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Four-Phase Model (FFPM)



Questions & Answers About the Four-Phase Model (FFPM)™

What are the Four Phases?

What are some distinguishing aspects of the model? How is it different from other models?

How was the Fennell Four-Phase Treatment (FFPT)™ developed?

Why do doctors need to treat patients differently in the different phases?

How can a model developed by a social worker be of serious use to a doctor in a medical practice?


Q. What are the Four Phases?

A. The Four Phases are:

Phase 1 - Crisis. The individual moves gradually or swiftly into an emergency stage at onset of illness or trauma. This phase is characterized by multiple forms of trauma and great urgency. The primary task of the individual, caregivers and clinicians is to cope with trauma.

Phase 2 - Stabilization. The individual discovers that he/she fails, sometimes repeatedly, to return to normal regardless of interventions or the individual's behavior. The task here is to initiate stabilization and life restructuring.

Phase 3 - Resolution. The individual recognizes deeply that his/her old life will never return. Early in this phase most experience profound existential despair. The task here is to begin establishing an authentic new self and start developing a supportive, meaningful philosophy or spirituality.

Phase 4 - Integration. The individual defines a new self in which illness may be an important factor, but it is not the primary one in his/her life. Integration of the illness into a meaningful life becomes the cure the individual seeks.

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Q. What are some distinguishing aspects of the model? How is it different from other models?

A. Most illness models describe acute conditions where the illness follows a well-established, unidirectional trajectory. The Fennell Four-Phase Treatment (FFPT)™ approach captures instead the ambiguous, frequently changing, cyclic, long-term nature of chronic illness. This illness model recognizes and integrates trauma concepts as an essential component in the treatment regime.

The model recognizes that individuals may move backward and forward in the phases. Many individuals with chronic illness are caught in a Phase 1 Crisis/Phase 2 Stabilization loop because they are not helped to move beyond the acute model of illness, where cure is expected to follow sickness. Each plateau period they experience seems to signal a cure to them, their families, friends, coworkers and doctors. They attempt to return to the old life, only to find that they relapse, which sets off a new Crisis. Even individuals who have achieved Phase 4 Integration may experience Phase 1 disruptions if another illness or a severe life crisis occurs. These individuals have, however, learned how to move through the Phases, so they are able to achieve a new Integration more swiftly.

The model recognizes and utilizes to positive effect the personal involvement of the clinician in the assessment and treatment of the individual. It takes into consideration the fact that clinicians also suffer frustration with the ambiguities of chronic illness and are subject to damaging cultural stereotypes related to some illnesses.

The model is an umbrella paradigm which includes a broad variety of assessment and therapeutic practices. It also suggests additional techniques for moving individuals and their significant others through the phase process.

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Q. How was the Fennell Four-Phase Treatment (FFPT)™ developed?

A. Patricia Fennell began developing this Four-Phase theory in the 1980s. It developed out of her observation that approaches in the treatment of chronic syndromes like chronic fatigue syndrome were meeting with repeated and frustrating failure. She recognized that the methods often failed by creating false dichotomies between body and mind, illness and disease, integration and cure.

By shifting the illness paradigm to a more systems-inclusive framework, she found that she was able to achieve better results with patients. She began publishing in the early 1990s, and the Fennell Phase Inventory assessment instrument she developed together with Dr. Leonard Jason and his team at DePaul University has been tested empirically on CFS populations, with good results.

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Q. Why do doctors need to treat patients differently in the different Phases?

A. Patients with chronic illnesses are not a homogeneous group -- even patients with the same chronic condition, whether it be cancer, depression, arthritis, cardiovascular disease, fibromyalgia or something else. The physical, emotional and social needs of a patient in the early stages of the chronic illness experience can be considerably different from the needs of a patient who's been ill for several years.

Patients in Phase 1 are usually so filled with urgency that the doctor will not be able to carry out many interventions, even if several are desirable. This patient is in the Crisis phase, and when people are in crisis they can't do more; they need to do less. This is where constructing a team becomes very important (the team concept is key in the Phase approach). The physician can order a referral to a social worker who can help the patient figure out how to cope with the trauma of the Phase 1 Crisis, assess the patient's activity level, and help his/her family with all the adjustments they will have to make.

Primarily, the doctor will need to treat the crisis together with the physical symptoms. It will also help to focus on a very small number of simple activities, usually the self-care activities of daily living. If patients can be brought to focus on those activities alone, they may also manage to carry out a limited number of medical protocols successfully.

It is less likely they will carry out physical therapy or exercise. Phase 1 patients are often too ill. They may even be bedridden. To give Phase 1 patients too many interventions can worsen the situation. The patients will not comply with protocols, they won't improve and everyone gets frustrated. As a consequence, when doctors identify a Phase 1 patient, they should probably attempt to introduce only the most necessary protocols until the patient stabilizes into Phase 2.

Patients in Phase 2 can consider broader areas of activity, not just their ADLs. They may still have significant problems with exercise, however. Structured exercise is often a highly desirable intervention from the medical point of view. But when an individual has difficulty walking for two days after something as basic as walking up a flight of stairs, it is hard for them to contemplate an exercise program. It takes education, but more importantly, a restructuring of all their activities.

In Phase 2, doctors should pay particular attention to a patient's family, friends and (if applicable) their workplace or school. When individuals first become ill, they may get support from those around them. When the illness persists, however, and the individuals don't return to normal, family members, friends and coworkers often get angry. Many have assumed additional duties to help the sick person, and they want to be relieved of what they thought was a temporary obligation. Patients often respond to these reactions by trying to look and act as though they're better, because this is what's expected of them. They may attempt to do more than they can handle and precipitate a relapse. As a consequence, clinicians need to pay close attention to how the patients' social/interactive world is responding. They may need to carry out family or workplace interventions if they want patients to continue following desired protocols.

If Phase 2 patients believe a doctor is becoming frustrated by their failure to improve, they may begin selective reporting or even misreporting. One sign that patients have entered the relative stability of Phase 2 is that they start to search out others of like kind, and they concurrently seek "better" medical help which they believe will provide them with the ever-elusive cure that they and their significant others want. In other words, they may engage in "doctor hopping."

Patients in the early stages of Phase 3 may seem more desperate, even suicidal, compared to Phase 2 patients. This is because they have actually grasped the chronic nature of their condition and its ambiguity. It is important for clinicians to recognize that Phase 3 desperation differs from that in Phase 1, and it needs to be treated differently.

On the other hand, if Phase 3 patients get the proper assistance and have learned to adapt to their chronic situation, they can become much more sophisticated about their symptoms and disabilities and can handle them better than patients in earlier phases who may actually be having less pain or dysfunction.

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Q. How can a model developed by a social worker be of serious use to a doctor in a medical practice?

A. The Four-Phase Model can help save you time and money, treat patients more effectively, and is adapted to the solution-focused medical environment. It can greatly reduce practitioner frustration. We have also developed an empirically tested instrument, the Fennell Phase Inventory that you can use in your assessment protocol.

The Fennell Four-Phase Treatment (FFPT)™ is a unique way of conceptualizing illness that allows patients, caregivers and clinicians to better assess, treat and manage all varieties of chronic illness and trauma. Using a structure similar to Kubler-Ross' for death and dying, Fennell's model defines Four Phases of adaptation that chronic illness patients experience and describes how best to utilize the characteristics of each Phase to assess the individual's situation and then treat and manage it. The model presents an integrated systems approach which deals with all aspects of the individual's illness -- the physical/behavioral, the psychological and the social/interactive.

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Adapted from Patricia Fennell's Grand Rounds consult for physicians at Walter Reed Army Hospital in Washington, DC.

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