Chronic Illness and Assertiveness

Setting firm boundaries for better health

Posted Aug 15, 2019

Katie Willard Virant
Source: Katie Willard Virant

One of the most life-changing aspects of chronic illness is the increase in fatigue.  It’s not “I overdid it a little bit at the gym today” tiredness; rather, it’s “I have to sit down in the shower because I might pass out” exhaustion.  We are almost always more or less tired, and we’ve learned (or we’re learning) to read our body’s energy levels and limit activity accordingly.  Many of us can do this pretty effectively.  That said, it can be extra-challenging when our need for rest bumps up against other people’s wishes and expectations.  For many of my clients, it’s so difficult to say “no” to others that they swallow their own needs and jeopardize their health.  In this month’s blog, I’ll analyze this phenomenon and offer strategies to mitigate the stress surrounding it.

Conflict is Normal

Conflict is an expectable part of living in this world.  We have our needs and wishes; every other person around us has their needs and wishes.  “Countless times each day, most of us are reminded that the people around us do not seek the same outcomes we do. (Ames, Lee & Wazlawek, 2017).”  If you are someone who fears and dreads conflict, you are going to be highly anxious multiple times a day.  Conflict is like traffic: We may not like it, but we can’t escape it.  Acceptance, then, is a key first step.  Remind yourself that conflict is not an aberration; rather, it’s the norm.

The High Cost of Conflict Avoidance

Some people are so anxious about conflict that they will do anything to make it go away, even if it means agreeing to things they do not want.  Here’s the dirty little secret to this strategy:  You haven’t eliminated conflict; you’ve just moved it from the interpersonal to the intrapsychic realm.  Imagine that someone is asking something of you that you don’t want to give.  Your stomach may clench up; you may be sweating more than usual; you can feel your heart rate accelerate.  You say yes in an effort to make those uncomfortable feelings disappear.  Problem solved, right?  Not so fast.  Now you’re living with both sides of the conflict inside of you: the side that says, “Just go along and don’t make waves” and the side that says, “Why did I just agree to something that is not in my best interest?”  Remember that lousy feeling the next time you’re asked for something you don’t want to give:  Your acquiescence doesn’t make the conflict go away; it just makes it something you’re holding all by yourself.  

Analyze Your Fear of Saying No

It’s worth asking yourself what feels so worrisome about saying “no”.  People often say that they can’t bear having someone displeased with them.  If you identify with this statement, I wonder if you can probe more deeply into this feeling.  Play the scene out in your mind:  You tell someone “no” and they are unhappy with you.  In your fantasy, do they scream at you?  Throw things?  Strike you? Storm off and refuse to speak to you ever again?  It may be that your rational mind recognizes that these scenarios are unlikely, but your more primitive self believes them to be probable.  If this is so, I’m wondering what your early experiences of conflict were like.  If your parents or other attachment figures reacted to your “no” with excessive anger, it may be that you have some therapeutic work to do to separate the past from the present.  

Many people, particularly women, fear coming across as “not nice” when their needs bump up against another person’s needs.  Again, let’s think about this.  What does it mean to “be nice”?  Does it mean that you have to agree to everything requested of you?  Does it mean that you cannot act to meet your own needs?  A recent New York Times article cites research affirming cultural perceptions that women are expected to agree to requests more frequently than men (Bennett, 2019, August 6).  If this disparity makes you angry, use that anger to say “no” more frequently and change the perception!

Assertiveness is Not Aggression

People who have difficulty setting boundaries for themselves often see only two options:  acquiescing (being passive and never saying no) or reacting with indignant anger (“How DARE you ask that of me! What is wrong with you?!”).  There is a wide middle ground here, however, and it’s called assertiveness.  

“Being assertive means that you express yourself effectively and stand up for your point of view, while also respecting the rights and beliefs of others (Mayo Clinic, 2017)."  What are the rights of others?  They have the right (a) to have needs and desires; and (b) to ask to have those needs and desires met.  While they have the right to ASK you to comply with their wishes, you have the right to decline to do so.  Conceptualizing interactions in this way takes some of the anxiety out them.  Rather than evaluating whether the other person is within his rights to make a specific request of you, you can simply note that “others have the right to ask; and I have the right to say no.”

This mantra - “they can ask and I can say no” - will serve you if you receive pushback when you do say no.  People may not graciously accept “no”; instead, they may try to get you to change your mind.  Simply repeat your “no,” recognizing that you are being assertive and not aggressive.  If they veer into aggression, you can set a firm boundary by saying, “It appears that you are not accepting my ‘no.’”  

What if the other person does get upset with you for saying no?  It can happen, especially if the other person is someone used to getting his own way in interactions with you.  You may be tempted to feel guilty, believing that you “did something to them” when you said no.  Take a breath and remind yourself that they are upset because they are not getting what they want - and that it is not your job to give them what they want.  

Practice Makes Perfect

If you have difficulty asserting yourself, start small.  Challenge yourself to say no in relatively minor situations.  When the check-out clerk asks for your phone number to be entered into the store system, say, “No, I don’t give out my number.”  When you get a call from a random stranger seeking to sell you something, say, “No, I’m not interested.”  Notice how these interactions go for you.  Are you becoming more comfortable as you practice?

Think ahead.  We all can name at least a few people in our lives who make a lot of demands on us.  Anticipate your interactions with them and practice ahead of time saying no.  If “no” feels too difficult in the moment, you can always say, ‘I’ll think about that and get back to you.”  This “buying time” strategy can give you the breathing room to make a decision that feels right to you rather than a hasty cave-in provoked by external pressure.

Value Yourself, Your Time and Your Energy

Those of us who live with chronic illness are very aware that time and energy are valuable commodities.  We spend so much time managing our symptoms that we have little leftover.  When others ask us to meet their needs, they are asking us to give them something very valuable.  It’s up to us to be the gatekeepers of these assets.

Is it difficult for you to say “no”? How has that been challenging in living with chronic illness?  How are you working on being more assertive?  


Ames, D., Lee, A., & Wazlawek, A. (2017).  Interpersonal assertiveness:  Inside the balancing act.  Social and Personality Psychology Compass, 11(6).

Bennett, J. (2019, August 6).  Welcome to the 'No Club'.  The New York Times.

Mayo Clinic Staff.  "Stress Management."  Mayo Clinic, 9 May 2014.