Whole Person Integrated Care (WPIC) IEEE Presentation

A Healthcare Transformation Strategy Supported by a Novel Spreadsheet-Based Software Framework

I will be presenting at the IEEE Global Humanitarian Technology Conference (GHTC) in San Jose on Oct. 20, 2017. GHTC focuses on bringing together people to address critical issues for the benefit of the people around the globe through the deployment and application of humanitarian technologies.

The presentation will describe a healthcare transformation strategy called Whole Person Integrated Care (WPIC). I will discuss how WPIC couples a novel Spreadsheet-based Software Framework (SSF) and a care delivery model that focus on increasing efficiency and effectiveness through evidence-based knowledge and action.

This strategy: 1) integrates “sick care” (treatment of health problems) with “well care” (prevention and self-management) and 2) addresses both physical and psychological problems affecting a patient’s health. The SSF currently utilizes Microsoft Excel to create simple, low-cost, and flexible software solutions that capture, import, export, transform, integrate, organize, store, analyze, render, and exchange data and information. Using a node-to-node (point-to-point) network architecture, clinicians, researchers, patients, and others can connect securely and resiliently, anywhere and anytime, across national and organizational boundaries. This allows collaborators to build, share, evaluate, and evolve evidence-based knowledge and analytic models. The shared knowledge and models are used to make projections, reveal existing problems, identify risks, and offer solutions that support decisions for clinical and business process improvement. 

Included will be a live demonstration of an SSF application recently piloted in a Federal health information technology program, a review of existing SSF tools, and a proposal for an open source community to enable the SSF to develop apps that work on all platforms and devices.

Case for a Collaborative Health-Support Software System - Part 2 of 3

In my previous post, I presented a case for using collaborative health-support software systems in loosely-coupled networks of healthcare professionals and consumers. This post focuses on how to implement such systems and networks in a way that increases value to the consumer.

How Using Health-Support Software in Loosely-Coupled Networks Promotes High-Value Care

When people use health-support software in loosely-coupled networks, they increase care value by:

• Fostering coordinated care
• Delivering consumer-centered cognitive support
• Sharing decision-making.

Fostering Coordinated Care

Coordinated care is a strategy for ensuring that consumers being treated by multiple providers in loosely-coupled networks—including primary care physicians, biomedical and mental health specialists, and wellness coaches—who work together in a synchronized manner to deliver high-value services. Methods for implementing this strategy include the use of personalized health-support software to deliver whole-person integrated care and support medical home deployment.

Using Personalized Health-Support Software

Healthcare providers delivering coordinated care in loosely-coupled networks require different types of health-support software. That's because providers in the network typically work at different locations, use disparate information systems, and are from different healthcare disciplines that require different health information. For example, a primary care physician, being a generalist, needs a broad spectrum of patient information covering patients' biomedical, psychological, and environmental factors (including data about current medical conditions, medications being taken, allergies, vital signs, basic lab results, medical history, stress and other emotional factors, etc.). While all providers would benefit from similar information, a specialist would benefit from a more in-depth sub-set of data related to their area of specialization.

A cardiologist, for example, would benefit from data related to heart functioning.[1] A dentist would benefit from data about previous dental work done, dental x-rays, existing medical conditions affecting teeth and gums, etc. A mental health practitioner would benefit from detailed information about the relationship between a person's thoughts, emotions, and behavior, as well as psychosocial data, etc. A holistic (integrative/integrated medicine) practitioner would benefit from addition information about the mind-body connection, metabolic functioning, etc. Furthermore, the consumer would benefit from a personal health profile report that includes risk-appraisal, current health status, and self-management information in lay language. That means successfully coordinating care requires use of many different health-support software in loosely-coupled networks.

In other words, health-support software should be personalized, that is, tailored to each person's particular requirements.

Delivering Whole-Person Integrated Care

Delivering whole-person integrated care has two components:[2]

1. The whole-person part focuses on improving a person's health and wellbeing by addressing one's physical health (body), mental/psychological health (mind), and the mind-body connection ("holistic" health). In other words, it views an individual as a whole entity, whose body and mind are interconnected.
2. The integration part refers to integrating well-care with sick-care. Instead of viewing sick-care (treatment of illness and dysfunction) and well-care (preventions and self-management of chronic conditions) as two separate avenues in the road to health, sick-care/well-care integration refers to an integrated care delivery system.
   Instead of viewing sick-care and well-care as two separate avenues in the road to health, this integrated approach involves a new kind of coordination and collaboration between (a) medical and related sick-care practitioners focused on the diagnosis and treatment of health problems and (b) well-care practitioners focused on prevention, recovery and well-being, as well as peak performance.[3]
   

An example of the whole-person integrated care approach is when people with chronic illnesses receive care from their medical providers, along with coaching, instruction and social support from a health education and support program. While the people's doctors deal with medical issues (including medical procedures and medication subscriptions), the health program focuses on enabling and motivating the individual to self-manage chronic conditions (such as diabetes) by developing healthy attitudes and beliefs, emotions, coping strategies, psychosocial relationships, and life satisfaction, as well as gaining essential awareness, knowledge and skills.[4]

Since this type of whole-person integrated care involves multidisciplinary teams of providers, as well as the consumer's social connections, the individuals involved form a loosely-coupled network. The health-support software they use, therefore, should focus on:

• Giving the providers timely information about consumers' progress and blocks
• Enabling the professionals to collaborate easily and efficiently
• Sparking helpful conversations among the social networks
• Educating and instructing the consumers, as well as providing ongoing health status feedback.

Deploying Medical Homes

Instead of a fragmented healthcare delivery system as exists today, continuity of care through medical home makes a person's primary care physician responsible for coordinating the services rendered by the multidisciplinary team of providers working with the person.[5][6] Health-support software for medical homes[7] focus on enabling the providers to know what each other is doing, their care the deliver is better connected, which helps improve quality and reduce costs by avoiding duplication of tests, medication conflicts (e.g., due to drug-drug interactions[8]), inappropriate or conflicting procedures, etc.

Delivering Consumer-Centered Cognitive Support

Consumer-centered cognitive support assists healthcare providers and consumers in finding useful answers, making valid health decisions, collaborating effectively, and taking competent, responsible action. This support increases care value through use of collaborative health-support software that:

• Analyze and help interpret voluminous, complex diagnostic, treatment, and outcomes data
• Identify existing and threatening physical and mental health problems
• Search for scientifically validated options (diagnostic, treatment and preventive)
• Help develop high-value (effective and efficient) plans of care
• Enable loosely-coupled networks of providers, consumers and researchers to share and discuss lessons learned (e.g., observations, insights, hypotheses, explanations, and anecdotal information)
• Continually evolve clinical knowledge by providing ongoing process and outcomes data to researchers for evaluating, building and modifying evidence-based guidelines.[9]

Promoting Provider Competence

Collaborative health-support software can promote provider competence by delivering consumer-centered cognitive support information. That is, provider's diagnostic and treatment decisions, and the implementation of those decisions, can be supported and improved through by the software's data analyses, care-plan assistance, and evidence-based guidelines.

Promoting Consumer Competence

In addition to assisting healthcare providers, consumer-centered cognitive support helps consumers acquire the knowledge, skills, and characteristics needed to make wise decisions and act in ways that improve one's health and wellbeing.

For health-support software to promote consumer competence, it should collect and analyze comprehensive, valid, reliable (complete, accurate, and dependable) data. These data are facts and figures, collected on multiple occasions (over time), which include:

• Internal biological measures (biometrics) such as height, weight, blood pressure and other vital signs, cholesterol level, blood glucose and other blood component levels, imaging studies and lab tests, illnesses, allergies, genetics, etc.
• Psychological measures of mood and emotions, cognitions (thoughts and beliefs), behaviors (e.g., exercise, eating, sleeping, smoking, substance and alcohol use), social relationships, learning styles and (dis)abilities, significant past experiences (e.g., memories, traumas), etc.
• Healthcare treatments, including medications taken, procedures received, and their outcomes
• Preventive actions, such as inoculations, wellness coaching, and health education
• Demographics, which include age, gender, finances, ethnicity, etc.
• Environmental conditions, past and present, including neighborhood crime levels, pollution, etc.

All these data must be analyzed using valid computational methods that generate actionable information that helps consumers make valid predictions, build useful knowledge and skills, make sound decisions, increase positive motivation, improve physical health, and have greater peace of mind (e.g., reducing mental stress and emotional distress). This information should include:

• Trends and tendencies, which give insights into what is likely to happen in the future by studying what has been happening in the past and in the present
• Associations (relationships, interactions) showing the connection between body, mind and behavior
• Warnings and alerts indicating, for example, when it's time for a medical check-up or inoculation, when there are possible drug-drug interactions a person is having serious medication side-effects, if one's lab tests indicate a health problem, etc.
• Guidelines and instructions informing a consumer about how to deal with a risk factor or health.[10]

Sharing Decision-Making

Shared decision-making occurs when healthcare consumers are able to make knowledgeable decisions about their own care in collaboration with their providers. It reflects the principle of self-determination and involves respecting people's right to define their own view of what is good for them and to pursue that view, as well as to give others the authority to make particular health care decisions for them. To make shared decision-making successful, healthcare providers must not only to understand consumers' needs and develop reasonable ways to meet those needs, but they must also present the alternatives in a way that enables consumers to make a knowledgeable choice. They must also take into account consumers' attitudes, preferences, and values.[11]

The Center for Shared Decision Making[12] employs decision-making coaches who use various decision-making aids, including pamphlets and videos, to help consumers examine and weigh their options about tests and treatments. Collaborative health-support software can be useful in shared decision-making by offering similar, computer-generated information to loosely coupled networks of coaches and consumers.

To summarize: High-value care—both provider-supplied and self-care—relies, in part, on the use of continually evolving, personalized, health-support software in loosely-coupled collaboratives to:

• Foster coordinated care
• Deliver consumer-centered cognitive support that promotes competent both professionally-rendered care and self-care
• Enable shared decision-making.

In my next post, I'll introduce and describe the first collaborative health-support software system.

References and Notes:
[1] Data useful to a cardiologist includes the location of chest pain, ST elevation or depression, Q waves or left bundle branch block, T wave inversion or hyperacusis, CKMB and Troponin T or I levels, and heart imaging studies, etc.
[2] http://curinghealthcare.blogspot.com/2008/02/patient-centered-life-cycle-value-chain.html
[3] http://wellness.wikispaces.com/Tactic+-+Well-Care+Sick-Care+Integration
[4] http://curinghealthcare.blogspot.com/2008/12/whole-person-approach-to-diabetes.html
[5] http://coordinatedhealthcare.com/index.php/hcnews/1-medicalhome.html
[6] http://wellness.wikispaces.com/Tactic+-+Implement+the+Advanced+Medical+Home+Model
[7] http://www.nhds.com/ccrplus.html
[8] http://www.fda.gov/cder/consumerinfo/druginteractions.htm
[9] http://curinghealthcare.blogspot.com/2009/01/consumer-centered-cognitive-support.html
[10] http://curinghealthcare.blogspot.com/2009/02/competent-healthcare-consumer.html
[11] http://bioethics.gov/reports/past_commissions/making_health_care_decisions.pdf
[12] http://www.dhmc.org/shared_decision_making.cfm

A Whole-Person Approach to Diabetes Health Education Part 4 of 4

In my last post, I discussed the effect of mental stress and personality characteristics on a diabetic people's ability to control their blood glucose levels. In this post I focus on the role of health information technology in support of health education programs.

The Role of Health Information Technology

What do people with diabetes (and other chronic conditions) need in order to overcome their psychological obstacles and promote healthy living? As previously discussed in this paper, they must have adequate knowledge and understanding, positive emotions, rational attitudes and beliefs, effective coping skills, and motivation. That means they not only have to be aware of their physical health problems and ways to manage them, but they must also be aware of how their mental health (attitudes, emotions and mental stress) affects their blood glucose and how to control it. Achieving this daunting goal requires health coaching and counseling, of course.

The coaching and counseling services can be enhanced through interactions with other people and use of health information technologies. These people may be healthcare professionals, family and friends, and even "virtual acquaintances" through Internet-based social networking (e.g., peer-support groups). The health information technologies include web sites, educational software, psychologically-based self-help software tools, and personal health records (PHRs).[1]

Unfortunately, we are in the "Stone Age" when it comes to most health information technology. Current day PHRs are not very useful to the typical consumer/patient, and could be much more useful to professionals.[2]

What is needed is an easy, low-cost way for comprehensive physiological and psychological data to be transformed into useful personalized information. This information should increase people's awareness of their current health status and risks, as well as provide information that increases their ability to manage their diabetes. Today's PHRs are very immature regarding these types of capabilities.

By way of full disclosure, I've been developing such a health information software program for over two decades, called the Personal Health Profiler™ (PHPro™). The PHPro is a major departure from the kinds of PHRs in use today. It promotes more rapid and complete understanding of a person's physiological, psychological and mind-body functioning and risks; it provides ongoing feedback and instruction; and it helps a person developing effective coping strategies. The information presented by the PHPro comes from analysis of detailed data about the relationships between a person's:

• Internal dynamics—including coping skills, problematic physical signs and symptoms, co-existing illnesses, emotions, mental stress, and cognitions (attitudes, beliefs, expectations, etc.).
• Behaviors—including diet, exercise, alcohol and substance use, sleep, etc.
• External influences/causes—including stressful interpersonal relationships, stressful and unhealthy physical (e.g., work, living) environments, economic pressures, etc., as well as supportive conditions that promote good health.
• Medications—including possible side-effects, drug-drug interactions, and precautions.
• Demographics—including gender, age, ethnicity, socioeconomic status, etc.

In addition, the PHPro provides these essential functions:

• "Pushes" targeted information to consumers and professionals to fill knowledge gaps and increase understanding, instead of requiring that the information be "pulled" by them. This means exceptional "findability;" that is, navigating to and accessing relevant information is a breeze compared to the complex and often convoluted process required to obtain and filter desired information from typical web portals and search engines.
• Identifies key life stressors and health risks, as well as a person's underlying attitudes, beliefs and emotions, which help focus coaching and counseling efforts, and improve self-management.
• Delivers warnings, alerts and other essential feedback, so necessary adjustments can be made to plans of care in a timely manner.
• Uses a structured, personalized coping strategy methodology that helps a person attain more adaptive coping skills.
• Identifies potential medication side-effects, drug-drug interaction, and precautions to minimize prescription errors and manage problematic medication issues.
• Supports well-care/sick-care integration.[3]
• Continually evolves using flexible software modules, data sets and algorithms that are all transparent and easily modifiable.
• Accommodates any current and future data and technology standards.[4]
• Continually feeds a knowledge base with de-identified personal health information to support research efforts for continually improving care effectiveness.

These capabilities make the PHPro a useful tool supporting a whole-person approach to diabetes health education.

International Diabetes Health Education Program
I am honored to be part of an international, interdisciplinary group that has been collaborating for about eight months on developing integrating whole person health information technology, social support, and health coaching and education. Our efforts aim at enabling and motivating diabetic people to manage their condition effectively by developing healthy attitudes and beliefs, emotions, coping strategies, psychosocial relationships, and life satisfaction, as well as gaining essential awareness, knowledge and skills.

I will discuss more about this exciting collaboration in future blog posts.

Conclusion

Effective self-management of diabetes (and other chronic illnesses) is difficult for many individuals because it involves a complex interaction between both psychological and physiological (mind and body) factors. A whole-person approach to diabetes health education is therefore important. It combines self-care instruction, coaching and counseling, and innovative health information technology tools to build knowledge and competence, establish effective coping skills, and motivate diabetic people's motivation by helping overcome psychological obstacles.

References:
[1] National Guideline Clearinghouse. 2006 May. Available at this link
[2] Beller, SE. Health Information Technology: Past Predictions, Current Reality, and Future Potential - Part 1. 2008 Nov. Available at this link
[3] Beller, SE. Well-Care Sick-Care Integration. Available at this link
[4] Beller, SE. Art of Health Knowledge Creation and Use. Available at this link

A Whole-Person Approach to Diabetes Health Education Part 3 of 4

In my last post, I began an in-depth examination of the psychological factors influencing blood glucose control, starting with the effects of emotional depression and effectiveness of one's coping skills. In this post I focus on the effect of mental stress and personality characteristics.

Mental Stress and Diabetes Management

Health Effects of Stress
Prolonged mental (emotional, psychological) stress can cause persistent high blood glucose levels. Mental stress can be caused by many different things, including problems in one's marriage, job, health, or finances. When people are anxious, angry, guilty or ashamed about such problems, their mental stress triggers the "fight-or-flight response" in their bodies. This automatic response prepares their bodies to take action to deal with a perceived danger by fleeing from it or attacking it, even if those problems pose no real physical threat.

In preparation for the threat, various hormones (including adrenalin, noradrenalin and cortisol) surge through the body. This biological process raises blood glucose levels in order to increase one's energy level to help handle the threat. Since diabetic people have insufficient or ineffective insulin, the glucose piles up in the blood and can result in persistent hyperglycemia. This rise in blood sugar under mental stress almost always happens to people with Type 2 diabetes, although it may be mixed in Type 1 diabetics (i.e., blood glucose levels rise for some and drop for others). Physical stress (such as illness or injury), on the other hand, causes higher blood glucose levels in people with either type of diabetes.

Another way mental stress can raise blood glucose levels is by interfering with one's self-care. For example, any diabetic person (Type 1 or 2) who is under mental stress may drink more alcohol, use illicit drugs, exercise less, forget (or not have time) to check one's blood glucose, fail to plan proper meals, etc.

Mental Stress Reduction Methods
Learning to control one's mental stress is therefore very important. Some people find relaxation therapy helpful. Relaxation techniques may include breathing exercises, progressive relaxation, exercise, and positive thinking. Another way to reduce mental stress is to develop more effective coping skills. And still another is to change some of the things in one's life that are creating stress.
Stress reduction methods can be learned by reading self-help books and listening to recording, meditating, receiving psychological counseling, obtaining assertiveness training, joining a support group, etc. The benefits of stress reduction on lowering blood glucose are clearest with Type 2 diabetes since stress blocks the body from releasing insulin. But even those with Type 1 diabetes can benefit from reducing their stress levels because it can help them take better care of themselves.[1]
Helping people deal with their mental stress in diabetes health education programs is, therefore, another way to improve outcomes.

Personality Characteristics and Diabetes Management

How well a person manages his or her health, including diabetes and other chronic conditions, can be understood in terms of four health personality types: Activists, Wannabes, Inactives and Ignorers/Deniers. Each personality type has its own set of attitudes, beliefs, emotions, motivations, and behaviors.

Activists
Activists' attitudes about managing their health can be expressed by the attitude: "I believe I can do whatever must be done, and I'm willing to do it!" This positive, adaptive way of thinking reflects a joy of living and a willingness to manage one's health competently.
In terms of their character traits, Activists tend to be confident, motivated, aware, rational, and assertive. They seek knowledge about their health status and risks to help them make wise decisions and take responsible action. They try to understand how to avoid health problems and self-manage chronic conditions by using their knowledge to live healthily. Activists, therefore, are rational people who manage their physical and mental health using positive, proactive coping strategies, such as:

• Trying to understand what caused the problems and thinking of different ways to handle it.
• Determining what has to be done to manage their condition and then adhering to an effective plan of care.
• Talking to people about what they are going through and seeking advice or help.
• Viewing their health problem as something that helps them change or grow in a good way.
• Rationally accepting that their condition cannot be cured, which minimizes their emotional distress while motivating them to do what is necessary to avoid complications.

The more a diabetic person's character traits resemble an Activist, the more likely he or she is to manage the condition effectively.

Wannabes
A second group of individuals is the "Wannabes" (want-to-be). Wannabes think and talk about improving their health and wellbeing, and are willing to learn about healthy living, but they never seem to act on it, or do so half-heartedly. This is because they tend to have attitudes and beliefs such as:

• "I may be able to do what's required to improve my health, but I'd rather not deal with it right now."
• "I'm not sure what to do."
• "I'm just not ready."

As a result, Wannabes tend to be aware—or are willing to be aware—of their health problems and risks, but they lack the self-confidence and motivation they need to actually do something about it. Their self-doubt and lack of drive may come from the belief that they may not be able to do things the way they should. This uncertainty, in turn, may cause them to avoid making decisions and changing their behaviors for fear of failure; they don't want to be ashamed or embarrassed if they try, but do not succeed.

Wannabes, therefore, tend to cope with their doubts and fears through avoidance. For example, they may:

• Try to feel better by doing enjoyable or interesting things, rather than focus on managing the health problem.
• Act as if there is no problem, or try not to think about it.
• Express negative emotions by yelling or crying, taking it out on others, or avoiding certain people, rather than doing something constructive.
• Hope a miracle will somehow make things better or that one's wishes or prayers would be answered, rather than gaining knowledge and self-managing their health problem.
• Resign themselves that nothing can be done, even though this is an erroneous assumption.

While some of these coping strategies may alleviate their emotional distress temporarily, it is a maladaptive in the long-term since it fosters procrastination. Their inaction, in turn, allows their health to deteriorate. Nevertheless, there are several positive aspects of the Wannabe personality.
Since Wannabes think and talk about improving their health and wellbeing, they may be willing to participate in a whole-person diabetes health education programs that help them gain knowledge about their health problems and risks, as well as help them understand how to manage their diabetes. And they may be agreeable to wellness coaching and counseling offered through the program, which focuses on overcoming their self-defeating psychological obstacles and developing more adaptive coping strategies. Useful health information technologies would also help them gain the knowledge and skills they need. The goal is to help them become more like the Activists, so they will be motivated, capable, and psychologically prepared to manage their diabetes.

Inactives
A third personality type is the "Inactives." They think about their health on occasion, but do not believe they should or can do anything to manage their diabetes. This is because they tend to have attitudes and beliefs such as:

• "I doubt I'll be able to do what's required to improve my health and prevent complications, so why even bother."
• "I don't deserve to be sick…it's not my fault…so why should I have to be the one to do anything about it"—or—"I do deserve to be sick…Illness is my punishment…I'm just getting what I deserve."

Inactives, therefore, doubt that they can deal effectively with their health risks and problems. Some of them also believe they do not deserve what has happened to them, which makes them feel resentful and angry. The mental stress this causes not only distracts them from focusing on constructive health improvement activities, but it can actually raise their blood glucose levels as discussed earlier. Some Inactives, on the other hand, may believe they deserve to be sick due to self-loathing, or there is no hope and they are doomed.

The result is that the Inactives, like the Wannabes, lack the self-confidence and motivation they need to improve their health and manage their diabetes. What makes Inactives less likely to change their unhealthy lifestyles is that:

• Their self-doubt is stronger because it comes from the belief that they are not able (rather than may not be able) to do what is necessary to manage their health effectively.
• Their inertia (inaction) may be exacerbated by (a) fear that they will be shamed if they try to manage their health but fail, (b) the belief that there is no good way to manage their health, and (c) despair related to the belief they deserve to be ill.

The end result is poor management of their diabetes.

The way Inactives attempt to cope with their pessimism, fear, anger, resentment, and despair is similar to the negative avoidance strategies the Wannabes use. And, as with the Wannabes, the maladaptive coping strategies of the Inactives may alleviate their emotional distress temporarily, but hurt them in the long-term since their inaction allows their health problems to worsen.
Nevertheless, since Inactives think about their health and wellbeing on occasion, it is possible for them to become more focused and motivated through the help of wellness coaching, counseling, and useful health information technologies. They may, for example, be willing to gain greater knowledge about their problems and learn constructive strategies for dealing with them. And they may be willing to get help to use the knowledge they gain to self-manage their diabetes by helping them:

• Overcome their inertia, changing their self-defeating psychological obstacles (including self-doubt, fear, anger and shame)
• Replace their negative avoidance-based coping strategies with the positive strategies of the Activists.

Ignorers/Deniers
"Ignorers/Deniers" just don't focus on their health. These people "close their eyes and ears" to information about healthy living. They refuse to acknowledge or accept they have health problems or risk factors; or they refuse to do anything about it. These maladaptive behaviors are a consequence of a self-destructive mindset that includes attitudes and beliefs such as:

• "I do not accept there's a problem with my health" – despite convincing evidence to the contrary.
• "I'm fine the way I am … It doesn't matter what others say" – even though their health is deteriorating, relationships are crumbling, and overall quality of life is suffering.
• "I'm different … I'm special … I'm not like those other people … Nothing's going to happen to me!" – false sense of security and invincibility.
• "I don't trust doctors" – an attitude based on gross overgeneralization.
• "Getting help is a sign of weakness ... A strong person handles one's own problems" – an irrational belief driven by pride and based on distorted measure of self-worth.

Ignorers/Deniers, therefore, differ from the other personality types in important ways. Following are some examples:

• The three other types of individuals think about their health and, when confronted with a health problem, many question whether they are able to do what is necessary to improve things, which may make them feel anxious due to self-doubt. Nevertheless, they may be willing to learn and act responsibly despite their anxiety and doubt. Many Ignorers/Deniers, however, are so terrified by the notion that their diabetes may lead to serious complications that they avoid thinking about their health—preferring, instead, to pretend everything is all right. As a result, Ignorers/Deniers may refuse to accept the reality of their situation, even when confronted with the threat that they are likely to die from their health problems, because such possibilities are just too painful to consider. Although this denial and self-deception may keep their fear in check for a while, their inaction and ignorance makes them very vulnerable to worsening health.
• If Ignorers/Deniers did think about their health, many would feel hopeless and helpless, believing they are incapable of managing their illness effectively. And those who portray an air of invincibility are likely covering up great self-doubt and fear; or they may even be delusional.
• Some Ignorers/Deniers may also be so distrustful of the healthcare profession that they won't even consider seeing a doctor, often until it's too late.
• While health problems may cause other personality types to become sad, or even depressed, for a time, they are able to get themselves motivated and begin to take constructive action because they want to live and be happy. Ignorers/Deniers, on the other hand, may be so lonely and depressed that they believe they have nothing for which to live. For them, the prospect of living longer in chronic emotional pain isn't motivating. This prevents them from having the drive and focus needed for constructive action.
• While other individuals are willing to get help when they need it, Ignorers/Deniers may have been so influenced by their cultures that they believe seeking assistance for personal problems is a sign of weakness.
• Unlike the other personality types, Ignorers/Deniers may have physical addictions or powerful psychological compulsions that prevent them from focusing on healthy living until they reach "rock bottom," which, unfortunately, may be too late.

What this means is that Ignorers/Deniers rely on some of the same maladaptive coping strategies as the Wannabes and Inactives.
Because these thoughts, feelings and reactions are so deeply ingrained in their personalities, getting through to Ignorers/Deniers is very difficult. However, all is not lost! Through wellness coaching, counseling, innovative self-help software, they may be influenced by the "reframing" methods discussed earlier.

Dealing with a person's lack of trust may require intervention by a wellness coach or counselor who takes the time to establish a close, positive relationship with the Ignorer/Denier, and who has the knowledge and experience to gain the person's confidence.
As for Ignorers/Deniers with addictions or compulsions, lengthy psychotherapy (and possible medications) may be needed before they acknowledge their problems and are willing to deal with them.

In diabetes health education courses, wellness coaches and counselor should begin by focusing on helping Ignorers/Deniers understand and reframe their maladaptive beliefs and attitudes. This will enable them to be more open to gaining knowledge and awareness of their diabetes. Innovative health information technologies that help focus and entice them to break through their negative mindsets and resistance would also be helpful. Once Ignorers/Deniers stop deceiving themselves, have a stronger desire to live and enjoy life, gain trust, are more aware and open to receiving help, and are no longer controlled by their addictions/compulsions, they can be treated as Inactives or Wannabes as appropriate.

In my next post, I discuss the role of health information technology supporting innovative diabetes health education programs.

References
American Diabetes Association. Stress. See http://www.diabetes.org/type-1-diabetes/stress.jsp
Patrick Ober, M.D. How Does Stress Affect Diabetes And How Can I Better Manage Stress? See http://abcnews.go.com/Health/DiabetesLivingWith/story?id=3845034

A Whole-Person Approach to Diabetes Health Education Part 2 of 4

In my last post, I presented an overview of the mind-body approach to diabetes health education. In this post I give a more in-depth examination of the psychological factors influencing blood glucose control, starting with the effects of emotional depression.

Psychology of Diabetes: How Mind Affects Health

Diabetes requires extreme changes to many people's lifestyles. They must change from a sedentary to health-conscious lifestyle. Instead of eating junk food and watching television, they have to begin eating healthy food, exercise regularly, monitor their blood sugar level multiple times a day, control their blood pressure and cholesterol, have regular eye and foot exams, stop smoking, and possibly take medications (which may include self-injection). Adopting these lifestyle changes and adhering to these self-management routines requires education and guidance, of course. Many diabetic individuals, however, need more than knowledge and instruction. The reason: Psychological obstacles interfere with their ability and willingness to make such dramatic lifestyle changes.
These psychological obstacles may include maladaptive (inappropriate, detrimental) attitudes, coping skills, and emotions. For example:

• Lack of self-confidence is enough to deter some people from even trying to change their lifestyle since they expect to fail.
• Just looking at a sugary snack can cause some people to worry about the life-threatening aspects of their disease, or feel depressed and angry that they must deprive themselves.
• Failure to keep up their exercise routine or eating poorly can also make them feel those same negative emotions. Unhealthy behavior can also make them feel guilty or ashamed for not doing what they should.

Unfortunately, instead of motivating them to control their diabetes, these attitudes and emotions can have the exact opposite effect; they may cause diabetic people to stop trying because they feel hopeless and helpless. Or equally harmful, they may deal with their painful feelings by ignoring their health through denial and self-deception. Following are some examples of the deleterious effects of these psychological obstacles on diabetic individuals.

Depression and Diabetes Management

Health Effects of Depression
Research shows that depression in diabetic people is associated with poorer diet and medication adherence, functional impairment, and higher health care costs.[1][2] This is often a vicious cycle. When the demands of diabetes care or complications of the disease lead to depression, a person feels overwhelmed, hopeless, helpless, and exhausted. These feelings, in turn, destroy one's motivation, which impairs self-management. Failure to manage one's diabetes results in greater health problems, which exacerbate the depression. And the cycle repeats.

Likewise, depressed people are unlikely to modify their behaviors to extend their lives because the prospect of living longer in chronic emotional pain shatters their willingness to change. Furthermore, depressed diabetic individuals may refuse to acknowledge that their illness can severely harm or kill them because the idea is too emotionally painful to accept. This means that the threat of serious complications or death is not a powerful motivator for some. In fact, the odds are nine to one that a person will fail to make substantial lifestyle changes, even if facing probable death!

Dealing with Depression
Fortunately, there are effective ways to help diabetic people overcome the psychological obstacle of depression. For example, compelling discoveries in the fields of cognitive science, linguistics and neuroscience are demonstrating the promise of "reframing" techniques. One useful reframing method helps depressed people develop a vision of "joy of living" rather than a "fear of dying," since joy can be a more powerful motivator than fear. Incorporating this kind of reframing approach into diabetes health education can promote positive changes in people's way of thinking, resulting in increased motivation to live more healthily.[3]

Diabetic people also need good coping strategies for dealing with depression (and other emotional disturbances). Some coping strategies attempt to reduce one's emotional distress by promoting adaptive (effective, useful) ways of thinking, feeling, and acting when trying to manage their illness (or other problems); other strategies, however, are maladaptive. Ten common strategies people use include five adaptive and five maladaptive coping methods.

The five positive, adaptive coping strategies help a person solve a problem or learn to accept it with minimal distress:

• Logical Analysis involves trying to understand what caused the health problem and different ways to handle it.
• Problem Solving involves developing specific plan of action to manage the problem, implementing it, learning from the results, and then modifying the plan and trying again if necessary.
• Social Support involves explaining the problem to other people and asking them for advice or help; this includes peer group support.
• Positive Reappraisal involves viewing the problem as helping the person change or grow in a good way, find new faith, or learn valuable lessons.
• Rational Acceptance involves accepting—without undue emotional distress and without self-defeating behaviors—that nothing can be done to cure one's illness; at the same time, it encourages the person to do what is necessary to prevent complications.
• The five negative, maladaptive coping strategies fail to resolve one's problems, do not enable healthy acceptance, and may even make the situation worse:
• Behavioral Distraction involves trying to feel better emotionally by doing enjoyable or interesting things, rather than dealing with the health problem proactively or coping with it through positive reappraisal and rational acceptance. While it may help reduce a person's emotional distress temporarily, this strategy is maladaptive because it will never improve the situation, does nothing to help one cope with it long-term, and can actually make matters worse through inaction. This strategy wastes precise time that could be better spent trying to understand and deal constructively with the problem.
• Cognitive Avoidance involves acting as if there is no problem, or trying not to think about the problem. As with behavioral distraction, the strategy may help reduce one's emotional distress temporarily, but it will never improve the situation, does nothing to help one cope with it long-term, and wastes precise time.
• Emotional Discharge involves expressing negative emotions by yelling or crying, taking it out on others, or avoiding certain situations. As with the previous two strategies, this one may help reduce one's upset temporarily, but it will never improve the situation and does nothing to help one cope with it long-term. In addition, this strategy may annoy other people who could have been helpful and push them away.
• Wishful Thinking involves hoping a miracle will somehow make things better, or that one's wishes or prayers would somehow be answered. This, too, may help reduce one's emotional distress temporarily, but it will never improve the situation, does nothing to help one cope with it long-term, and wastes precise time.
• Resignation happens when a person determines that nothing can be done to fix a problem, so he or she does nothing, while remaining in an emotionally distressed state of anxiety, depression (hopelessness and helpless), and/or anger. This, too, is obviously maladaptive.

It stands to reason, therefore, that helping depressed persons in diabetes health education programs deal with their depressions—through reframing, coping skill training [4], and other methods—will result in better outcomes (i.e., more effective control of blood glucose, blood pressure, etc.).
In my next post, I discuss how mental stress and personality factors affect diabetes management.

References:
[1] Ciechanowski PS, Katon WJ, Russo JE. Depression and diabetes: impact of depressive symptoms on adherence, function, and costs. 1: Arch Intern Med. 2000 Nov 27;160(21):3278-85. See http://www.ncbi.nlm.nih.gov/pubmed/11088090

Gonzalez JS, Safren SA, Cagliero E, Wexler DJ, Delahanty L, Wittenberg E, Blais MA, Meigs JB, Grant RW. Depression, self-care, and medication adherence in type 2 diabetes: relationships across the full range of symptom severity. 1: Diabetes Care. 2007 Sep;30(9):2222-7. See this link

[2] Anderson RJ, Freedland KE, Clouse RE, Lustman PJ. The prevalence of comorbid depression in adults with diabetes: a meta-analysis. Diabetes Care. 2001 Jun;24(6):1069-78. See this link

[3] Deutschman, A. Change or Die. 2005 May. See this link

[4] Grey, M. Coping and Diabetes. Diabetes Spectrum. 2000 13(3),167. See this link
Grey, M. & Berry, D. Coping skills training and problem solving in diabetes. Curr Diab Rep. 2004 Apr;4 (2):126-31

A Whole-Person Approach to Diabetes Health Education Part 1 of 4

In this series of posts, I focus on diabetes health education aimed at promoting effective self-management of this chronic condition. In particular, I discuss why a whole-person (mind-body) approach to diabetes health education is essential. After all, a good deal or research shows how glycemic (blood sugar) control in persons with diabetes may be significantly influenced by psychological factors.[1][2]

Overview: The Mind-Body Connection and Diabetes

Effective self-management of diabetes mellitus (DM) and other chronic illnesses is difficult for many individuals. Their problem stems from a powerful interaction between psychological and physiological factors. This mind-body connection is the bases for a whole-person approach to diabetes health education.

Physiological Perspective

From a physiological (body, biomedical) perspective, DM is a heterogeneous metabolic disorder characterized by hyperglycemia, a serious condition of elevated blood glucose (high blood sugar) level. Hyperglycemia is caused by defective insulin secretion, resistance to insulin action, or both.[3] The causes and treatment of hyperglycemia differ in the two types of diabetes.

Two Types of Diabetes

Type 1 diabetes is the consequence of an autoimmune-mediated destruction of pancreatic β-cells, which may be due to such things as genetics, poor diet (malnutrition), and environment (virus affecting pancreas). The result is insulin deficiency and requires insulin treatment for survival.

Type 2 diabetes, on the other hand, is typically characterized by insulin resistance, which means the body produces adequate insulin levels but cannot effectively utilize it; and in some cases, the body fails to produce sufficient insulin. This may be due to gene mutations and environmental factors, such as an inactive lifestyle or poor diet, which may act as a trigger for someone with such a genetic tendency, as well as by chronic stress and low birth weight (and associated fetal malnourishment). Treatment of Type 2 diabetes is aimed at reducing insulin resistance through diet, exercise and drug therapy, and, for some people, may eventually require regular insulin injections to keep their blood glucose levels in control.

Potential Medical Complications of Diabetes

There are many potential long-term complications of diabetes. They include loss of vision, renal failure, foot ulcers and amputation, as well as gastrointestinal, urinary, cardiovascular, and sexual problems. Effective glycemic control avoids or postpones these complications.

Psychological Perspective

From a psychological (mind, mental health) perspective, a diabetic person's knowledge, attitudes, and emotions are key. These mental functions and emotions interact to determine how well he or she is likely to manage the illness. That is, diabetic people who control their blood glucose effectively:

• Understand proper diet, exercise, medication, self-monitoring, etc.
  
• Use ongoing feedback to modify their behaviors
  
• Have healthy, rational attitudes (beliefs, thoughts, and perceptions)
  
• Maintain positive emotions
  
• Have a sense of competence and confidence (self-efficacy)
  
• Control their mental stress.

Having this knowledge, awareness, way of thinking, feelings, confidence, and coping ability gives people the proper focus and tools to successfully manage their condition. Being psychologically equipped in this manner makes them more likely to change their lifestyles in a positive way and adhere to their plans of care over the long-term. This is why a whole-person (mind-body) approach to diabetes health education is so important.

In my next post, I will offer an in-depth examination of these psychological factors.

References:
[1] Rose M, Fliege H, Hildebrandt M, Schirop T, Klapp BF. The network of psychological variables in patients with diabetes and their importance for quality of life and metabolic control. Diabetes Care. 2002 Jan;25(1):35-42. See http://care.diabetesjournals.org/cgi/content/full/25/1/35/F2
[2] Dharmalingam, M. Psychological distress and diabetes: Clinical and metabolic connections. International Journal of Diabetes in Developing Countries. 2005 25(4):92-97.
[3] Gavin III JR, Alberti KGMM, Davidson MB, DeFronzo RA, Drash A, Gabbe SG, Genuth S, Harris MI, Kahn R, Keen H, Knowler WC, Lebovitz H, Maclaren NK, Palmer JP, Raskin P, Rizza RA, Stem MP : Report of the expert committee on the diagnosis and classification of diabetes mellitus. Diabetes Care. 1997 20:1183-1197. See http://care.diabetesjournals.org/cgi/content/full/25/suppl_1/s5

The Whole-Person Integrated-Care (WPIC) Wellness Solution: Part 5

In my last post [click here for the first of the series], I discussed the personalities, coping strategies, and health-related needs of the third type of individual, the "Inactives." I now conclude this series by examining the fourth and most resistant group: the "Ignorers/Deniers."

Simply put, Ignorers/Deniers just don't focus on their health. This is for a variety of reasons, which I'll be discussing. First, these people "close their eyes and ears" to information about healthy living. They refuse to acknowledge or accept they have health problems or risk factors, or they refuse to do anything about it. These maladaptive behaviors are a consequence of a mindset they adopt, which includes thoughts such as:

• "I do not accept there's a problem with my health" – despite convincing evidence.
• "I fine the way I am … It doesn't matter what others say" – even though their health is deteriorating, relationships are crumbling, and overall quality of life is suffering.
• "I'm different … I'm special … I'm not like those other people … Nothing's going to happen to me!" – a false sense of security and invincibility.
• "I don't trust doctors" – an attitude based on gross overgeneralization.
• "Getting help is a sign of weakness ... A strong person handles one's own problems" – an irrational belief driven by pride and based on a distorted measure of self-worth.

Ignorers/Deniers, therefore, differ from the other personality types in essential ways; for example:

• The three other types of individuals think about their health, and when confronted with a health problem, many question whether they can make good decisions and help improve things, which may make them anxious due to self-doubt. Nevertheless, despite their anxiety and doubt, they are willing to learn and act wisely. Many Ignorers/Deniers, on the other hand, are so terrified by the notion they may have (or get) a severe illness that they avoid thinking about their physical and emotional health—preferring, instead, to pretend everything is all right. As a result, Ignorers/Deniers may refuse to accept the reality of their situation, even when confronted with the threat that they will probably die from their health problems; to them, the thought of being or being ill is too great to consider. Although this self-deception may keep their fear in check for a while, their inaction and ignorance make them vulnerable to worsening health and personal problems.
• If Ignorers/Deniers did think about their health, many would feel hopeless and helpless, believing they cannot deal with serious illnesses or personal problems. And those who portray an air of invincibility are likely covering up great self-doubt and fear, or they may be delusional.
• While other types of individuals may have valid concerns about finding a competent healthcare practitioner, some Ignorers/Deniers are so distrustful of the healthcare profession that they won't even consider seeing a doctor, even if they are in pain or distress, often until it's too late.
• While health problems may cause other types of people to become sad or even depressed, for a time, they can get themselves motivated and begin to take constructive action because they want to live and be happy. Ignorers/Deniers, on the other hand, may be so lonely and depressed that they believe they have nothing for which to live. For them, living longer in chronic emotional pain isn't motivating. And when confronted with the knowledge that their health risks can kill them, many Ignorers/Deniers deny the facts because the idea of dying is also too emotionally painful for them to acknowledge; the threat of death, therefore, isn't a motivator. In fact, the odds are great that such a person will fail to make substantial lifestyle changes, even if facing probable death. This prevents them from having the drive and focus needed for constructive action.
• While other individuals are willing to get help when needed, Ignorers/Deniers may have been so influenced by their cultures that they believe seeking assistance for personal problems is a sign of weakness.
• Unlike the other personality types, Ignorers/Deniers may have physical addictions or powerful psychological compulsions that prevent them from focusing on healthy living until they reach "rock bottom," which, unfortunately, may be too late.

What this means is that Ignorers/Deniers rely on some of the same "avoidance" coping strategies as the Wannabes and Inactives; that is, they may:

• Try to feel better by doing enjoyable or interesting things rather than gaining knowledge and developing a plan of action
• Act as if nothing has happened or trying not to think about their problems
• Resign themselves that nothing can be done to improve the situation, even though they lack adequate understanding and fail to exert sufficient effort.

As I discussed in my previous posts, these coping strategies are maladaptive in the long term since the inertia (inaction) they promote allows their health risks to emerging as serious problems and their existing health problems to worsen.

Because these thoughts, feelings, and reactions are so deeply ingrained in their personalities, getting through to Ignorers/Deniers is very difficult. However, all is not lost! Consider the following:

• There are compelling discoveries in cognitive science, linguistics, and neuroscience about how "reframing" serious health-related issues can help motivate resistant people to change. For example, instead of trying to break through the denial of Ignorers/Deniers through threats they will die, it may be much more helpful to reframe the issue in a way that focuses them on a vision of "joyful living" rather than a "fear of dying," since joy is a more powerful motivator than fear [reference]. This kind of reframing changes the mental structures that shape one's view of the world; it typically requires months of psychological counseling to break through the thoughts and feelings that block Ignorers/Deniers' awareness and motivation to change.
• When cultural influences create a "machismo" attitude, in which Ignorers/Deniers perceive getting help as a sign of personal weakness or failure, cognitive-behavioral counseling can combat that belief. In addition, innovative self-help software that guides the person toward healthier behavior and thinking can be helpful. One focus would be reframing the situation from (a) getting help revealing weakness to (b) receiving help when needed and using it to improve one's life is a sign of wisdom and personal strength, whereas refusing help is childish and self-destructive.
• Dealing with a person's lack of trust may require the intervention of a wellness coach who takes the time to establish a close, positive relationship with the Ignorer/Denier and has the knowledge and experience to gain the person's confidence.
• As for Ignorers/Deniers with addictions or compulsions, lengthy counseling (and possible medications) may be needed before they acknowledge their problems and have the will to confront them.

Regarding wellness programs, the Ignorers/Deniers are the least likely to participate. Engaging them is critical, such as offering meaningful incentives to take a self-assessment and speak with a wellness coach. The initial goal of such wellness counseling should focus on understanding and helping reframe their beliefs and perceptions. This will enable them to be more open to gaining awareness about their health situation. Innovative technologies that help focus and entice people to break through their negative mindsets and resistance would be helpful. Once Ignorers/Deniers stop deceiving themselves, have a stronger desire to live and enjoy life, gain trust, are more aware and open to receiving help, and are no longer controlled by their addictions/compulsions, they can be treated as Inactives or Wannabes as appropriate.

The Whole-Person Integrated-Care (WPIC) Wellness Solution: Part 4

In my last post, I discussed the personalities, coping strategies, and need of the "Wannabes." This time I examine the "Inactives."

Inactives think about their health on occasion but do not believe they should or can do anything to improve their health and wellbeing. This is because they tend to have thoughts such as:

• "I doubt I'll be able to do what's required to improve my health, so why even bother."
• "I don't deserve to be sick…it's not my fault…so why should I have to be the one to do anything about it"—or—"I do deserve to be sick…Illness is my punishment…I'm just getting what I deserve."

Inactives doubt that they can deal effectively with their health risks and problems, which causes them great stress. Some also believe they don't deserve what happened to them, making them resentful and angry. This stress and resentful anger not only distract them from focusing on constructive health improvement activities; it is also likely to worsen their physical health since illnesses such as coronary heart disease and cancer may be exacerbated by a negative psychological state (for examples of how this mind-body connection affects one's health, see: this link, this link, and this link). Other Inactives may have different views, such as believing they deserve to be sick and there's no hope because they are doomed.

The result is that the Inactives, like the Wannabes, lack the self-confidence and motivation to improve their health and wellbeing. But what makes Inactives less likely to change their unhealthy lifestyles is that:

• Their self-doubt is stronger because it comes from the belief that they are not able (rather than may not be able) to (a) make the correct decision about treatment for an existing problem or (b) make the attitude and behavior changes required for better health and wellbeing.
• Their inertia (inaction) may be exacerbated by (a) fear that they will be shamed if they try to improve their health and failure causes them to resist taking constructive action, (b) the belief that there is no good way to solve their health problems or prevent their health risks from becoming problems, and (c) despair related to the belief they deserve to be ill.
• Their stress and resentful anger likely worsen their health through distraction and the adverse effect of negative emotions on physiology.

Furthermore, they will likely look for reasons for not adhering to the wellness care plan, such as:

• Money problems that prevent them from carrying out their wellness plan of care (e.g., buying more healthy foods, a gym membership, prescribed medications, diagnostic tests, etc.)
• Family and other demands consume their time and thus make lifestyle change difficult.
• Physical handicaps or cognitive impairments.

The result is that Inactives fail to deal with their health risk and problems promptly and effectively while simultaneously worsening their health and wellbeing through inertia and emotional distress.

The way Inactives attempt to cope with their pessimism, fear, anger, resentment, and despair is similar to the negative avoidance strategies the Wannabes use. That is, they may

• Try to feel better by doing enjoyable or interesting things rather than focusing on the problem.
• Act as if nothing has happened or try not to think about their problems.
• Express negative emotions by yelling or crying, taking it out on others, or avoiding certain people rather than doing something constructive.
• Hope a miracle will make things better or that one's wishes or prayers will be answered, rather than gaining knowledge and developing a plan of action.
• Resign themselves that nothing can be done to improve the situation, even though they lack adequate understanding and fail to exert sufficient effort.

While these coping strategies may alleviate their emotional distress temporarily, they are maladaptive in the long term since their inaction allows their health risks to emerging as serious problems and their existing health problems to worsen.

Nevertheless, since Inactives think about their health & wellbeing on occasion, it is possible for them to become more focused and motivated with the help of wellness coaches/counselors and helpful health information technologies. They may be willing, for example, to take health risk assessments that evaluate their health status, especially if they have concerns about their physical or emotional health. They may also be willing to gain greater knowledge about their problems, risks, and constructive strategies for dealing with them, although they will likely have to be convinced (through counseling and maybe incentives) to use these tools and professionals. And they may be willing to get help to:

• Use the knowledge they gain to make a treatment decision for dealing with an acute physical or mental health problem.
• Implement a wellness care plan designed to self-manage a chronic condition.
• Make positive lifestyle changes to avoid a risk factor from becoming a health problem.

All this means they will need wellness counseling, which should focus on the following:

• Overcoming their inertia, changing their self-defeating cognitive and emotional blocks (including self-doubt, fear, anger, and shame)
• Replacing their negative avoidance-based coping strategies with the positive approaches of the Activists.

This counseling should include powerful forms of persuasion in which well-care professionals--using next-generation health information technologies, which I will describe in a future post--help increase their willingness to take responsible action that improves their health and wellbeing. This is likely to involve significant effort focused on changing beliefs/thoughts. I have previously posted about the relationship between beliefs and physical health, starting at this link.

In my next post, I examine the fourth most challenging personality type: the "Ignorers/Deniers."

The Whole-Person Integrated-Care (WPIC) Wellness Solution: Part 3

In my last post, I explained why "Activists" — the first of four types of people affected by influential psychological characteristics — tend to be healthiest and why they are most likely to take advantage of wellness programs. In addition, I discussed how they have the kind of personality traits that enable them to cope with health-related issues through positive action and rational acceptance. In this post, I discuss a second group of individuals with different personalities and coping strategies: the "Wannabes."

Wannabes talk about improving their health & well-being and are willing to learn about healthy living, but they never seem to act on it or do so half-heartedly. This is because they tend to have thoughts such as:

• "I may be able to do what's required to improve my health, but I'd rather not deal with it right now."
• "I'm not sure what to do."
• "I'm just not ready."

As a result, Wannabes tend to be aware--or are willing to be aware--of their physical and mental health problems & risks, but they lack the self-confidence and motivation they need when it comes to doing something about it. Their self-doubt and lack of drive may come from the belief that they may not make correct decisions about preventing or treating their problems. This uncertainty, in turn, may cause them to avoid making decisions and changing their attitudes & behaviors for fear of failure; i.e., they don't want to be ashamed or embarrassed if they try but fail. Or if they believe there's no acceptable way to solve their health problems or prevent their health risks from becoming problems, they will likely take no action.

Wannabes, in other words, tend to cope with their doubts and fears through avoidance. What they do, for example, is:

• Try to feel better by doing enjoyable or interesting things rather than focusing on the problem.
• Act as if nothing has happened or try not to think about their problems.
• Express negative emotions by yelling or crying, taking it out on others, or avoiding certain people rather than doing something constructive.
• Hope a miracle will make things better or that one's wishes or prayers will be answered, rather than gaining knowledge and developing a plan of action.
• Resign themselves that nothing can be done to improve the situation, even though they lack adequate understanding and fail to exert adequate effort.

While some of these coping strategies may temporarily alleviate their emotional distress, they are maladaptive in the long term since they foster procrastination, which allows their health risks to become severe and worsen their existing health problems. Nevertheless, there are several positive and negative aspects of the Wannabe personality.

On the positive side, since Wannabes think and talk about improving their health & well-being, they will likely want to participate (to some degree) in health promotion programs that:

• Evaluate their health status, especially if they have concerns about their physical and/or emotional states.
• Help them learn about their problems or risk factors, including understanding the pros & cons of different treatment and prevention options.

On the negative side, Wannabes are likely to procrastinate when it comes to:

• Using their knowledge to make decisions about dealing with (treating) acute physical or mental health problems
• Acting on wellness plans designed to self-manage chronic conditions and avoid complications
• Making positive lifestyle changes to prevent risk factors from becoming health problems.

If they have money problems—which prevent them from carrying out their wellness plan of care (e.g., buying more healthy foods, a gym membership, prescribed medications, diagnostic tests, etc.)—they may use it as an excuse for not making a firm decision or adhering to the wellness care plan.

If they have family and other demands that consume their time and thus make lifestyle change difficult, they will likely use it as an excuse for non-action. And if they have physical handicaps or cognitive impairments, they will likely use these limitations as excuses for inaction.

All this means they will need wellness counseling focused on modifying their self-defeating cognitive and emotional blocks (including self-doubt, fear, and shame) and changing their avoidance-based coping strategies. The goal is to help them become more like Activists. Only then will they be willing to take responsible action that improves their health and well-being.

In my next post, I'll examine the third personality type: the "Inactive."

The Whole-Person Integrated-Care (WPIC) Wellness Solution: Part 2

Last week, in part 1 of the WPIC solution, I began defining a new type of wellness program based on a whole-person integrated-care (WPIC) model, which takes a whole-person (mind, body, spirit, and environment) view of health, and which coordinates sick-care with well-care across the entire healthcare continuum. I included an introductory discussion of the value proposition of such a wellness program and its goals and methods. I also mentioned that (at least) four types of people with different character traits require different approaches to wellness due to their other thoughts, emotions, behaviors, knowledge & understanding, and coping strategies. In this post and future ones, I examine these differences.

Definitions

Since I'm presenting additional terms, let me take a moment to define them:

• Thoughts refer to a person's attitudes, beliefs, perceptions, assumptions, reasoning, expectations, memories, "self-talk," and other mental processes (i.e., one's cognitions).
• Emotions refer to a person's feelings and moods (i.e., one's affect).
• Behaviors are what a person does (i.e., one's actions).
• Knowledge & understanding are related terms, which I discuss in some detail at this link. Briefly, knowledge refers to information someone knows about essential things, such as relevant people, things, places, times, reasons, rules, and methods. Understanding, on the other hand, is being able to apply that knowledge when doing such things as:
  
  • Explaining, interpreting, discovering, and gaining insights into the nature of things
  • Noticing contradictions/inconsistencies
  • Using logic and evidence to support decisions, make accurate predictions, and judge/evaluate things rationally and sensibly
  • Creating and imagining
  • Focusing attention on what's important (i.e., having good situational awareness), being prepared to act, and justifying one's beliefs/hypotheses.
• Coping strategies are adaptive or maladaptive ways of thinking, feeling, and acting when dealing with problematic situations. Following are ten common coping strategies people tend to use. The first five are positive strategies because they help a person solve a problem or learn to accept it with minimal distress. The latter five are negative strategies because they fail to resolve one's issues or enable healthy acceptance.
1. Logical Analysis is a positive approach strategy in which a person tries to understand what caused the problem and think of different ways to handle it.
2. Social Support is another positive approach strategy in which a person explains the problem to someone or asks others for advice or help. This can help determine what, if anything, can be done to solve it.
3. Problem-Solving is another positive approach strategy in which, after logical analysis, a person determines that a problem can be solved and what has to be done to solve it. Then, a specific action plan is created and implemented, and the person learns from the results and modifies the plan accordingly.
4. Positive Reappraisal is another positive approach strategy in which a person views a problem as helping him/her change or grow in a good way, find new faith, or learn valuable lessons. This strategy can be used whether or not a problem can be solved.
5. Rational Acceptance is a positive non-action strategy in which a person accepts—without undue emotional distress and self-defeating behaviors—that nothing can be done to solve a problem, so s/he does nothing except adopt a rational way of thinking about it, which fosters psychologically healthy acceptance.
6. Behavioral Distraction is a negative avoidance strategy in which a person tries to feel better emotionally by doing enjoyable or interesting things rather than trying to solve the problem or cope with it through positive reappraisal and rational acceptance. While it may help reduce one's upset temporarily, this strategy is maladaptive because it will never solve the problem and does nothing to help one cope with it long-term. This strategy wastes precise time that could be better spent trying to understand and deal constructively with the problem rather than letting things get worse.
7. Cognitive Avoidance is another negative avoidance strategy in which a person simply acts as if there is no problem or tries not to think about the issue. As with behavioral distraction, the strategy may help reduce one's upset temporarily. Still, it will never solve the problem and does nothing to help one cope with it long-term, as well as wasting precise time.
8. Emotional Discharge is another negative avoidance strategy in which a person expresses negative emotions by yelling or crying, taking it out on others, or avoiding certain people or situations. As with the previous two strategies, this one may help reduce one's upset temporarily, but it will never solve the problem and does nothing to help one cope with it long-term. In addition, this strategy may annoy other people, push them away, and waste precise time.
9. Wishful Thinking is another negative avoidance strategy in which a person simply hopes a miracle will make things better or that his/her wishes or prayers will be answered. As with the other avoidance strategies, this one may help reduce one's upset temporarily, but it will never solve the problem and does nothing to help one cope with it long-term, as well as wasting precise time.
10. Resignation is a negative non-action strategy in which a person determines that nothing can be done, so s/he does nothing while remaining in an emotionally distressed state of anxiety, depression (hopelessness and helplessness), and/or anger.

Describing the Characteristics of Four Types of Individuals

As I discussed in my previous post, wellness programs should address the particular needs of (at least) four types of people: Activists, Wannabes, Inactives, and Ignorers/Deniers. In this post, I present the Activists. They are most motivated to deal actively and eagerly with health & wellbeing issues and are most likely to take advantage of wellness programs.

Activists

Activists' attitudes about managing their physical and mental health can be summed up in thoughts such as: "I believe I can do whatever must be done, and I'm willing to do it!" Such views reflect a joy of living and a willingness to take constructive action to reduce fear, uncertainty, and doubt through problem-solving (if their health problems can be resolved) or rational acceptance (if the problems can't be fixed). Activists tend to be confident, motivated, aware, rational, and assertive regarding their character traits. From a whole-person integrated-care perspective, they seek knowledge about their physical and mental health status and risks to help them make wise decisions. And they try to understand how to avoid health problems, self-manage chronic conditions, treat existing problems most safely and cost-effectively, and use their knowledge to live healthy lifestyles. Activists, in other words, are rational people who deal with their physical and mental health problems (existing conditions and risks) by using positive, proactive coping strategies, such as:

• Trying to understand what caused the problems by thinking of different ways to handle it
• Talking to someone about what they are going through and asking certain people for advice or help.
• Determining what must be done to solve a problem and then using a specific action plan.
• Viewing a problem as something that helps them change or grow in a good way, find new faith, or learn valuable lessons
• Rationally accepting when a problem cannot be solved to minimize their emotional distress.

When dealing with an existing health problem, Activists actively seek knowledge and guidance to understand the pros & cons of different treatment options. And when dealing with their health risks, they seek to understand the pros & cons of varying prevention options. If Activists have money problems—which prevent them from carrying out their wellness plan of care (e.g., buying more healthy foods, a gym membership, prescribed medications, diagnostic tests, etc.)—they strive to find a way to afford what they need, including political action. If they have family and other demands that consume their time and thus make lifestyle change difficult, they find ways to make time available. And if they have physical handicaps or cognitive impairments that interfere, they will explore alternative approaches to health improvement that accommodates these limitations. Finally, the more a person's character traits resemble an Activist, the more likely s/he is to gain from a wellness program and improve his/her health and wellbeing. In my next post, I examine the Wannabes and Inactives.

The Whole-Person Integrated-Care (WPIC) Wellness Solution: Part 1

In this post, I discuss how to bring high value to the healthcare consumer through a new wellness program we're developing, offering a whole-person integrated-care solution. I welcome your questions and comments.

What is Whole-Person Integrated Care?

As the name implies, whole-person integrated care has two related parts: Whole-Person care and Integrated care.

Whole-Person Perspective

Whole-person perspective focuses on improving a person's health and well-being by addressing one's physical health (body), mental/psychological health (mind), and the mind-body connection ("holistic" health). In other words, it views an individual as a whole entity whose body and mind are interconnected.

The whole-person perspective is critical for preventing and cost-effectively treating health problems because it helps lower overall healthcare expenditures, improve care outcomes, and enhance well-being since many physical disorders and psychological issues are related; for example:

• Disturbances of physiology that are related in some way to situational/psychological conditions but without actual permanent end-organ damage, such as migraines, functional bowel disease, and types of chronic pain
• Disturbances where actual physiological and psychological pathologies are evident, such as hypertension, peptic ulcer disease, hyperthyroidism, asthma, and chronic skin disorders
• Severe physiological disorders that tend to appear or flare up with significant life changes and stress, such as disturbances in autoimmunity
• Mental health problems caused by biomedical factors such as delirium, dementia, organic hallucinosis, and organic delusional, mood, personality, and anxiety syndromes
• Illnesses such as coronary heart disease and cancer may be helped with adjunctive treatments which promote changes in patients' behaviors (e.g., improve eating, sleeping, and exercise habits) and psychological states (e.g., reducing resentful anger and stress-proneness)
• Emotional difficulties are often associated with medical illnesses and procedures such as AIDS, bone marrow transplants, severe burns, heart or liver transplants, end-stage kidney disease entailing dialysis, hip fracture, open-heart surgery, and plastic surgery.
• Maladaptive behaviors and attitudes that have noticeable deleterious health effects on oneself and/or others, such as substance and alcohol abuse, anorexia, bulimia, obesity, smoking, unsafe sex, recklessness, suicidal tendencies, and abusive behavior toward others.

A whole-person approach is essential, therefore, because:

• Up to half of all primary care physicians' cases are either accompanied by or constitute psychological (emotional and behavioral) problems.[1]
• Psychological problems cause, exacerbate or impede the healing of many physical illnesses.[2]
• Psychological treatment (of emotional and behavioral problems) helps remedy many physical ailments and thus reduces overall medical costs.
• People who are physically and psychologically healthy have greater peace of mind, are more focused and energized, are more productive, make fewer mistakes, have fewer accidents, and are more satisfied with their lives and work.

Integrated-Care Model

Integrated care brings together well-care and sick-care:

• Well-care focuses on preventing physical, mental, and mind-body health problems from occurring or worsening, achieving a sense of emotional well-being and peace of mind through healthy living, wise decision-making, and responsible action to deal with distressing life situations, and using effective coping strategies.
• Sick-care treats acute, sub-acute, and chronic health problems (physical, mental, and mind-body) through traditional allopathic procedures and/or complementary and alternative methods.

Thus, instead of viewing sick-care and well-care as two separate avenues on the road to health, this integrated approach involves a new kind of coordination and collaboration between (a) medical and related sick-care practitioners focused on the diagnosis and treatment of health problems and (b) well-care practitioners focused on prevention, recovery, and well-being, as well as peak performance.

By integrating sick-care & well-care in this way, overall healthcare costs would be reduced, health outcomes would be improved, and people's quality of life and productivity would be increased. These desirable results would be achieved by coordinating efforts to prevent and treat illness and dysfunction. This integrated approach is vital to solving the current crisis and bringing greater value to the consumer.

Altogether Now: Whole-Person Integrated Care

This whole-person integrated care strategy offers a sensible way to help people:

• Remain healthier longer through better self-care/self-maintenance
• Recover from illness and dysfunction more quickly and avoid complications of chronic disease through greater compliance with plans of care.
• Gain greater peace of mind by removing or coping with stress more effectively.
• Save money through reduced sick-care expenditures.
• Be more productive and focused through reduced stress and emotional distraction.

Employers also benefit when employees are healthier, happier, and more focused. These benefits include increased employee productivity and employee retention, lowered healthcare expenditures, reduced sick time, and fewer workplace accidents and errors.

It is crucial to solving the healthcare crisis by reducing overall expenditures.

Implementing this strategy requires a new kind of wellness program that:

• Performs a comprehensive health and well-being assessment and generates a whole-person health profile that includes a full mind-body work-up.
• Uses the health profile to create an individualized wellness plan focused on improving one's health, happiness, and achievement through lifestyle changes, wise decision-making, and effective coping skills.
• Provides ongoing guidance and support from networks of wellness coaches/counselors who use the health profiles and collaborative communication tools to increase the person's knowledge, understanding, and motivation.
• Supplies essential information that enables sick-care practitioners to understand more fully:
• How to handle the interplay between a person's physical problems, mind-body health needs, emotional drivers & obstacles, and psychological boosts & blocks
• Complementary & alternative intervention options to traditional medical treatments.

What is the Goal of Whole-Person Integrated Care?

The goal of such a program is to improve people's health and well-being by helping them reduce their stress & distress levels (i.e., increasing peace of mind) and change their maladaptive behaviors (i.e., making lifestyle/ compliance changes) via counseling & education process that deals with the interactions between one's:

• Cognitions (beliefs, attitudes, perceptions, thoughts)
• Emotions
• Behaviors
• Level of Knowledge & Understanding
• Coping strategies.

How is it Done?

The Whole-Person Integrated Care process is also personalized; it is tailored to the needs of different types of individuals with drastically different characteristics:

• Activists are motivated to deal with health & well-being issues actively
• Wannabes talk about improving their health & well-being but never seem to act on it or do so half-heartedly
• Inactives think about their health on occasion but do not believe they should or can do anything to improve their health & well-being.
• Ignorers/Deniers are not health conscious because they don't accept that they have health problems or risk factors or don't care.

In the next post in this series [at this link], I examine the character qualities of these four groups, i.e., the cognitions, emotions, behaviors, knowledge & understanding, and coping strategies that promote or impede one's willingness and ability to adhere to healthy living strategies.

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[1] Research shows that a significant percentage of all primary care billing is for stress-induced or behaviorally-related disorders, with a minimum of about 20 percent of patients in a primary-care practice suffering specifically from anxiety or depression. And if one assumes undiagnosed complaints are related to underlying anxiety disorders or depression, the proportion of patients seeking treatment for psychological reasons jumps to 40 to 50 percent. Depression alone, the fourth most disabling illness worldwide, has been estimated to cost the United States $83 billion in 2000. Of this amount, $57 billion is attributed to depression-related absenteeism, reduced productivity at work, and the value of lifetime earnings lost due to suicide-related deaths, leaving $26 billion in direct out-of-pocket expenses for healthcare treatment costs.

References: Goleman, D. (December 14, 1994). Push is on for Family Doctors to Spot Psychiatric Problems. New York Times. Available here AAFP white paper on providing mental health care services by family physicians - American Academy of Family Physicians Commission on Health Care Services. American Family Physician. (May 1, 1995). Available at http://www.findarticles.com/p/articles/mi_m3225/is_n6_v51/ai_16874729 NIMH Sequenced Treatment Alternatives to Relieve Depression (STAR*D) Study at http://www.nimh.nih.gov/healthinformation/stard_qa_general.cfm

[2] A growing body of research in mind-body medicine demonstrates an undeniable interplay between biomedical, psychological, and social factors and points specifically to a causal link between mental/emotional problems and many physical illnesses. The field of psychoneuroimmunology demonstrates that stressful life events can adversely affect the immune system. Other researchers are identifying "coronary-prone behaviors" such as insecurity and a perceived lack of self-efficacy. Still, others find a connection between optimism, coping skills, and physical health. Potentially high-cost, medically dangerous behaviors — such as excessive consumption of alcohol, use of illicit drugs, violence, and unsafe sex — also find their roots in behavioral disorders. For example, researchers found that depression is a precursor to heart disease, with certain depressed patients being 50 percent more likely to develop or die from heart disease than those without such symptoms, even though they had no prior history of heart disease. Depression, therefore, likely affects the mind and physical health by being linked to increased blood pressure, abnormal heart rhythms, and chronically elevated stress hormone levels, which can increase the heart's workload.

References: Borysenko, J. (1988). Minding the Body, Mending the Mind. New York: Bantam Cousins, N. (1990). Head First: The Biology of Hope and the Healing Power of the Human Spirit. New York: Viking Penguin Dienstfrey, H. (1991). Where the Mind Meets the Body. New York: Harper Collins Gordon, J. S. & Bresler, D. (Eds.). (1984). Mind, Body, and Health: Toward an Integral Medicine. New York: Human Sciences Press Gordon, J. S. (1990). Stress Management. New York: Chelsa House Ornstein, R., & Sobel, D. (1988). The Healing Brain. New York: Simon & Schuster Ornstein, R., & Sobel, D. (1990). Healthy Pleasures. Reading, Mass: Addison-Wesley Kroenke, K. (2002). Psychological medicine: Integrating psychological care into general medical practice. BMJ;324:1536-1537. Available at http://bmj.bmjjournals.com/cgi/content/full/324/7353/1536 Huggins, C.E. (March 1, 2006). Depression and heart disease often go hand in hand. Reuters Health. Available at http://go.reuters.com/newsArticle.jhtml?type=healthNews&storyID=11380752&src=rss/healthNews