Control Trumps Fear When it Comes to Adherence to Exercise in Cystic Fibrosis

I’m getting a lot of ideas for posts as I prepare for this talk in a couple of weeks at the NACFC in Minneapolis.  I am speaking about motivation and exercise, one of my favorite subjects, and am quite happy to be doing it.

Today I reviewed an article published in Thorax 2004; 59: 1074-80, by Moorcraft et al, entitled Individualized Unsupervised Exercise Training in Adults with Cystic Fibrosis: a 1 year randomized controlled trial. Here are a few reasons why this is a well designed study and one to believe:  1) it is (in CF terms) a pretty long term study.  Most others are only weeks to a few months in duration. 2) It was randomized, a short-fall of many other exercise in CF studies. 3) After an initial training session, it was unsupervised and the exercises (though structured by a trainer) were done at home–so the positive results are  good news about adherence and sustainability of a program.  The patients were, however, given frequent contact by phone and/or clinic and were actively encouraged and motivated to continue.

The results were indeed positive.  After a year, a significant training effect was shown in the training group and there was a lesser decline in lung function in those trained when compared to controls. But, as important as that is, that is not why I am writing this.  The most important point of the article to me was in the summary, where the authors state:

“Every effort must be made to adapt the exercise to fulfill the wishes of the patients and integrate it with their lifestyle.  This study shows that benefit can be obtained with an individualized home-based programme.  In the long term, motivation must be sustained by the individual and the clinician must strive to engender an exercise habit.  A flexible approach to encouraging exercise and an enthusiastic approach from the staff should not be underestimated.  A feature that favours exercise adherence in CF is that the patients perceive it as an area over which they have control and that, unlike other treatments, fear of their disease does not drive adherence to exercise (my emphasis).  Instead, they have a positive outlook on exercise regarding it as a normal activity which they can enjoy.”

I don’t know about you, but I think that fear sucks.  It doesn’t feel good.  It incapacitates me when it comes to rational thinking, and over the long haul, it frankly shrinks my brain.  It is true that sometimes fear works to motivate.  If that weren’t true, I probably wouldn’t have made that phone call to my doctor when I coughed up blood.  I feared for my life, and a phone call was made.  Fear works in acute situations.  It is the flight aspect in the fight or flight response to the mountain lion on the bike path.  Ok, bad analogy.

The point is that as a long term motivator, fear is a BAD choice.  Chronic fear leads to increased stress hormones which lead to depression and brain shrinkage.  Neither helps with adherence to any kind of program, let alone one where you must insert significant energy, as in an exercise habit.

Control, however…now THAT is powerful.  To me, seeing and feeling my body respond to exercise over the long haul is not so much about control as it is empowerment.  I feel actual empowerment over at least part of my body…and this is not a common feeling for one living with a disease such as cystic fibrosis.  This empowerment leads to confidence in other areas as well, and makes one think twice about negating the effects of all that work by, for instance, missing treatments.

Thinking about going to the gym or going out for a run just like any other “normal” person makes me feel more “normal.”

Now think about a kid…an adolescent with body image issues and control issues who is angry and in denial about living with CF.  How helpful do you think a little dose of empowerment and normalcy might be?  Trying to instill a little fear into him or her would lead one direction…the one you don’t want to go.  Helping them to feel good about how well they respond to an exercise program and encouraging them to exercise because it is what we ALL should do…that works!

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T: Taking Contol of and Responsibility for Your Health

Is it Take or Bring?

I never know.  But for purposes of my acronym, it has to be Take.

T is for:  Take complete control of what you can, and take complete responsibility for each of your actions.  In a word, be accountable to yourself, because if not you, then who?

When it comes to living with ongoing health challenges, it is very easy to surrender control––to doctors, to “experts,” to nurses, to your spouse, to family members who “know what is best for you,” to your horoscope, etc.  The problem with this is that it leads to a “crisis in confidence,” as Margaret Moore et al discuss in their white paper entitled, The obesity epidemic: a confidence crisis calling for professional coaches (  A true crisis occurs when we let others control what happens to us.  When we consistently let others decide for us, we gradually lose the belief that we have our own answers.  Then we are in trouble.

Marty Seligman, the “father” of positive psychology, demonstrated the severity of what happens when control is not an option on some very unlucky dogs back in the late 1960’s.  These poor creatures were first “taught” to become helpless (an unforeseen outcome of the experiment) as they were harnessed to another dog while receiving random, painful electrical shocks given simultaneously to both dogs.  One dog in the pair had a lever it could press to end the shock.  The dog without the lever would also receive the benefit of the shock ending, but this seemed as random as the shocks.   To the second dog, pain was random and inescapable.

Subsequently, both dogs were placed in a box with a shallow board dividing it into two sides.  When a shock was applied on one side of the box, the dog simply needed to hop over the divider to escape the pain.  The dogs from the previous experiment that had been taught to press a lever to stop the pain found this option immediately. What do you think the dogs that had “learned” that pain was inescapable did?  They simply lay down and accepted the pain.  They didn’t even look for an escape!  They had learned helplessness.

What do these poor dogs teach us?

We need to find where we do have control, any control, and cease it!  You may not have control over your cancer returning after a remission; but if it does, you have control over how and if you want it treated.  You have no control over how long you have to wait for an organ transplant, but you have complete control of what you will do while you wait.  You may not have control over how bad your next flare of MS will be, but you do have control over how much rest you get as you wait for your health to stabilize.

What you take charge of can be small.  It can be as simple as determining the time you will go to sleep.  But it needs to be your sole responsibility.  And you get to reap both the benefits AND the costs of whatever it is…

That brings me (or takes me…I don’t know) to responsibility, the other half of the “Take” strategy.

Taking responsibility for everything you do is really a corollary of “Take control of what you can” because if you take control, then by definition, you are responsible.  Conversely, when you let someone else decide, you have no responsibility for the outcome.  Good or bad, someone else made it happen.  The good news is…it’s not “your fault” when something goes wrong.  You get to blame someone else.  The bad news is that when something goes well…how can you claim any credit?  When your successes are not perceived as being brought upon by YOU, you don’t get to develop self-efficacy.

Self-efficacy is simply a person’s belief that they are capable of reaching a goal or achieving a certain level of performance. . Self-efficacy is huge in importance when it comes to happiness…so important that it will get its very own post someday soon.  Guess what is the opposite of self-efficacy?  Helplessness.

I read somewhere that E+R=O or, Event + Response= Outcome.  I would give credit to whomever came up with it, if I could remember, but such is the state of my hippocampus.  Anyway, I like it.  It’s very clear, and obviously true.  If we think of our illness as the Event, and our overall Wellbeing and Happiness as the Outcome, then R (response) is clearly quite important, right?  R is about taking control, and taking responsibility.

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