How to classify psychosocial interventions in chronic disease?

Maes has designed a cubical model to structure the variety of interventions which are offered to patients with chronic diseases. This model distinguished between three different dimensions along which an intervention can be located:

• Intervention aims
  Quality of Life interventions and self-management interventions
• Intervention level
  The individual patient, a group of patients or the social and physical environment of the patient
• Interventional channel
  This is can be either in a way of direct face-to-face contact between the psychologist and the patient, or in a way of indirect interventions. For example with self-help, lay people or other health care professionals.

Intervention aims: Quality of Life interventions

Quality of Life intervention focus on restoring and improving the physical, psychological and social well-being of the patient and his/her immediate environment. This is done by stimulating a process of adaption to and/or acceptance of the disease. QoL interventions focus on reducing stress, reducing pain, or reducing problems related to performance of everyday activities which cause physical, emotional or social limitations.

Physical training programs are in most cases part of larger (multicomponent) rehabilitation programs, for example for patients with CHD, cancer or diabetes. These programs have beneficial effects on morbidity and mortality and it has effect on quality of life and well-being of patients (with anxiety and/or depression) as long as patient engage in physical activity.

Stress management programs have positive effects on quality of life, but also on disease progression and mortality in patients with e.g. cancer, CHD, diabetes and HIV. Cognitive restructuring is a stress management program which focuses on changing cognitions which can influence your behaviour and emotions.
The Hook is a cognitive restructuring program. Its aim is to help post myocardial infarction patients gain control over their emotional reactivity to daily stressors. At the start of the group session, participants are asked to describe an incident in which they became angered, irritated or impatient. This introduction is followed by a group discussion around three questions. The first question is What is behaviour modification?. By asking this question, the therapist introduces a general idea of cognitive change (“You can gain control over your emotional reactivity by changing your way of thinking”). When confronted with a stressful situation, you have a choice between changing the situation/people involved in the situation, or changing the way you think about the situation. The second question asked is What is impatience/irritation?. This questions is asked to make patients more aware of the type of stressor that leads to frustration, irritation and anger. The metaphor of the hook is introduced to describe this type of response (you are hooked). The third question is What can we do about it?. By asking this question the therapist introduces to a cognitive strategy to get to grips with one’s emotional activity and to label the stressor as  a ‘hook ‘instead of an unfair situation. The patients’ perceptions of the stressors will change, causing the emotional arousal to go down and getting more in control of their emotions.
Relaxation is another way of stress management. It is used alone or in combination with other techniques to enhance stress management skills of patients. It can be used individually or in a group setting. Examples of relaxation are progressive relaxation, guided imagery and  breathing techniques. It is also effective for treating hypertension.
(Mindfulness) meditation is about being aware in the very present moment. It involves observing thoughts, emotions, sensations and perceptions as they arise moment by moment. Whatever thoughts, emotions, sensations and perceptions arise, they must not be judged, manipulated or tried to get rid of.
Time management can be effective when planning activities, functional limitations should be taken into account. It focuses on the conservation of energy for important personal goals and obligations.
Life skills training focuses on acquiring the necessary social skills to communicate adequately about the disease, e.g. communicating about functional limitations, asking for help when needed, problem-solving in case of practical problems.

Social support interventions are about obtaining social support, assertiveness training and social support groups/interventions.
Obtaining social support is important for patients suffering from chronic diseases who have a good social network to cope more adequately with their disease. This can have a positive impact on their QoL, morbidity and mortality. It is important for patients to learn to identify and use sources of social support in their personal environment. Obtaining social support from the family is important, not only in terms of well-being and QoL, but also in terms of disease management (e.g. adherence to medical advice). Family members should be informed on how they can effectively support the patient. Some patients need practical support, others are more in need of emotional support, yet this can change over time. Sometimes family members are also in need of support.
Assertiveness training can be effective especially for those who have developed (symptoms of) social anxiety concerning their illness. Assertiveness training is about learning how to talk about the disease to others and learn not to be ashamed of the disease. This can impact not only your QoL, but also one’s disease management.
Social support groups/interventions have been set up to exchange information and offer each other support. It is especially important if the personal network of the patient is not capable of providing adequate social support to the patient. It can help the patient to overcome the feeling of being stigmatised and to talk to others about the disease and its consequences.

Palliative care focuses on acceptance of the disease when cure/recovery is no longer feasible. Psychotherapy can help for those with anxiety and depression. It was set up to reduce anxiety and depression in a group of HIV gay men after their first diagnosis. Cognitive behavioural therapy was directed at an increased sense of control for the patients to develop better coping. Pariticpants were taught how to identify dysfunctional thoughts about HIV by challenging these thoughts and replace them by more functional thoughts, for example changing I am dying into I have a chronic disease. Participants were taught to identify maladaptive coping strategies (e.g. denial or substance abuse) and replace these by more adaptive coping strategies. Relaxation exercises were taught and practiced at least twice daily at home. The results were positive for anxiety and depression, adaptive coping strategies, social support and immune functioning.

Intervention aims: self-management

It is important to change lifestyle and to be and stay adherent to medical advice to chronic patients. Changes as a consequence of chronic disease are taking medication, regular doctor visits, going to the hospital, changing unhealthy behaviours (stop smoking, using less salt in your meals), adopting healthy behaviours (physical exercise, having regular meals, getting enough sleep), and engaging in a variety of specific self-management behaviours (for diabetes patients to monitor blood sugar levels, and for RA patients to maintain regular physical activity).

Behaviour techniques used to increase self-management:

• • Self-monitoring: observing the behaviour, including its antecedents and consequences
  • Goal setting
  • Shaping the process of change: defining subsequent small steps in order to reach the final goal
  • Self-reinforcement: rewarding yourself when you have reached a (sub)goal
  • Stimulus control: adapting the environment, capitalising on stimuli that control the desired behaviour
  • Behaviour contracting: contract between patient and health professional
  • Modelling/observational learning

Often combinations of intervention techniques are used. Self-management programs produce stronger effects on (disease management) outcomes than educational interventions, since those are limited to the provision of information.

The Arthrisis Self-Management Program (ASMP) is a self-management program developed as a community based program for mild to moderate RA patients. The aim is to improve health behaviour and health status for those patients by using cognitive-behavioural techniques and by increasing self-efficacy with respect to RA. Patients were asked to set personal and realistic goals for each week in a written contract and to report it back to the group. Immediately after the intervention positive effects were found on self-efficacy, health behaviours, depressed feelings and mood in general.

Intervention levels

Psychologists are mostly educated within an intervention paradigm that supports the idea that effective interventions are intensive, direct forms of intervention targeted at the problems of individual patients (“doing a lot for a very small amount of patients”). If psychologists are to make significant contribution to the care of chronic patients, they should go for numbers, rather than for the most intensive and personally satisfying form of treatment.

Social engineering refers to interventions that aim at modifying the home, work or leisure environment of the patient to facilitate normal functioning of the patient in everyday life. Psychologists often underestimate the relevance of interventions on an environmental leve. The acceptance of changes in the environment by both patients and family members may require psychological guidance.

The Dutch Heart and Health program is a program offered to groups of about 8 patients and their partners, during cardiac rehabilitation. The aim of the program is to improve QoL and health behaviour. Each session is devoted to a particular topic, like artherosclerosis and lifestyle factors, and each session is structured the same way. The first part is an informational part by a member of the cardiac rehabilitation team who answers patients’ questions with respect to a specific topic. The second part focuses on cognitive behaviour therapy. The program has shown positive results on QoL, smoking cessation, eating habits and use of health care resources.

Intervention channel

Many psychologists prefer direct psychological interventions. Those are often delivered by themselves over indirect interventions. But, this is not correct from a cost-effectiveness point of view, since many patients don’t need intensive interventions, plus direct interventions offered by psychologists are not always superior.

From a cost-effectiveness perspective, training other health care professionals in psychological principles is an important task for (health) psychologists. In some cases, other health care professionals are in a better position to deliver interventions to patients.

The Heart Manual Program is given to CHD patients upon discharge from the hospital by trained nurses. Patients and nurses assess together what a good starting level for daily physical activity would be. This has to be a level that would still be feasible for the patient on a bad day. It is based on the principles of goal setting and pacing (gradually increasing level of physical activity), cognitive restructuring and relaxation. Every other week there is telephone contact with the trained nurse to evaluate the progress and to motivate the patient. Results of this program are less anxiety and depression one year after discharge and less use of health care resources.

Conclusions

• Psychological interventions for chronic diseases can be divided in two groups
  • Interventions aimed at restoring/improving QoL
  • Interventions aimed at improving self-management
• Interventions focusing on QOL have an impact on self-management/health status and interventions focusing on self-management have an impact on QOL
• The ageing population together with the fact that medical care has improved leads to a growing population of patients suffering from chronic diseases → increased focus on the development of group programs and self-help programs
• Online intervention programs get more and more attention
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