News and Views The “Whole-Person” Approach: Understanding the Connection Between Physical and Mental Health Patrice V. Sminkey, RN
T he practice of case management was founded on a whole-person approach, putting the individual literally at the center of the process. A person-centric practice requires that all clinicians, and in particular professional case managers, become fully aware of the importance of the mental and emotional aspects of a health event, whether acute or chronic. It is well known that an individual’s emotional and mental state impacts health and healing. At the same time, however, the emotional dimensions of chronic conditions can be overlooked. Furthermore, it can be difficult to diagnose mental health conditions such as depressive disorders when someone is medically ill. As researchers have observed, physical symptoms such as difficulty sleeping, undereating, or a lack of energy may be associated with the disease or could be a sign or symptom of a depressive disorder (Turner & Kelly, 2000). Therefore, the onus is on clinicians, including board-certified professional case managers, to be highly aware of the mental/behavioral health impact of physical illnesses. The best perspective, as described in the article “Assessing the Whole Person: Case Managers Take a Holistic Approach to Physical and Mental Health” (see page 140, this issue), is to see physical and mental health as the two halves of an integrated whole.
SEEING THE WHOLE PERSON Professional case managers need not have in-depth expertise in mental health to gain a fuller awareness Address correspondence to Patrice V. Sminkey, RN, Commission for Case Manager Certification, 1120 Route 73, Suite 200, Mount Laurel, NJ 08054 (ccmchq@ ccmcertification.org). The author reports no conflicts of interest. DOI: 10.1097/NCM.0000000000000094
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of the total person. Many factors—observing closely and attentively, engaging with the patient one-onone, using open-end questions as part of motivational interviewing around the individual’s health goals (Tahan & Sminkey, 2012), and taking the time to truly listen—can add significantly to the ability of the professional case manager to fully assess the whole person in the context of his or her physical and mental health. With greater awareness, the case manager is able to optimize the individual’s understanding of his or her health status or condition. A person who does not feel heard or does not believe that others understand how he or she feels is less likely to be engaged in learning about self-care or the importance of adherence to the physician’s orders. Many years ago, when I was a nurse in a hospital setting, one of the patients on our floor was a young single mother who had just undergone abdominal surgery. Being fairly young and inexperienced with taking a whole-person approach, I launched into instructions about wound care because the woman’s surgery had required a large incision. The more I talked, though, the less engaged she seemed to be. I could see her mind was elsewhere. Only later did I understand that this woman had three small children to support, and she was worried about what would happen to them if she couldn’t work. Details about wound care were simply not as important to her in that moment as her family. If I had been able to see her as a whole person, I would have understood that her emotional/mental state (especially financial worries and a lack of resources in her support network) was impacting her physical health and ability to even contemplate her self-care. As practitioners well know, professional case management can be the deciding factor in whether someone’s “health” is defined narrowly only in terms of his or her physical condition, or a broader perspective is taken to gain a fuller view of the whole
Professional Case Management Vol. 20/No. 3
Copyright © 2015 Wolters Kluwer Health, Inc. Unauthorized reproduction of this article is prohibited. PCM-D-15-00005_LR 154
24/03/15 1:33 AM
CCMC News and Views person. For the case manager who truly practices holistically, there is no delineation between “physical health” and “mental health.” The case manager understands that one cannot be separated from the other any more than one’s leg or arm, heart or lungs, can be completely independent from the rest of the body.
THE POWER OF EMPATHY Taking a whole person approach also enhances the case manager’s ability to use empathy as a tool to connect, build rapport, and ultimately empower the individual. With empathy, the professional case manager neither assigns nor assumes how the person feels, such as in response to being diagnosed with a chronic condition, the onset of a severe illness, or a serious injury and/or disabling condition. Rather, empathy reminds the case manager that a diagnosis or change in health status—even one that does not appear to be “serious” in a clinical context (e.g., in situ cancer that is at an early or precancerous stage)—has the potential to trigger emotional and mental health changes in the individual. Suddenly the individual may think of herself differently. Or, the person may have a heightened awareness of his mortality. The change can be profound and permanent. For example, in acute care settings, case managers typically witness a range of reactions among individuals who are in the first stages of coping with a serious diagnosis. Reactions may differ. Some may follow the pattern known as the five stages of grief as described by the late Elisabeth Kübler-Ross in her seminal book, On Death and Dying. The stages are denial, anger, bargaining, depression, and acceptance (Kübler-Ross, 2014). The case manager may observe the person putting on a brave face or even acting jovially with friends and family. When alone, however, the individual becomes angry, depressed, and/ or scared. A professional case manager who observes such behavior would likely speak with the treating physician about further assessment/screening and diagnosis, which may lead to counseling, medication, or other support to address the mental and emotional issues. As advocates, professional case managers are
in a unique position to use their communication skills to find out how the person feels, what his or her fears and anxieties are, what he or she needs, and how to find the right solutions. In these situations, empathy translates to I understand and I hear you—even I see you and your attempts to manage a challenging change in health status. It may be as simple of touching someone’s hand or giving that person your full attention, which broadcasts, “I want to understand where you are with what you are going through. Help me to assist you to hear the information I have for you. Help me to assist you in letting me assess you accurately—physically, mentally, and emotionally.”
THE CASE MANAGEMENT DIFFERENCE Seeing the person and understanding the connection between physical and mental health are the essence of a holistic, person-centered approach. Here, the professional case manager can make a difference, both one-on-one with the individual (the “client” who receives case management services) and also within the context of the transdisciplinary care team, ensuring that, amid complex and sometimes fragmented components of care, the focus remains on the individual, bringing together physical and mental health.
REFERENCES Kübler-Ross, E. (2014). On death and dying: What the dying have to teach doctors, nurses, clergy, and their own families. New York: Scribner Reprints. Tahan, H., & Sminkey, P. (2012). Motivational interviewing: Building rapport with clients to encourage desirable behavioral and lifestyle changes. Professional Case Management, 17(4), 164–165. Turner, J., & Kelly, B. (2000). Emotional dimensions of chronic disease. Western Journal of Medicine, 172(2), 124–128. Patrice V. Sminkey, RN, is the Chief Executive Officer of the Commission for Case Manager Certification (CCMC), the first and largest nationally accredited organization that board-certifies case managers. To date, more than 35,000 professionals have been awarded the Certified Case Manager certification. For more information, please see www.ccmcertification.org.
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Professional Case Management 155
Copyright © 2015 Wolters Kluwer Health, Inc. Unauthorized reproduction of this article is prohibited. PCM-D-15-00005_LR 155
24/03/15 1:33 AM
T he practice of case management was founded on a whole-person approach, putting the individual literally at the center of the process. A person-centric practice requires that all clinicians, and in particular professional case managers, become fully aware of the importance of the mental and emotional aspects of a health event, whether acute or chronic. It is well known that an individual’s emotional and mental state impacts health and healing. At the same time, however, the emotional dimensions of chronic conditions can be overlooked. Furthermore, it can be difficult to diagnose mental health conditions such as depressive disorders when someone is medically ill. As researchers have observed, physical symptoms such as difficulty sleeping, undereating, or a lack of energy may be associated with the disease or could be a sign or symptom of a depressive disorder (Turner & Kelly, 2000). Therefore, the onus is on clinicians, including board-certified professional case managers, to be highly aware of the mental/behavioral health impact of physical illnesses. The best perspective, as described in the article “Assessing the Whole Person: Case Managers Take a Holistic Approach to Physical and Mental Health” (see page 140, this issue), is to see physical and mental health as the two halves of an integrated whole.
SEEING THE WHOLE PERSON Professional case managers need not have in-depth expertise in mental health to gain a fuller awareness Address correspondence to Patrice V. Sminkey, RN, Commission for Case Manager Certification, 1120 Route 73, Suite 200, Mount Laurel, NJ 08054 (ccmchq@ ccmcertification.org). The author reports no conflicts of interest. DOI: 10.1097/NCM.0000000000000094
154
of the total person. Many factors—observing closely and attentively, engaging with the patient one-onone, using open-end questions as part of motivational interviewing around the individual’s health goals (Tahan & Sminkey, 2012), and taking the time to truly listen—can add significantly to the ability of the professional case manager to fully assess the whole person in the context of his or her physical and mental health. With greater awareness, the case manager is able to optimize the individual’s understanding of his or her health status or condition. A person who does not feel heard or does not believe that others understand how he or she feels is less likely to be engaged in learning about self-care or the importance of adherence to the physician’s orders. Many years ago, when I was a nurse in a hospital setting, one of the patients on our floor was a young single mother who had just undergone abdominal surgery. Being fairly young and inexperienced with taking a whole-person approach, I launched into instructions about wound care because the woman’s surgery had required a large incision. The more I talked, though, the less engaged she seemed to be. I could see her mind was elsewhere. Only later did I understand that this woman had three small children to support, and she was worried about what would happen to them if she couldn’t work. Details about wound care were simply not as important to her in that moment as her family. If I had been able to see her as a whole person, I would have understood that her emotional/mental state (especially financial worries and a lack of resources in her support network) was impacting her physical health and ability to even contemplate her self-care. As practitioners well know, professional case management can be the deciding factor in whether someone’s “health” is defined narrowly only in terms of his or her physical condition, or a broader perspective is taken to gain a fuller view of the whole
Professional Case Management Vol. 20/No. 3
Copyright © 2015 Wolters Kluwer Health, Inc. Unauthorized reproduction of this article is prohibited. PCM-D-15-00005_LR 154
24/03/15 1:33 AM
CCMC News and Views person. For the case manager who truly practices holistically, there is no delineation between “physical health” and “mental health.” The case manager understands that one cannot be separated from the other any more than one’s leg or arm, heart or lungs, can be completely independent from the rest of the body.
THE POWER OF EMPATHY Taking a whole person approach also enhances the case manager’s ability to use empathy as a tool to connect, build rapport, and ultimately empower the individual. With empathy, the professional case manager neither assigns nor assumes how the person feels, such as in response to being diagnosed with a chronic condition, the onset of a severe illness, or a serious injury and/or disabling condition. Rather, empathy reminds the case manager that a diagnosis or change in health status—even one that does not appear to be “serious” in a clinical context (e.g., in situ cancer that is at an early or precancerous stage)—has the potential to trigger emotional and mental health changes in the individual. Suddenly the individual may think of herself differently. Or, the person may have a heightened awareness of his mortality. The change can be profound and permanent. For example, in acute care settings, case managers typically witness a range of reactions among individuals who are in the first stages of coping with a serious diagnosis. Reactions may differ. Some may follow the pattern known as the five stages of grief as described by the late Elisabeth Kübler-Ross in her seminal book, On Death and Dying. The stages are denial, anger, bargaining, depression, and acceptance (Kübler-Ross, 2014). The case manager may observe the person putting on a brave face or even acting jovially with friends and family. When alone, however, the individual becomes angry, depressed, and/ or scared. A professional case manager who observes such behavior would likely speak with the treating physician about further assessment/screening and diagnosis, which may lead to counseling, medication, or other support to address the mental and emotional issues. As advocates, professional case managers are
in a unique position to use their communication skills to find out how the person feels, what his or her fears and anxieties are, what he or she needs, and how to find the right solutions. In these situations, empathy translates to I understand and I hear you—even I see you and your attempts to manage a challenging change in health status. It may be as simple of touching someone’s hand or giving that person your full attention, which broadcasts, “I want to understand where you are with what you are going through. Help me to assist you to hear the information I have for you. Help me to assist you in letting me assess you accurately—physically, mentally, and emotionally.”
THE CASE MANAGEMENT DIFFERENCE Seeing the person and understanding the connection between physical and mental health are the essence of a holistic, person-centered approach. Here, the professional case manager can make a difference, both one-on-one with the individual (the “client” who receives case management services) and also within the context of the transdisciplinary care team, ensuring that, amid complex and sometimes fragmented components of care, the focus remains on the individual, bringing together physical and mental health.
REFERENCES Kübler-Ross, E. (2014). On death and dying: What the dying have to teach doctors, nurses, clergy, and their own families. New York: Scribner Reprints. Tahan, H., & Sminkey, P. (2012). Motivational interviewing: Building rapport with clients to encourage desirable behavioral and lifestyle changes. Professional Case Management, 17(4), 164–165. Turner, J., & Kelly, B. (2000). Emotional dimensions of chronic disease. Western Journal of Medicine, 172(2), 124–128. Patrice V. Sminkey, RN, is the Chief Executive Officer of the Commission for Case Manager Certification (CCMC), the first and largest nationally accredited organization that board-certifies case managers. To date, more than 35,000 professionals have been awarded the Certified Case Manager certification. For more information, please see www.ccmcertification.org.
Vol. 20/No. 3
Professional Case Management 155
Copyright © 2015 Wolters Kluwer Health, Inc. Unauthorized reproduction of this article is prohibited. PCM-D-15-00005_LR 155
24/03/15 1:33 AM
