Reprinted from "Self-Management" issue of Visions Journal, 2003, 1 (18), pp. 4-5
Self-management refers to an active engagement of the health care consumer in dealing with his or her disorder, meaning that the person with the disorder is an active participant in care, rather than someone who simply follows recommendations and complies with the treatment plan developed by a health professional. According to an organization that promotes care for chronic disorders, self-management is defined as follows:
Patients must take better care of themselves to keep their chronic illnesses under control, and need to be trained in proven methods of minimizing complications, symptoms and disability…But effective self-management means more than telling patients what to do. It means giving patients a central role in determining their care, one that fosters a sense of responsibility for their own health. Using a collaborative approach, providers and patients work together to define problems, set priorities, establish goals, create treatment plans and solve problems along the way.
In order for self-management of a disorder to be possible, the person needs access to appropriate information so that he or she can be sufficiently well-informed to participate actively in managing the disorder. This emphasis on access to health information contrasts with the older model in which the person relies entirely upon the health professional’s understanding of the disorder. The health care consumer, including those with mental illness, needs to learn not only the benefits associated with a particular treatment, but also information about potential costs including financial cost and the effort and skills that may be required in order to achieve those benefits.
Costs include any financial outlay associated with this treatment, as well as the relative expense of this treatment compared to others of equivalent effectiveness. Although a significant proportion of mental health clients have the cost of medications covered by government plans, it remains true that a substantial number of individuals receiving treatment from the mental health system, especially those receiving treatment for depressive or anxiety disorders, must themselves cover all or most of their medication costs. Furthermore, most of the cost of psychotherapeutic treatments such as cognitive-behavioural therapy are covered by individuals receiving the treatment. Therefore, a frank discussion of relative costs of therapeutically-equivalent treatment alternatives is necessary for patients to be able to actively participate in management of their disorder. Rational decision-making relies on balancing the costs and benefits of a course of action.
Skills or Practices Needed to Self-Manage Disorder
Effective self-management is not merely a matter of taking in clinical facts, but of acquiring particular behaviours required to manage an illness. One can readily see this for an illness like diabetes, where the patient must often learn how to self-administer tests of blood glucose levels. But a similar reasoning applies to mental disorders. There are skills and practices that have been shown in research to significantly enhance management of various psychological and psychiatric disorders such as relapse prevention in bipolar disorder, structured problem-solving in major depression, and relaxation training in generalized anxiety disorder.
In order for a person to be a truly active participant in the disease management process, he or she must also be informed about the rationale for a given option, which entails a clear explanation as to why this particular treatment — or, these treatment alternatives — is likely to be effective. Providing the person with a plausible explanation, even one that acknowledges gaps in our evidence-based knowledge, allows the individual to be an active participant in decision-making and gives a message of respect for this individual’s capacity to make important decisions about his or her own health. The role of the health professional in this regard is to give the person reasons to actively participate in treatment, rather than merely to elicit passive compliance with a treatment regimen.
Self-management strategies are well developed for some mental health problems: the profusion of self-help books for depression and anxiety reflects the number of research trials showing that self-management strategies can be very helpful for these disorders. In the area of alcohol addiction, research has shown the utility of self-management approaches for those with milder forms of alcoholism. For disorders such as schizophrenia and bipolar disorder, the development of self-management techniques are less developed, but there is an emerging recognition that individuals suffering from these severe disorders have an important role to play in management of the disorder. In particular, a promising approach is to work with affected individuals to identify strategies for recognizing the onset of relapse at an early stage and implement a plan to avert the episode or minimize its severity and impact. For example, a person suffering from bipolar disorder who realizes from warning signs that a manic episode is beginning can mobilize clinical or social support and substantially reduce the negative impact of this episode on his or her life.
Self-management is a crucial component of an approach to health care known as chronic disease management. This approach has become very influential over the past decade. It was initially developed to improve the care of chronic disorders such as diabetes, arthritis or asthma, disorders for which the traditional ‘cure model’ was inadequate. These are disorders where it is not simply a matter of making a diagnosis, applying the appropriate treatment, curing the illness and finally sending the patient on her way; instead, these chronic disorders involve recurrent episodes of illness, often with residual symptoms between acute episodes. Chronic disorders require an ongoing management plan that includes a coordinated response by health professionals, the patient and their family.
Only in the last few years has the chronic disease management (CDM) model been applied systematically to mental disorders. The first mental disorder to be approached in CDM terms has been major depression, but it can only be a matter of time before the CDM model is applied to anxiety disorders, bipolar disorder and schizophrenia. A number of mental disorders show the characteristics typical of chronic illnesses: recurrent episodes, residual symptoms, management rather than cure, and the need for active self-management by consumers and family members. Perhaps the CDM model will eventually become the dominant framework for mental health intervention.
But mental health problems raise a particular question from a CDM/self-management perspective: are individuals with psychiatric disorders able to participate meaningfully and effectively in self-management practices? Can they integrate the often-complex information that is available about mental disorders, make coherent and rational decisions regarding treatment options and acquire the self-care skills needed to manage the disorder? In particular, concern has been raised that individuals with psychological or psychiatric disorders might refuse effective treatments when these treatments would benefit them because of the impact the mental disorder has on their cognitive and emotional function. Concerns of this type have motivated an increase in the availability of involuntary treatment mechanisms such as compulsory community treatment (where an individual suffering from a mental disorder is required to comply with specific treatments in the community). One can argue that recourse to compulsory community treatment lies at the other end of a care continuum from self-management initiatives.
My view is that we must first acknowledge that individuals in the throes of an acute mental health crisis such as severe depression or paranoid psychosis may be incapable at that time of grasping relevant information or balancing the costs and benefits of treatment options; furthermore, certain individuals experience a degree of ongoing psychiatric/psychological disturbance that substantially impairs their capacity to actively participate in management of the disorder. However, one must not go too far in doubting the capacity of individuals with mental disorders to engage in self-management. Most people with mental illness, most of the time, are quite able to comprehend clearly-explained information, apply this information to making rational decisions and acquire skills needed to manage their disorders. Individuals with mental disorders have considerable and largely-untapped capacity to engage in self-management practices, to function as an integral part of the disease management process.
In order to show what self-management looks like in practice, let me describe a self management tool for depression that has been in development for the past two years. The Self- Care Depression Program is a self-help manual for depressed individuals written by two psychologists (Dr. Randy Paterson and me), as a way of providing depressed individuals with knowledge of depression and strategies to gain better control of depressive symptoms. It was developed as a project of the Mental Health Evaluation and Community Consultation Unit at the University of British Columbia. The self-management strategies explained in this manual can be used as a sole approach by individuals with mild to moderate depressive symptoms or used in combination with evidence-based depression treatments, such as antidepressant medication or cognitive-behavioural therapy, for more seriously depressed persons. The Self-Care Depression Program was designed to be concise, clearly written, evidence-based, and fairly straight-forward to apply in a step-by-step manner.
Besides clearly explaining the biopsychosocial model of depression, the Self-Care Program provides instruction in applying the skills of:
Depressed individuals typically reduce their levels of activity in the areas of self-care, social involvement, personal projects and fitness. This can be changed by learning to set action goals that are feasible, specific and gradually increased.
Depressed individuals often have difficulty with effective problem-solving, tending to overestimate barriers, underestimate personal resources, and to plan action in an unsystematic way. This can be changed by learning to apply a structured problem-solving strategy.
Depressed individuals usually think about themselves, their current situation and their future prospects in an unrealistically negative and unfair manner. This can be changed by a method known as cognitive restructuring, through which one learns to identify these distorted beliefs, challenge them systematically and replace them with more fair and realistic beliefs.
We did not want any depressed person to lack access to this self-management tool because of cost barriers, so we made the manual available free-of-charge and accessible via PDF at www.mheccu.ubc.ca/publications. Furthermore, we encourage any individual or health professional to copy this manual and distribute it as widely as possible.
I predict that someday all individuals with psychological or psychiatric disorders will be offered self-management training delivered through manuals or workshops. When individuals who have suffered from mental disorders and their families discover the potential benefits of active participation in care, they may come to expect self-management support from the mental health system. This kind of expectation from consumers of mental health services, combined with gradual implementation of a chronic disease management model, may well revolutionize the delivery of mental health care in this province.
About the authorDan is a psychologist who works in the Psychiatric Assessment Unit at Vancouver Hospital and also serves as a consultant with the Mental Health Evaluation and Community Consultation Unit, a mental health services research group at UBC. His publications have been in the areas of evidence-based mental health practice and emergency psychiatry. He is the co-author of the Self- Care Depression Program