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Engaging Difficult Patients & Families
Thomas W. Bishop, PsyDDepartment of Family
Medicine
Finding Change with Primary Care
Disclosure Statement of Financial Interest
I, Thomas W. Bishop, Psy.D. DO NOT have a financial
interest/arrangement or affiliation with one or more organizations that could be
perceived as a real or apparent conflict of interest in the context
of the subject of this presentation.
Overview Discuss the contrast between
engagement and intervention. Setting things up for success in
therapy. Touching on Stage of Change with
attention to “where do we go?” Thoughts on engaging parents. The art and mechanics of child/adol
focused therapy. A nod to the potential role of positive
psychology.
The Engagement Level of Intervention
Specific Interventions
Engagement of Pt’s & Families in Participating in Interventions
The Practice of Family Systems
Family Staff
ChildCommon Tasks (Family & Staff) Soothe Develop Trust Manage Conflict
Consultation Directives Join Focus Promote Competence Collaborate
Interviewing Strategy
Behavioral Health Issues
Developmental Functioning
Family Context
Physical Limitations
Practice Constraints
Engaging Challenging Patients
Communication Skills Reflection Respect Listening Collaboration Compassion
– Verbal & nonverbal
Core skills in relating Empathy – Accurate Understanding
demonstrated through verbal & nonverbal means in building rapport and eliciting information through understanding.
Genuineness – congruence between verbal and non-verbal expressions, not overemphasizing roles, flexibility with roles, and spontaneity.
Positive Regard – Respect demonstrated through commitment, understanding, acceptance, and warmth.
Nonverbal cues in expressing warmth
Tone of voice Facial expression Posture Eye contact Touching Gestures Physical proximity Synchrony of behavior with
patient Energy level
Effective Verbal Behaviors
Relevant & thought-provoking questions– Open ended vs closed ended
questions. Verbal attentiveness Directness & confidence in
presentation Interpretations – careful Concreteness Identifying & labeling
expressed feelings
Taking a Developmental Perspective
Infant/Child– Speaking through play/art– Modeling in the room– Inaccuracy of verbal reports– Metaphors
Adolescent– Tend to avoid direct eye-contact– Task of role differentiation– Trust & respect
Others– Be aware of limitations and review
functioning with care givers. – Paper, markers, and props
Preschool & Primary-Age Children
Use combination of open-ended & direct questions.
Do not attempt to assume too much control over the conversation.
Gain familiarity with children’s experience & use this in developing questions.
Reduce the complexity of interview context.
Utilize props and be more in the moment.
*See Hughes & Baker, 1990
Elementary-Age Children Rely on familiar settings &
activities. Allow children to use props &
drawings. Avoid consistent eye contact. Provide contextual cues –
pictures, colors, examples, metaphors – along with words. *See Hughes & Baker, 1990
Adolescents Be aware of their
developmental task – individuation, idealism, abstract thinking, & emotions.
Direct more attention and questions.
Tend to avoid direct eye contact.
Build trust.
Key Elements in Interviewing
Using art work Interviewing begins in the lobby Parent and child – how to split time Modeling while engaging Always an intervention Levels of interviewing – questions and
observations ABC Mother who felt overwhelmed
something not working Scaling questions Three wishes and magic question
Interviewing Skills in Seeking Solutions
Practitioners’ non-verbal behavior.
Echoing or asking for clarification.
Open-ended questions. Summarizing. Tolerating/using silence. Noticing clients non-verbal
behavior. Self-disclosure. Noticing process. Complimenting. Affirming parent’s perceptions
Strategies for Change Precontemplation Contemplation Preparation Action Maintenance
Consciousness RaisingSocial LiberationHelping Relationships Emotional
ArousalSelf-Evaluation Commitme
nt Environmental ControlRewardCountering
Terms Consciousness Raising – A new piece of information or
advice can spark curiosity or openness.
Social Liberation – Sometimes a structure in society that supports the need for change can propel people to consider change more seriously.
Helping Relationships – Any effort can be furthered by the support of others.
Emotional Arousal – Calling on emotions is an effective means of motivating the process along.
Self-re-evaluation – This is an effective process to move people towards the preparation and action stage.
Terms Continued… Commitment – Saying things like “I believe I can
change” or “I am willing to change” indicates a commitment.
Environmental Control – Identify places and people that may not support your plan for change and develop a strategy to work with them.
Countering – This means doing something different. Find alternative ways of approaching situations and individuals.
Reward – Identify and allow rewards after goal has been accomplished.
Changing Stripes…Beginning Adventures
I - Ignore
G – Get a Clue
N – Now What?
I – I am Ready!
T – Try It!
E - Encourage
Four Underlying Principles of Motivational
Interviewing Express empathy Develop
Discrepancy Roll with
resistance Support self-
efficacy*See Miller & Rollnick, 2002
Empathic Affirmation• Empathic understanding and
responding are helpful, but those that amplify negative feelings are counterproductive.
• Empathic affirmation that moves parents closer to looking at solutions is more helpful. For example:
“You feel depressed and hopeless about your life” vs “I can see that things are very discouraging right now. What gives you hope that this problem can be solved?”
Key Tools in Seeking Solutions
Empathy Returning the Focus to the
Parent Amplifying Solution Talk…
Difference Questions
Amplifying Solution Talk Encouraging parents in
seeking solutions begins with parents considering what they would like to be different.
Can they even imagine situations being different?
Have parents provide as much detail as possible.
How to Gain Trust…Potential Blind Spots
Listening to each family member. Demonstrating respect for family
members. Developing an understanding of the
family’s past experiences, current situation, concerns, and strengths.
Responding to concrete needs quickly. Establishing the purpose of
involvement with the family. Being aware of one’s own biases and
prejudices. Validating the participatory role of the
family. Being consistent, reliable, and honest. Engaging and involving fathers and
paternal family members
Engaging Parents Tuning into self and others Focused listening Clarification of role and purpose Respect Clear and accurate response to
parent questions Honesty Dependability Identification and support of parent’s
strengths
The Pennsylvania Child Welfare Training Program
Engaging Parents Seeking to understand the parent’s
point of view Culturally sensitive practice Connecting agency goals with parent
goals Investment in parent success Outcomes-oriented practice Regular feedback Confrontation Demand for work
The Pennsylvania Child Welfare Training Program
Returning the Focus to the Parent
Parents may tend to focus on the problem and/or what they would like others to do differently – not how agencies, schools, and others are blamed.
Try:
What gives you hope that this problem can be solved?
When things are going better, what will you notice you doing differently?
What is it going to take to make things even a little bit better?
If your close friend were here, what would they suggest for you to do to make things better?
Suppose a miracle happened and the problem were solved. What is the first thing you would notice that would tell you that things were better? What would others notice?
Seven Key Solution-Focused Strategies
Identifying strengths in a problem situation.
Exploring past successes. Finding and using exceptions to the
problem. Facilitating a positive vision of the
future. Scaling questions. Encouraging commitment. Developing action steps.The Pennsylvania Child Welfare Training Program
Solution-Building Questions Tell me about the times when this
problem is a little bit better? How did you make this happen? What else? What are you doing differently during
those times when things are a little bit better?
What would your best friend tell you when things are going a little bit better for you?
The Pennsylvania Child Welfare Training Program
How to Gain Trust…Potential Blind Spots
Listening to each family member. Demonstrating respect for family members. Developing an understanding of the family’s
past experiences, current situation, concerns, and strengths.
Responding to concrete needs quickly. Establishing the purpose of involvement
with the family. Being aware of one’s own biases and
prejudices. Validating the participatory role of the
family. Being consistent, reliable, and honest. Engaging and involving fathers and paternal
family members
Impact & Effectiveness of Education
Oral instruction alone is not likely to be as effective as other methods.
Information handouts can be effective:
• When the topic is of interest and concern.
• If accompanied by a personalized oral message from the provider.
• When teaching complicated sequences of skills.
Do not underestimate the impact of modeling, coaching, and role-playing.**See Glascoe, Oberklaid, Dworkin, & Trimm (1998)
Be Aware of….
The “Trickiness” of verbal instructions.
It is suggested that 20% of the adult population reads below the 8th-grade level.
The agenda’s that may be in the room.
Myths about Child Therapy
Some argue that family therapy will fail to attend to the child’s own symptoms.
Family therapists argue that child’s symptoms indicate that family dysfunction is pathological.
Some hold that child therapy must be long term.
Young children should be excluded from family therapy.
Traumatized children will grow up to be emotionally flawed.
Children should not be included in treatment planning.
Severe and chronic behavioral difficulties will require big complex solutions.
The therapist is more of an expert on parenting.
Being Solution-Focused & Brief…
Begins with finding the “right” problem.– John Dewy: Any problem that is well-
defined is half-solved (Parnes, 1992)
Family and child therapy techniques can compliment each other – the use of both family play and art therapy techniques.
– I.e. Family house, adventure activities, grief art work.
It may be helpful to integrate Narrative Therapy ideas.
– The telling and re-telling of the evolving story allows for acknowledgement of competency and empowerment.
Could implement a “Habit Control Ritual.”– Journal victories and losses over a problem
and celebrate successes.
**See Selekman, 1997. Solution-Focused Therapy with Children: Harnessing Family Strengths for Systemic Change
Thoughts on the Therapeutic Process
Again, keep a developmental perspective.
Winnicott (1971): One must have in one’s bones a theory of the emotional development of the child and the relationship of the child to the environmental factors.”
– Make use of “not knowing”– Talked of a “holding environment.”– Made use of the “Squiggle Game.”
Post-modern therapist.– Reflection-in-action vs Reflection-on-action
Deeper Strategies Instilling Hope. “Building of
Buffering Strengths.”
Courage. Interpersonal
skill. Rationality. Insight. Optimism. Honesty. Perseverance.
Realism. Capacity for
pleasure. Putting troubles
into perspective.
Future mindedness.
Finding purpose. Seligman, APA Monitor, Dec. 1998
Building Resilience Being empathic. Communicating effectively & listening
actively. Changing “negative scripts.” Loving children in ways that help
them feel special & appreciated. Accepting children for who they are &
helping them set realistic expectations & goals.
Helping children experience success by identifying and reinforcing their “islands of competence.”Brooks & Goldstein, 2001
Building Resilience Cont….
Helping children recognize that mistakes are experiences from which to learn.
Developing responsibility, compassion, and a social conscience by providing children with opportunities to contribute; Maintain routines.
Teaching children to solve problems & make decisions, as well as to set goals.
Disciplining in a way that promotes self-discipline.
Assist children in appreciating that change is part of life.
Brooks & Goldstein, 2001
Tools Gain understanding
– Watch & listen Always modeling –
3rd eye Non-verbal’s are
key Use what you have
– Props & metaphors See pt in context –
family, community, school
Keep your eye on the pt
Hope Theory
Hope reflects an individuals’ perceptions of their capacity to:
Clearly conceptualize goals.Develop the specific strategies to
reach those goals (pathways thinking).
Initiate & sustain the motivation for using those strategies (agency thinking).
Hope as an Agent of Change
Accentuating the determination that an individual can make improvements involves the following (in the context of relationship & community):
Hope FindingHope BondingHope EnhancingHope reminding
Hope FindingThere are three aspects in naming
and measuring hope: A personality disposition (trait)A temporary frame of mind
(state)Hope can occur at different
levels - general goals, goals in areas of life, or in specific goals.
Hope Bonding
Building a working alliance – given that the goals of the alliance coincide with hope goal thoughts, tasks coincide with pathways, and the bond translates to agency (motivation for change).
Hope Bonding Continued…
Building a hopeful alliance involves:Working to establish therapeutic
goals.Generating numerous ways
(pathways) to attaining goals established.
Examine how the relationship between the therapist & patient create the context/energy in which the patient can sustain effort in pursuing goals.
Hope Enhancing
Strategies and programs that typically involve:
Conceptualize reasonable goals more clearly.
Produce numerous pathways or strategies in attaining goals.
Strengthen the energy/motivation to maintain pursuit of goals.
Reframe obstacles as challenges to be overcome.** Making Hope Happen for Kids Program (Edwards & Lopez, 2000)
Narrative Approaches: G-Power
G What is the character’s goal?P Which pathways does the
character identify to use to move toward stated goal?
O What obstacles lay in the pathway?
W What source of willpower is keeping the character energized?
E Which pathway did the character elect to follow?
R Rethink the process – would you have made the same decisions and choices?
Pedrotti, Lopez, & Krieshok, 2000
Hope Reminding It is the strategy of encouraging
pt’s to become their own hope-enhancing agents.
The strengthening of one’s ability to daily identify goal thoughts and barrier thoughts – increasing self-monitoring.
Development of “mini interventions” in strengthening hope.
Theory of Personal Control
Learned Helplessness: The giving-up reaction, the quitting response that follows from the belief that whatever you do doesn’t matter.
Explanatory Style: The manner in which you habitually explain to yourself why events happen. It is a modulator of learned helplessness.Learned Optimism: How to Change Your Mind and Your Life - Seligman
Guidelines for Using Optimism
Use optimism when:– You are in an achievement
situation.– You are concerned in how you will
feel.– The situation is apt to be protracted
and your physical health is an issue.
– If you want to lead, inspire others, or want people to vote for you.Learned Optimism: How to Change Your Mind and Your Life - Seligman
Guidelines for Using Optimism
Do Not Use optimism when:– Your goal is to plan for a risky and
uncertain future.– Your goal is to counsel others
whose future is dim, do not use optimism initially.
– You want to appear sympathetic to the troubles of others – but may use it after confidence is established.
Learned Optimism: How to Change Your Mind and Your Life - Seligman
Key to Optimism UseAsk what the cost of
failure is in the particular situation.
If the cost of failure is high, optimism is the wrong strategy.
If the cost of failure is low, us optimism
Learned Optimism: How to Change Your Mind and Your Life - Seligman
From Pessimism to Optimism
Adversity Beliefs
– Distraction– Disputation– Distancing
Consequences
Arguing with yourself
Evidence Alternatives Implications Usefulness
Learned Optimism: How to Change Your Mind and Your Life - Seligman
Developing Capable Individuals…Seven Skills
Identification with viable role models.
Identification with & responsible for “Family” processes.
Faith in personal resources to solve problems.
Adequate development of intrapersonal skills.
Glen & Warner, 1982
Developing Capable Individuals…Seven Skills
Adequate development of interpersonal skills.
Well-developed situational skills. Adequate developed judgmental
skills.
Glen & Warner, 1982
“Like the fish who is unaware of the water in which it swims, we take for granted a certain amount of hope, love, enjoyment, and trust because these are the very conditions that allow us to go on living.”
David G. Myers, Ph.D.
Integrated Care Model Behavioral Health Consultant (BHC) member of
Primary Care team PCP and BHC often see patient together Integrated charts and treatment plan BHC appointments are conducted in exam room Open availability for BHC, 100% of time devoted
to integrated care Brief, focused, evidence-based behavioral
interventions and follow-up
Blending BHC into Primary Care
BHC is an embedded, full-time member of the primary care team
BHC provides brief, targeted, real-time interventions to address the psychosocial aspects of primary care
Primary Care Provider determines that psychosocial factors underlie the patient’s presenting complaints or are adversely impacting the response to treatment
BHC Points of Contact Well visits Consultations Follow-up Curb-side interactions
Integration in Context…Full Integration
Patient
Behavioral Health
ClinicianPhysician
• Supports cultural competency among staff
• Shared/coordinated responsibility of care
• To the patient it feels like primary care.
• Charting in one chart/one format
• Creates seamless spectrum of care
The Primary Care Team
Active Moments
• Consultation & Collaboration
• Participation in EVERY Well Child Exam - Peds
• Creation of Developmental Services
• Building of treatment guidelines
• Develop group approaches to bridge services
Level I: Screening• Infant Development Review• Child Development Review• Modified Checklist for Autism in Toddlers
(M- CHAT)• Pediatric Symptom Checklist• Edinburgh Postnatal Depression Scale
(EPDS)• Kindergarten Readiness.• Substance Abuse • Behavioral Intake
Levels II and III: Management and Referral
Tennessee Early Intervention Services (TEIS) Traditional psychotherapy Time Limited Intervention with a BHC for (1)
emotional/behavioral /parent training/ academic issue OR (2) A health status management/health behavior change issue
Appropriate community resourcesBehavioral health care/SA treatment for
parent or family memberSchool psychologists/psychoeducational
evaluation
Passive MomentsGroup office including BHC,
pediatrician, call nurse, and studentsConsultation occurs within Pediatric
Clinic“Traditional” Therapy on-siteDevelopmental Services on-siteChild Psychiatry Available Coordinated assessmentsTeaching atmosphereMaintaining a developmental & stages
of change perspective
BHC Consultation/Liaison Services
Can occur with or without patient presentCan include mental health and/or physical concernsAssist with diagnostic assessments
Health Condition AssessmentsOutcomes Research
BHC Collaboration
Make and coordinate referrals/follow-up Assist with continuity of care between PC
team and other community agencies (i.e., development of school groups, fostering relationships between agencies).
Collaborate with other mental health services
Maintain open communication with schools
BHC Interventions…Focused Client Interventions
Limit session time to 15-20 minutesLimit number of sessions Focus on specific concernsProvide parent trainingRisk factor reductionHealth Condition Management (e.g., obesity)
Crisis InterventionAssess crisis and needsEstablish a crisis planCoordinate immediate care
Training and Supervision
Health Condition Management•Obesity
–Brief solution focused interventions –May use classes and group care clinics–Assessment
•Behavioral Assessment System for Children, Piers-Harris 2 Self-Concept Scale, Children’s Eating Behavior Inventory, Children’s Depression Inventory •Dietary habits, activity level, parental attitudes toward food and activity•Readiness to change (Prochaska’s model)•Metabolic measures
•ADHD–Parent and child education groups–Assessment
•Behavioral Assessment System for Children, Parenting Stress Index, ADHD Symptom Checklist-4
Only those who look with the eyes of children can lose themselves in the
object of their wonderEberhard Arnold