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!