A Fragile Balance

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A Fragile Balance Using common sense
representations and a model of self regulation to
explain and enhance homebound seniors
participation in rehabilitation
Linda Richmond, Ph.D. Village Center for
Care Village Care of New York
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PARTICIPATION IN REHABILITATIONFalls are
a serious problem for older people, placing them
at risk for injuries that can adversely affect
health, functioning, and independence.Interventi
ons targeting risk factors have been found to
moderately reduce the risk of falling and
rehabilitation may improve both physical and
mental functioning following a fall-related
injury.Nevertheless, seniors often meet these
efforts with resistance and fail to comply with
rehabilitation regimens.
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A CASE EXAMPLE

• Homebound elderly, identified by their physicians
  as being at high risk for falling, were asked to
  participate in a falls prevention intervention
  that focused on providing strength and mobility
  through rehabilitative exercises, educating
  patients and their caregivers, and reducing
  environmental risk factors in the home. About
  half of the clients chose up front not to
  participate after agreeing, another 28 dropped
  out either before or within two weeks of the
  initial session of the ten who remained
  throughout the 10-week course, many refused to
  participate in all or part of the intervention.

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According to the physical therapist, who led
the intervention, Clients appear to be holding
things in a fragile balance and resist anything
that disturbs that balance, any
change.Research Question How can the
struggle for balance be used to explain and
enhance participation?
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Method

• Data Sources
• Interviews with physical therapist before and
  following session
• Observation of clients, PT, and interactions
• Review of PT progress and process notes
• Client record extraction

• Data Analyses
• Qualitative
• Content analysis
• Typologies

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FRAGILE BALANCE

• What are the homebound elderly balancing?
• Risk vs. Gain
• Control vs. Change
• Old Identity vs. New Identity
• Hope vs. Hopelessness

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EXPLAINING
PARTICIPATIONThrough work with patients with
serious illness, Howard Leventhal and colleagues
developed and tested a self-regulation model
that focuses on the way peoples representations,
or common-sense models, of illness threats
serve as targets for interpretation and for the
performance and appraisal of self-regulative
procedures. From the perspective of the model,
explaining participation in rehabilitation occurs
through identification of the patients
self-regulation system.
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The Self-Regulation Model
Cultural / Institutional roles, language
Complexity of Personal Environment Work/
Family/ etc.
Self Physical Cognitive Competence / efficacy
Paths that bypass representations
Behavioral Stage
Coping Procedures
Appraisal
Representation of Disease Meaning of symptoms
Act Plan
Situational Stimuli Inner Outer
Behavioral Stage
Act Plan
Coping Procedures
Appraisal
Representation of Fear
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Summary-- People are active problem
solvers.-- As common-sense biologists/physicians
they construct representations of their worlds
and themselves.-- Representations are abstract
and concrete/experiential.-- Self-regulation is
a process.-- Disease features shape
representations.-- Representations create goals,
shape selection of procedures and perception and
actual efficacy of procedures.-- Action plans
are instances of procedures in specific
contexts.-- Feelings of control of disease
and/or symptoms and emotions affects perceptions
of self competence.-- Beliefs about self (self
regulation strategies) moderate process.--
Institutional/social context moderate process.
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Symptoms (and their meanings) were the focus for
the elaboration of clients illness
representations.

• Physical symptoms (related to aging and decline)
• Fatigue
• Pain
• Weakness
• Emotional symptoms (related to loss and fear)
• Depression
• Anxiety

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Contextual Factorsof the homebound elderly

• Chronic, debilitating disease
• Reduced mobility
• Great isolation
• Growing sense of losing control over ones life

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Coping Procedures/Action Plans COPING
PROCEDURES were aimed at maintaining control
over The environment Social
interactions Self image
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ACTION PLANS implement procedures that
make sense given the nature of the
anticipated/current health threat, the nature of
the procedures relevant to controlling it, and
the vulnerability and resources of the
SELF.Environmental control/ Limiting the space
in which they move. Refusing to walk outside.
Not accepting modifications.Social
interactions/ Refusing to participate in the
intervention altogether. Manipulating the
session.Self image/ Maintaining an active
connection to the past. Focusing on what know
can do.
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Self assessments self regulation strategies
moderate coping
Coping Procedure Action Diagnostic
Treatment Plan
Representation of health threat
Appraisal
Somatic stimuli
Identity/Cause/Time-line Consequences/Control
Self Care Exercise Relax - sit Avoid risk
Symptom Checks Duration/severity Non adherence as
Body cant tolerate
Life Stress Minimize stress
Social Comparison Do more / do less
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Symptoms and Meanings Symptoms of fatigue,
pain, and weakness, signs of aging and decline,
rather than discrete illnesses or past events
such as falls, were used to describe their
conditions.

• I dont have any energy. I sleep a lot. Maybe
  Im ready for the end.
• I must confess Im not doing the exercises. I
  dont feel goodmaybe Im already dead. I just
  cant trust my walking.
• If I dont walk and keep quiet, theres no pain.
  Its only when I stir it up and keep active that
  theres pain.
• I feel Im going to collapsemaybe you should
  just give up on me.

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Physical Therapists Descriptions

• Her husband is dead seven years but she acts
  like it was last weekshe perseverates on issues
  that keep her nonfunctional.
• She was happy for me to come see her but was not
  interested in physical therapyshe would not do
  the exercises but would walk to the park and
  backone day she had taken down all the curtains
  and washed them in the bathtub.
• She doesnt want to get better. She hasnt
  learned the exercises. She wants nothing in her
  apartment changed.

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Differences in Representations

• Physical Therapist
• Representation framed in functional terms
• Goals are related to risk of falls
• Rehabilitation viewed as means to mastery

• Client
• Representation framed in physical (functional and
  somatic) and emotional terms
• Goals are holistic and related to general
  condition
• Maintaining integrity viewed as means to mastery

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Client-Centered Rehabilitation

• Create a Therapeutic Alliance
• Develop Common Goals
• Develop Shared Representations
• To change the identity of the problem
• modify the procedure
• increase real and perceived
  control