The school of self-management

In a perfect world, every Canadian with arthritis would have access to the kind of education and care that are the central mission of the Rheumatology Medical Day Treatment Program at Sunnybrook Health Sciences Centre in Toronto, or The Arthritis Program at York County Hospital in Newmarket, Ont.

Both programs use a team approach, with occupational therapists, physiotherapists, social workers, and pharmacists conducting group classes in patient education, exercise and self-management techniques; rheumatologists handle only essential aspects of treatment. People who go through either program “graduate” with a grounding in self-management, they have a solid understanding of their disease and its treatment, and they’re able to play a central role in their own care.

A very good alternative, says Dr. Elizabeth Badley, Director of the Arthritis Community Research and Evaluation Unit in Toronto, is the Arthritis Self-Management Program (ASMP), “which is well designed and developed and is actually taught by people with arthritis. Not all education needs to have rheumatologists involved.”

Indeed, the ASMP has been so successful that it was singled out as a “successtory” in 1997 and continues to be offered coast to coast, thanks to the Arthritis Society.

Shifting control to sufferers’ hands
Since 1989, when the ASMP was first introduced in British Columbia (it went national in 1992), participating has taught thousands of people to “take charge” of their arthritis. They’re more informed about their disease and better able to cope with it on a day-to-day basis. And, because they’re more informed, they’re also prepared and confident in their dealings with medical professionals.

They know what questions to ask, and inevitably come away with useful, practical information about medications and their side effects, potential prognoses for their condition, and exercises.

The six-week course is open to people with all forms of arthritis, their spouses and families, and anyone else who may be interested.

Journey towards confidence
The ASMP’s roots go back to the early 1980s at Stanford University Arthritis Centre in California, where Dr. Kate Lorig, a public health educator, was developing a new concept of arthritis management associated with learning. The thrust of her approach was teaching people how to become health self-managers — not to replace a physician’s care, but to help them gain the confidence to personally control their health condition, their pain, and ultimately their sense of well-being.

Next page: Sense of mastery leads to many benefits

She and her colleagues began with the assumption that if they taught people exercise and relaxation, they’d have less pain, more mobility, and fewer bouts of depression. While people did increase their exercise and relaxation enough to satisfy scientific measures, it wasn’t until Lorig incorporated the idea of “self-efficacy” — a concept developed by renowned Stanford psychologist Dr. Albert Bandura — that the program began to gel.

Bandura’s theories about people’s sense of personal control explore the significance of perceived self-efficacy in accomplishing everyday situations. If people with arthritis believe they can use their skills effectively to accomplish a set goal, not only are their chances of success increased but they gain a sense of personal power or “mastery.” It’s not just a matter of knowing how to do something, it’s believing you can.

One application of the theory is in predicting the extent to which people will benefit from medical treatment. Findings show that people with a strong sense of their ability to exercise control over their health conditions are the ones who benefit most from treatment.

With that crucial insight, Lorig revamped her arthritis program, with a greater emphasis on strengthening and enhancing self-efficacy.

“There are a lot of techniques to enhance people’s beliefs that they can do something,” she says. “We have people write a contract to perform a certain task, then we have feedback and problem-solving sessions about what they’ve actually done. We also do modeling: People who have arthritis teach others who have little experience of their real capacities. We put a high value on group work because peer pressure enhances efficacy.”

Less pain, less depression
People already felt better after taking Lorig’s self-help course. They felt more in control of their lives, more confident that they could do what they wanted. They experienced less pain, less fatigue, and very little depression. Lorig adjusted her program to accommodate training that would not only teach people how to manage their arthritis but also how to enhance this feeling of control. The expanded concept became the ASMP.

A key factor people learn to deal with is “learned helplessness,” the erosion of confidence any chronic disease can impose. For instance, if you find stairs a pain, you may stop dropping into a basement-level shop or visiting a second-storey friend. You become helpless in the face of those challenges. Or, if every time you experience a change in symptoms you feel you have to consult your doctor, you’ll become dependent. The ASMP teaches people how to avoid or get over such hurdles. It “injects” them with a healthy dose of self-efficacy, by giving them a take-charge attitude about every aspect of their arthritis.

Knowledge is power. The more you know, the more able you are to cope and the better you’re able to live with arthritis.

For more information on ASMP please see