Applying Theories, Perspectives, and Practice Models to Integrated

Applying Theories, Perspectives, and Practice Models to Integrated Health Module 3 Judith Anne DeBonis PhD Department of Social Work California State University Northridge

Module 3 Theories, Perspectives, and Practice Models in Integrated Health By the end of this module students will: Learn how a variety of theories, perspectives and practice models can be useful in their application to Integrated Health Identify and understand the impact of personal (practitioner and patient) practice and explanatory models on clinical practice and behavior Gain experience, skill, and confidence (through practice scenarios) in applying theories to practice – Increase more detailed knowledge and understanding of the application of Stage of Change theory to Integrated Health

The Basic Value of Theories 1 Theories help us to explain or predict behavior, to inform policy, guide practice and direct research. For behavioral health professionals: Inform the questions we ask Frame the comprehensiveness of our assessment Offer a vantage point that respects diversity and complexity Provide a lens through which we organize vast amount of information or view data “It is the theory that decides what we can observe.” Albert Einstein

Contribution of Theory to Integrated Health? 2 Assessment is part of treatment When conducted effectively, a good assessment is not just about diagnosis, but offers opportunities for the patient to identify strengths and gain insight and self-understanding. Theories can act as a roadmap for the questions to ask or for decisions about the direction taken in an assessment. It can offer options for strengthening the partnership with the patient and encourage practitioner’s to consider a variety of vantage points which can lead to a more comprehensive understanding of the patient’s experiences

Using Common Theories to Enhance Assessment 3 Environmental or Systems Theory Behavior is influenced by a person’s environment. Interventions aimed at the individual and the environment have potential for positive outcomes. Human Developmental Theory People have different needs and capacities related to the current phase of their life history. Grief and Loss Theory All persons experience losses that have the potential to result in feelings and reactions: denial, anger, depression, bargaining, and acceptance. No one should try to go it alone. Having access to a network of support may result in improved healthcare outcomes. Social Support Theory

Group Activity Generating Questions Associated with Theories Environmental or Systems Theory Human Developmental Theory Grief and Loss Theory Social Support Theory Applying the theory to your practice Think of your client population. What areas of a person’s life come to mind when you consider how these theories relate to that person? Brainstorm at least 2 questions for each theory that lead you to a better understanding of the person.

BioPsychoSocialSpiritual

Biological, Psychological, Social Relational and Spiritual Aspects—A Person-Focused Approach1 Purpose Contributions Collects information regarding history, development, biology, genetics, psychology, social, spiritual, and environmental aspects of health Offers a structure to examine current mental status Provides insight into personal strengths and weakness including social role, environmental resources, mental health and physical health Holistic- person and situation context Helps tie together theories to better understand aspects of the person and environment Gives integration and interconnectedness to contrasting qualities of the person Identifying possibilities for engaging micro and macro systems of practice

Group Activity Person and Environmental Focused Mandalas “We do not give priority to either the person or the environment, but rather see person and environment as inextricably related.” 1 1. Using the mandalas (on the next slide) of human behavior theories, consider how these various theories might be useful in practice with people who have a combination of health, mental health, and substance use disorders. 2. Start by examining a clinical case example, or reading a narrative written by a person living with one or more of chronic conditions. 3. Applying both the person-focused and environmental mandalas, examine how they interact and impact on the person’s experience.

Person and Environmental Focused Mandalas1 Person-Focused Environmental-Focused

Explanatory Models Take a few minutes to think about and discuss the following question: What is your explanatory model for mental health and substance use problems? Stories and experiences from real life Messages we carry with us Impact on our role as a social worker

Stress Vulnerability

History of Mental Disorders Ancient Egyptians did not differentiate between mental and physical illnesses4 Thought the heart was responsible for mental symptoms Later shifted to blaming, stigmatizing5 The label of mental illness became the entire definition of who the person is Stigma continues to be one of the largest barriers to understanding and treatment

Typical Reactions Towards Mental Illness6 Myths and misconceptions about mental illness: Depressed people should just “snap out of it” The mentally ill are dangerous, often commit crimes All mental illness involves psychotic episodes It’s fun to be manic Schizophrenia multiple personality disorder Families are the cause of mental illness Supportive therapy can’t help the mentally ill People with schizophrenia can only do low level jobs A schizophrenic is a schizophrenic is a schizophrenic Despite new scientific evidence and information, these ideas persist

Factors Contributing to Mental Health Disorders6 A combination of environmental and genetic factors contribute to mental illness Mental disorders are not caused by personal laziness or weak character No blood test for mental illness Common for individuals to blame themselves for their feelings, thoughts, and behaviors Common to feel embarrassed about them

The Stress Vulnerability Model7 Amount of vulnerability differs from person to person For some conditions, related to factors like early exposure to viral infection in utero Genetics, biological vulnerabilities Reduce person’s biological vulnerability and stress Factors include medication, coping skills, communication, and problem solving skills and structure Impacts vulnerability by either triggering the onset of the disorder or worsening the course Stress can include life events, relationships, etc. Illness/ symptoms Protective factors Stress in the environment Combinations of stress and vulnerabilities may lead to different types of a disorder Individuals and families can build protective factors to minimize or manage stress May help reduce severity of symptoms and impact the illness course positively

Group Activity How do the causal models of mental health disorders impact practice? What are some of the benefits that come from understanding the causal factors for mental health and substance use disorders? Does increased understanding help to reduce the associated stigma? What impact can knowledge about causal factors have on the person and the family? How would you apply the knowledge from the stress vulnerability model to help people reduce the severity of their symptoms and positively impact their illness course?

Practice Theory Models Take a few minutes to think about and discuss the following question: What are the essential components of your practice model for mental health and substance use problems? What is your belief about change? What motivates persons to take action on behalf of their health? How hopeful are you that recovery is possible? Can persons with chronic conditions also be resilient?

Practice Theory Models8 Assumptions of three dimensions: Human Behavior Change Process Assumptions and research about risk and resilience factors that affect human development and behavior Theories about how people change their thoughts, feelings, and behaviors in different situations Why do people behave as they do? What role does the environment play? How do people change? What activates or motivates the process? Interventions Skills Techniques Strategies Used in the practitionerclient interactions What activities can improve client adaptation or well-being?

Critical Examination of Theory8 “While practice theories have made positive contributions to social work practice, they all have strengths and limitations” 1 Scientific evidence does not support the theoretical assumptions 2 While there may be merit in the underlying theory, the intervention has not been adequately tested or shown to be effective 3 The theory is not broadly applicable to treating a wide range of psychosocial problems

Strengths and Resiliency

Consider An Example9 The individual is a college student in their junior year at the local university where classes began a little more than a week ago. Read the process recording and note your thoughts as you take in the information being presented Please note specific information that appears most important or significant to your beginning understanding While you may want more information, think of what immediately comes to mind in terms of defining the problem or diagnosis and how you would go about starting to work with this person? As a group, take time to collect and process findings.

Process Recording9 “ I called last week to make this appointment because I just felt that I was not going to make it. I felt so anxious and stressed at school the other day, I had to leave and did not attend my first class session. Actually, it was my first day back in school since taking a break last year. I had pushed myself too hard with work, school, and trying to keep the gay alliance going, I just couldn’t do it anymore. My drinking was getting worse and I was yelling at my partner so much I was always leaving to get away to clam down. My Dad would hit my Mother and he drank a lot. Maybe I am just too much like him”.

Basic Assumptions of Strengths Perspective10,11,12 Everyone possesses strengths How many Motivation is increased when strengths observations about are emphasized the previous case example were Cooperative, mutually respectful “strength-based?” relationships promote identification of client strengths What percentage of Focusing on strengths diminishes the the discussion temptation to blame or judge focused on problems or took a All environments—even the most bleak— deficit perspective? contain resources

Strengths-Based Practice? 9 Traditional models assume that “truth” is discovered only by looking at underlying and often hidden meanings that only professional expertise can understand? Medical/pathology vs. strengths/solution focus Shift in frames are not easy tasks Using the language of strengths is insufficient Frames provide a set of rules and expectations for behavior

Empowerme nt

Consider Some Examples13 “Examples of not seeing what is there and examples of seeing what is not there” “My patients don’t want to be empowered they want me to tell them what to do” “I want to empower my patients to improve their compliance with their treatment” “Some patients cannot be empowered due to age, education or culture” “I only use empowerment with some of my patients it’s in my bag of tricks but I wouldn’t use it with a newly diagnosed patient”

Empowering Approach?13 “Empowerment occurs when the practitioner’s goal is to increase the capacity of the client to think critically and make autonomous, informed decisions it also occurs when clients are actually making autonomous informed decisions” Reflect on your reactions Compliance vs. Adherence vs. Empowerment Empowerment is a process and an outcome No empowerment without respect Challenge – consider how fully the spirit of empowerment can be applied in clinical settings with various patient populations

Defining Empowerment for Health Empowerment isis aa process process by by which which people people gain gain mastery mastery over over their their lives.” lives.” 1414 J. J. Rappaport Rappaport Empowerment isis an an educational educational process process designed designed to to help help patients patients develop develop the the knowledge, knowledge, skills, skills, attitudes, attitudes, and and degree degree of of self-awareness self-awareness necessary necessary to to effectively effectively assume assume responsibility responsibility for for 15 their their health-related health-related decisions.” decisions.” 15 Feste Feste –– Anderson Anderson

Sharing of Power16 Compliance “You must do what I tell you.” An authoritative act designed to reduce patient autonomy and constrain freedom of choice Empowerment “Let’s decide together what is the best care for your conditions.” An agreement designed to support the promotion of self-management, taking into account the patients’ perspectives on their condition, their goals, expectations, and needs

Empowerment Applied17 Empowered Empowered Patients Patients –– “Own” “Own” Their Their Health Health Condition Condition Have skills for making decisions and changes as needed Make decisions and direct their life in a way that helps them meet their goals Active participants in: Are effective self-managers Have strong self-efficacy Setting goals Building action plans Identifying barriers Problem solving Comfortable and confident about taking needed action

How Do Patients Become Empowered?17,18 Through Through Self-Management Self-Management Education Education Traditional Patient Education Self-Management Education Offers information Teaches problem solving Defines problems Helps patients identify problems, make decisions, take actions Self-management compliments rather than substitutes for traditional patient education A partnership will require both educators and learners to interact with respect as equals

Paolo Freire19 “There “There isn’t isn’t Dialogue Dialogue Without Without Humility” Humility” The content of education based on true dialogue is not intended to convey information or impose ideas It is to provide an organized structure so individuals can – Identify their own goals – Initiate their own decisions and actions – Experience their own power Switching from a “banking” to a “problem–posing” approach to education “Education for liberation”

Bloom’s Educational Model About “Into,” “Through,” and “Beyond”20 Into Knowledge Through Skill Building Beyond Increasing self efficacy 1 Provide education and information on the basics Involve patients 2 Offer patients opportunities to put information or skills into action Help patients to learn through experience 3 Help patients go beyond the basics and fine-tune their skills Encourage patients to keep building on what they’ve learned

Group Activity Patient Education and Empowerment Using Bloom’s 3-step model of education (from the previous slide) and Freire’s model of empowerment, practice through role play how you might assess a patient’s educational needs and individualize the needs based on the three different steps. Based on these models, how might you modify or enhance any current patient educational materials that you’ve seen used in our healthcare system? Consider the advantages, disadvantages and impact of an individualized model vs. the “one size fits all” educational approach?

The Real Goal of Empowerment is Increased Self Efficacy 21 Patient Patient Empowerment Empowerment Increased Increased Sense Sense of of Self-Efficacy Self-Efficacy Enhanced Enhanced SelfSelfManagement Management Skills Skills “Increased self-efficacy allows patients to view disease and symptoms differently, giving more opportunities for effective self-management”21

Person Centered

Patient as Central to the Process16 Individuals Individuals Makes Makes Decisions Decisions About: About: Life-style The person is, in fact, the Taking medicine true manager of his or her Physical activity well being. Ultimately, the Blending information with personal culture, expectations, wishes, and attitude question is not whether patients will manage their health or diseases, but how they will manage.

Medical Model1 vs. Person-Centered Model of Care1 Traditional Medical Model Evolving Healthcare Model Person-Centered Model

Health Management

Important Changes in Health Management22 Three points: Chronic disease is the major reason for seeking healthcare in the U.S. Treating chronic medical conditions requires a different model of care The “new” models of care for chronic conditions require a change in both patient and provider roles The Global Burden of Disease, a study sponsored by the World Health Organization, projected that by the year 2020, mortality and disability from disease would shift from predominantly acute illnesses to chronic conditions.

1) Chronic Disease: The Major Reason for Seeking Healthcare in the U.S.22 Shift from acute illnesses to chronic conditions Chronic disease is the primary cause of disability in the U.S. Chronic disease accounts for 70% of all healthcare expenditures in the U.S. As many as 45% of the general population and 88% of persons aged 65 or older have at least one chronic condition

2) Treating Chronic Conditions Requires a Different Model of Care23

3) Need for Change in Patient and Provider Roles24,25 The “patient/professional” partnership involves collaborative care and self-management education Patients are expected to do what is needed on a daily basis Providers act as consultants, resource persons, and offer treatment suggestions Patient/Healthcare Provider Team Healthcare Providers Provide clinical expertise, experience with the chronic condition, and evidence-based knowledge Patients Know more about themselves, what motivate them, what they are willing to change, and what has helped them feel better

Care Management Priority: Integrating collaborative goal setting, action planning, and problem solving into routine medical care for patients with chronic conditions Wagner’s Chronic Care Model26 Chronic Care Model Coordination of Healthcare Services Multiple caregivers Multiple providers Modified Delivery System For chronic conditions Planned visits Active follow up Promote self-management Clinical & Demographic Patient Data Patient Empowerment Empowered patients: “Own” their health conditions Have the skills and confidence to make decisions and changes Effective self-management support: Community Resources Support additional services for patient and families Informed, Collaborative, Empowered Patient Educates patients about their roles in: Setting goals Building action plans Identifying barriers Problem solving Patient/Provider Partnership Improved Outcomes For developing & monitoring: Care plan decisions Program enrollment Outcomes Ongoing Activities Are services working? Follow up Feedback Reinforcement Prepared, Proactive Healthcare Providers Improved Health Outcomes are achieved when patients take an active role in their care. Social Work providers can serve to promote patient empowerment and behavioral activation which are essential to effective self-management.

Lorig’s Components of Self-Management 23,24,27 Living with a chronic condition requires patient self-management in three key areas: Medical Management Behavioral Management Take medicines, adhere to special diet, test blood sugars Adjust to life with chronic illness— maintain, change, or create new life roles Emotional Management Deal with emotional consequences of having a chronic condition

Group Activity Good Chronic Care Requires Self-Management “Growing evidence from around the world suggests that patients with chronic conditions do better when they receive effective treatment within an integrated system of care which includes self-management support and regular follow up.” 22 Consider the Following Questions: How would you create effective treatment that includes self-management support and regular follow-up? What characterizes a prepared practice team? What characterizes an informed practice team? What characterizes an informed activated patient?26 What specifically can social work providers do to promote patient empowerment toward behavioral activation?

Health Beliefs

Health Belief Model 3,28 Purpose Offers understanding or insight into a person: How the person prioritizes health and health problems Belief about the causes health problems or what symptoms mean Hopefulness about whether treatment will help Sense of how worthwhile certain actions might be in preventing disease or treating health problems or risks Contribution Helps individualize a comprehensive assessment: – What do you think caused your problems? – Why do you think it started when it did? – How does it effect you? – What worries you most? – What kind of treatment do you think you should receive?

Group Activity Beliefs about Pain The messages that “pain equals harm” and or that all pain is a signal that something is wrong can contribute to disability and distress for persons with chronic conditions.28 Consider the Following Questions: Brainstorm about some of the common beliefs about pain and how these might impact behavior. What types of questions might you ask to understand the person’s belief? How have they coped with pain? How could education and information be used to address these issues? What would the goal be?

The Client’s Theory of Change

The Client’s Theory of Change 29 Purpose Contribution An “informal” theory which explains a person’s : Helps to direct the focus of treatment based on the patient’s expertise and knowledge, reinforcing engagement and motivation Perceptions and views about the nature of the problem and it’s possible resolution Opinion about what is known to be helpful or unhelpful in dealing with the problem NOTE: this theory needs to be discovered through dialogue characterized by “caring curiosity” Highlights strengths and abilities in the patient that may have been overlooked or forgotten Provides details on previous experiences of change which offer opportunities to make a successful plan in the present

Activity Client’s Theory of Change Prompting a client to reflect on successful ways that they have coped or positively made changes in the past, can help to uncover resources (internal and external) used to resolve current problems.29 Consider the Following Questions: When the goal is to discover the client’s theory, what role and stance is the most effective for the practitioner to take? (Hint: there is more than one right answer here) Are the models of education (Lorig, Freire, Bloom) compatible with this theory? Could they be used in combination? How would a solution-focused approach serve the discovery of the client’s theory of change? (Be specific)

Stage of Change

Stage of Change Theory30 Purpose Contributions Identify the stages that changers go through Recognize change as a process Measure the person’s readiness to change and offer stage-matched interventions See every person in the process of change and intervene accordingly Identify what is needed at each stage to move through the process and make behavior change Recognize relapse as part of the change process Measure progress both through changes in stage or in changes in behavior

James Prochaska Stage of Change Guru Five Stages of Change30 1. Precontemplation 2. Contemplation 3. Preparation 4. Action 5. Maintenance

Stage of Change Details30 Five Stages of Change 1. Precontemplation 2. Contemplation 3. Preparation 4. Action 5. Maintenance People in this Stage Tip Offs 1. No intent to change yet, unaware or deny personal relevance 1. “There’s nothing I really need to change” 2. Aware of the problem, ambivalent about change 3. Getting ready to change, choosing a plan 4. Trying to change, not yet consistent in doing it 5. Practice being consistent, avoid slipping back 2. “It might be good for me, but it’s too hard” 3. “I’ve started to make small changes” 4. “I wish I was more consistent” 5. “I’m working hard not to lose the progress I’ve made”

10 Principles for Applying Stage of Change Theory 30,31,32 1 Change is a process rather than an event 6 Insight is necessary but not sufficient for permanent change Change is characterized by 2 stages People who are not in the action 7 stage may still be “actively” changing Identifying the person’s stage of readiness is essential to tailoring 3 interventions that will be most effective Understanding how to maintain 8 change is also a key to successful change 4 Moving one stage at a time is the most reasonable goal 9 5 Knowing the changer’s stage helps to individualize the approach 10 People can be at different stages for different problems The goal is for full freedom from the problem

Activity For each of the detailed Stage of Change principles that follow Consider the Following Questions: How does the principle support the goals of Integrated Health? If implemented, what changes would this principle make to your thinking or behavior or practices with the patients you encounter? What (if any) barriers exist which would limit the full use of the Stage of Change principles?

1 Change is a Process Rather Than an Event It is common for people to change gradually — from being uninterested, to considering a change, to deciding and preparing to make a change — over months and years.

2 Change is Characterized by Stages Each of the stages corresponds to an individual’s readiness to change — precontemplation (never), contemplation (maybe), preparation (will soon), action (doing it now), maintenance (sticking to it), and termination (never go back) — giving an indication of when change will occur.

3 Identifying the Person’s Stage of Readiness is Essential to Tailoring Interventions that will be Most Effective Associated Change Processes Per Stage A B C D E For each stage there are associated change processes — activities that people can apply or engage in to help modify thinking, feeling, and behavior— which explain how people progress through the stages. Doing the right things at the right times is the key.

4 Moving One Stage at a Time is the Most Reasonable Goal Because there is essential learning and experience that is gained from going through each stage, skipping stages is not a good idea. People will vary on the amount of time needed in each stage — both shifts in readiness and behavior change are measures of success.

5 Knowing the Changer’s Stage Helps to Individualize the Approach Healthcare providers, family, and friends can offer help that is more targeted to the person’s particular needs, and offer it in the best way, when they match the stage.

6 Insight is Necessary But Not Sufficient for Permanent Change Two mistakes to avoid in the process — trying to modify behaviors by becoming more aware or trying to modify behavior before there is insight about the problem. Either will likely to result in temporary change or may be an obstacle to progressing further.

7 People Who are Not in the Action Stage May Still be “Actively” Changing Prochaska found that only 10-20% of people were in action, more in contemplation and the most in precontemplation. However, since important changes in attitudes, feelings, intentions during early stages are the foundation for changes in behavior, all people should be included for participation regardless of their motivation level or intent to change. In In PrePreContemplation Contemplation In In Contemplation Contemplation In In Action Action

8 Understanding How to Maintain Change is Also a Key to Successful Change It is rare to overcome a problem on the first attempt —sometimes 3 to 4 tries are needed before change is permanent. Both recycling through the stages and relapses back to old behavior are common and considered necessary to learn how to sustain change.

9 People can be at Different Stages for Different Problems Each problem should be evaluated separately so that stage-matched strategies can be chosen.

10 The Goal is for Full Freedom from the Problem While improving a problem can help, discovering how to solve the problem is the aim and hope — leaving the person with zero or minimal risk from a particular behavior.

Group Activity Putting together the “theories” of change Considering both the Client’s theory of change and Prochaska’s stages of change: As a group, choose a case example that includes a patient in one of the Prochaska stages of change. Specify the area of behavior change that will be the focus of the conversation. Role play using 3 students per group – One student will portray a patient – One student will conduct the interview – The last student will take notes about the ways in which the interviewer was able to incorporate the theories and draw out the client’s theory of change. Discuss what worked well. What obstacles were encountered. How did it feel to play the patient? the practitioner?

Self-Determination Theory

Self-Determination Theory33 Purpose The initiation and maintenance of positive health behaviors is under the person’s control and therefore are highly dependent on self-care actions. Maximizing autonomy, competence and relatedness are essential for patients to be successful Contributions Human behavior plays an critical role in health outcomes and in the efficacy of treatments Practitioners can support patients by attending to their need for autonomy, competence, and relatedness Supports ethical ideals to empower patients to be active participants in healthcare decisions and actions

Autonomy, Competence, Relatedness33 What What Practitioners Practitioners Should Should Do Do and and Not Not Do: Do: Do More of These Support patients to explore resistances and barriers Give feedback Compliment mastery, skill Provide respectful, caring encounters Avoid These Suggesting incentives Motivating through authority Showing disapproval Over-challenging the patient beyond current capacity The patient/provider partnership is an important medium and vehicle for change.

Group Activity Self-Determination Theory Consider the Following Questions: How would you apply this theory? Where? When? How might this theory support an Integrated Health model? What circumstances might make it more challenging to apply? What types of responses would you anticipate from patients? family members? physicians?

In Closing Questions? Thoughts? Comments?

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