CBT in Patients With Chronic Illness

Psychiatrists are increasingly responsible for the care of individuals who have comorbid psychiatric and medical illnesses. Many medical illnesses, for example coronary artery disease, diabetes mellitus, and malignancies, are associated with both subclinical and full-blown anxiety and mood disorders.

Practitioners who employ a formulation-driven “toolbox” of interventions to facilitate patients’ adaptation to medical illness will improve their quality of life and adherence to treatment. Numerous meta-analyses and systematic reviews show cognitive- behavioral therapy (CBT) to be quite useful to these patients. The principles employed in CBT treatment protocols for medical disorders have been shown to help practitioners help patients cope more effectively.

A starting point to understand the CBT approach is to consider how people effectively manage adverse events. When encountering adversity, there is generally a variety of cognitive and emotional responses. Coping requires strategies in place to effectively manage emotions until they eventually become attenuated. Cognitively, people are “wired” to make sense of adversity; effective coping occurs when such explanations are not damaging (for example “this illness is my fault”). The presence of adaptive coping skills that can be deployed in emergencies increases good outcomes. Finally, developing a sense of a meaningful and positive future even in the presence of adversity is necessary for good adjustment. In conceptualizing the interventions needed, it is necessary to understand the patient’s mental model of the illness and its prognosis, as well as to obtain a history of how the patient has previously managed adversity. This assessment determines skills deficits (that is, an inability to decrease arousal), and sets targets for cognitive restructuring.

One critical skill to develop is to help a patient be a good consumer of health care. The complexity of medical decision making, the shift of treatments from inpatient to outpatient settings, the frustration of delayed appointments and test results: these are but a few examples of how navigating treatment can be burdensome, particularly when anxiety, grief, and physical pain are present. Education about the condition is vital and must be tailored to the needs of the patient. Such information may need to be repeated several times because of disturbances of concentration and memory associated with high stress, or co-occurring mood and anxiety disorders. The Internet as an educational tool is a double-edged sword, and clinicians should help patients access reliable websites.

Specific targets for treatment with CBT techniques include managing arousal with breathing training, progressive muscle relaxation, activity scheduling to help the patient take control of his or her time, and helping patients manage grief. Cognitive restructuring may be employed in situations where patients’ thoughts and behaviors in response to the illness are interfering with a good quality of life. For example, patients may withdraw from valued pursuits in response to the illness because of faulty assumptions (for example, “I won’t enjoy myself like before”). Cognitive restructuring may establish more functional and accurate ways to evaluate prospective situations and help patients be more fully engaged.

Adherence enhancement, another helpful strategy developed with CBT principles, significantly impacts illness management. It focuses attention on developing a collaborative therapeutic alliance that allows the patient to honestly discuss any problems adhering to treatment. The therapist then determines if such problems are practical (for example, financial, inadequate education) or psychological (for example, inadequate motivation, overwhelming stress, inaccurate beliefs, family beliefs) and then focuses on these problems with strategies that are tailored to increase the likelihood of adherence.

Psychiatrists may positively impact health and well-being by using these interventions in their patients with chronic health conditions. ■