lation of emotion (Fiscella et al., 1997; Levenson and Gottman, 1983; Levenson et al., 1994). The body’s homeostatic and allostatic regulatory systems connect emotional experience to the physiologic stress response (McEwen, 1998; Sapolsky et al., 1986), and the resulting changes in hormonal, immunologic, and neurochemical systems can influence the outcomes of chronic disease (Kiecolt-Glaser et al., 1997).

Family and Behavioral Risk Factors

Behavior also defines the influence of family relationships on chronic disease. Stable, secure, and mutual family relationships enhance consistent disease management behavior by permitting a sharing of the burdens associated with disease. Such relationships enhance joint “ownership” of disease, which often includes a partitioning of disease management responsibilities among the patients and others and reduces patients’ emotional and behavioral burdens. A family-focused approach is likely to maximize intervention effectiveness, whether or not family members other than the patient are directly involved. For example, at the simplest level, patient-focused interventions to alter diet might be only minimally effective if the patient’s spouse shops for food and prepares meals (Cousins et al., 1992).


Given the importance of family relationships, it is surprising that they have not been addressed more systematically and extensively in intervention research on the management of chronic disease. Table 5–1 indicates the relative amount of family-focused intervention research for several chronic diseases. Most family-based clinical-intervention research has concerned chronic diseases of childhood and adolescence (e.g., insulin-dependent diabetes, asthma). Family-focused intervention studies of dementia in the elderly (especially Alzheimer’s disease) are increasing, but relatively less attention has been directed to family-focused interventions for diseases of adulthood. For example, of the diseases with the highest cost to the United States health-care system—cardiovascular disease, chronic obstructive pulmonary disease, asthma, and non-insulin-dependent diabetes—the latter two have been the subject of very little family-focused intervention research (Campbell and Patterson, 1995).

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