Silver lining: a ray of hope through strength-based approach in the health care setting

INTRODUCTION

The value-based healthcare in the twenty-first century is achieved by promoting care management. Patient-centered care emphasizes providing care with respect and dignity and involves patients in every aspect of their health. In person-centered care, the strengths of the individual, family and community are assessed. At the individual level, physical, emotional, and cognitive dimensions are characterized by coping skills, capacities to solve problems and support or manage emotions through family and community support.¹ This approach looks at psychosocial problems from a broader perspective and analyzes persons in the context of the cumulative effects that psychological factors and the social environment in which they live have on their physical and mental health and capacity for function.² Psychosocial approaches will help design the psychosocial care plan in a holistic perspective to meet the bio-psychosocial, spiritual, and palliative care needs of the patient and family members/caregivers in the medical setting. It gives a better understanding and insight into the care framework for those part of the multidisciplinary, inter-disciplinary, and intra-disciplinary team when referring cases to people who are specialized in dealing with psychosocial issues.³ The strength-based approach challenges the traditional deficit model applied in psychosocial care practice, which takes an all-encompassing perspective. Creating a comprehensive portrait of each person's life and working in a multidisciplinary team collectively analyses the full capabilities and circumstances of individuals or families. This method emphasizes values, human talents, skills, and knowledge and is commonly used in the medical setting.⁴ Finding the strengths of the patients and their families and ideas to address their problems is helpful. This approach also encourages family members to recognize their strengths to complete treatment courses, adhere, to follow-up, and manage their career, family, and personal lives.⁵ Additionally, it fosters resilience, decision-making skills, and long-term well-being. SBA generally aids the patient and family members cope with difficulties and meet challenges.

This paper uses case illustrations to demonstrate how psychosocial care providers can do assessments and interventions based on a strength-based approach to improving the quality of life of patients and families. By utilizing the case study method, efforts were made to understand and explore how strength-based approaches can be utilized in the cases referred for psychosocial assessment and psycho-social care plans for the patients who are accessing neurosurgical services in a tertiary care hospital. The study analyzed a few cases from the case files maintained in the department to describe how a strength-based model had better outcomes in various domains of life. The study received ethical clearance was sought from the Institutional Ethics Committee.

CASE SERIES

Case 1

Mr. S, is a 38-year-old unmarried man hailing from a lower socio-economic background, from Urban Bangalore. He presents to the neurosurgery unit with complaints of poor posture, difficulty in sitting, walking and had difficulty moving his neck. Past medical history revealed the patient had filariasis, intellectual disability, and epilepsy. The patient had Atlantoaxial dislocation and the condition was not surgically correctable. The case was referred to the psychosocial care providers for emotional support and neuro-education.

The strength based psychosocial assessment revealed patient was starving to avoid bowel and bladder functions, was also felt he has to depend on his mother and sister-in-law for activities of daily living. He has good treatment adherence and family members were extremely supportive and care was provided adequately. He was hopeful about his recovery. He was self- motivated and started providing emotional support to his mother, the primary caregiver. The family had been living in their ancestral property as a joint family in an urban slum in Bangalore and they were running a small shop which was adequate for their daily needs. The resilience of family members was indicated through the arrangement of taking turns for caretaking, which keeps them pushing back to their homeostasis. It was also identified patient had adequate community support, neighbours and the religious institution were helping him in the care context. The community was supportive of the family and rendered adequate support whenever required in terms of financial crisis, emotional support and taking care of the shop. There was a lot of strength was identified among patients and family members which helped to design the strength-based intervention. The outcome was seen as improved coping skills of the patient, self-care, interaction with family, quality of life and reduced caregiver burden.

Case 2

Mr. X, 35 years old married female, educated up to graduation, homemaker, and hailing from middle socioeconomic status. She was presented with severe headache, vomiting and nausea, double vision, weakness in lower limbs, and being diagnosed as suffering from medulloblastoma grade IV, located in the deeper side of the brain; thus, the option of surgical interventions was ruled out. The case was referred to the psychosocial care providers (MPSW) to initiate psycho-social services. The detailed assessment was carried out using the strength-based approach and identified that the patient has good resilience and spirituality. She had integrity towards her past life and believed that God would be extending her life if more responsibilities were fulfilled. The patient also had good primary support, but the children were worried about after effect of the condition and surgery. However, the son trusted the treating team and was providing more strength for the patient. Initially, the intervention focused on information and education about the disease and the need for palliative care. The next level was on the possible outcome, psychological support and medication for pain, and preparation for the dying process. The family was supportive throughout the treatment process, and they were empowered to help the patient to involve in spirituality to encompass meaningful life. The patient underwent surgery without fear and gave hope to the family members. An NGO in the community was identified, and the team coordinated the continued palliative care of the patient at home.

Case 3

Mrs. A, 48 years old married woman educated till Degree, government employee belonging to middle socio-economic status, was presented with optic glioma at the tertiary hospital. The case was referred after the initial diagnostic tests for psycho-social care involving breaking the bad news and empowerment. After the initial assessment, the outcome and complications post-surgery were explained to her and her family members that the surgery might lead to blindness. A detailed assessment focusing on individual and familial strengths was conducted. The extended family members who were living with the patient were the greatest strength of the patient. The patient had expressed her fear of undergoing surgery at the initial time of admission. The spirituality and the resilience she had while dealing with other problems in life were identified as her major individual strengths. The focus of counselling was on these strengths that she has.

The ability to learn new skills was another strength of the patient. The family members were informed about the condition and the need to undergo surgery. Also, the opportunities in the community were assessed. It was found that there was a centre that would help the people in learning braille and help in advocating the rights of blind people. The patient underwent surgery through family support, which she believed would relieve her from the pain and future suffering. After surgery, the patient lost her vision, and in the initial stage, she had many challenges in preparing herself for reality. The team contacted the employer and explained the current condition, and they were willing to extend their support. Through enhancing the primary, secondary, and tertiary social support patient developed better coping strategies and resilience which made her recover from emotional aspects and build psychological well-being. She started to adapt to the environment through training and learned braille.

The environmental work changes were made per the recommendations from the community centre, and the patient started to work.

DISCUSSION

The above case illustrations depict practice through strength-based approach. The assessments were conducted, plans were made, and interventions were done focusing on the strengths present in various domains. The patients were admitted at neurosurgery department of a tertiary health care centre. As each case were differing in the nature, the interventions were tailor made which was planned using the details strength assessment of the patients and were apt for each case. The whole process of service delivery through strength-based approach and outcome is depicted in the Figure 1.

In the assessment the psychosocial care provider gathered information, analyzed and synthesized to get the concise picture of the patients, their needs and strengths. Unlike the medical model, the focus and importance were given to the patient's ability and their environment.

Psychosocial care providers used a variety of methods, including interviews, group discussions, strengths charts, inventories, and checklists, to identify the patient's strengths. Among the various models for assessment. ROPES model developed by Graybeal was used in one of the above cases in assessing the strengths. This model followed the steps as review, overview, presentation, exercise and summary of strength assessment and is based on bio-psycho-socio cultural and spiritual domains.⁶ For a strengths-based approach to be successful, a thorough evaluation of the patient and their life experiences is essential. In order to build on the patient's innate skills, the practitioner should employ language that shows the patient that they are capable of succeeding. The success of the strengths approach is heavily influenced by the patient's aspirations.⁷

The analysis based on the strength-based approach provided better understanding on innate, acquired/learned, supportive strengths in personal, family, social and health domains of life in each of the cases which is showing in Table 1.

In the research strengths are categorized into innate, learned, and supportive strength. The capacities bestowed at birth are known as innate strengths. The essential quality that distinguishes each person is derived from their innate strengths. The disease condition, however, may also result in a decline in these abilities.⁸ These strengths in the examples included physical prowess, mental prowess, intelligence, personality, and unique talents and skills. Learned strengths are those that are developed through socialization and life experiences, such as education, professional relationships, occupational knowledge, and competence, and acquired talents in unique tasks. Additionally, the manner of coping mechanisms might be categorized under this category. Direct personal relationships with family, friends, colleagues, social and professional groups, or the government are examples of supportive strengths.⁸ In addition to these, the patients' strengths included employment income, life insurance, health insurance, government pensions, and social security programmes.

The analysis of the strengths of the patient allowed the psychosocial care providers to develop tailor made intervention plan and these interventions resulted in empowerment and recovery.⁹ The strength-based approach in psychosocial care practice focuses more on enhancing the provision of services, support networks, resources, and opportunities for the patients since it places a significant emphasis on their involvement in the decision-making process. The SBA-based interventions aim to help individuals have more effective, empowered, and content lives.¹⁰ Positive strength-based interventions have the ability to lessen anxiety and discomfort while enhancing resilience, wellbeing, and life satisfaction.⁸

Strength based approach vs problem solving approach

The strength-based approach helps patients identify strengths that might have been hidden because of the current crisis. The approach does not ignore the problems; instead, they define them differently. It is a re-discovery of resources available for dealing with the problems. In contrast to SBA, which defines the patient's future vision and hopes, problem-solving approaches begin by identifying and characterizing the issue. The case illustrations could have been seen from a deficit perspective as well. However, when the focus shifted from deficits to strengths, the patients and practitioners' satisfaction in case management differed. While in SBA, the patient determines their hopes for the future, the practitioner is more involved in diagnosing the problems.¹¹ The facilitator's role in providing a practical solution is emphasized in the problem-based approach from the initial stage to the evaluation. It is decided to what extent the problem has been solved during the evaluation that follows the exercise. On the other side, the strength-based approach relies on the patient and the psychosocial care practitioner working together, with the goals being limited only by their ingenuity. The evaluation is a continuous process in which the patient reframes the evaluation's objectives in a subjectivist manner. The strength-based strategy is, therefore, more objective and involves ongoing issue resolution.

Protective factors on SBA

The strength-based approach has certain protective factors that help achieve empowerment and improved resilience. Alliance and self-reliance combine information from the personal and professional realms to provide solutions. The therapeutic relationship is central to the patient's well-being, and personal strengths and contributions help understand that all individuals can do things and needs to be met. The approach is curious about people and looks for interests or other qualities that might be used to help them, and it believes in people's capability to change. Positive risk-taking is another factor that encourages resilience development and helps people increase their capacity to handle challenges in the present and the future. It is widely established that most individuals want a say in decisions that (may) enable them to live independent lives and maximize their freedom.¹² All of the strength-based approach principles can aid people in doing this.

Cultural barriers/challenges in strength-based practice

Cultural barriers may make it more challenging to practice in a strengths-based way. The organizational cultures in which psychosocial care practitioners operate impact them. Workers' ability to employ strengths-based techniques will be constrained despite the increased emphasis on strengths-based practice if services are commissioned, performed, managed, and inspected in a way that avoids risk, looks for fast fixes, and prioritizes outputs above outcomes.^13,14 However, it is assumed that high competence is needed to carry out strengths-based care practice in the usual psychosocial environment, so it is not very extensively employed in psychosocial care practice.¹⁵

CONCLUSION

The strength-based approach is one of the approaches which came differently from the deficit models of psychosocial practice. In India, the practice of a strength-based approach for interventions in various fields is in its infancy. The legislations have provisions that support a strength-based approach. Mental Health Care Act 2017 recognizes the capacity of each individual to take decisions about their treatment and also asks the care providers to look into the empowerment of the patients. RPWD Act 2016 also provides provisions as resources available that can act as strengths for people with disability for their empowerment.

Funding: No funding sources

Conflict of interest: None declared

Ethical approval: Not required

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