Essentials of Complementary and Alternative Medicine (June 1999)

B
EHAVIORAL
 R
ESPONSES
: T
YPES OF
 C
OPING
Behavior is the observable response of an individual to life events, and it may be generally classified as adaptive (restoration of homeostasis, or movement toward 
growth) or maladaptive (perpetuation of sickness). As discussed in the preceding sections, behavior is largely determined by the individual's appraisal of the situation 
and level of emotional/physiological arousal. However, there are other  environmental contingencies that are critical in determining an individual's health or 
illness-related behavioral responses.
There is general consensus that certain behaviors are associated with health and well-being, such as eating a healthy diet; regular exercise; moderation in alcohol 
use; abstinence from hard drugs and unsafe sex; participation and meaningful involvement with family, friends, and community rituals; or the practice of meditation or 
prayer. Moreover, when an individual is ill, other behaviors may be required, such as regularly taking medication, self-monitoring practices, physical therapy or other 
rehabilitation programs, and keeping appointments with health care providers. Each of these behaviors appears to be relatively straightforward, and yet many, if not 
most, people do not adhere to these recommendations.
It is common for some individuals to simply lack the skills or experience needed to perform the expected behavior. When they then attempt the behavior, they 
experience frustration rather than success. This lack of positive reinforcement decreases the likelihood of trying again. In some cases, the critical factor in failure to 
change behavior is an external barrier, such as prohibitive cost or lack of transportation. At times, an individual may be cognitively/affectively inclined to perform a 
behavior, but family, friends, and others strongly oppose it. This may be related to the fact that the behavior is incompatible with sociocultural standards (e.g., 
participation in an alternative therapy approach such as meditation or biofeedback) or that other barriers exist (e.g., lack of insurance coverage).
In certain situations, family and friends may inadvertently enable the continuation of a behavior, such as alcoholism or overeating, by failing to address the problem or 
by making excuses for the individual. With chronic illness, some individuals may unconsciously adopt the  sick role. Typically, when someone behaves in a way that 
identifies them as sick, they are (temporarily) allowed certain privileges, such as the right to seek care and support from health care providers and family, and are 
relieved of certain responsibilities. In chronic illness, however, the sick role may be maladaptive in that it provides a disincentive for recovery. The medico-legal 
designation of impairment and compensation for disability may actually create a reward for illness behavior.
When an individual is anxious and distressed, instinctive behavioral responses may be activated, including inhibition (e.g., avoidance, phobias); compulsive behavior 
(e.g., addictions, binging and purging [in bulimia], compulsive handwashing); or search for safety (e.g., agoraphobia, repeated requests or demands for diagnostic 
tests, clinging dependency on others). In many cases, the anxious patient's decision-making may be inflexible and repetitive, and the behavioral repertoire is limited 
and poorly adaptive.
PROVIDER-PATIENT INTERACTION
Doctor-patient interactions in behavioral medicine are guided by certain fundamental tenets of the therapeutic relationship. The interaction is characterized by 
collaboration and shared responsibilities. The doctor's role includes:
1. Providing an expert knowledge base and clinical practice of medical and behavioral sciences, including taking a careful clinical history and ordering appropriate 
tests (e.g., physical examination, psychometric testing, laboratory studies).
2. Guiding the diagnostic and treatment process toward the identification of specific problems, goals, and therapeutic options.

3. Serving as a teacher (providing didactic instruction or assigning reading or other self-help homework) and coach (providing encouragement and suggestions) for 
the patient.
The patient is encouraged to:
1. Actively participate in the healing process.
2. Begin an educational process and exploration of both the disease and the sickness.
3. Engage in self-help activities to modify dysfunctional attitudes and behaviors.
4. Assume responsibility as captain of the health care team.
Nonspecific therapist characteristics of warmth, respect, and equanimity under pressure appear to influence therapy outcomes (
52
). The effective behavioral medicine 
therapist is both pragmatic and flexible and takes an active role in structuring the therapy agenda (
25
, 
26
 and 
27
). The treatment plan is problem-oriented and has 
specific, measurable short- and long-term goals and objectives. In general, the focus of behavioral medicine is on current problems in functioning. However, there are 
circumstances in which exploration of past events, such as traumatic experiences, is indicated, particularly in the latter stages of treatment after acute symptom relief 
has been achieved. Throughout therapy, the therapist gives and elicits feedback about improvement, strategies, and reactions to the treatment.
Although behavioral medicine is frequently practiced in a traditional one-to-one doctor-patient format, treatment may involve a  multidisciplinary team of different 
specialists who have distinct skills. The involvement of family and significant others is recognized as critical to the healing process. The concept of  healing community 
is perhaps best illustrated by the frequent use of group therapies in behavioral medicine.
THERAPY AND OUTCOMES
Treatment Options
P
SYCHOTHERAPEUTIC
 S
TRATEGIES
Effective cognitive-behavioral therapy (CBT) is based on a clear formulation of each individual case, and a comprehensive treatment plan that focuses on the patient's 
specific problems and goals. However, therapy is also guided by certain generic objectives:
1. Establish a collaborative partnership with the patient.
2. Assist in development of enhanced self-awareness and self-monitoring.
3. Teach the patient methods of relaxation to decrease physiological arousal.
4. Help the patient identify the relationship between events; automatic thoughts; and affective, physiological, and behavioral responses.
5. Promote the patient's ability to  respond rather than react to stressful situations.
6. Guide the patient in cultivating a more integrative, realistic, and adaptive set of attitudes.
7. Encourage the development of effective problem-solving strategies and other behavioral skills that enhance the patient's sense of mastery and self-efficacy.
8. Support the practice of health enhancement and relapse prevention strategies.
Cognitive Techniques
A variety of techniques can be used to guide the patient in the identification and modification of automatic thoughts that influence health behaviors and coping with 
chronic disease (
Table 26.1
). Self-monitoring exercises, such as keeping a journal and thought recording, can enhance awareness of negative, distorted thoughts and 
maladaptive self-talk. Imagery, visualization techniques, and role playing may be helpful for patients who have difficulty identifying automatic thoughts, and these 
techniques can provide an opportunity to consider different strategies for thinking through a difficult situation.
Table 26.1. Cognitive Techniques
With an enhanced ability to monitor thought processes, the patient can work on developing rational alternatives based on a realistic assessment of problems and 
options. Patients are encouraged to consider their automatic thoughts as  hypotheses that can be tested and modified as they acquire more accurate information, 
learn new skills, and refine coping strategies. A cognitively-oriented health care professional can also encourage an alternative, more flexible set of attitudes about 
dealing with stressful situations (e.g., patience, self-control,  letting go). Peer-group therapy with others who are dealing with similar issues (e.g., chronic pain, cancer, 
addictions) provides an excellent opportunity to compare personal experiences, attitudes, and belief systems. Many individuals are more willing to acknowledge and 
adopt the attitudes and behaviors of a peer who is successfully coping with a similar problem than to accept the advice of a health care professional. Although 
cognitive techniques are often very effective in modifying schemas, sustained change is greatly facilitated by a concurrent change in habitual behavior patterns that 
reinforce those attitudes and beliefs.
Behavioral Techniques
Most patients can identify maladaptive behaviors that interfere with their activities of daily living or medical treatment. Limitations or complete avoidance of certain 
activities; excessive behavior (e.g., taking too much pain medication, overeating); or interference with normal interpersonal interactions are commonly observed in 
clinical settings. 
Table 26.2
 lists a variety of behavioral techniques that can be employed to facilitate adaptive coping and lifestyle modification. A  behavioral analysis 
is usually done early in the course of treatment to establish a baseline frequency of behaviors that are targeted for change. For example, a patient who has an eating 
disorder may be instructed to keep a food diary (a record of the time of, location of, and amount eaten at meals; degree of hunger; and associated environmental 
triggers such as stress), whereas a patient in cardiac rehabilitation may be instructed to record the number of miles walked each day. Patients frequently observe that 
carefully tracking and recording information about their behavior result in greater depth of awareness and understanding, and can lead to a significant decrease in 
maladaptive behavior. Not only are the data collected useful in the development of practice exercises, but they can also help with identifying distorted cognitions as 
well as be used to monitor progress in treatment.

Table 26.2. Behavioral Techniques
Many patients find that having a  written list of coping strategies enhances their ability to deal with pain, anxiety, or other severe symptoms. Patients usually report that 
it is difficult to concentrate, remember, and make decisions when they are in severe distress. Likewise, it is hard to develop creative solutions to problems or consider 
alternatives in this state. The therapist can assist the patient in the development of a specific protocol of coping behaviors for different situations. With repeated 
practice and refinement, patients learn to modulate their thoughts, feelings, and behavioral responses in actual situations.
It is not uncommon to find that patients struggling with chronic illness have certain basic deficits in assertiveness, effective communication, time management, and 
problem-solving skills. For example, many patients are frustrated after an appointment with their doctor because “he didn't spend much time with me,” or “I left with 
unanswered questions.” Skills training usually involves both didactic instruction and homework practice. For instance, the therapist may suggest that the patient 
observe the behavior of another group member, read material on the topic of assertiveness, write down a list of concerns and questions to ask the doctor, rehearse 
what he or she intends to ask with a friend, and practice this new behavior in an actual situation (e.g., at the next appointment with the doctor).
One of the most useful skills that a patient can learn is the development of an  action plan. Many patients are aware that they should modify their behavior, and they 
may even initiate efforts to change, only to find that it is more difficult than they imagined. An action plan is a detailed analysis of specific goals (e.g., “I plan to learn 
yoga and practice it three times a week”); supports (e.g., “I will sign up for the class with my sister”); resources/barriers (e.g., child care, cost of class, transportation); 
and specific actions to be taken (e.g., “I will call tomorrow about when the next class starts”).
Relaxation Techniques
Behavioral medicine programs generally provide instruction in one or more methods of relaxation training, such as progressive muscle relaxation (
53
), diaphragmatic 
breathing, autogenic training (
54
), or biofeedback (
55
). The mastery of one or more of these techniques provides the individual with a readily available tool to use in 
situations when autonomic nervous system arousal makes coping difficult. In addition to eliciting the physiological benefits of the relaxation response, advanced 
relaxation techniques, such as self-hypnosis, guided imagery, and meditation, can be used to augment the effectiveness of traditional cognitive-behavioral 
approaches, such as imagery, desensitization, cognitive restructuring, and adaptive self-statements (
41
, 
56
, 
57
 and 
58
). A more detailed description of the use of 
relaxation techniques in behavioral medicine can be found in the references and in other chapters in this volume. However, the following cases illustrate how 
behavioral techniques can help the patient cope with stressful life events.
C
ASE
 E
XAMPLES
CASE 1
When he was initially seen, Mr. M was a 50-year-old married white man who was referred to the psychiatry and behavioral medicine service by his neurosurgeon. 
The referral and subsequent hospitalization was precipitated by an emergency call from Mr. M's wife after he made statements to her threatening suicide and voicing 
homicidal thoughts toward individuals at the workmen's compensation insurance company with whom he had been dealing over approximately the past 10 months 
since he injured his back at work. Frustrated by continued delays and paperwork, and developing a growing sense of paranoia about “being messed with,” he had 
threatened over the telephone to “come down there and blow someone's head off so you'll listen to me and get me some help.”
Mr. M had worked for 25 years at his company, and he was noted to be a diligent, highly regarded employee by his employers. Approximately 10 months before his 
psychiatric hospitalization he had injured his back lifting a box at work. Subsequent work-up revealed herniations of three lumbar discs, and he underwent L2–L5 
fusion without complications. However, despite the surgery, narcotic analgesic medication, and regular physical therapy, Mr. M continued to experience severe back 
pain that radiated down both legs.
The first several days of hospitalization focused on the completion of a comprehensive biopsychosocial evaluation, including reevaluation by his neurosurgeon and 
a consultation with an anesthesiologist specialist in pain management. Psychological testing revealed severe depression (Beck Depression Inventory score of 44 of 
a highest possible score of 63) (
59
), but no evidence of psychosis or significant personality disorder. Mr. M also demonstrated extreme hopelessness (Hopelessness 
Scale score of 15 of a highest possible score of 20) (
60
), which is considered to be a significant risk factor for suicide. On the Survey of Pain Attitudes (SOPA) (
61
), 
the patient exhibited a profound sense of loss of control over his pain, a belief that only surgery or medication could provide relief, and a pervasive belief that his 
pain was unfair and that his family and health care providers did not understand either the extent of his pain or the degree of his disability.
In individual psychotherapy sessions, Mr. M's history and basic schemas began to emerge. His father died when Mr. M was 12 years old, and as the oldest child he 
needed to start working to help support his family. Years later, one brother died in an alcohol-related car accident, and another brother committed suicide after years 
of dealing with drug abuse that he developed while in combat in Vietnam. Mr. M acknowledged a sense of guilt that he “could have done something” to have 
prevented their deaths. He attributed his depression to the injury, and also believed that the injury caused his inability to now be a “good provider” for his family.
The early phases of treatment included collaboration between Mr. M and the treatment team in the development of a detailed problem list and treatment plan. Drug 
therapy was begun with an antidepressant (sertraline [Zoloft]) and a nonsteroidal anti-inflammatory agent (nabumetone [Relafen]), and Mr. M also began a series of 
epidural blocks performed by the anesthesiologist.
Mr. M was seen in individual and marital cognitive-behavioral psychotherapy and began attending a chronic pain management group that met twice a week. Initially, 
the focus of therapy centered on his hopelessness, agitation, anxiety, and suicidal and homicidal thoughts. For several days, Mr. M was encouraged to keep a pain 
log, which is an hourly record of pain intensity as well as associated thoughts, feelings, activities, and the effects of pain relief interventions. In both individual and 
group sessions, Mr. M learned of the basic mechanisms and pathophysiology of chronic pain, and through the various self-monitoring assignments he began to 
identify factors (thoughts, emotions, social situations) that either intensified or relieved his pain. The therapy sessions were augmented with homework assignments 
that included readings and worksheets from the book Managing Pain Before It Manages You (
62
). His wife was actively involved in the educational and treatment 
process, and she provided feedback regarding his behavior at home and suggestions regarding his unrealistic expectations of both himself and others. Gradually, 
Mr. M's insomnia, nightmares, and mood improved, and he was discharged to the partial hospitalization program after 10 days.
For the next six months, Mr. M attended a weekly chronic pain management group, augmented by several marital sessions with his wife. In group therapy, he 
learned techniques of relaxation, including diaphragmatic breathing, meditation, and visualization. He further developed and refined his pain control  toolbox, 
including a self-directed exercise program of water walking at a nearby heated pool, as well as communication and assertiveness skills that he was able to use when 
dealing with his physicians, attorneys, and workmen's compensation company representatives.
The therapy group provided support and an opportunity to rehearse skills in dealing with his ongoing disability hearings, and provided feedback and challenge to his 
negative and helpless attitudes. For example, soon after joining the group, Mr. M came in very depressed about the upcoming Thanksgiving holiday. With support 
from the group, he was able to identify his distress at not being “a good grandfather” because he would not be able to throw the football with his grandsons. 
Furthermore, he expected that he would be “a burden” to the entire family because of his pain, intolerance of “all the noise,” and his inability to participate in all the 

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The therapy group provided support and an opportunity to rehearse skills in dealing with his ongoing disability hearings, and provided feedback and challenge to his 
negative and helpless attitudes. For example, soon after joining the group, Mr. M came in very depressed about the upcoming Thanksgiving holiday. With support 
from the group, he was able to identify his distress at not being “a good grandfather” because he would not be able to throw the football with his grandsons. 
Furthermore, he expected that he would be “a burden” to the entire family because of his pain, intolerance of “all the noise,” and his inability to participate in all the 
preparations and activities. Other group members shared their similar thoughts and feelings, but challenged his assumptions and rigid beliefs about what others 
would think or feel. They suggested that he could go out in the yard with his grandsons even if he couldn't join the game, and that later he could play a board game 
with them. If he should experience an exacerbation of pain or become fatigued, he could go and rest briefly. Mr. M came to the next group meeting in an excellent 
mood and with an overall diminished pain level, and he reported his great sense of accomplishment in dealing with the holiday.
Over the next months he continued to develop a more flexible and realistic attitude regarding his abilities and limitations, and showed greater creativity in solving 
problems as they arose. He also returned to his church and began volunteer work visiting members who were homebound due to illness, an activity he found 
exceptionally rewarding. A year after his initial hospitalization, he still attends group therapy approximately once a month, and he is doing well. As he is apt to tell 
new members, “I still hurt, but I don't suffer anymore.”
CASE 2
Ms. C is a 47-year-old married white woman who had previously had a baseline mammogram at age 40 on the recommendation of her gynecologist, but had not had 
a follow-up and had only irregularly done breast self-examinations (an example of only partially effective public education efforts). After watching a TV show on 
breast cancer, Ms. C again scheduled a mammogram, and she was subsequently referred to a general surgeon after a suspicious 1.5-cm mass was identified. The 
surgeon performed a biopsy the next day that revealed infiltrating ductal carcinoma. When the surgeon called Ms. C to discuss the biopsy results, he referred her to 
the hospital's cancer resource center, and she was contacted that day by a trained volunteer who was a breast cancer survivor herself. Ms. C and her husband were 
invited to come to the center and view a computer-assisted multimedia program on the surgical, medical, reconstructive, and psychosocial options available for the 
treatment of breast cancer before her appointment the next day with her surgeon. The cancer center volunteer offered to serve as a navigator, or guide, through the 
maze of the health care system and to coordinate the various services that Ms. C and her family might find useful.
Ms. C and her husband met with the surgeon to discuss treatment alternatives. Together, they agreed on lumpectomy with axillary node dissection, which is a 
breast-conserving surgery that is equally effective compared with total mastectomy for early stage cancer, but is associated with better postoperative body image 
and sexual functioning (
31
, 
46
). After meeting with the surgeon, Ms. C consulted with a nurse clinician to discuss the details of the upcoming surgical procedure and 
postoperative care (see reference 
40
 for further discussion of the benefits of presurgical psychological preparation).
Two days later, Ms. C arrived at the hospital early in the morning and successfully underwent surgical resection of the tumor. Ms. C's state legislature had previously 
passed a law requiring insurance carriers to provide coverage for 48-hour postoperative hospital care in uncomplicated breast cancer surgery. This allowed Ms. C 
and her family to meet again with the nurse clinician regarding wound care and home instructions. It also provided an opportunity for the volunteer navigator to 
accompany Ms. C to one of several breast cancer support groups held weekly at the hospital. Although initially somewhat reluctant to attend a group dealing with 
such a personal matter, Ms. C was favorably influenced by information on the group provided by a video she watched in her hospital room, a pamphlet provided by 
the volunteer, and the strong recommendation of her doctor.
Following surgery, a course of radiotherapy (5 days per week for 5 weeks), followed by chemotherapy (doxorubicin [Adriamycin] and cyclophosphamide [Cytoxan]) 
for the next several months were prescribed. The cancer support group focused on case management, referral for consultation when indicated, patient education, 
emotional support, and the development of coping skills (
9
, 
10
, 
31
, 
46
). For example, Ms. C consulted a hypnotherapist before beginning chemotherapy and was 
thus able to manage the nausea and vomiting with the techniques she learned (
63
). Later, she and her husband met with a marital therapist to discuss Mr. C's 
anxiety about sexual activity and irrational fear that he could cause a recurrence of cancer by touching her breasts.