We have talked about contemporary literature, and the political and recovery models which inform current thinking about self-management, but in a clinical setting we need to know where the individual client sits with regard to these models. As will be demonstrated, the beliefs people have will dictate the strategies they are prepared to endorse, and this includes any treatment proposals.
Leventhal et al.'s (1980) self-regulatory model is a model about "illness beliefs" and provides a framework for understanding the self-regulation processes that determine health-related behaviours, such as self-management. It is made up of interrelated components.
The first component is the interpretation of the health problem. People confronted with a health problem, in this case, BD, must first get to grips with the health problem itself and what it seems to them to involve. The ways in which people think about (interpret) their health problem creates a representation of that problem. This representation gives personal meaning to the health problem and is organised around five themes:
(1) What is it? (identity): the label given to the health problem such as a medical, or self-diagnosis.
(2) Why has it happened? (cause): the perceived cause of the health problem, which can, for example, be based on cultural ideas, myths or medical knowledge.
(3) How long will it last? (time line): an estimation of how long the health problem or the phase of the health problem will last, and whether it will recur.
(4) What effects will it have? (consequences): a prediction about possible effects on the person's life, which can be about finance, relationships, the person's own health, etc., and can be seen as positive or negative, and serious or minor.
(5) What can I do to make it go away? (cure/control): the possibility that the health problem can be cured or ameliorated and perceptions of control over the health problem by the client and/or others.
The second component concerns how an individual copes with or manages his or her own health problem. According to Leventhal et al., beliefs or cognitive representations about the health problems described above provide a framework which functions to guide a return to, or maintenance of, a state of good health. Two broad forms of coping have been described. These are "approach coping (for example, "take the pills" or "joining self-management groups") and "avoidance coping" (for example, disengagement or venting).
The third component is the individuals' appraisal of their coping strategy. The individual evaluates the effectiveness of the coping strategy and decides whether to continue it or use a new one. Not everyone will move to this stage, especially where avoidance is a form of coping, and is not recognised as such.
Leventhal et al. postulate that the association between health problem representations and emotional responses, such as fear, can lead to avoidance coping as a protective measure. For example, if self-management is seen as symbolic of having a feared health problem, then non-adherence, or changing the identity of the health problem to something more trivial, may be a strategy to avoid exposure to threat.
Avoidance coping is also linked to Weinstein's (1984) concept of unrealistic optimism. Individuals vary in their optimism, and those whose optimism is unrealistically high may, for example, interpret their health problems as follows: "It isn't serious"; "they've got it wrong" and "it's normal—other people have highs and lows". They may then not monitor for early warning signs and fail to develop appropriate strategies to avoid or prevent escalation of episodes. In addition, they may feel so safe that they are very likely to engage in dangerous behaviours, such as sleep-disrupting activities. For these reasons, if the individual's optimism is unrealistic, it is likely to lead to avoidance of self-management.
Just as individuals with BD have beliefs about their health problems, they also have beliefs about their ability to carry out health-related behaviours. These seem to be crucial in the stages of self-regulation of health behaviours.
Bandura (1977) used the term self-efficacy not as a trait, but to describe people's beliefs about the extent to which they can control a particular behaviour in a particular situation. Self-efficacy beliefs are associated with feelings of helplessness (Seligman, 1975). In learned helplessness, individuals perceive their responses as futile, leading to failure to initiate coping responses.
Self-efficacy is a widely applied construct in models of health behaviour and is considered one of the best predictors of health behaviour (Conner & Norman, 1996). One of the advantages of learning self-management may be that practising new coping skills increases self-confidence, and a new self model ("self as able to manage health problem") is formed.
The building up of self-efficacy beliefs or self-confidence is aided by having an expert tutor. Bray et al. (2001) found that when people first take responsibility for their own health, an expert tutor is vital. They investigated the role of what they term "proxy efficacy", which they define as the belief that another person has the skills and ability to deal with issues on our behalf, a belief that, in turn, increases people's confidence to carry out health-enhancing behaviours. It is speculated that having a credible fellow sufferer as tutor may further enhance the individual's perception of capability and efficiency. A final and important point about Bray's work is that it gives a rationale for why self-management might be effective besides being acceptable to people with BD.
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