Behavioral Management in

Chronic Illness
Chronic disease is associated with high levels of uncertainty.
Patients need to change their behavior as part of a new lifestyle of
self-care. They also have to endure debilitating and demanding
treatments. These are some of the factors that make adjustment to
chronic medical illness psychologically demanding.
• It is generally accepted that around a quarter of
patients with chronic medical problems have
clinically significant psychological symptoms. In
some cases, these psychological symptoms
themselves are associated with physical
morbidity. For example, when medical factors are
controlled for, the risk of myocardial infarction
increases 4- to 5-fold as a result of the presence
of depressive symptoms.1 Even in the absence of
overt psychological or psychiatric disorder,
patients have to regulate often-complex and ever-
changing thoughts, feelings, and behaviors.
WHAT IS COGNITIVE THERAPY?
• Two patients may have the same physical
health problems, yet have markedly different
psychological responses. For example, a man
with multiple sclerosis who believes that his
ability to make a useful contribution to life is
finished is likely to experience depressed
mood and avoidance of previously
enjoyed activities.
• But a different man with the same condition
who acknowledges that his life will have to
change, but who believes that he will be able
to discover new ways to make a contribution,
is likely to make a better psychological
adjustment to his illness.
• These differences in patient psychological
responses can be understood by examining
patients' thoughts about their illness. This is a
fundamental principle behind cognitive
therapy—a focused, structured, collaborative,
and usually short-term psychological therapy
that aims to facilitate problem solving and to
modify dysfunctional thinking and behavior
 Coping interventions for
powerlessness, Hopelessness,
Sensory deprivation, sleeplessness
• POWERLESSNESS:
• When you feel powerless, you feel afraid to express your needs because you
fear (often rightly) that what little you have will be taken from you.  You may
have learned powerlessness if you were kept in powerless positions repeatedly
and/or over long periods of time (possibly during childhood) by those who used
external forces (money, physical strength, legal status, and/or military force) to
control you. You may have been abused as a child, a partner or spouse, an
employee, a soldier, or you may have been the victim of racial or ethnic attacks. 
Such prolonged abuse can cause you to become afraid to feel even your own
needs, i.e., to admit to yourself that you need something.  You become
immobilized.  And in certain critical ways you stop growing, you cease to thrive.
 Overcoming Powerlessness
• The first step to overcoming learned powerlessness is to learn to feel
entitled to your personal rights.  You have the right to live a life free
from physical, emotional, sexual, and financial mistreatment.  You
have the right to be treated with respect, to earn a livable income, to
be informed of matters that affect you, and to express yourself freely
(without harming others).  Most importantly, you have the right to
ask for what you need (even though you may be turned down) and
to fight for what you need and want (even if you are turned down!). 
This list of "legitimate entitlements" is easier to read than to
experience.  Most people who have learned powerlessness barely
feel entitled to speak, let alone to speak freely.  Often professional
therapy is necessary to overcome the ingrained patterns.  Never the
less, to overcome learned powerlessness, you must gradually,
haltingly, but persistently lay claim to each and every human right,
one after the other.
• Hopelessness:
• A subjective state in which an individual sees
limited or unavailable alternatives or personal
choices and is unable to mobilize energy on
own behalf.
 Related Factors Causing Hopelessness

• Abandonment; 
• prolonged activity restriction creating
isolation; 
• lost beliefs in transcendent values/God;
• long-term stress; 
• failing or deteriorating physiological condition
 9 Types of Hopelessness
•  Alienation (Attachment)
• Alienated individuals believe that they
are somehow different. Moreover, they
feel as if they have been cut loose, no
longer deemed worthy of love, care, or
support. In turn, the alienated tend to
close themselves off, fearing further
pain and rejection.
  Forsakenness (Attachment and
Survival)
• The word “forsaken” refers to an
experience of total abandonment that
leaves individuals feeling alone in their
time of greatest need. Recall Job in the
Old Testament, crumpled over and
covered with sores, pleading with a
seemingly indifferent God.
 Uninspired (Attachment and
Mastery)
• Feeling uninspired can be especially
difficult for members of underprivileged
minorities, for whom opportunities for
growth and positive role models within
the group may be either lacking or
undervalued.
 Powerlessness (Mastery)
• Individuals of every age need to believe
that they can author the story of their
life. When that need is thwarted, when
one feels incapable of navigating one’s
way toward desired goals, a feeling of
powerlessness can set in.
 Oppression (Mastery and
Attachment)
• Oppression involves the subjugation of
a person or group…. The word
“oppressed” comes from Latin, to “press
down,” and its synonym, “down-
trodden,” suggests a sense of being
“crushed under” or “flattened.”
Limitedness (Mastery and Survival)

• When the struggle for survival is

combined with a sense of failed mastery,
individuals feel limited. They experience
themselves as deficient, lacking in the
right stuff to make it in the world. This
form of hopelessness is all too common
among the poor as well as those
struggling with severe physical handicaps
or crippling learning disabilities.
 Doom (Survival)
• Individuals weighed down by this form of
despair presume that their life is over, that
their death is imminent. The ones most
vulnerable to sinking into this particular
circle of hell are those diagnosed with a
serious, life-threatening illness as well as
those who see themselves worn out by age
or infirmity. Such individuals feel doomed,
trapped in a fog of irreversible decline.
Captivity (Survival and Attachment)

• Two forms of hopelessness can result from

captivity. The first consists of physical or
emotional captivity enforced by an individual or
a group. Prisoners fall into this category as well
as those help captive in a controlling, abusive
relationship. We refer to this as “other-
imprisonment.”…An equally insidious form of
entrapment is “self-imprisonment. This occurs
when individuals cannot leave a bad relationship
because their sense of self will not allow it.
Helplessness (Survival and Mastery)

• Helpless individuals no longer believe that

they can live safely in the world. They feel
exposed and vulnerable, like a cat after being
declawed or a bird grounded by a broken
wing. Trauma or repeated exposure to
uncontrolled stressors can produce an
ingrained sense of helplessness. In the words
of one trauma survivor, “I was terrified to go
anywhere on my own … I felt so defenseless
and afraid that I just stopped doing anything.”
 Overcoming Hopelessness
• Forsakenness (Attachment and
Survival
• If you feel forsaken, it is important to get outside of your
head to see if your inner reality is an accurate reflection
of the outside world. Most people who feel forsaken are
overgeneralizing from a relatively small sample of
experiences. With more extensive sampling, it is highly
likely that they will encounter more hope-promoting
responses from others. The antidote to all-or-nothing
thinking is thinking in shades of gray–opening oneself up
to the continuum of possibilities for one’s life.
 Doom and its offshoots (Doom,
Helplessness, Captivity)
• Those who feel doomed as a result of a medical or psychiatric
diagnosis may “jump to conclusions.” The best antidote for jumping to
conclusions is “examining the evidence.” If you are diagnosed with a
serious illness, do your homework and get the facts. For example,
Harvard anthropologist Stephen Jay Gould was diagnosed with a rare
abdominal cancer at the age of 40. When told that the median survival
time for someone with this disease was only 8 months, he did some
research. In his essay, “The Median Isn’t the Message,” Gould shared
how his knowledge of statistics helped him to “examine the evidence.”
He was able to tell himself, “Fine, half the people will live longer. Now
what are my chances of being in that half?” After factoring in his age,
his relatively healthy lifestyle, the early stage of diagnosis, and the
quality of healthcare available, Gould arrived at a far more hopeful
prognosis. In fact, he lived another 20 years before succumbing to an
unrelated illness.
  Powerlessness and its Offshoots
(Powerlessness, Oppression, Limitedness)

• Three cognitive distortions frequently underlie feelings of

powerlessness: discounting the positive, personalization,
and labeling. When individuals cannot appreciate their
talents and gifts, they are prone to discount any evidence
of personal success or effectiveness. Examining the
evidence is a good strategy for dealing with discounting the
positive. One way to do this is to make a list of successes,
particularly in the general domain you are discounting. For
example, if you are prone to discounting a good grade on
an exam, write down any past successes of an intellectual
nature. If you tend to discount a work or social
achievement, reflect on past occupational or group-related
achievements.
• It is common for those who are oppressed to
engage in personalization and self-blame. A strategy
for counteracting self-blame is reattribution. This
involves considering all the likely causes of negative
emotions.
• When individuals feel limited because of a perceived
physical or intellectual disability, they may fall prey
to labeling. To attack harmful labels, “define your
terms.” For example, if you feel or are labeled
“stupid,” reflect on the actual definition of the term.
Are you always “making bad decisions”? Are you
always “careless” and “unable to learn”? Unless this
description, taken directly from the “American
 Sensory Deprivation
•  is the deliberate reduction or removal
of stimuli from one or more of the senses.
Simple devices such as blindfoldws or
hoods and earmuffs can cut off sight and
hearing, while more complex devices can also
cut off the sense of smell, touch, taste,
thermoception (heat-sense), and 'gravity'.
Sensory deprivation has been used in
various alternative medicines and in
psychological experiments
 Overcoming Sensory Deprivation
• 2 Restricted Environmental Stimulation Therapy (REST)
• Chamber REST
• In chamber REST, subjects lie on a bed in a
completely dark and sound reducing (on average,
80 dB) room for up to 24 hours. Their movement is
restricted by the experimental instructions, but not by
any mechanical restraints. Food, drink and toilet
facilities are provided in the room and are at the
discretion of the tester. Subjects are allowed to leave
the room before the 24 hours are complete; however,
fewer than 10% actually do.
Flotation REST
• In flotation REST, the room contains a tank or pool. The flotation medium consists
of a skin-temperature solution of water and Epsomsalts at a specific gravity that
allows for the patient to float supine without worry of safety. In fact, to turn over
while in the solution requires "major deliberate effort." Fewer than 5% of the
subjects tested leave before the session duration ends, which is usually around an
hour for flotation REST.

• For the first forty minutes it is reportedly possible to experience itching in various
parts of the body (a phenomenon also reported to be common during the early
stages of meditation). The last 20 minutes often end with a transition from beta or
alpha brainwaves to theta, which typically occur briefly before sleep and again at
waking. In a float tank, the theta state can last for several minutes without the
subject losing consciousness. Some use the extended theta state as a tool for
enhanced creativity and problem solving.  

• Spas sometimes provide commercial float tanks for use in relaxation. Flotation
therapy has been academically studied in the USA and in Sweden with published
results showing reduction of both pain and stress].  The relaxed state also involves
lowered blood pressure and maximal blood flow.
The five sensory deprivation techniques

• (a) wall-standing: forcing the detainees to remain for periods of some

hours in a stress position, described by those who underwent it as being
"spreadeagled against the wall, with their fingers put high above the head
against the wall, the legs spread apart and the feet back, causing them to
stand on their toes with the weight of the body mainly on the fingers";
• (b) hooding: putting a black or navy colored bag over the detainees' heads
and, at least initially, keeping it there all the time except during
interrogation;(
• c) subjection to noise: pending their interrogations, holding the detainees
in a room where there was a continuous loud and hissing noise;
• (d) deprivation of sleep: pending their interrogations, depriving the
detainees of sleep
• (e) deprivation of food and drink: subjecting the detainees to a reduced
diet during their stay at the center and pending interrogations.
 Social Support System and Family Chronic
Illness

• Positive social support (family or friends)

plays an important role in one’s ability to
make healthier choices. Social support
means being able to access people that a
person can rely upon if needed.
• The support of family and friends during a crisis
has long been seen to have a positive
emotional effect on people. However, this
support also has a physical benefit as well.
During stressful times, people tend to
experience higher blood pressure and heart
rates.  However, the presence of friends or
family members has been shown to reduce
these rates among people during difficult
periods.
• In terms of chronic disease, the support of
family or friends has been shown to lessen
the chance that one will become sick or die
from heart disease. Research conducted at
Brigham Young University and the
University of North Carolina showed that
people who did not have strong social
support were 50% more likely to die from
illness than those who had such support.
• Family and friends are also important for those who have
been diagnosed with chronic disease such as heart disease,
high blood pressure and diabetes.2  Having such support
systems is beneficial in helping patients follow a physician's
recommendations. Strong social support will help patients
adhere to their medical regimen by reminding them to: 
• Keep their medical appointments
• Monitor their blood sugar and blood pressure
• Take their medicines
• Get regular exercise
• Eat healthier foods 
• Finally, family and friends can also provide
practical support, such as rides to the doctor
or pharmacy, going to the supermarket, and
offering childcare during health care
visits. The encouragement of friends and co-
workers can motivate people who have been
ill to take steps to be more active and get
back to work more quickly than those who
do not have a strong support system.