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Though genes played a part, the near total prior absence of diabetes in this population (and its continued rarity among less-stressed Pima tribes in Mexico) shows that something more than genetic heritage accounts for the disease's surge. Trauma is largely to blame. The Pimas lost their culture and self-determination and what they got in return were conditions that support disease. The Pima are an extreme case, but in their isolation, they prove the larger picture. The good news: Looking at those who rated lowest, the program more than doubled their sense of meaning and purpose and increased their ability to manage their stress by a whopping 40 percent. Adam tells the story of a patient in her early fifties who was experiencing back and neck pain. In his consultation with her, it came out that her mother had recently passed away. She was dealing with real grief, and that was exacerbating her physical complaints (emotional pain can trigger inflammation in the body). She had cared for her mother for a long time, and for the better part of a decade, that was what had made her life meaningful. Now that her mother had passed, she felt adrift and without purpose. She was grieving not just for the loss of her mother but for her loss of identity as a caretaker. This patient was missing a key component of healing. If she wanted to feel better, she had to address her wellness on all levels, not just the physical. She needed to become whole again. In that case my conception of the responsibility function is a fifty-fifty approach, the counselor's responsibility being that of providing a sensitive, permissive, understanding atmosphere, and the client's responsibility being to use that climate as a ground for his problem solving activity. I wonder if that in any way gets at what you mean, Mr B? Mr B: Well, it seems to me that the counselor has even greater responsibility. He has information that the client doesn't have. Isn't it only fair that he give that information to the client? In some respects the counseling situation seems to be a teacher-pupil relationship and if that is so then the client is really being cheated.

Inst: You object to the fact that the counselor doesn't take more responsibility for guiding the client. Had this occurred early in the course the leader might have preferred to reflect B's puzzlement or concern about this topic. At this point, however, the leader tries to answer B's question directly, stating his opinion as a personal opinion. Evidently it would have made little difference whether the leader reflected B's attitude or gave his own opinion, since B clearly wants to express his own view in a somewhat challenging way. Type 2 diabetes prevalence accurately gauges status in society. In general, in industrialized countries, the less power, money, and status of a group, the higher the incidence. Childhood trauma--like being an abused child, or having a parent who was incarcerated, mentally ill, or abusing substances--is also associated with higher risk for diabetes later in life. Trauma also plays out in the much higher incidence of diabetes among military veterans, in whom the rate is more than twice that of non-veterans. The most common narrative blames diabetes on behavior, or, to be more specific, eating too much, eating the wrong foods, or sedentary behavior. It is true that people who exercise regularly and eat nutritiously are healthier, no matter what stress they're under or what genes they have. On the other hand, it's also true that people who do those things often have power to begin with, giving them time and resources to exercise and to buy and prepare healthy foods. It is harder to adopt such healthy behaviors when you have little power. So while it is true that disadvantaged people, on average, display less healthy behavioral choices and worse health than people who are more privileged, their health problems don't come strictly from those behaviors. Stress and environment play much bigger roles. She could--and did--try acupuncture for the pain, and some gentle exercises, but the bigger goal was for her to figure out what would make her life feel purposeful again. She needed to make some plans to find a sense of meaning and take steps to make it happen. Adam suggested she look into volunteer work in which she could use her compassion and skills to care for others. Where do you want to be in twenty years? What kind of work do you want to be doing? If you'll no longer be working then, what do you want to spend your days doing?

What kind of relationship do you want to have with your kids, your friends, your significant other? Where do you want to be living? And, even more important, are you acting in accordance with those life goals? If you are, that's fantastic news. The fact that he is willing to object to and contradict the instructor's opinion is one measure of the climate which exists. Here the leader must quickly and intuitively make a decision as to the course he is to follow. As a participant, he could continue with the opinion he has stated, trying to relate it to B's statement. But where a contribution is clearly imbued with considerable personal Mr B: Yes, it seems that way to me. As a matter of fact, all the examples of directive counseling given in Rogers' article seem extreme -- they're not instances of good directive counseling. There are very few traditional counselors who give a lot of advice and reassurance, or take over the life of the client. Inst: Your feeling then is that Rogers has been extremely unfair in the selection of the examples. Miss C: I would agree with Mr B in some respects. I was reading Alexander and French (Psychoanalytic Therapy) the other night -- They're psychoanalysts, supposedly middle of the road in the directive-nondirective continuum, yet in many instances they were certainly nondirective in their approach. It is also true that people's health behaviors are influenced by the conditions of their lives. I put choices in quotes to make the point that while they do have different lifestyle behaviors now--less activity and eating more processed foods, for example--the Pimas' behavioral choices were foisted on them by the changing conditions of their lives. By ignoring the context, the concept of choice is often used as a weapon against marginalized people. The context of people's lives determines their health, which is why blaming them for poor health or praising them for good health is harmful and misses the point. People usually can't directly control the most significant contributors to their health. It is also true that poor people are often too busy making ends meet (striving to feed their family, protecting their right to food stamps against means testing, finding and keeping housing, working multiple jobs, and so on) to spend time on the relative luxury of gym workouts and fresh home-cooked meals.

They're often necessarily preoccupied working on very basic survival needs. To be clear, the scope of diabetes is not limited to people with low power. There is a range of contributory factors beyond the social determinants. Regardless, if you have diabetes (or any disease! Keep going. If you sense a gap between what you want your life to be and what you're currently doing, then keep reading. We have some tools that can help. Take Action Define your goals. The first step in aligning your actions with your life mission is to identify what that mission is. Take some time today to look over the questions in the box that follows and write out your answers to the ones that matter to you. Any that don't apply to your life, skip over. For ones that do matter to you, be as detailed as you can in your envisioning. Choose one thing you want most. Inst: It's pretty confusing sometimes when we're forced to label things, isn't it? Miss C: It certainly is. You hardly know where you should stand in regard to the different techniques and points of view in psychotherapy. Mr B: That's right. In talking to analysts you get a different impression than when you read what they write. When they speak about their methods you get the impression that they're using nondirective methods pretty heavily.

Mr R: I've watched analysts work, too; Mr K: They can't be nondirective if they draw conclusions for their clients. That seems to vitiate the philosophical basis for the whole The instructor tries to convey this in this response, and in number 6. We're all born with challenges in our genetic code and our life circumstances that make us vulnerable to disease, and this is one of the challenges you were dealt. Your body was genetically vulnerable to challenges with glucose regulation and some combination of factors triggered that genetic propensity. We can't get away with blaming diabetes on fatness, either. While type 2 diabetes is more common among heavier people compared to those in the normal weight category, the vast majority of obese people don't have diabetes. We're at the brink of a paradigm shift in diabetes care. The old and still-entrenched paradigm focuses on high weight, poor diet, and lack of physical activity as the causal factors for the high incidence of diabetes and fails to raise sufficient awareness of the impact of stress and the political, environmental, and social structures that have created and continue to feed the prevalence of diabetes. To help you challenge the current paradigm, let's examine one of the most misguided beliefs: promoting weight loss for treatment and prevention of diabetes. The American Diabetes Association, for example, recommends, Diet, physical activity, and behavioral therapy designed to achieve and maintain >5 percent weight loss should be prescribed for patients with type 2 diabetes who are overweight or obese. They denote their recommendations as Evidence Category A, meaning there is clear evidence from well-conducted, generalizable randomized controlled trials that are adequately powered. The National Institute of Diabetes and Digestive and Kidney Diseases, which conducted research to examine the DPP, corroborates the value of recommending DPP, declaring that the DPP showed that people who are at high risk for type 2 diabetes can prevent or delay the disease by losing a modest amount of weight. Look over your list. What feels the most urgent and desirable to you? What do you really want in your life, starting now? Do you want more meaningful work? Better connection to your spouse? To find the love of your life?