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Book Reviews   |    
Managing Chronic Illness Using the Four-Phase Treatment Approach: A Mental Health Professional's Guide to Helping Chronically Ill People
Reviewed by Jayendra K. Patel, M.D.
Psychiatric Services 2005; doi: 10.1176/appi.ps.56.6.759
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by Patricia A. Fennell; New York, Wiley, 2003, 439 pages, $58

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Taking care of individuals with chronic illness is serious work that demands a thoughtful, organized, and dedicated approach. Patricia A. Fennell, chief executive officer of Albany Health Management, Inc., New York, has extensive clinical experience in managing such individuals and, through her work and publications, is regarded as an expert in the field. Her expertise is evident through the insights she shares with us about chronic illnesses and their heterogeneity in Managing Chronic Illness Using the Four-Phase Treatment Approach: A Mental Health Professional's Guide to Helping Chronically Ill People.

Fennell proposes a model for management of chronic illnesses such as chronic fatigue syndrome and multiple sclerosis by using a systems approach that comprehensively integrates the biological, psychological, sociocultural, and spiritual dimensions to determine the common elements underlying their manifestation and management. This model considers that a person's body, mind, family, friends, clinicians, colleagues, and community are essential contributors to the total system. Changes that occur in one part of the system affect all other parts. The four phases experienced by people with chronic illness include crisis, stabilization, resolution, and integration. Although these phases are sequential, the model recognizes that individuals may move backward and forward and sometimes exhibit signs of being in more than one phase simultaneously. The treatment approach assumes that patients who successfully navigate the four phases will achieve integration rather then cure. Fennell writes, "most of the assumptions of this model are neither novel nor original."

The first phase, described as crisis, is when the acuity of the illness causes the person to seek professional intervention. Fennell points out that developing chronic illness is not a matter of choice or intention but an imposition upon the individual. The therapist, as the coordinator of the treatment, plays a huge role. Communication with other disciplines is considered critical in effective implementation of pharmacologic and nonpharmacologic treatments. Specifically, the therapist aligns with the patient almost unconditionally, validating the enormous burden the patient has to bear. Together, they attempt to overcome obstacles that are impeding treatment and creatively deal with socioenvironmental issues that are aggravating the illness by using pragmatic solutions. Personal narrative is considered an important tool in developing and implementing an individualized treatment plan.

Besides psychoeducation, the patients are also introduced to the distinction between content and process in their lives. The treatment promotes working with the family early on to identify their trauma as it relates to the patient and his or her chronic illness. Phase II, or the stabilization phase, helps patients stabilize and begin restructuring their activities to fit with the limitations imposed by their chronic illness. In phase III, the most important intervention involves the development of meaning; this is clearly perceived as not an easy task and, again, not a sustainable one. The basic tenet here is that people with chronic illnesses must contemplate issues of meaning and attempt to formulate their own individual philosophies or spiritual answers if they wish to integrate their illness into their lives. Phase IV involves integration. The patients integrate their illness into a whole and meaningful life and do not identify with their illness only but, rather, see themselves as individuals with interests and engagements, despite physical limitations. The main goal is integrating the patient's suffering as a part of a meaningful, sustaining, and even rewarding life.

This book is divided into three major parts. The three chapters in part I prime the reader through an overview of the four-phase model and its attributes and discuss the general setting and perceptions of chronic illness in our society. Part II provides a detailed description of each phase in separate chapters, using such tools as clinical vignettes, checklists, and tables. In part III, the author capitalizes on the strengths of the model postulated to discuss a paradigm shift that needs to occur in taking care of persons with chronic illness.

The book is well written and easy to read. However, readers may have to exercise patience during the theoretical discussion in the first two chapters. The pages will move quickly with the introduction of the clinical vignettes from chapter 3 onwards, when the model starts coming together.

Clinicians who treat patients with chronic illness will find that they are already implementing many interventions that are suggested in this text. However, the appeal of this model lies in timing these interventions in a phase-specific manner and delivering them as a comprehensive yet flexible plan. This does demand experience and dexterity. Thus feasible implementation of the whole model in the general community without losing fidelity to its basic tenets may not be easy. Although the author assures the reader that third-party reimbursement is possible, it may not be universally so, and especially for the amount of time needed to implement various elements of the model.

The evidence used by the author to assert the "robustness" of the whole model is rather scant, but that does not take away from what it has to offer. Clearly, there is a need to collect research data by using randomized treatment paradigms to confirm the intuitive but substantial potential apparent in this model. Such research data, although necessary for getting HMO reimbursements, is important for the patients and clinicians to formulate a clear understanding of the benefits and risks of such interventions. Most important, research data may evolve this model into an even better treatment paradigm that can be generalized to other chronic conditions.

This book will be appreciated by all clinicians and individuals who deal with chronic illnesses and is a must read for therapists involved in such work. Although the content is not directed toward schizophrenia, bipolar disorder, or other chronic mental illnesses, the book contains enough pearls of wisdom to enhance their treatment too. The author deserves tremendous credit for her work.

Dr. Patel is assistant professor of psychiatry and director of the schizophrenia research and bipolar disorder programs in the department of psychiatry of the University of Massachusetts Medical School in Worcester.

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