While I intertwine many approaches to care, I devote a lot time building self-efficacy through strategies for self management. In this blog, I will explore active strategies specifically because, while passive strategies such as education can be tailored to the individual to be more relevant, they don’t carry the same evidence of support as active cognitive and behavioral approaches. Psychologist Dr. Thomas L. Creer is considered one of the first to establish and develop the concept of self-management for children with asthma. He grew his theories as an extension of Bandura’s self-efficacy writings. He later expanded his work across other conditions. Implicit in self-management approaches are themes of agency, mindfulness, acceptance and commitment therapy, cognitive behavioral therapy, and biopsychosocial components.
Consistent elements of strategies for self management include:
-self-efficacy building/feeling empowered
-self-monitoring of symptoms
-goal setting
-action planning
-shared decision making
-problem solving/resource utilization
-self-tailoring/self discovery
-support (therapeutic alliance with practitioners and relationships with significant others.)
Do not assume that people with like diagnoses, or like cultural or racial groups all have the same needs. That being said, I do make sure I ask about all domains with informed cultural competence. Be mindful not to make assumptions about resources or skills a person possesses.
Reducing pain interference through self-management allows individuals to persist in valued tasks longer. This can lead to greater satisfaction of task completion versus task interruption. Increasing activity tolerance by reducing pain interference is a common goal. It is important to know that targeting self-management can improve this. A reduction in pain intensity may occur, but is not the metric of success here. Improved hopefulness, activity tolerance, engagement, and joy are.
In my last blog (here) where I discussed self-efficacy through my mom’s pain experience, self discovery was a consistent theme. She was always exploring options for relief. In this way, the patient can become their own pain clinician. Even small amounts of success with a strategy can help foster empowerment. This process is a salient enabler of strategies for self-management. With strategy utilization, a person can begin to learn that taking an action or changing their thought pattern can have an impact on how they feel. It can reduce a person’s sense of helplessness, and encourage them to keep developing strategies. If you ascribe to neuroplastic and predictive processing models of pain, then self-discovery could also be considered relevant for novelty and repetition for neuroplastic change and updating expectations of an internal model. Repetition is important for learning.
Once we have an idea for a strategy, we practice it in the clinic, together. It allows the person to trial the strategy in a supported way. We can tailor it to the individual and make modifications if we need to. The purpose of this is to help give a sense of some initial success. We can have a conversation about the various ways and opportunities in which the strategies can be used and reduce barriers to implementation. Initially I suggest using a strategy as much as they believe they can do it. I don’t place demands on this. I don’t want to promote guilt or shame. It can be useful to ask how confident a person is that they can implement a strategy. You can ask this as a percentage or as a 0-10. If they state below 7/70% then problem solving is necessary to find an approach that they are more confident in. Upon their return, I ask “Did it work for you? How did you feel when you used the strategy?” Did the person find success with it, experience barriers, or not like it altogether?
Feeling supported by a person’s network and clinicians is a feature of successful strategies for self-management. Shared decision making, and problem solving are elements of this. Strategies must address problems that the person identifies as important. Strategies should be designed individually. I do not use canned strategies for this reason. I do not have pre-printed instructions for strategies. Strategies are always developed with the individual. I want to keep shared decision making and problem solving prominent. There are plenty of studies that focus on specific strategies of breathing and exercise, but I want to center the patient and explore their values and interests with them. Instead of introducing something new and perhaps unwelcome or forced, I’d rather start with a known high value target.
I always start with “finding joy.” I ask people what they really love. Something that makes them happy or smile. Perhaps something that they really miss. It can be anything, nature, a past time, a television show, a past experience. And then I harness whatever that thing is. Does the patient have pictures from a favorite vacation that they can go back and look at? Do they love sunsets? tall buildings? looking up under a tree canopy? I go online and search for images of whatever it is. If there are people in the images I make sure to match the person’s demographics to my search terms. I look through the images with them, putting their favorites in a document and printing them in color and emailing them if the person has email. I make it as easily accessible as possible. After doing this, I ask how the person feels. Sometimes I hear a simple “I liked it”, “It made me feel relaxed”, or “I was able to forget about my pain.” What is important to highlight is that whatever that thing was that they were viewing, helped them to experience less distress and felt positive to them. This process can be quick, I find that even when I’m seeing someone for an initial evaluation I have time to do this. Sometimes after a few visits they are able to tell me that they didn’t even need to look at the physical images anymore. They could recall the image and experience the joy and relief from them. I sometimes utilize these images for graded exposure if this is something the person needs. I’ve had people identify if the flower was leaning right or left, what direction was the puppy looking, is that the right leg or left leg etc.
A person I saw recently, identified swimming and floating and a past vacation in the Caribbean as something that makes them really happy. They would talk about the color of the water, the weightlessness, the sun etc. This person also really loves animals. Did you know there are pigs that swim in the Caribbean? I pulled images up and this individual could not stop smiling at the swimming pigs. We searched images on the internet that highlighted this, and got even more specific as she saw images and noted what she liked about them. Maybe it was a particular shade of blue, the animals expression, whatever it is. I printed the images out and emailed them. I advised to look at them daily, and in particular when a flare up begins. They were excited to do this as they really liked the images that were found. The next visit the person told me that imagining floating consistently delayed flares by ten minutes and that they felt more relaxed when viewing the images. This helped the person learn that they have the ability to influence symptoms proactively. It helped them feel that they had tools to better manage, and derive joy.
Multiple studies address the value of follow up sessions after the initial bout of care to better support problem solving through shared decision making to address these concerns. I will sometimes email or call a patient after they have been discharged from my care, to check in with them. Sometimes they feel they may be ready for the next evolution in their goals or feel they have had a setback and need some support to get back on track. This is normal, they have not failed if they experience this. This sense of support and partnership is highly valued by my patients. Self-management is a continuum. Helping people develop this understanding helps with acceptance, empowerment, thoughts of helplessness, self love, and feeling supported.
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