Supported self management: Step 3: Assist
The third step of SSM is to help your patient learn self-management skills.
Help the patient find a starting point
Help your patient to decide which skill to learn first or what problem to address first. For example, if a depressed patient is inactive and socially isolated, it might be appropriate to begin with behavioural activation (see below). If the patient is having overly negative and self-critical thoughts, cognitive restructuring may be a good place to begin (see below). If the patient feels overwhelmed by a life situation, consider beginning with structured problem-solving.
Provide ongoing support
Ongoing support might include encouraging the patient to keep practising the skills and helping the patient learn new skills and set new goals. The feasibility of providing ongoing support depends partly on time pressures in your practice. Ongoing support might only be possible for some patients, but it will make the intervention more effective.
Explain self-management skills
Although each self-management workbook or program takes a somewhat different approach and emphasizes particular skills, most cover certain core skills. For depression, three core skills are behavioural activation, cognitive restructuring and structured problem-solving.
People who are depressed typically become less active. They withdraw from social contacts, neglect self-care and become less active in hobbies or other activities. The patient may see this as a way of conserving strength, but inactivity typically worsens the depressed mood and slows recovery.
Behavioural activation is taught in a step-by-step way. Target activities are identified. Targets are often social or self-care activities that have become less frequent with the onset of depression. The patient is encouraged to make an activation plan that is:
- specific, describing in a concrete way what exactly is going to be done
- realistic, with goals that are modest and feasible, even if the patient continues to feel low
- written into a schedule and crossed off when completed. Crossing off a completed goal may initially be the only real reward, showing that the person has met a challenge and done something useful for recovery.
This skill addresses the cognitive side of depression. People who are depressed often think about themselves and their situation in an unrealistically negative way. This can show up as harsh and unfair self-criticism, a pessimistic approach to the current situation and unrealistically negative expectations for the future.
Changing this thinking style starts with teaching the patient how to identify depressive thoughts that are unrealistic, unfair and distorted. There are common depressive thinking styles; for example, some people magnify negative aspects of a situation or label themselves in a denigrating way.
The person learns to use a set of questions to identify more fair and realistic thoughts; for example, asking, "Can I get more evidence about the situation?" or "What would I say to a friend in the same situation?" The person must practise fair and realistic thoughts in situations where they would normally think in a harsh and negative manner. When these depressive thoughts appear, the person must challenge the negative thoughts and practise fair and realistic alternatives.
People who are depressed may have considerable difficulty solving problems. They tend to overestimate the severity of a problem, underestimate their own resources and feel stymied in coming up with a plan. Helping patients who are depressed to solve problems increases their sense of competence.
Structured problem-solving starts by identifying a particular problem that is not too difficult. The patient then identifies three actions that would at least move in the direction of a solution and lists the advantages and disadvantages of each action. Finally, the patient chooses one action and starts to put it into effect. This involves making a plan that is specific, realistic and scheduled. As the patient develops problem-solving skills, more difficult problems can be addressed.
Self-management tools focused on other mental health problems will, of course, teach a different set of skills (e.g., relaxation, graduated exposure to situations).
Psychiatry in primary care toolkit
The Psychiatry in Primary Care App has been decommissioned.
The revised print version of Psychiatry in Primary Care is avaible through the CAMH store.