However, most studies which use cognitive and psychological strategies to effect behavioral changes have reported high rates of relapse despite initial success, often due to negative external or social influences. Thus, to enhance self management, there is a need to take into consideration both internal needs (assessment of individual needs, learning skills and goal setting) and external support (e.g. families, organizations, neighborhoods, and communities) to encourage and reinforce the use of learned skills to sustain positive behavior and self management on a long term basis. Adding to these emerging concepts in behavioral medicine is equifinality, i.e. diverse approaches may achieve similar end. Thus, a multi-component program offering a broad range of intervention approaches may tailor the pluralistic needs of people with diabetes or chronic disease.