Applying Theories and Models in Integrated Health: Module 3 Overview

Applying Theories, Perspectives, and

Practice Models to Integrated Health

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Judith Anne DeBonis PhD

Department of Social Work

California State University Northridge

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By the end of this module students will:



Learn how a variety of theories, perspectives and practice

models can be useful in their application to Integrated Health



Identify and understand the impact of personal (practitioner

and patient) practice and explanatory models on clinical

practice and behavior



Gain experience, skill, and confidence (through practice

scenarios) in applying theories to practice 

–

Increase more detailed knowledge and understanding of the

application of Stage of Change theory to Integrated Health

The Basic Value of Theories …

1

Theories help us to explain or predict behavior, to

inform policy, guide practice and direct research.

For behavioral health professionals:



Inform the questions we ask



Frame the comprehensiveness of our

assessment



Offer a vantage point that respects

diversity and complexity



Provide a lens through which we organize

vast amount of information or view data

“It is the theory

that decides

what we can

observe.”

Albert Einstein

Contribution of Theory to Integrated Health? 

2

Assessment is part of treatment

When conducted effectively, a good assessment is not just

about diagnosis, but offers opportunities for the patient to

identify strengths and gain insight and self-understanding.

Theories can act as a roadmap for the

questions to ask or for decisions about the

direction taken in an assessment. It can offer

options for strengthening the partnership with

the patient and encourage practitioner’s to

consider a variety of vantage points which

can lead to a more comprehensive

understanding of the patient’s experiences

Using Common Theories to Enhance

Assessment 

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Behavior is influenced by a person’s environment.

Interventions aimed at the individual 

and

 the environment

have potential for positive outcomes.

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People have different needs and capacities related to the

current phase of their life history.

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All persons experience losses that have the potential to

result in feelings and reactions: denial, anger, depression,

bargaining, and acceptance.

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No one should try to go it alone.  Having access to a

network of support may result in improved healthcare

outcomes.

Group Activity

Generating Questions Associated with Theories…

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…

Think of your client population.

What areas of a person’s life

come to mind when you

consider how these theories

relate to that person?

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Biological, Psychological, Social Relational

and Spiritual Aspects—A Person-Focused

Approach

1



Collects information regarding

history, development, biology,

genetics, psychology, social,

spiritual, and environmental aspects

of health



Offers a structure to examine

current mental status



Provides insight into personal

strengths and weakness including

social role, environmental

resources, mental health and

physical health

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Holistic- person and situation

context

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Helps tie together theories to better

understand aspects of the person

and environment

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Gives integration and

interconnectedness to contrasting

qualities of the person

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Identifying possibilities for engaging

micro and macro systems of

practice

Group Activity

Person and Environmental Focused Mandalas…

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”

1

1.

Using the mandalas (on the next slide) of human behavior

theories, consider how these various theories might be useful

in practice with people who have a combination of health,

mental health, and substance use disorders.

2.

Start by examining a clinical case example, or reading a

narrative written by a person living with one or more of

chronic conditions.

3.

Applying both the person-focused and environmental

mandalas, examine how they interact and impact on the

person’s experience.

Person and Environmental Focused Mandalas

1

Person-Focused

Environmental-Focused

Explanatory Models

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Stories and experiences from real life



Messages we carry with us



Impact on our role as a social worker

Take a few minutes to think about and discuss the following question:

Stress

Vulnerability

History of Mental Disorders



Ancient Egyptians did not differentiate between mental and

physical illnesses

4



Thought the heart was responsible for mental symptoms



Later shifted to blaming, stigmatizing

5



The label of mental illness became the entire definition of who

the person is



Stigma continues to be one of the largest barriers to

understanding and treatment

Typical Reactions Towards Mental Illness

6

Myths and misconceptions about mental illness:

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Depressed people should just “snap out of it”



The mentally ill are dangerous, often commit crimes



All mental illness involves psychotic episodes



It’s fun to be manic



Schizophrenia = multiple personality disorder



Families are the cause of mental illness



Supportive therapy can’t help the mentally ill

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People with schizophrenia can only do low level jobs



A schizophrenic is a schizophrenic is a schizophrenic

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Factors Contributing to Mental Health

Disorders

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No blood test for mental illness



Common for individuals to

blame themselves for their

feelings, thoughts, and

behaviors

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Common to feel embarrassed

about them

The Stress Vulnerability Model

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Amount of vulnerability differs

from person to person

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For some conditions, related

to factors like early exposure

to viral infection in utero

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Reduce person’s biological

vulnerability and stress

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Factors include medication,

coping skills, communication,

and problem solving skills

and structure

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Impacts vulnerability by either

triggering the onset of the disorder

or worsening the course

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Stress can include life events,

relationships, etc.

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Combinations of stress and vulnerabilities

may lead to different types of a disorder

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Individuals and families can build

protective factors to minimize or manage

stress

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May help reduce severity of symptoms

and impact the illness course positively

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Group Activity

How do the causal models of mental health disorders

impact practice?



What are some of the benefits that come from understanding

the causal factors for mental health and substance use

disorders?



Does increased understanding help to reduce the associated

stigma?



What impact can knowledge about causal factors have on the

person and the family?



How would you apply the knowledge from the stress

vulnerability model to help people reduce the severity of their

symptoms and positively impact their illness course?

Practice Theory Models

Take a few minutes to think about and discuss the following question:

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What is your belief about change?

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What motivates persons to take action on

behalf of their health?

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How hopeful are you that recovery is

possible?



Can persons with chronic conditions also be

resilient?

Practice Theory Models

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Assumptions and

research about risk

and resilience factors

that affect human

development and

behavior

Why do people behave as

they do?  What role does

the environment play?

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Theories about how

people change their

thoughts, feelings,

and behaviors in

different situations

How do people change?

What activates or motivates

the process?

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Skills

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Techniques

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Strategies

Used in the practitioner-

client interactions

What activities can improve

client adaptation or well-being?

Critical Examination of Theory

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“While practice theories have made positive contributions to social

work practice, they all have strengths and limitations”



Scientific evidence does not support the theoretical

assumptions



While there may be merit in the underlying theory, the

intervention has not been adequately tested or shown to

be effective



The theory is not broadly applicable to treating a wide

range of psychosocial problems

1

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Consider An Example

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

Read the process recording and note your thoughts as you

take in the information being presented



Please note specific information that appears most important

or significant to your beginning understanding



While you may want more information, think of what

immediately comes to mind in terms of defining the problem or

diagnosis and how you would go about starting to work with

this person?



As a group, take time to collect and process findings...

Process Recording

9

“ I called last week to make this appointment because I just felt

that I was not going to make it.  I felt so anxious and stressed at

school the other day, I had to leave and did not attend my first

class session.  Actually, it was my first day back in school since

taking a break last year.  I had pushed myself too hard with

work, school, and trying to keep the gay alliance going, I just

couldn’t do it anymore.  My drinking was getting worse and I

was yelling at my partner so much I was always leaving to get

away to clam down. My Dad would hit my Mother and he

drank a lot. Maybe I am just too much like him”.

Basic Assumptions of Strengths

Perspective

10,11,12



Everyone possesses strengths



Motivation is increased when strengths

are emphasized



Cooperative, mutually respectful

relationships promote identification of

client strengths



Focusing on strengths diminishes the

temptation to blame or judge



All environments—even the most bleak—

contain resources



How many

observations about

the previous case

example were

“strength-based?”



What percentage of

the discussion

focused on

problems or took a

deficit perspective?

Strengths-Based Practice? 

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Medical/pathology vs. strengths/solution focus

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Using the language of strengths is insufficient

Frames provide a set of rules and

expectations for behavior

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Consider Some Examples

13

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”

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“My patients don’t want to be empowered…they want me to

tell them what to do”



“I want to empower my patients to improve their compliance

with their treatment”



“Some patients cannot be empowered due to age, education

or culture”



“I only use empowerment with some of my patients…it’s in my

bag of tricks but I wouldn’t use it with a newly diagnosed

patient”

Empowering Approach?

13

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”



Compliance vs. Adherence vs. Empowerment



Empowerment is a process and an outcome



No empowerment without respect



Reflect on your

reactions



Challenge –

consider how

fully the spirit of

empowerment

can be applied in

clinical settings

with various

patient

populations

Defining Empowerment for Health

Empowerment

is a process by which people

gain mastery over their lives.”

14

J. Rappaport

Sharing of Power

16

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“You must 

 do what I tell you.”

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“

Let’s decide

 together what is

the best care for your

conditions.

”

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Empowerment Applied

17

Empowered Patients – “Own” Their Health Condition

Make decisions and direct

their life in a way that helps

them meet their goals

Have skills for  

making decisions 

and changes as needed

Are effective  

self-managers

Active participants in:



Setting goals



Building action plans



Identifying barriers



Problem solving

Have strong  

self-efficacy

Comfortable and confident

about taking needed action

How Do Patients Become Empowered?

17,18

Through Self-Management Education

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

Offers information



Defines problems

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

Teaches problem solving



Helps patients identify

problems, make

decisions, take actions

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s

Paolo Freire

19

“There isn’t Dialogue Without Humility”



The content of education

based on true dialogue is not

intended to convey

information or impose ideas



It is to provide an organized

structure so individuals can

–

Identify their own goals

–

Initiate their own decisions

and actions

–

Experience their own power

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n

“Education for liberation”

Bloom’s Educational Model

About “Into,” “Through,” and “Beyond”

20



I

n

t

o

…

K

n

o

w

l

e

d

g

e

1



Provide education and information on the

basics



Involve patients



T

h

r

o

u

g

h

…

S

k

i

l

l

B

u

i

l

d

i

n

g

2



Offer patients opportunities to put

information or skills into action



Help patients to learn through experience



B

e

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d

…

I

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c

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a

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i

c

a

c

y

3



Help patients go beyond the basics

and fine-tune their skills



Encourage patients to keep building

on what they’ve learned

Group Activity

Patient Education and Empowerment



Using Bloom’s 3-step model of education (from the previous

slide) and Freire’s model of empowerment, practice through

role play how you might assess a patient’s educational needs

and individualize the needs based on the three different steps.



Based on these models, how might you modify or enhance any

current patient educational materials that you’ve seen used in

our healthcare system?



Consider the advantages, disadvantages and impact of an

individualized model vs. the “one size fits all” educational

approach?

The Real Goal of Empowerment is Increased

Self Efficacy…

21

“Increased self-efficacy

allows patients to view

disease and symptoms

differently, giving more

opportunities for effective

self-management”

21

P

e

r

s

o

n

C

e

n

t

e

r

e

d

Patient as Central to the Process

16

Individuals Makes Decisions About:



Life-style



Taking medicine



Physical activity



Blending information

with personal culture,

expectations, wishes,

and attitude

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.

Medical Model

1

 vs.

Person-Centered Model of Care

1

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t

Important Changes in Health Management

22

Three points:



Chronic disease is the major reason for

seeking healthcare in the U.S.



Treating chronic medical conditions

requires a different model of care



The “new” models of care for chronic

conditions require a change in both

patient and provider roles

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.

1) Chronic Disease:  The Major Reason for

Seeking Healthcare in the U.S.

22



Shift from acute illnesses to chronic conditions



Chronic disease is the primary cause of disability in the U.S.



Chronic disease accounts for 70% of all healthcare

expenditures in the U.S.



As many as 45% of the general population and 88% of

persons aged 65 or older have at least one chronic condition

2) Treating Chronic Conditions Requires a

Different Model of Care

23

3) Need for Change in Patient and Provider

Roles

24,25

The “patient/professional” partnership involves

collaborative care and self-management education



Patients are expected to do what is needed on a daily basis



Providers act as consultants, resource persons, and offer

treatment suggestions

P

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s

Provide clinical expertise,

experience with the chronic

condition, and evidence-based

knowledge

P

a

t

i

e

n

t

s

Know more about themselves,

what motivate them, what they

are willing to change, and what

has helped them feel better

Wagner’s Chronic Care Model

26

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.

Lorig’s Components of Self-Management 

23,24,27

Living with a chronic condition requires patient

self-management in three key areas:

M

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Group Activity

Good Chronic Care Requires Self-Management

“

Growing evidence from around the world suggests that patients with

chronic conditions do better when they receive effective treatment within an

integrated system of care which includes self-management support and

regular follow up.” 

22

C

o

n

s

i

d

e

r

t

h

e

F

o

l

l

o

w

i

n

g

Q

u

e

s

t

i

o

n

s

:



How would you create effective treatment that includes

self-management support and regular follow-up?



What characterizes a prepared practice team?



What characterizes an informed practice team?



What characterizes an informed activated patient?

26

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i

o

n

?

Health Beliefs

Health Belief Model 

3,28

P

u

r

p

o

s

e

Offers understanding or insight into

a person:



How the person prioritizes health

and health problems



Belief about the causes health

problems or what symptoms

mean



Hopefulness about whether

treatment will help



Sense of how worthwhile certain

actions might be in preventing

disease or treating health

problems or risks

C

o

n

t

r

i

b

u

t

i

o

n



Helps individualize a

comprehensive assessment:

–

What do you think caused

your problems?

–

Why do you think it started

when it did?

–

How does it effect you?

–

What worries you most?

–

What kind of treatment do

you think you should

receive?

Group Activity

Beliefs about Pain

The messages that “pain equals harm” and or that all pain is a signal that

something is wrong can contribute to disability and distress  for persons with

chronic conditions.

28

C

o

n

s

i

d

e

r

t

h

e

F

o

l

l

o

w

i

n

g

Q

u

e

s

t

i

o

n

s

:



Brainstorm about some of the common beliefs about pain

and how these might impact behavior.



What types of questions might you ask to understand the

person’s belief?  How have they coped with pain?



How could education and information be used to address

these issues?  What would the goal be?

The Client’s Theory of Change

The Client’s Theory of Change 

29

P

u

r

p

o

s

e

A

n

“

i

n

f

o

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m

a

l

”

t

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x

p

l

a

i

n

s

a

p

e

r

s

o

n

’

s

:



Perceptions and views about the

nature of the problem and it’s

possible resolution



Opinion about what is known to

be helpful or unhelpful in dealing

with the problem

NOTE: this theory needs to be

discovered through dialogue

characterized by “caring curiosity”

C

o

n

t

r

i

b

u

t

i

o

n



Helps to direct the focus of

treatment based on the patient’s

expertise and knowledge,

reinforcing engagement and

motivation



Highlights strengths and abilities

in the patient that may have been

overlooked or forgotten



Provides details on previous

experiences of change which

offer opportunities to make a

successful plan in the present

Activity

Client’s Theory of Change …

P

r

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p

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s

.

2

9

Consider the Following Questions:



When the goal is to discover the client’s theory, what role and

stance is the most effective for the practitioner to take? (Hint:

there is more than one right answer here)



Are the models of education (Lorig, Freire, Bloom) compatible

with this theory? Could they be used in combination?



How would a solution-focused approach serve the discovery of

the client’s theory of change?  (Be specific)

Stage of Change

Stage of Change Theory

30



Identify the stages that

changers go through



Measure the person’s

readiness to change and offer

stage-matched interventions



Identify what is needed at

each stage to move through

the process and make

behavior change

P

u

r

p

o

s

e

C

o

n

t

r

i

b

u

t

i

o

n

s



Recognize change as a

process



See every person in the

process of change and

intervene accordingly



Recognize relapse as part of

the change process



Measure progress both

through changes in stage or in

changes in behavior

James Prochaska

Stage of Change

Guru

F

i

v

e

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a

g

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s

o

f

C

h

a

n

g

e

3

0

1.

Precontemplation

2.

Contemplation

3.

Preparation

4.

Action

5.

Maintenance

Stage of Change…Details

30

F

i

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t

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s

o

f

C

h

a

n

g

e

1.

Precontemplation

2.

Contemplation

3.

Preparation

4.

Action

5.

Maintenance

P

e

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p

l

e

i

n

t

h

i

s

S

t

a

g

e

1.

No intent to change yet,

unaware or deny personal

relevance

2.

Aware of the problem,

ambivalent about change

3.

Getting ready to change,

choosing a plan

4.

Trying to change, not yet

consistent in doing it

5.

Practice being consistent,

avoid slipping back

T

i

p

O

f

f

s

1.

“There’s nothing I

really need to change”

2.

“It might be good for

me, but it’s too hard”

3.

“I’ve started to make

small changes”

4.

“I wish I was more

consistent”

5.

“I’m working hard not

to lose the progress I’ve

made”

10 Principles for Applying Stage of Change

Theory 

30,31,32

1

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1

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Activity

For each of the detailed Stage of Change principles

that follow…

Consider the Following Questions:



How does the principle support the goals of Integrated Health?



If implemented, what changes would this principle make to your

thinking or behavior or practices with the patients you encounter?



What (if any) barriers exist which would limit the full use of the

Stage of Change principles?

1

Change is a Process Rather Than an Event

It is common for people to change gradually —

from being uninterested, to considering a

change, to deciding and preparing to make a

change — over months and years.

2

Change is Characterized by Stages

Each of the stages corresponds to an individual’s

readiness to change — precontemplation (never),

contemplation (maybe), preparation (will soon),

action (doing it now), maintenance (sticking to it),

and termination (never go back) — giving an

indication of when change will occur.

3

Identifying the Person’s Stage of Readiness is

Essential to Tailoring Interventions that will

be Most Effective

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For each stage there are associated change processes — activities

that people can apply or engage in to help modify thinking, feeling,

and behavior— which explain how people progress through the

stages.  Doing the right things at the right times is the key.

4

Moving One Stage at a Time is the Most

Reasonable Goal

Because there is essential learning and

experience that is gained from going through

each stage, skipping stages is not a good idea.

People will vary on the amount of time needed in

each stage — both shifts in readiness and

behavior change are measures of success.

5

Knowing the Changer’s Stage Helps to

Individualize the Approach

Healthcare providers, family, and friends

can offer help that is more targeted to the

person’s particular needs, and offer it in

the best way, when they match the stage.

6

Insight is Necessary But Not Sufficient for

Permanent Change

Two mistakes to avoid in the process —

trying to modify behaviors by becoming

more aware or trying to modify behavior

before there is insight about the

problem.  Either will likely to result in

temporary change or may be an

obstacle to progressing further.

7

People Who are Not in the Action Stage May

Still be “Actively” Changing

Prochaska found that only 10-20% of people were in action, more in

contemplation and the most in precontemplation.  However, since important

changes in attitudes, feelings, intentions during early stages are the

foundation for changes in behavior, all people should be included for

participation regardless of their motivation level or intent to change.

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8

Understanding How to Maintain Change is

Also a Key to Successful Change

It is rare to overcome a problem on the first attempt —sometimes 3

to 4 tries are needed before change is permanent. Both recycling

through the stages and relapses back to old behavior are common

and considered necessary to learn how to sustain change.

9

People can be at Different Stages for Different

Problems

Each  

 problem should be 

evaluated separately 

    so that stage-matched

strategies can be chosen.

1

0

The Goal is for Full Freedom from the

Problem

While improving a problem can

help, discovering how to solve

the problem is the aim and hope

— leaving the person with zero

or minimal risk from a particular

behavior.

Group Activity

Putting together the “theories” of change…



Considering both the Client’s theory of change and

Prochaska’s stages of change:



As a group, choose a case example that includes a patient in

one of the Prochaska stages of change.  Specify the area of

behavior change that will be the focus of the conversation.



Role play using 3 students per group

–

One student will portray a patient

–

One student will conduct the interview

–

The last student will take notes about the ways in which the

interviewer was able to incorporate the theories and draw out the

client’s theory of change.



Discuss what worked well.  What obstacles were encountered.



How did it feel to play the patient? the practitioner?

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Self-Determination Theory

33

The initiation and maintenance of

positive health behaviors is under

the person’s control and therefore

are highly dependent on self-care

actions.



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

Human behavior plays an

critical role in health outcomes

and in the efficacy of treatments



Practitioners can support

patients by attending to their

need for autonomy,

competence, and relatedness



Supports ethical ideals to

empower patients to be active

participants in healthcare

decisions and actions

Autonomy, Competence, Relatedness

33

What Practitioners Should Do and Not Do:

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

Support patients to explore

resistances and barriers



Give feedback



Compliment mastery, skill



Provide respectful, caring

encounters

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Suggesting incentives



Motivating through authority



Showing disapproval



Over-challenging the patient

beyond current capacity

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Group Activity

Self-Determination Theory …

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:



How would you apply this theory? Where?

When?



How might this theory support an Integrated

Health model?



What circumstances might make it more

challenging to apply?



What types of responses would you anticipate

from patients?  family members?  physicians?

In Closing…

Thoughts?

Comments?

References:

Applying Theories, Perspectives, and Practice Models to Integrated Health

1.

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Allyn & Bacon.

2.

Curtis, R., & Christian, E. (2012). 

Integrated care: Applying to theory to practice. 

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3.

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4.

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5.

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Stigma

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13.

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14.

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15.

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17.

Lorig, K. (2001). 

Patient education: A practical approach.  

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18.

 Lorig, K. (2003). Self-management education: More than a nice extra. 

Medical Care 6

, 669-701.

19.

Freire, P. (1971). 

Educacao como practica de libertad: Edzione Italiana

. Arnoldo Mondaton Editore.

20.

 Bloom, B. S. (1985). 

Developing talent in young people

. New York: Ballantine Books.

21.

 Gonzalez, V. M., Goeppinger, J., & Lorig, K. (1990). Four psychosocial theories and their application to patient education and clinical

practice. 

Arthritis Care and Research.

22.

Murray, C. J., & Lopez, A. D. (1996). 

The global burden of disease: A comprehensive assessment of mortality and disability from

disease, injuries, and risk factors in 1990 projected to 2020

.  Cambridge, MA:  Harvard School of Public Health.

23.

Lorig, K., Holman, H., Sobel, S., Laurent, D., Gonzalez, V., & Minor, M. (2000). 

Living a healthy life with chronic conditions: Self-

management of heart disease, arthritis, diabetes, asthma, bronchitis, emphysema, and others. 

Boulder, CO: Bull Publishing CO.

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 Lorig, K., & Holman, H. (2004). 

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25.

 Funnell, M. (March 2000) Helping Patients Take Charge of Their Chronic Illnesses.  Family Practice Management.

26.

Wagner, E. H. (1998). Chronic disease management: What will it take to improve care for chronic illness. 

Effective Clinical Practice,

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27.

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Clinical Outcome Measure

.  JAMA 

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28.

Hunter, C. L., Goodie, J. L., Oordt, J. L., & Dobmeyer, A. C. (2012). 

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29.

Robinson, B. (2009). When therapist variables and the client’s theory of change meet.  

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30.

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33.

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