Review Article Behavioral Medicine Methods in Treatment of Somatic Conditions

Abstract

Background:
The aim of this article is to present a short review of noninvasive, nonpharmacological treatment methods used in somatic illnesses that fall under the umbrella of approach called behavioral medicine.

Methods:
The narrative review method was applied in the study. Science paper databases, including PubMed, had been used to retrieve papers on therapeutic methods used in clinical setting that meet the broad criteria of behavioral medicine definition as stated in the Charter of International Behavioral Medicine Society.

Results:
Main groups of methods, disorders in which they are being employed and their effectiveness, have been identified.

Conclusions:
Behavioral medicine is grouping treatment methods and interventions that hold large potential for clinical setting. Two groups of methods can be distinguished by the scrutiny and level of evidence gathered in their effectiveness assessment; for biofeedback, guided imagery, and hypnosis techniques, comprehensive evidence reports in the framework of U.S. Evidence Synthesis Program exist. Meditation techniques, disclosure therapies, and relaxation methods are less well assessed. Broader employment of behavioral medicine therapies in clinical setting is possible after addressing two major problems in the field, which are deficiencies in quality evidence of effectiveness for many of the methods and their insufficiencies in underlying therapeutic mechanism knowledge.

Full text

Review Article
Behavioral Medicine Methods in Treatment of Somatic Conditions
Joanna Białkowska ,
1
Jakub Juranek ,
2
and Joanna Wojtkiewicz
3
1
Department of Psychology, Sociology of Health and Public Health. School of Public Health, Collegium Medicum, University of
Warmia and Mazury, Clinical University Hospital in Olsztyn, 10-900 Olsztyn, Poland
2
Institute of Psychology, Polish Academy of Sciences, Jaracza 1, 00-378 Warsaw, Poland
3
Department of Pathophysiology, School of Medicine, Collegium Medicum, University of Warmia and Mazury,
10-900 Olsztyn, Poland
Correspondence should be addressed to Joanna Wojtkiewicz; joanna.wojtkiewicz@uwm.edu.pl
Received 12 May 2020; Revised 30 August 2020; Accepted 27 October 2020; Published 3 November 2020
Academic Editor: Diane Ruge
Copyright © 2020 Joanna Białkowska et al. This is an open access article distributed under the Creative Commons Attribution
License, which permits unrestricted use, distribution, and reproduction in any medium, provided the original work is
properly cited.
Background. The aim of this article is to present a short review of noninvasive, nonpharmacological treatment methods used in
somatic illnesses that fall under the umbrella of approach called behavioral medicine. Methods. The narrative review method
was applied in the study. Science paper databases, including PubMed, had been used to retrieve papers on therapeutic methods
used in clinical setting that meet the broad criteria of behavioral medicine definition as stated in the Charter of International
Behavioral Medicine Society Results. Main groups of methods, disorders in which they are being employed and their
effectiveness, have been identified. Conclusions. Behavioral medicine is grouping treatment methods and interventions that hold
large potential for clinical setting. Two groups of methods can be distinguished by the scrutiny and level of evidence gathered in
their effectiveness assessment; for biofeedback, guided imagery, and hypnosis techniques, comprehensive evidence reports in the
framework of U.S. Evidence Synthesis Program exist. Meditation techniques, disclosure therapies, and relaxation methods are
less well assessed. Broader employment of behavioral medicine therapies in clinical setting is possible after addressing two major
problems in the field, which are deficiencies in quality evidence of effectiveness for many of the methods and their
insufficiencies in underlying therapeutic mechanism knowledge.
1. Introduction
Since before the emergence of modern medicine, it has been
observed that behavior and states of mind have relation with
health and illness. This important understanding, broadly
present in ideas of ancient thinkers like Aristotle, Galen,
and Islamic Golden Age Persian physicians like Abu Zayd
Al-Balkhi and `Ali b. al-`Abbas al-Majusi (latinized: Haly
Abbas), had been somewhat subsided over time with the
successful raise of mechanistic paradigm in medicine that
followed works of academics such as William Harvey and
his explanation of heart functioning as a pump or Rene
Descartes notion of mind and body as utterly separate
“machineries”[1, 2]. As late as the first half of 20
th
century,
the reemergence of awareness that crucial links exist between
behavior, mental processes, and body functioning was
witnessed. With rise of behaviorism and works of figures
such as Ivan Pavlov, previously undescribed connections,
like between central nervous and digestive system, mediated
by conditioning, became exposed. Accumulation of such
knowledge leads to eventual advent of psychosomatic med-
icine [3] and later distinct from its forebearer—behavioral
medicine [4, 5].
Behavioral medicine is interdisciplinary field, integrating
and using psychosocial, behavioral, and biomedical knowl-
edge relevant to health and illness, in an effort to understand
fundamental biobehavioral mechanisms of well-being and
serve the needs of clinical diagnosis, intervention, disease
prevention, and health promotion [6–8]. It incorporates con-
ceptual meanings of the term “behavioral”on four distinctive
levels, as elucidated by Weiss and Schwartz [5, 9]. At the pri-
mary level, “behavioral”means relation with concepts and
techniques derived from behavioral therapy, as the behav-
ioral medicine field was first inspired by advances in operant
Hindawi
BioMed Research International
Volume 2020, Article ID 5076516, 12 pages
https://doi.org/10.1155/2020/5076516

conditioning and the emergence of biofeedback theory. The
second level pertains broader health relevant concepts and
techniques, which are subsets of wider, more general psycho-
logical knowledge, like ideas originating from positive psy-
chology and findings coming from affiliated discipline of
health psychology. The third level is “behavior”conceptual-
ized also in wider context of social sciences like sociology or
anthropology, enabling appreciation of variables like social
support or spirituality in context of health. The fourth level
translates “behavioral”as functional, meaning interest in
common, high-level principles that apply to the functioning
of different systems at various levels of reality, keeping an
open door for potentially usable and significant wisdom
coming from far related, or unrelated, fields, spanning from
physics to ecology.
The interests and interdisciplinary character of behav-
ioral medicine is responsible for its strong interrelation with
other health oriented disciplines and subdisciplines that have
rooting in psychology, namely, psychoneuroimmunology
[10], psychoendocrinology [11], psychooncology [12], and
the broadest, earlier mentioned, psychology of health [13].
A common trait of all these health-related fields is emphasis
on holistic bio-psycho-social (or—as extended by recent
propositions—bio-psycho-socio-cultural [13]) approach to
health [14].
Due to its interdisciplinary aspect, the essence of combin-
ing knowledge from broad spectrum of areas with the aim to
facilitate synergy, blending skills and ideas, behavioral medi-
cine has proved to be currently, and ventures to be in the
future, a fertile ground for deriving useful and innovative
strategies for the prevention, diagnosis, and treatment of a
wide range of health problems. Much potential is being rec-
ognized in this field in terms of new treatments and improv-
ing cost-effectiveness of health care systems [15].
Realization of behavioral medicine potential depends on
proper research and availability of information regarding
existing solutions in that framework. The aim of this paper
is to review contemporarily applied and researched interven-
tions used in the treatment of somatic conditions, falling into
the domain of behavioral medicine by its definition.
Although formal birth of this discipline had taken place just
in the year 1977 (with the founding Yale Conference on
Behavioral Medicine [16]), treatments included in this review
often have longer history. The inclusion criterion in this
paper was given treatment matching the scope of behavioral
medicine definition, as outlined in the Charter of Interna-
tional Behavioral Medicine Society [7], and not its history
or theoretical origin.
2. Review of Therapeutic Method Groups
Interventions falling into behavioral medicine category are
primarily nonpharmacological techniques, originating from
the appreciation of the interrelations between the body and
mind. Many of them are based on the employment of princi-
ples of learning (conditioning), or recognition of the impor-
tance stress (of various origins) has on organism (including
its significant impact on functioning of the immune system).
Treatment approaches include a group of biofeedback
methods, relaxation techniques (also biofeedback supported
relaxation), disclosure interventions, hypnosis, guided imag-
ery and visualization techniques, meditation, and bulk,
stress-management programs. Some of the methods amal-
gamate and share common features, benefiting from noni-
diosyncratic mechanisms; for example, types of meditation
can include focus on briefing, visualizations, and relaxation,
and several of the methods possess common aspect of being
founded on principles of learning. Many of the separate tech-
niques are often combined and administered under a joint
umbrella of stress-management programs [17–24].
Two separate groups of methods can be distinguished by
the scrutiny and level of evidence gathered in their effective-
ness assessment; for biofeedback, guided imagery, and hyp-
nosis techniques, comprehensive evidence reports in the
framework of U.S. Evidence Synthesis Program exist, and
so unified style summarizing tables depicting condition and
outcome area effectiveness are provided. The remaining
methods’effectiveness and area of application are reported
in the text or different form of tables.
3. Biofeedback
Associated with the founding roots of behavioral medicine
movement in science and connected with the first sense of
term “behavioral”—meaning related to behavioral therapy
and methods—biofeedback techniques rely primarily on the
principles of operant conditioning. The essence of the wide
group of these interventions is learning by individual how
to voluntarily control body processes—which are commonly
falsely considered involuntary—for health benefits or symp-
tom control. That is why, the term “treatment,”emphasizing
the curing goal of these methods, but accentuating passivity,
is better replaced here with the word “training,”highlighting
the need of active patient participation in the learning and
thus curing process. Biofeedback methods substantially
employ equipment that converts physiological input from
the body into auditory or visual signals that constitute the
feedback for the patient. With such feedback, a person can
clearly learn how their mental states are resembled in the
physiological state of the system targeted in particular bio-
feedback intervention and try modifying and managing it,
typically with support of a qualified practitioner. Instrumen-
tation used in different biofeedback methods measures
muscle activity, skin temperature, electrodermal activity
(sweat gland activity), respiration, heart rate variability,
blood pressure, brain electrical activity and blood flow [25].
Biofeedback techniques are employed in two modes: alone
(less often) or combined with stress management, relaxation,
psychotherapeutic and other techniques [17].
One of the most common biofeedback trainings involves
electromyography (EMG), conveying feedback regarding
muscle activation, the intensity of muscle contraction, and
manifestation of muscle fatigue [26]. Electromyography
feedback in clinical setting has been pioneered in the 1920s
by Edmond Jacobson [27–29]. It has been tried since, to treat
various conditions, among which are arthritis [30], asthma
[31], Bell’s palsy [32], cerebral palsy [33, 34], hand dystonia
[35, 36], repetitive strain injury [37], and spasmodic
2 BioMed Research International

torticollis [38]. It has proved to be the most efficacious in the
treatment of various kinds of chronic pain [25], headaches
(tension, migraine, or of mixed origin) [39, 40], temporo-
mandibular disorder [41], and constipation [42].
Another biofeedback method is thermal biofeedback. It is
associated with self-regulation of skin temperature [43]. This
type of biofeedback is usually performed with the use of skin
temperature sensors, called thermistors, attached to fingers,
with visual or tonal feedback to the subjects. Thermal
biofeedback is usually administered with other modalities
of biofeedback techniques and demonstrated to be useful in
the treatment of Raynaud’s disease [43], headaches [44],
and chronic pain conditions [25, 45].
The idea behind yet another biofeedback mode—skin
conductance feedback—is to deliver person information
about sweat gland activity, which is closely correlated with
sympathetic nervous system functioning [46]. With very
short response time falling in the range of below two seconds,
skin conductance activity (SCA) feedback—known also as
EDA (electrodermal activity) or GSR (galvanic skin
response) feedback—provides superb sensitivity to emo-
tional changes [25]. This biofeedback technique receives a
lot of attention as a complementary epilepsy treatment
with encouraging outcomes reported regarding its effi-
ciency [47–50]. Other medical uses have been and are being
studied, including employment of this technique in support
of controlling glucose levels in type 2 diabetes [51], treatment
of Tourette syndrome [52], and headaches [53].
Another example of biofeedback technique is heartrate
variability (HRV) feedback. It involves monitoring either
heart rate alone or heart rate plus respiration. Data regarding
heart rate is collected via electrocardiograph (EKG) monitors
or plethysmographic sensors on the finger or earlobe [25]. It
is has been tried and used in a variety of disorders, with mul-
tiple potential pathways for its therapeutic effects proposed
[54, 55]. Best results were reported in treating recurrent
abdominal pain [56], chronic muscle pain [57], and cyclic
vomiting [58].
Arguably, the most popular biofeedback application
could be electroencephalogram (EEG) neurofeedback
(EEG-NFB)—a method which takes advantage of the fact
that particular brain wave patterns correlate with specific dis-
orders and syndromes [59]. Improvement in functioning in
these disorders may be possible due to the changes in the
amplitudes or overall proportion of brain wave types. These
changes occur as a result of teaching the patient to strengthen
the desired brain wave frequencies, amplitudes, or potentials
and inhibit the undesirable ones. There are three main proto-
cols used in EEG-NFB interventions. The most commonly
used is the frequency training, in which the goal is changing
the power ratio of the EEG frequency bands. It is mostly used
in attention deficit hyperactivity disorder (ADHD) and
autism spectrum disorders treatment [60, 61]. Slow cortical
potential (SCP) is a second kind of popular neurofeedback
protocol, based on modulating specific (slow) event-related
potentials (negative or positive); it is also mainly used in
ADHD. In somatic disorders, a third protocol is however
most widely used. It is coherence training. The aim of this
method is promoting the coherence of activity (frequency
as well as amplitude and phase) of different brain regions.
Theoretical foundation for this protocol lay in the fundamen-
tal observation that specific decoherence (or distorted con-
nectivity) often accompanies particular disorders.
EEG neurofeedback is widely used to treat epilepsy [62];
it is also being administered in novel capacities to treat con-
ditions such as fibromyalgia [63] or chronic prostatitis [64]
and is commonly adopted in rehabilitation, for example, in
patients with amyotrophic lateral sclerosis (ALS) [65], stroke
[66], spinal cord [67], and traumatic brain injuries [68, 69].
Doubts about utility of neurofeedback methods exist and
stem mainly from three reasons, as comprehensively outlined
by Thibault and Raz [70]. One reason is the deficiency of
methodologically high-level, large, quality-controlled, and
randomized studies proving its effectiveness in vast amount
of conditions it is applied to. Another cause is existence of
the so-called sham neurofeedback effects: placebo-like, posi-
tive results, obtained using feedback taken from the activity
of other than the trained person brain or similarly irrelevant
source [71]. The third reason is lack of widely acknowledged
and established mechanisms that would explain the claimed
therapeutic benefits. The research work addressing these
problems is however already being conducted, with good
outlook regarding accumulation of better evidence consider-
ing effectiveness and establishment of the psychological and
neural mechanisms underlying clinical benefits [72].
Current EEG neurofeedback techniques serve as an inspi-
ration for developing more advanced brain-subject feedback
loops, employing the functional Magnetic Resonance Imag-
ing (fMRI) systems. This relatively new (emerging in year
2003) biofeedback expanse area is still mostly field of ongoing
research with potential yet to be evaluated, less a ground of
mature clinical applications [73–75]. The surge of interest
in this subject has been reported in the last decade, and
promising new technical advances and protocols are in devel-
opment. Examples of these are the decoded neurofeedback
(DecNef) technique—aiming at inducing a specific activity
pattern within a target brain region—and functional
connectivity-based neurofeedback (FCNef), in which the
goal is changing functional connectivity between different
regions [74].
In the beginning of the 21
st
century, the Task Force of the
Association for Applied Psychophysiology and Biofeedback
plus the Society for Neuronal Regulation formulated criteria
for designated levels of evidence-based clinical efficacy of
psychophysiological interventions. They span from level
1—not empirically supported—to level 5—efficacious and
specific [76]. According to Yucha and Montgomery [25],
who rated evidence of efficacy in conformance with the
abovementioned criteria in 2008, there were eleven (see
Table 1) conditions for which biofeedback training could be
considered either as “efficacious and specific”or as “effica-
cious”(level 5 and level 4) and further nine conditions in
which it was rated as being probably efficacious (these
include arthritis, diabetes mellitus, and urinary incontinence
in males), with additional eighteen were possibly efficacious
(level 2). The one condition which fits into the “efficacious
and specific”level is urinary incontinence in females. General
effectiveness (level 4) has been stated for anxiety, attention
3BioMed Research International

deficit hyperactivity disorder (ADHD), chronic pain, consti-
pation in adults, epilepsy, headache in adults, hypertension,
motion sickness, Raynaud’s disease, and temporomandibular
disorder (TMD).
More recent report compiled under the auspices of the
US Veterans Health Administration Evidence Synthesis Pro-
gram (EVP) [77, 78] concluded (see Table 2) there is strong,
high-confidence evidence for biofeedback intervention effi-
cacy in clinical conditions like pain resulting from migraine
or tension headaches and urinary incontinence in men after
a prostatectomy. Moderate evidence was found supporting
beneficial effects in fecal incontinence and stroke treatment.
Contrary to summary by Yucha and Montgomery [25],
hypertension, woman urinary incontinence outcomes for
fibromyalgia, was described as providing no benefits, but
with low-confidence evidence base. For the vast majority of
other biofeedback clinical applications, the authors of the
report abstained from conclusions stating insufficient data.
4. Hypnosis
Hypnosis is a method of inducing in an individual a state of
hypnotic trance, a mode of deep relaxation and focus with
increased suggestibility and suspension of critical faculties.
In this special state of consciousness, two types of suggestions
can be made to the affected person: direct hypnotic sugges-
tion, made while the person is in trance, which alters behav-
ior or perception while the trance persists, and posthypnotic
suggestion that alters behavior or perception after the trance
ends. Typical hypnotherapy consists of hourly or half-hourly
sessions with a practitioner; additionally, group hypnosis
interventions also exist. Some medical health specialists
introduce hypnosis in 10-15-minute sessions along with their
regular clinical work. In some cases, patients are taught to
induce self-hypnosis (which is also accomplished by post-
hypnotic suggestion) [78].
Similarly to other techniques described here, hypnosis
has been tried in many medical contexts. Effectiveness has
been reported in irritable bowel syndrome [79], headache
treatment [80, 81], chronic pain, and anxiety [82]. There is
probable effectiveness of hypnotherapy as relief support in
oncological and odontological procedures and promising
outlook in interventions in diabetes and the human papil-
loma virus [83]. There are reports suggesting a positive role
hypnosis can play for the functioning of the immune system
[20]. The report developed in Evidence Synthesis Program
Table 1: Medical conditions for which evidence suggests biofeedback therapies are “efficacious and specific”(level 5) and “efficacious”(level
4) according to a work by Yucha and Montgomery [25]. Types of biofeedback therapy approaches are listed next to each condition.
Efficacy evidence level
5—efficacious and specificCondition Method
Urinary incontinence
in females Pelvic floor muscles biofeedback
Efficacy evidence level
4—efficacious
Anxiety Biofeedback (various modalities, including EMG and EEG)
Attention deficit
hyperactivity disorder EEG biofeedback
Chronic pain Biofeedback (EMG, thermal & EEG biofeedback—utilization for given disorder
best determined by consulting literature for that specific condition)
Constipation in adults EMG and manometry biofeedback
Epilepsy EEG biofeedback
Headache in adults EMG biofeedback
Hypertension Thermal, electrodermal response (EDR), heart rate, EMG, or direct blood pressure
biofeedback
Motion sickness Galvanic skin response (GSR) biofeedback
Raynaud’s disease Thermal biofeedback
Temporomandibular
disorder EMG biofeedback
Table 2: Health conditions for which biofeedback interventions had evidence of a positive effect on diagnosis-related, secondary, or global
outcomes according to the U.S. Department of Veterans Affairs Evidence Synthesis Program (ESP) report published in 2019 [77].
Condition Diagnosis-related outcomes Secondary outcomes Global outcomes
Fecal incontinence X
Headache X X X
Stroke X
Urinary incontinence after prostatectomy X X
4 BioMed Research International

supported conclusion about evident positive effect of hypno-
therapy in cancer-related care and obesity treatment. Proba-
ble positive effects were pointed in irritable bowel syndrome
and reducing anxiety related to undergoing medical proce-
dures [77] (see Table 3).
Some authors suggest hypnosis is underused in medical
setting, considering its already known utility [84]. Applica-
tion and effectiveness of hypnosis in medical setting depend
on obeying fundamental rules, which encompass the need
and willingness of the patient to get rid of the complaint,
believe in the method, and trust in the practitioner applying
it [85]. An important factor worth mentioning in the context
of hypnotic treatment effectiveness is specific individual dif-
ference characteristic: susceptibility to hypnotic suggestion,
referred to as hypnotic suggestibility (also known as hypno-
tizability or hypnotic susceptibility [86]). It is a trait relatively
stable, measurable by means of several standard procedures,
partially heritable [87]. Some authors suggested it to be a core
variable in responsiveness to hypnotherapy in clinical setting
[88]. Meta-analysis approach, however, exhibited only small
and moderate effects of this trait in the mediation of hypnotic
therapy effectiveness [86]. Research shows most medical
patients regardless of hypnotic susceptibility may benefit
from the integration of hypnotic therapies into their medical
care, as so hypnotizability testing is rather recommended to
detect cases of low susceptibility, who may benefit more from
alternative approaches [87].
5. Guided Imagery and Visualisations
A precise definition of guided imagery has been stated by
Rider and Achterberg [89] in their 1989 paper, where they
describe it as “the internal experience of a perceptual event
in the absence of the actual external stimuli.”Guided imagery
is thus invoking one or more senses experience with the use
of imagination and guidance of specially designed instruc-
tion. Concentrating attention on envisioned images and sce-
narios reduces uncomfortable thoughts and feelings and
distracts the mind from unwanted and negative state [90].
There are reports suggesting stress reduction effects and
elevation of the immune system functioning in people treated
with the guided imagery technique [23]. Additionally, pain
relief effects had been observed [91]. In 2005, Roffe and col-
leagues [92] in their studies researching guided imagery
effectiveness in cancer patients concluded it as playing an
adjuvant, psychosupportive, and comfort increasing role,
but with no compelling evidence suggesting positive effects
on physical symptoms.
The EVP report [93] notes a high level of confidence for
usefulness of guided imagery techniques in arthritis/rheu-
matic disease and potential positive effects in interventions
regarding Parkinson’s disease, stroke, cancer, and menstrual
disorders (see Table 4). A beneficial role has been also noted
in supporting patients treated in Intensive Care Units (ICU)
and persons undergoing cardiac surgery procedures.
6. Relaxation Techniques
Relaxation techniques are a large set of methods that are
commonly being divided into two main categories: somatic-
(also called “physical”) and cognitive- (also called “nonphys-
ical”) based approaches. The physical category includes for
example pure behavioral relaxation training, progressive
muscle relaxation, deep breathing, the Alexander technique
and Feldenkrais method (education techniques aiming at
establishing a heightened awareness of movements), and
Mitchell’s simple physiological relaxation [94–96]. Cognitive
or nonphysical approaches include, among others, autogenic
training—first described already in 1932 [97]—and Benson’s
method [98, 99] which are more focused on accomplishing
the relaxation state by a person following the specially crafted
instructions, rather than physical work with the body.
Relaxation techniques have been administered to support
curing and treatment of various clinical conditions (see
Table 5). Multiple relaxation methods are used as an adju-
vant to treat pain. Progressive muscle relaxation (PMR)
(combined with guided imagery) in cancer patients brought
positive results in pain relief [100]. The Mitchell metho-
d—administered for one month—managed to reduce symp-
toms accompanying fibromyalgia [101]. An older review of
usefulness of relaxation techniques in acute pain manage-
ment showed however poor performance of these methods
[102]. Relaxation techniques proved to be useful in treat-
ments of nausea of different origins, chemotherapy-caused
[103, 104] or pregnancy-related [105]. Beneficiary effects
have been reported in Chronic Obstructive Pulmonary
Disease (COPD) (regarding both respiratory functions
improvement and better psychological wellbeing) [106] and
in ischaemic heart disease recovery efforts [107]. Relaxation
Table 3: Health conditions for which hypnosis interventions had
evidence of a positive effect on diagnosis-related, secondary, or
global outcomes according to the U.S. Department of Veterans
Affairs Evidence Synthesis Program (ESP) report published in
2019 [77].
Condition Diagnosis-related
outcomes
Secondary
outcomes
Global
outcomes
Anxiety in cancer
patients X
Breast cancer
care X
Obesity/weight
loss X
Table 4: Health conditions for which guided imagery interventions
had evidence of a positive effect on diagnosis-related, secondary, or
global outcomes according to the U.S. Department of Veterans
Affairs Evidence Synthesis Program (ESP) report published in
2019 [77].
Condition Diagnosis-
related outcomes
Secondary
outcomes
Global
outcomes
Arthritis/rheumatic
diseases X
Cancer X
5BioMed Research International

techniques are commonly used as accompanying methods to
alleviate symptoms and improve psychological health in ill-
nesses, like edema, anxiety, and depression in postmastec-
tomy lymphedema patients [108] or distress in people with
diabetes [109].
7. Disclosure Interventions
The theoretical basis of the disclosure intervention methods
lays in the supposition that inhibition of psychologically sig-
nificant thoughts and feelings has adverse health conse-
quences, [19, 110]. In the 1980s, Pennebaker et al. in their
correlational studies uncovered a pattern suggesting that
not disclosing stressful experiences to others (e.g., spouse
death, Holocaust survivorship, incest, and personal failures)
is related to poorer health [111, 112]. Pennebaker and Beall
aimed later at reversing emotional suppression by developing
an experimental paradigm in which individuals could dis-
close and process stressful experiences [113, 114].
The most commonly employed technique in this
approach is “written emotional disclosure”or “expressive
writing”that consists of 15 to 30-minute long sessions (often
repeated in consecutive days) of writing essays on personally
experienced stressful events. Sometimes instead of written,
verbal descriptions are used [115], or the disclosure takes
place by means of drawing or combination of writing and
drawing [116].
The disclosure-based methods have been employed in
many health problem contexts, exhibiting modest benefits
in chronic pain (limited in rheumatoid arthritis, far better
performance in fibromyalgia, mixed in headaches, cancer
pain, pelvic pain, and abdominal pain) [113] and noticeable
positive effects in wound healing [117, 118]. Earlier, grander
reviews in the form of meta-analysis produced mixed conclu-
sions regarding disclosure interventions efficacy. Frisina and
colleagues [119] reported significant positive improvements
in health in clinical populations, with greater impact on
physical than psychological health outcomes. In contrast,
Meads and Nouwen concluded the nonexistence of emo-
tional disclosure effects and suggested the reassessment of
the method validity [120]. What appears to be of crucial
importance in the context of disclosure effectiveness is the
consideration of additional moderating factors such as emo-
tional expressivity and baseline affect [121, 122], cognitive-
emotional processing [123], social constraints [124], and eth-
nicity and form of the writing instruction [125].
8. Meditation and Mindfulness Interventions
Meditation is a practice in most general terms grounded in
controlling focus of attention. It is referred in the classical
languages of Buddhism—Sanskrit and Pali—as samādhi, ety-
mologically meaning “gathering the mind and placing it
upon an object”[126]. It can be categorized on the broadest
level into three types. Concentration meditation depends on
focusing attention on an object until quieting of the thoughts
occurs in a subject’s mind. Mindfulness meditation on the
other hand emphasizes nonjudgmental openness to contents
that arise in the mind spontaneously, not following and sus-
pending reactions to them, promoting expanded awareness
of present moment. Contemplative meditation is a mixture
integrating both approaches, trying to combine focus with
mind openness [127, 128].
Mindfulness meditation is the basis of mindfulness inter-
ventions. These interventions share the core premise of
mindfulness—a process of openly attending, with awareness,
to one’s present moment experience—however referred by
name to intervention schemes and programs [129].
A substantial body of research evidence, comprehen-
sively reviewed by Sampaio and colleagues, cites important
effects of meditation on not only body function parameters
like reduction in respiratory frequency, slower heart rate,
and reduced electrical conductivity of the skin [130] but also
significant neuroendocrine and neurochemistry effects
including structural changes to brain areas [131]. Other
worth noticing positive influences on health and treatment
that had been observed encompass a damping effect on T
CD4+ lymphocyte reduction in adults infected with HIV-1,
increased NK (Natural Killer) cytolytic activity [132–134],
reduced risk for mortality in patients with coronary disease
[135], and numerous evidence for enhancement in mood
and well-being, decrease in stress, anxiety, and depression
symptoms in healthy and ill individuals [134, 136, 137].
9. Discussion
A short review of the most prominent groups of therapeutic
methods in the field of behavioral medicine shows a large
potential in the context of contemporary health care system
use. One of the main advantages of the reviewed methods is
their intrinsic noninvasive and pharmacology free essence.
This characteristic positions them as promising alternatives
for treating conditions in which pharmacological or other
types of therapies are burdened with harmful risks. A good
example here might be the problem of pain treatment. Cur-
rently, opioid analgesics are associated with one of the biggest
US public health crises: the opioid crisis. Research showed
that overwhelming majority of the opioid abusers began their
addiction with prescription medications, primarily for
chronic pain [138, 139]. Pain, and particularly chronic pain,
is the condition for which many of the reviewed behavioral
medicine treatment methods proved to be efficacious, with
Table 5: Health conditions treated with relaxation techniques with
reported positive effect outcomes [101–107].
Condition Method
Cancer pain Progressive muscle
relaxation
Fibromyalgia Mitchell method
Nausea—chemotherapy-caused Progressive muscle
relaxation
Nausea—pregnancy-related Benson’s method
Chronic Obstructive Pulmonary
Disease
Various relaxation
techniques
Ischaemic heart disease recovery Various relaxation
techniques
6 BioMed Research International

a high level of confidence. Various biofeedback techniques,
especially EMG, HRV, and thermal feedback, had been suc-
cessfully administered in pain treatment—including chronic
pain. Utility in this context has also been reported for relax-
ation techniques, with some more moderate evidence also
found for hypnosis and guided imagery. Broader implemen-
tation of the best techniques from behavioral medicine reper-
toire at specific pain problems in clinical populations can
bring relief to patients reducing the need of using medication,
thus lessening the risks and potential of negative conse-
quences associated with painkiller drugs. It is worth men-
tioning that usage of alternative, nonpharmacological
treatments of pain was much more common in years before
the emergence of opioid crisis [140].
Another distinctive advantage of behavioral medicine treat-
ments is the fact that many of them are founded on learning
processes and rely on training. This provides possibilities
unavailable to other therapies, like surgery or pharmacother-
apy. Persons treated with the learning-based therapies
acquire skills and knowledge, meaning that in very many
cases (those not requiring specialized apparatus like fMRI
feedback), they can apply the treatment to themselves when-
ever necessary on their own. Furthermore, they keep the
trained skill and can use them long after they acquired it
and also possibly apply it outside the original illness context.
Relaxation, expanding mindfulness, and self-hypnosis are
skills which can beneficially be applied in health and even
outside of health related context, for the rest of life. This
means contact with some of the behavioral medicine tech-
niques means arming people with useful techniques they
can apply for promoting their health and improve wellbeing
in the long term. This in turn might equal more years lived
in better health and less strain on health care system.
Another leverage associated with many of the reviewed
methods is their big potential in the context of convenient,
remote, offsite use (eHealth) [141, 142]. Used case examples
have already been reported for mindfulness, relaxation tech-
niques, and hypnosis administered via tools such as smart-
phone applications or tele-sessions in which the therapist
uses video call capabilities to remotely conduct intervention
with a patient [129, 141, 143]. Automation and saving poten-
tial are clearly visible here.
Behavioral medicine-derived medical treatment field is
also affected with problems. The issue repeatedly mentioned
in the literature is deficiency of high-quality research that
would enable drawing definitive conclusions regarding the
effectiveness of many of the considered methods [71, 93]. Till
now, only minority out of plentitude of mentioned here
interventions had been conclusively confirmed or rejected
as useful therapies in given conditions. Until effectiveness
will be established with high-quality evidence, the dissemina-
tion of behavioral medicine therapies in medical setting will
understandably not be high. Another major problem, along
insufficiency of effectiveness evidence in many of the use
cases, is similar deficit of empirically sound explanations of
mechanisms underlying therapeutic benefits. Solving these
two major deficiencies is a key prerequisite for enhancing
the use of behavioral medicine treatment approaches in clin-
ical setting.
10. Conclusions
A behavioral medicine framework provides wealth of
methods for use in the treatment of multitude somatic health
conditions. Those alternative approaches hold substantial
potential in terms of reducing risks and unwanted negative
consequences in cases where they can effectively substitute
pharmacological or invasive therapies. Another useful area
of employment for these methods is complementary and
supporting role along the main treatment. Broader dissemi-
nation and popularization of these techniques can occur
when insufficiencies regarding evidence of effectiveness and
underlying curing mechanisms will be tackled.
Conflicts of Interest
The authors declare no conflict of interest.
Authors’Contributions
JB, JJ, and JW are responsible for the conceptualization, writ-
ing and original draft preparation, review, and editing. All
authors have read and agreed to the published version of
the manuscript.
Acknowledgments
This study was supported by statutory grant No. 61610001-
100, from the University of Warmia and Mazury in Olsztyn,
Poland.
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