1. Village Center for Care Village Care of New York
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

2. PARTICIPATION IN REHABILITATION Falls are a serious problem for older people, placing them at risk for injuries that can adversely affect health, functioning, and independence. Interventions 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.

3. 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.

4. 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?

5. 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”

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

7. EXPLAINING PARTICIPATION Through work with patients with serious illness, Howard Leventhal and colleagues developed and tested a “self-regulation” model that focuses on the way people’s 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 patient’s self-regulation system.

8. 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
Representation
of Disease
Meaning of symptoms
Coping
Procedures
Appraisal
Act
Plan
Situational
Stimuli
Inner & Outer
Behavioral Stage
Act
Plan
Representation
of Fear
Coping
Procedures
Appraisal

9. Summary -- People are active problem solvers
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.

10. 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

11. Contextual Factors of the homebound elderly
Chronic, debilitating disease
Reduced mobility
Great isolation
Growing sense of losing control over one’s life

12. Coping Procedures/Action Plans
COPING PROCEDURES were aimed at maintaining control over:
The environment
Social interactions
Self image

13. 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.

14. 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 can’t tolerate
Life Stress
Minimize stress
Social Comparison
Do more / do less

15. 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 don’t have any energy. I sleep a lot. Maybe I’m ready for the end.”
“I must confess I’m not doing the exercises. I don’t feel good…maybe I’m already dead. I just can’t trust my walking.”
“If I don’t walk and keep quiet, there’s no pain. It’s only when I stir it up and keep active that there’s pain.”
“I feel I’m going to collapse…maybe you should just give up on me.”

16. Physical Therapist’s Descriptions
“Her husband is dead seven years but she acts like it was last week…she perseverates on issues that keep her nonfunctional.”
“She was happy for me to come see her but was not interested in physical therapy…she would not do the exercises but would walk to the park and back…one day she had taken down all the curtains and washed them in the bathtub.”
“She doesn’t want to get better. She hasn’t learned the exercises. She wants nothing in her apartment changed.”

17. 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

18. 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