgets the effectiveness of a professional nurse in this
role (Smith 1989; Luck 2010). At the same time that nurses
may chafe at the constraints imposed on their relationships
with patients (Allen 2004), taking on the role of health
coaching reinforces professional interests by securing nurs-
ing’s position in the organizational structure of health, and
delineates not only what knowledge nurses manage but also
how they transfer this knowledge to patients who in turn self-
manage. This is a repeated pattern in nursing’s occupational
history, cf. in healthcare institutions, where, as McPherson
(1996) observes, the ability to take up ‘precise and standard-
ized methods of executing tasks consolidated nursing’s posi-
tion as critical to efficiently run hospitals while
strengthening nurses’ claim to a unique professional body of
knowledge’ (91; see also Allen 2004).
As society faces an ageing demographic, nurses present
themselves as competent and cost-effective providers of care
and education to a growing population experiencing
chronic and complex health challenges. At the same time,
and it is here we see some tensions in the discourse, the
health coaching skills of nurses are leveraged by health sys-
tems administrators to prepare patients to independently
manage chronic illness as a means to distribute professional
care across a larger number of patients, and to delegate
responsibility for health outcomes to the patients themselves.
Confer, to extend current clinician resources and reach a
greater range of patients, healthcare organizations support
patient coaching not necessarily because of the presumed
relational benefits but because it can be accomplished in
person, over the telephone, or via the computer. However,
the effectiveness of coaching using alternative modalities to
in-person visits appears to be inconclusive in terms of affect-
ing clinical biomarkers of chronic illness (Parry, Kramer and
Coleman 2006; Navicharern, Aungsuroch and Thanasilp
2009), and a recent systematic review of the economic advan-
tages of tele-health interventions contested the claim that
telemedicine is a cost-effective alternative to conventional
means of healthcare delivery (Whitten et al. 2002). What is a
consistent change in the nature of healthcare encounters,
whether in person or remote, is a shift to ‘self-care’ including
a requirement that patients take up the complex monitoring
and decision-making rituals that are part of chronic illness
management. This initiative is often conceptualized as secur-
ing patient autonomy in chronic illness care, and while
health coaching makes visible the contribution of nurses in
chronic illness care, it renders invisible the work that is
shifted to patients and families to meet the demands of
guidelines and protocols (May 2007, 2010).
Recent literature on health coaching tends to highlight
the gains in clinician efficiency health coaching offers, and

appears less concerned with this shift in the burden of care.
For example, a number of researchers have investigated the
effectiveness of health coaching by assessing measures associ-
ated with chronic illness such as blood pressure, blood cho-
lesterol, blood glucose, body weight, diet, exercise and
medication adherence (cf. Vale et al. 2002; Whittemore
et al. 2004; Melko et al. 2010). The significance of Smith’s
(1989) recommendations described above can be read in
the shift in focus this research demonstrates, away from the
relational aspect of health coaching and toward measuring
the effectiveness of the intervention. This direction ensures
that patient education remains the responsibility of skilled
professionals who lay claim to accountability for patient edu-
cation. Recent research in health coaching is testing this
claim, investigating the effectiveness of non-licensed health-
care providers using a coaching approach (Bennett et al.
2010). This reflects another turn in health-care as resources
to compensate skilled providers for this work shrink and
demands for educational resources to support self-manage-
ment grow. As the practice of coaching evolves, the emphasis
in the scholarly literature is on identifying specific tech-
niques to improve the effectiveness and assessing the prod-
ucts of coaching with a focus on those strategies that can
deliver the necessary outcomes at the lowest cost (Anderson
and Halley 2008; Sacco et al. 2009). The literature is silent
on the implications this direction holds for nurses and
patients, and perhaps most significantly, on what it means to
have good care, and a good life, in the context of chronic
illness.
TENSIONS IN THE DISCOURSE: BEST
PRACTICE OR BEST CARE?
The theoretical foundations of coaching mark a rhetorical
shift in discourse about nursing practice from the belief in
the clinician as expert to that of the clinician as coach.
Through actively partnering with patients in their chronic ill-
ness care, nurses are seen to come alongside patients and
coach them to take up the best evidence and incorporate
this knowledge into their daily practices to improve illness
control and decrease complications. This form of health
coaching supports nursing’s professional interests to demon-
strate ethical comportment in practice as well as to secure a
place as a valuable, valued member of the healthcare team.
At the same time, health coaching serves corporate inter-
ests to deliver cost- and time-efficient care by transferring to
patients much of the work required for the monitoring and
management of their illness and in so doing, to decrease the
burden of illness on the larger society (May 2010; Kendall
et al. 2011). It is worth considering how nursing’s profes-
 2012 Blackwell Publishing Ltd
Health coaching for chronic illness self-management
sional interests and these corporate interests unfold when
they intersect in the patient because when professionals
transfer the work of self-management, they also transfer the
moral practices of what it is to live well with a chronic dis-
ease. Confer, healthcare professionals and administrators
may use clinical practice guidelines based on scientific ‘evi-
dence’ about chronic illness care to make decisions about
patient care in the ‘best interests’ of patients but do so from
a different vantage point than people themselves – a point
that links back to Foucault’s claim that power ⁄ knowledge
practices, and in particular the medical or expert gaze, bring
into being a particular body as well as situated practices of
managing that body. And as noted previously, if the clinical
encounter can no longer be seen as autonomous or private,
then we need to understand better what May (2010)
describes as the ‘organizing interfaces of corporate forces’
(317). Patient-centred coaching practices that highlight
patient’s experiences run up against aggregate-level data
(the ‘evidence’) intended to guide chronic illness manage-
ment, often through forms that bureaucratize care through
technologies such as care pathways and clinical guidelines
(May 2010). Given this difference in perspective and inter-
ests, it is important to consider whether the ‘best’ practices
organized around bodies with chronic illness also contribute
to best care, and relatedly, how the values embedded in the
discourse – responsibility, choice, autonomy – may be
enacted in a life lived with chronic illness.
Annemarie Mol (2008) is an ethnographer and philoso-
pher who examines the problems that arise when the
patient’s body intersects with the institutional body of
chronic illness. At this intersection, Mol situates possibilities
of the reciprocal and relational nature of good care, but jux-
taposes these to healthcare practices primarily informed by a
logic of choice. That is, those practices that both highlight
and demand patient autonomy most often read as individual
decision-making, as a defining goal of practice. Choice, and
especially free choice, is a problematic figure for people with
chronic illness not least because this emphasis individualizes
the broad conditions of living that contribute both directly
and indirectly to illness and its management, and in so doing
locates responsibility for outcomes with patients. As Kendall
and colleagues (2011) observe, in a context organized by a
logic of choice, when people experience poor health, the
‘assumption is that they have not practiced ‘good’ self-
management’ (93).
Similarly, in Mol’s (2008) analysis, choice is centred in
the figure of the consumer who freely chooses among the
products on offer, or in the figure of the citizen who is able
to ignore the demands of his or her particular physical body
to participate freely in the body politic. Neither figure has
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LM Howard and C Ceci
full relevance for a life framed by the concrete concerns of
chronic illness, where the demands of the body, at the very
least, must be continually taken into account. These limita-
tions of the centring of choice in healthcare practices high-
light a paradox of what is often called ‘patient-centred care’
– more choice may not lead to good care (Mol 2008).
This is a valuable perspective to bring to the problem of
coaching because, ideally or theoretically, the coaching rela-
tionship is thought to rely on a ‘transfer’ of power from
nurse to patient, including the power to make good choices.
The coaching relationship is characterized by the nurse
searching for connections between the patient’s experiences
and current situation as an entry point to managing illness
care. Figured as a reciprocal relationship, the nurse and
patient are seen to be in dialogue where the nurse identifies
openings for possible interventions through active listening
and specific questioning and then tailors information to the
patient’s unique context. However, choice on its own is an
ideal, one which care providers may perceive as generally
available to patients and in so doing neglect the complexities
of a life lived with illness (Mol 2008). While chronic disease
protocols may provide rules to guide illness care, living with
a chronic condition requires complex adjustments and read-
justments contingent on the outcome of the previous
‘choices’.
And the material conditions of choice in chronic illness
are complex; to choose one medication or another testing
regime might have enormous consequences. Mol (2008)
offers as an example the situation of a patient with diabetes.
The nurse asks the patient to test his blood glucose levels five
times a day on 1 day each week over a 3-week period to pro-
vide information for regulating medication. The test results
guide the medication adjustment and this adjustment will, in
turn, correct the patient’s fluctuating blood glucose levels for
improved disease control. The patient is interested and able
to perform the testing; however, when he leaves the clinic, he
finds he cannot make the time at work or access a clean space
for performing the intense testing routine. He is also embar-
rassed to perform tests in front of colleagues. He returns to
the clinic with too few test results to safely change the medi-
cation. In the terms of the current preoccupations of self-
care, the patient has failed to exercise his responsibility to
adequately self-manage; he may be labelled non-compliant
or insufficiently concerned about his health. Health coach-
ing attuned primarily to outcomes risks overlooking both the
practicalities and complexities of ‘self’-management.
In Mol’s terms, the above example confirms that a prac-
tice of ‘tinkering’ is often necessary to produce improve-
ments in daily life, a practice that exists at some distance
from our current preoccupation with making choices to
6  2012 Blackwell Publishing Ltd
achieve satisfactory indicators. The activity that is fore-
grounded is not decision-making (what choice can be
made?) but working out what might work best, what might
be helpful. For patients living with the caprice of a chronic
illness, the requirement to ‘make’ choices may simply
become burdensome through the bewildering array
‘options’ that arrive fully formed. To return to the analysis of
Kendall and colleagues (2011), the dominant discourse
arrayed around ideals of choice ‘underestimates the condi-
tions which make self-management (im)possible’ (94).
The shift toward consumerism in health-care created an
opening for and bolstered the ideal of choice; however,
choices in health-care are neither autonomous nor straight-
forward. There are social conditions, physical limitations,
clinical guidelines, clinicians and civic responsibilities
around choice that render it not so free as one would like to
think. Situated in a complex web of social relations, choice
rarely comes down to something as straightforward as an
individually autonomous act. Struhkamp (2005), like Mol,
invites us to consider choice as a practice or rather as an
effect of the material conditions and social relations that
together come to constitute the activities of care. Autonomy
becomes an effect of these arrangements rather than a qual-
ity that inheres in people. So rather than enclosed and
autonomous, we are encouraged to think people and their
choices, abilities and possibilities, as constituted through a
constant interaction with a material and social world. And so
it is in matters of chronic illness care, choice is larger than
selecting one option or another; it is an interactive perfor-
mance among individuals, care professionals, physical envi-
ronments and social contexts (Kendall et al. 2011).
FAULT LINES IN HEALTH COACHING FOR
‘SELF’-MANAGEMENT
The theoretical foundations of health coaching suggest that
the relationship between coach and patient is interdepen-
dent and the relational practices of the coach are intended
to support patients to navigate the complex terrain of a life
lived with chronic illness. Much of the research literature on
coaching, however, reveals that this idea (l) of interdepen-
dence fails to extend beyond the theoretical underpinnings
of coaching. The institutional resources that support coach-
ing do so in anticipation of products: good health outcomes,
good measures of illness, and compliance with the medical
regime and with best evidence (Butterworth, Linden and
McClay 2007; Huffman 2007; Luck 2010; Cooke 2011). Yet
good care, as Mol (2008) argues, is not (or not only) about
predicting or measuring outcomes, it is about ongoing,
responsive relationships where clinicians and patients each

tinker with the complexities of the individual situation and
the generalities of the evidence. While coaches prepare
patients to physically participate in the monitoring and
adjusting required for active chronic illness self-manage-
ment, and work to mediate these practices through caring
relationships, the structures around the coaching relation-
ship (measuring, following guidelines) exert an influence
which may yield something quite different than good care
and the ability to lead a good life. Much of the coaching
research reveals a relentless interest in treating the illness
entity and mobilizing persons who live with the illness as par-
ticipants in the war on disease in their own body (DeBusk,
Miller and Superko 1994; Vale et al. 2002; Hughes 2003). To
be a good patient is to have good numbers and to be a good
clinician is to have patients interested in producing good
numbers. The structures around coaching, such as disease
monitoring guidelines and behaviour modification strate-
gies, assume that patients are equal in their abilities to per-
form their role in self-management. While health coaches
attempt to leverage the patient’s existing resources to suc-
cessfully engage in their chronic care, they are challenged by
the asymmetries in both physical and mental capabilities of
patients that the health system fails to account for, or to
accommodate, in pursuit of good outcomes. Coaching is
reduced to a transaction of activities performed in service to
good measures. In bringing Mol’s (2008) logics of care and
choice to the problem of coaching, the boundaries of care
and choice become more visible. The focus on patient
choice with its narrow understanding of autonomy creates
problems for clinicians and patients alike; the investment in
making choices neglects the situations influencing choice
with disciplining effects for both.
If ‘good’ self-care, as it is taken up in the health manage-
ment discourse, is to aspire to rational self-sufficiency, then
health coaches would ruthlessly enjoin patients to participate
in activities that yield good numbers and good control of
chronic illness. Coaching, if taken up in a manner consistent
with its theoretical foundations, attends to the juxtaposed
allegiances patients with chronic illness face: their commit-
ment to quality of life and the obligations to disease manage-
ment, the desire to live well with a chronic illness and to live
well within their community. The ‘choices’ patients make
which affect their health will also affect their social relations
and their relations with the health system.
There is a shift in self-management education that aligns
with other shifts in culture such as corporate involvement in
day-to-day workings of illness and a consumerist approach to
health. The focus on enhanced self-management education,
through health coaching, shifts the attention away from the
structural problems in health-care and toward the so-called
 2012 Blackwell Publishing Ltd
Health coaching for chronic illness self-management
autonomous person as responsible for managing the difficul-
ties of a life lived with chronic illness. A closer look at health
coaching reveals a fissure in health-care that is occupied by
professional and institution centeredness. To problematize
the activities involved in self-management as supporting the
patient’s right to choose probes a crack in the foundation of
how individual choice is understood and enacted in health-
care. The complexities of making deeply difficult choices
about health, and the misalignment of the structures around
choice-making in health, can place choice and action at odds
and subsequently place our patients at odds with the pro-
grammes, people and networks intended to provide support.
What it is to have choices, good care, and a life well lived
with chronic illness may not easily align.
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