Continuity and change?: Exploring reactions to a guided self-management intervention in a randomised controlled trial for IBS with reference to prior experience of managing a long term condition

Self-care interventions which have been evaluated using RCTs are currently being promoted as an effective strategy for improving quality of life, health and utilisation outcomes for individuals suffering from a range of long-term health conditions. Techniques such as cognitive re-structuring form the bases of self-management interventions and dedicated self-care education training has been attributed with beneficial outcomes including improving people's confidence in their ability to take care of themselves and engagement in collaborative shared decision making with health professionals [1-4]. The success of these interventions has been predicated in large on outcomes relating to: changes in behavior (the changing of diet, relaxation, and 'planned activity'); decreased utilization of health services; and attitude (self efficacy) or being better able to 'cope with symptoms'.Behaviorally orientated self-management educational programmes work include reference to stages, critical periods, developmental tasks and notions of maturation. Psychological outcome measures such as 'self-efficacy' are viewed as being enhanced through a number of mechanisms, the most effective of which is 'performance attainment' (i.e. actual experience of the success of actions) whilst depression and anxiety are viewed as impairing both self-efficacy beliefs and the ability to engage in those behaviours that might increase self-efficacy [5].Individuals entering self-management programmes as part of an RCT are viewed as having the potential to self-manage and learn new 'skills' once they have followed a formulaic. However, RCTs are not usually designed in a way which enables the distinction of the effects of past experience when testing new interventions and there is a tendency to treat the person as a blank sheet as far as prior patient experience and management of a long term condition is concerned. We know from the sociological literature on the experience of chronic illness that disruption t