April 27, 2020

By Amy Bucher, Ph.D.

I’m a psychologist who designs programs to help people cope with challenging health problems, and I rely on several techniques from behavioral health to do my job.
Many of the people who use the programs I design have a serious health condition that significantly impacts their day-to-day life. My interventions usually focus on physical health behaviors like eating and taking medication, but mental and emotional health are core components of overall well-being. So, we also consider how people cope emotionally with their physical illnesses. 

When I interview people with serious health conditions, there are some common moments when experiencing negative emotions is more likely:

● Receiving the diagnosis
● Having to significantly change a lifestyle factor, like giving up a favorite food or limiting exposure to    germs through isolation
● Experiencing uncomfortable or painful symptoms
● Feeling “different” or being embarrassed because of changes in functioning 
● Dealing with medical bills and the financial burdens of illness
​● Working hard at healthy behaviors, but seeing slow progress

The cumulative experiences of these moments can lead people to experience stress, anxiety, feelings of depression or grief, sometimes above clinical thresholds. According to one meta-analysis, people with type 2 diabetes are about twice as likely to experience clinical depression during their lifetimes than people without diabetes. Another study used historical rates of depression in people with type 2  diabetes to predict that by 2027, 33% of women with the condition and 18% of men will meet diagnostic criteria for depression.

The two behavioral health frameworks I use when creating program content for people’s mental health as they cope with chronic illness are the acceptance and commitment theory (ACT) and cognitive behavioral therapy (CBT). They can both help to reduce the distress associated with chronic illness. Each is suited to a different type of emotional challenge, so I typically use both depending on the situation. 

ACT: Learning to Accept Difficult Emotions 

The central idea in ACT is that people’s thoughts and feelings are affected by the events they experience, the people they meet and the environment they live in. For example, if a person is diagnosed with multiple sclerosis (MS), it might bring them complicated feelings that include both relief (at having an answer) and grief (at the symptoms to come). And for them to cope with these emotions, they must work towards accepting them. 
ACT also posits that people’s core values drive their behaviors. If someone deeply values creativity, their behavior will reflect that, and might look different than the behavior of someone who values stoicism or discipline. If someone dwells in the negative emotional space created by an uncontrollable context like an MS diagnosis, that likely doesn’t reflect their core values. 
Techniques from ACT could help someone get “unstuck” from those emotions so they can pursue more value-consistent actions. By accepting their emotions, someone practicing ACT acknowledges the negative emotions they’re experiencing but tries not to dwell on them. Coaching might include visualization exercises, such as imagining the negative feelings swelling over you like a wave and then receding back into the ocean, leaving you on the shore.

CBT: Challenging and Improving Thought Patterns 

CBT works on the premise that people’s thoughts influence their feelings and their behaviors. If their thought patterns are systematically biased, then questioning and changing them can help improve how people feel and help them behave in ways that better support their goals. An underlying idea in CBT is that the thoughts driving many depressive or anxious responses are not objectively true. Rather, they are particularly negative interpretations that a person can make more positive. 
There are a few common patterns present in the distressing thoughts accompanying depression and anxiety. They include:

● All or none thinking: anything less than perfection is failure.
● Personalization: decidng something negative is related to you—your actions, your decisions, your performance — even if it’s likely not related to you at all.
● Catastrophizing: predicting the worst possible outcomes even if evidence doesn’t support them.

CBT teaches people to recognize and challenge negative thinking patterns, and substitute more realistic alternatives. Chances are, they may repeatedly fall prey to the same type of cognitive pattern. That means they can learn specific tactics to talk back to those thoughts.

When to Choose ACT or CBT?

Typically, I draw techniques from both ACT and CBT as they have complementary roles to play in people’s ability to cope. I start by asking whether a person’s negative feelings are reasonable reactions  or the result of an overly negative interpretation of events. For someone with MS, it might look like this:

● Reasonable reaction: “I’m grieving that my symptoms make it hard for me to play soccer.”
​● Negative interpretation: “I’m a worthless person now that I can’t play soccer anymore.” 

For someone experiencing the first reaction, I try to offer techniques to cope with, and ultimately accept, their feelings. I might recommend an ACT-based exercise such as imagining negative feelings as a bully pulling a rope in tug-of-war. What if you drop the rope? The focus isn’t on changing the emotions, but rather learning to withstand them and make positive choices despite them.
For people experiencing the second situation, I ask people to pinpoint upsetting thoughts, write them down and identify which type of cognitive pattern they represent. As people get better at recognizing the thoughts, they can practice “talking back” with more realistic interpretations. With repetition, these CBT-based techniques can become almost automatic.
With both ACT and CBT, it’s important to set expectations that reducing distress takes time and effort. The first attempts are likely to be difficult and may feel unnatural. But it’s worth it because health means body and mind.         

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