Promoting Optimal Self Care

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Promoting Optimal Self Care

• Dr Alf Collins
• Consultant in Pain Management Somerset

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Self Care in the NHS Plan (2000)
NHS
Primary Care
Intermediate Care
Self Care
Preventive Care
Secondary Care
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Self Care 2006
Self Care
Intermediate Care
Preventive Care
Primary Care
Secondary Care
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• Health and Social Services should empower people
  to live as fruitful and independent a life as
  they would wish

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A Whole Systems Approach to Self Care

• System philosophy promotes self care
• System structures promote self care
• Fuzzy edges making the membranes between
  health and illness more porous
• Ensuring we all try to have empowering
  conversations with people we serve

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About me.

• I am a full-time clinician and director of an
  integrated primary/secondary care pain management
  service
• In 15 years as a consultant, I have never got rid
  of anyones pain.

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Pain management
Managing life with pain
Managing pain
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Self-care and self-management
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Suffering
Expectation of others
Expectation of self
Idealised self
Hitting the expectation wall (Hitting the symptom
wall)
Self as is
Frustration, anger, anxiety Grief, loss,
impotence, despair
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Do-be-do-be-do the importance of self

• Many people define themselves by their (ability
  to carry out their) social roles and
  responsibilities (activities)
• Promoting optimal self-care means (amongst other
  things)
• helping people reappraise these roles
• and work on self-defining activity goals

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Goal-directed self-care
Reasonable goals Self-adjustment
Self-management skills acquisition
Acceptance Readiness to change
Best evidence disease/ symptom management
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Explanation, reassurance
You have 3 degenerate discs in your
spine. Dont worry the pain will ease when they
fuse
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Pain microfractures of healing (fusing) discs
Avoid pain and potentially painful situations
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Stopped work a year ago
Core identity threatened, key social and family
role lost
Less money family struggling
Despair, despondency, depression
Suicide attempt
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Promoting self care..
I believe your pain is caused by the muscles
doing more than they want right now. Gentle,
paced activity helps most people. Shall we talk
about ways we can support you in pacing yourself
into gently doing a little more over time?
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Self-care reinforced

• Non-pathological definition supports activity and
  self-efficacy
• Unambiguous description not open to
  misinterpretation
• Facilitative style shall we discuss rather
  than you should do

becomes
Potentially passive avoider
Active coper
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• Ensure front line staff receive appropriate
  training inprinciples of self-care
• Ensure professionals change the way that
  consultations are conducted in order to
• Develop a more equal relationship with patients
• Modify the way that people seek help by
  challenging their beliefs about their condition

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Principles of optimal self-care

• Biomedicine is a belief system that does not
  optimally support people with conditions that it
  cannot cure
• The relationship between the severity of any
  condition and HRQOL is complex
• Beliefs and expectations appear to be strong
  predictors of HRQOL, adherence to treatment and
  outcomes from treatment
• For people with longer term conditions, lifestyle
  change is inevitable being in a degree of
  control of the process is fundamentally important

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Biomedicine, impairment and disability
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Cellular pathology
Organ pathology (impairment)
Symptoms
Disability
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Impairment and disability
disability
Disabling conversations
Enabling conversations
impairment
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The psychology of living with a long term
condition
impairment
thoughts
symptoms
context, meaning
feelings
Afferent input
beliefs
Actions/behaviours
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The key role of beliefs

• To say that someone believes something is to say
  that they will behave in a predictable way in
  specified circumstances. Damasio 1999
• Belief is the mental scaffolding that supports
  the appraisal of new information. Dennett 2000
• Man is what he believes. Chekhov

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The self-regulatory model (Leventhal 1998)

• People respond to illness in a dynamic way, based
  on their evaluation of illness (illness
  beliefs/illness models/illness representations)
  and their understanding (beliefs) about
  healthcare.
• These illness models predict behaviours,
  adherence to healthcare advice and outcomes from
  healthcare interventions

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Overview of the SRM

• Health threats may be
• Internally generated (symptoms)
• Externally generated (diagnoses)
• This leads to illness representations
• What is it? How long will it last? What caused
  it? How will it affect me? What can be done about
  it?
• Associated with symptom/diagnosis labelling
• Does all this make sense? Is there a coherent
  story here? Does the doctors story fit with
  mine?
• Beliefs influence actions
• Im only going to do what the doctor says if it
  makes sense

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Disability Worried? Sick? Or worried sick?
Culture, development
symptom
Anxiety, fear
Worse symptoms at lower thresholds
Threatening illness beliefs
Doctors
Catastrophic thinking
Experience, conditioning
Disuse, Disability, Depression
Avoidance
The fear-avoidance loop
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The importance of beliefs
95 of patients with angina have unhelpful
health-related beliefs
Angina is a mini heart attack
angina at lower level of activity
deconditioning less efficient use of oxygen in
myocardium
reduce activity to prevent angina further
damage to heart
Lewin, B. 1997, Journal of Psychosomatic Research
43453-462
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Evidence?

• 95 of patients with angina have unhelpful
  health-related beliefs
• 87 patients waiting for CABG, challenging beliefs
  and winding back fear-avoidance cycle led to
• No angina in 30
• Significant reduction in angina in 70
• No CABG in 50
• Lewin RJ Heart 199982654-55

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The importance of change
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Change

• When people develop a LTC, lifestyle change is
  inevitable
• Being in a degree of control of the process is
  fundamentally important
• Many people look to healthcare interventions in
  order to obviate the need for change

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AmbivalenceWill I? Wont I?
The change agenda is big, unwieldy and.it changes
Selectively reinforcing self-professed change
statements is a fundamental skill for all
healthcare workers (MI style)
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Stages of change motivation to change behaviour

• Beliefs (about symptoms and treatment)
• Acceptance of symptoms

Pre-contemplation
How confident are you that you can do
this? What might hold you back?
contemplation
Self-efficacy
planning
Skills acquisition
action
relapse
maintenance
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Today and tomorrows healthcare workers

• Today
• Diagnostician
• Treater
• Healthcare advisor

• Tomorrow
• Diagnostician
• Treater
• Healthcare partner
• Educator
• Navigator
• Guide
• Change management specialist

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Its possible to have a good quality of life if
you have cancer. Its not possible if you are
depressed.
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Optimising self care is not a nice to know its
a need to know
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