An estimated 99 million Americans live with chronic illness. The majority have not received effective treatment or optimal disease control.1 Health services research indicates that it is the design of the care system, not the specialty of the physician or allied health professional, that is the primary determinant of the quality of chronic care.2 Collaborative relationships with health care providers can help patients and families acquire effective medical, preventive, and health maintenance interven­tions.3 Moreover, collaborative care between health care providers can help improve outcomes and adherence to self-care programs. Patient adjustment to requirements to maintain their health is improved when reinforced by each professional involved in his or her plan of care. They even develop adaptations to improve their own abili­ties to maintain the results achieved by treatment when accountability is empha­sized by all members of their health care team.

Adaptive behavioral responses can include resignation, disengagement or a refusal to help themselves. Some patients present with denial, avoidance, repressed anger or depression. These are largely unconscious responses that stop imagination or emotions from threatening a patient’s sense of self. All represent defense mecha­nisms that can impair results of treatment if not addressed or are dismissed as noncompliance.