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NORTHWEST AIDS EDUCATION AND TRAINING CENTER
2015 Co-occurring Disorders Conference
Yakima, WA
The Spirituality of Adherence
NW AETC
NAVOS
Learning Objectives
• Articulate three primary components of spirituality and how they relate to behavioral health and adherence to treatment
• Gain an interdisciplinary understanding of how and why some Evidence Based Practices incorporate spirituality better than others
• Understand how to positively impact adherence to a treatment with a client experiencing co-occurring disorders using an Evidence Based Practice
Adherence
The World Health Organization defines adherence as
“The extent to which a person’s behavior… corresponds with agreed recommendations from (with) a health care provider”
Definition of Spirituality
• Spirituality is a matrix of contextualized values, beliefs and practices . . .
• expressing an orientation to and a process of perceived human flourishing . . .
• found in individual, communal, and transcendent connections to reality
• In research interviews, clients and clinicians note that spirituality centers on:- Experiences that offer a fundamental sense of being part of a larger whole
- Supportive communities of affirmation and accountability
- Nourishing individual well-being and hope
Community – Passion – Hope
Transcendent Connections: Joy, Compassion, Beauty, Awe
Culture, Spirituality & Human Health
Emergent Human Systems Theory; Graves, 2008
Six Levels of Human Relations
Transcendent – Unifying Connections across Difference
- Truth, Beauty, Goodness, Justice, Loyalty to Loyalty
- Ethics/Common Good/Altruism
- Norms of Cross-Cultural Relationships (appreciation, mutuality, acceptance)
- Spirit/Wisdom/Deep Understanding
Cultural - Social Interaction Dependent on Shared Language,
Symbols, and Purpose
Psychological – Mental Constructs
Biological – Biological Process & Organisms
Physical/Atomic – Atoms & Molecules
Subatomic/Elemental – Quantum Mechanics, Wave/Particle Duality
Subatomic/Elemental
Physical
Biological
Psychological
Cultural
Transcendent
Spirituality and Medical Issues
• Spirituality can be described as an innate part of a client’s basic structure that may not be developed or recognized & is awakened from a dormant state by an internal or external catalyst.
• Stress of living with an illness can encompass stigma, anger, guilt, shame, emotional distress
• Meaning & purpose in life & connectedness are major attributes of spirituality (Simoni, Martone, & Kerwin, 2002)
• When spirituality is addressed there can be an improvement in the immune function and particularly health-related quality of life (Dalmida, 2006)
• Effective spiritual assessments can help take the nuanced nature of a person’s spirituality into account.
4 Components of Healing
• Culture • Culture
Physical Spiritual
BehaviorSocial
Adherence
The World Health Organization defines adherence as
“The extent to which a person’s behavior… corresponds with agreed recommendations from (with) a health care provider”
Adherence: Intentional vs. Unintentional
Adherence Non-Adherence
Intentional You say it; consumer accepts itActive disregard of treatment recommendations• Belief• Perceptions• Doubts • Choices
Unintentional Passive participation, externally mediated
Passive disregard of treatment recommendations• Cognitive• Physical• Health illiterate
Causes contributing to Non-Adherence
Consumer-related
Provider-related?
Lack of understanding or disagreement w/diagnosisLack of involvement in treatment decision-making Decreased health literacyHealth beliefs & attitudes re: effectiveness of txMotivation, “forgetfulness”
Socio-Economic Decreased Social Support= Decreased AdherenceFinancialTransportation issuesNo sick leave benefit, long wait times
Therapeutic Therapy requires leaving current support systemMedication side effectsDiffering perception of wellness/illness/”success”
Systems Provider is judgmental, or consumer perceives judgmentTime/scheduling limitationsClinic or agency policies/procedures
Spiritual Lack of a supportive community around treatment goalsTreatment conflicts with client or community values
Case Scenario
• Cathy is a 20 year old Asian American, female identified, woman who is diagnosed positive with HIV
• She is non adherent with HIV medication and adherent with high blood pressure medication
• She has attended 2 individual sessions of counseling for depression
• She attends AA group every week
• She is expressing interest in her spirituality but not her childhood experience of attending Catholic church
• *********************************************************
• The medical and behavioral health staff have exchanged Releases of Information but each believes the other should talk about spirituality with the client
• What are the spiritual issues and how could they be discussed with the client?
The Primacy of Relationship to Communication
• A core principle of effective communication is relationship with another person
• People have a natural drive toward relationships and often long for acceptance
• The common experience of trauma can result in a belief of non-acceptability or being unlovable
• Many people try and hide these aspects of themselves and work at keeping them submerged
• Developing a meaningful relationship with a client is key to adherence
Relationship is Key to Communication
Communication with an Evidenced-Based Practice
• Stages of Change & Motivational Interviewing- One EBP effectively used with different consumer populations and behaviors
- Includes brief intervention strategies that focus on principles of client autonomy, change talk, commitment, collaboration
• Two active components: Relational (focused on empathy & the primacy of relationship) & Technical (introduction & reinforcement of consumer change talk)
• Providers acquire skills to improve interactions with consumers
OARS & Change
• “The meaning of words has to be actively negotiated”
• “Words have a unique effect in the mind of each person, because each person’s experience is unique”(WIMHRT, 2009)
• OARS
• Open-ended questions
• Affirmations
• Reflective Listening
• Summary
Dynamics of Motivational Interviewing
Stages of Change Model
Counseling, Adherence, WRAP: A Spiritual Common Ground
- 1) A focus on therapeutic relationship
- 2) A desire to move into more relationships that positively support the individual
- 3) A sense of zest, or energy
- 4) Increased knowledge of oneself and the other person in the relationship
- 5) Encouragement of hope (a desire to take action both in the growth-fostering relationship and outside of it)
- 6) An overall increased sense of worth
WRAP
• The Wellness Recovery Action Plan, or WRAP plan, consists of identifying what keeps us well, pre-crisis triggers, supportive networks, and a plan to stay in recovery even in the event of a crisis.
• WRAP can help the consumer develop and adhere to a wellness plan that includes preventive actions encompassing the 4 components of healing, particularly spirituality
• Focus on Spirituality:• Connect with supportive community• Explore individual passion
- In a particular environment- Involving specific activities- Including a quality of relationship that makes the passion worth pursuing in the
face of difficulty or inconvenience
• Identify opportunities for growth that can nurture hope
Spiritual Assessment
• “Check a box” style: conventional
• Spiritual history style: HOPE (Eagger), FICA (Pulchalski), functional/substantive (Swinton)
• Recovery style: • H – Helping Communities - traditions of human flourishing (cultural,
ethnic, religious), family and friends, supportive groups providing accountability
• O – Options & Opportunities – being aware of possible choices to achieve goals
• P – Passions & Practices – identifying activities that bring joy or peace despite hardship or inconvenience in pursuing such activities
• E – Experiences – being aware of past events that point to barriers and opportunities for adherence to treatment plans
Skills to Take Home
• MI is one effective communication process for developing tx plans
• OARS could be means of helping to motivate change for developing tx plans
• WRAP can provide the structure – how to evaluate goals & integrate spirituality into tx plan.
• The process of developing spirituality of adherence with clients1) Identify communities – non-supportive and supportive2) Identify client’s passions & their traditions of human flourishing (spirituality)3) Using WRAP to help client to become aware of how communities, passions, & hope support wellness and adherence to a mutually agreed to tx plan
• Recovery style spiritual assessment along with spiritual history
• Repeat the process! It takes repetition to change behaviors
Spirituality of Wellness: Community, Passion, Hope
References
• Canda, Edward R. and Leola Dyrud Furman. (1999). Spiritual diversity in social work practice: The heart of helping. New York: The Free Press.
• Comstock, D.L., Hammer, T.R., Stentzsch, J., Cannon, K., Parsons, J., & Salazar II, G. (Summer 2008). Relational-Cultural theory: A framework for bridging relational, multicultural, & social justice competencies, Journal of Counseling & Development, 86, 279-287.
• Dalmida, S. (2006). Spirituality, mental health, physical health, & health-related quality of life among women with HIV/AIDS: Integrating spirituality into mental health care, Issues in Mental Health Nursing, 27 (2), 185-198.
• Fallot, Roger D., ed. (1998). Spirituality and recovery from mental illness. New Directions for Mental Health Services Series 80. San Francisco: Jossey-Bass Publishers.
• Fowler, James. (1995). Stages of faith: The psychology of human development and the quest for meaning. San Francisco: Harper.
• Gordon, Elizabeth and John Corr. (2010). The spirituality and mental health project. Washington State Mental Health Transformation Project.
• Graves, Mark. (2008). Mind, Brain, and the Elusive Soul: Human Systems of Cognition and Spirituality. Burlington, VT: Ashgate Publishing.
• Gregory, Jr., H, Orden, O., Jordan, L., Portnoy, G., Welsh, E., Betkowski, J., Wolfman Charles, J., DiClemente, C. (2012). New directions in capacity building: Incorporating cultural competence into the interactive systems framework, American journal of Community Psychology, 50, 321-333.
• Hudley, C., & Taylor, A. (2006). What is cultural competence and how can it be incorporated into preventive interventions? In N.G. Guerra, E. Smith (Eds.), Preventing youth violence in a multicultural society (pp. 249-269). Washington, DC, USA: American Psychological Association. Doi: 10.1037/11380-010
• Huguelet, Philippe and Harold G. Koenig, eds. (2009). Religion and Spirituality in Psychiatry. New York: Cambridge University Press.
• Koehn, C.V. (2010). A relational approach to counseling women with alcohol & other drug problems, Alcoholism Treatment Quarterly, 28 (1), 38-51.
References
• Kurtz, Ernest and Katherine Ketcham. (1992). The spirituality of imperfection: Storytelling and the search to wholeness. New York: Bantam Books.
• Luhrmann, T.M. (2007). Social defeat and the culture of chronicity: Or, why schizophrenia does so well over there and so badly over here? Culture, Medicine, and Psychiatry 31, 135-172.
• Miller, W.R., & Rollnick, S. (2002). Motivational interviewing: Preparing people for change (2nd ed.). New York, NY, USA: Guilford Press.
• Miller, W.R., & Rose, G.S. (2009). Toward a theory of motivational interviewing, American Psychologist, 64, (6), 527-537.
• Rastogi, Mudita and Elizabeth Wieling, eds. (2005). Voices of color: First-person accounts of ethnic minority therapists. Thousand Oaks, CA: Sage Publications.
• Rennebohm, Craig. (2008). Souls in the Hands of a Tender God: Stories of the Search for Home and Healing on the Streets. Boston: Beacon Press.
• Simoni, J., Martone, M., & Kerwin, J. (2002). Spirituality & psychosocial adaptation among women with HIV/AIDS: Implications fro counseling, Journal of Counseling Psychology, 49, 139-147.
• Swinton, John. (2001). Spirituality and mental health care: Rediscovering a ‘forgotten’ dimension. Philadelphia: Jessica Kingsley Publishers.
• WA Institute for Mental Health Research & Training. (2009). WA State certified peer counselor training manual.
• World Health Organization. 2003. Advocacy for mental health. Mental Health Policy and Service Guidance Package, Geneva.
Thanks For Attending Our Workshop!
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