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Engaging Difficult Patients & Families Thomas W. Bishop, PsyD Department of Family Medicine Finding Change with Primary Care

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Engaging Difficult Patients & Families. Finding Change with Primary Care. Thomas W. Bishop, PsyD Department of Family Medicine. Disclosure Statement of Financial Interest. I, Thomas W. Bishop, Psy.D . - PowerPoint PPT Presentation

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Engaging Difficult Patients & FamiliesThomas W. Bishop, PsyDDepartment of Family MedicineFinding Change with Primary Care

Disclosure Statement of Financial InterestI, 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 InterventionSpecific InterventionsEngagement of Pts & Families in Participating in InterventionsThe Practice of Family SystemsFamilyStaffChildCommon Tasks (Family & Staff)SootheDevelop TrustManage ConflictConsultation DirectivesJoinFocusPromote CompetenceCollaborateInterviewing StrategyBehavioral Health IssuesDevelopmental FunctioningFamily ContextPhysical LimitationsPractice ConstraintsEngaging Challenging PatientsCommunication SkillsReflectionRespectListeningCollaborationCompassionVerbal & nonverbal

Core skills in relatingEmpathy 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 warmthTone of voiceFacial expressionPostureEye contactTouchingGesturesPhysical proximitySynchrony of behavior with patientEnergy levelEffective Verbal BehaviorsRelevant & thought-provoking questionsOpen ended vs closed ended questions.Verbal attentivenessDirectness & confidence in presentationInterpretations carefulConcretenessIdentifying & labeling expressed feelings

Taking a Developmental PerspectiveInfant/ChildSpeaking through play/artModeling in the roomInaccuracy of verbal reportsMetaphorsAdolescentTend to avoid direct eye-contactTask of role differentiationTrust & respectOthersBe aware of limitations and review functioning with care givers. Paper, markers, and props

Preschool & Primary-Age ChildrenUse combination of open-ended & direct questions.Do not attempt to assume too much control over the conversation.Gain familiarity with childrens experience & use this in developing questions.Reduce the complexity of interview context.Utilize props and be more in the moment.

*See Hughes & Baker, 1990Elementary-Age ChildrenRely 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, 1990AdolescentsBe 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 InterviewingUsing art work Interviewing begins in the lobbyParent and child how to split timeModeling while engagingAlways an interventionLevels of interviewing questions and observationsABCMother who felt overwhelmed something not workingScaling questionsThree wishes and magic questionInterviewing Skills in Seeking SolutionsPractitioners 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 parents perceptionsStrategies for Change PrecontemplationContemplationPreparationActionMaintenanceConsciousness RaisingSocial LiberationHelping RelationshipsEmotional ArousalSelf-EvaluationCommitmentEnvironmental ControlRewardCounteringTermsConsciousness 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 ContinuedCommitment 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 StripesBeginning AdventuresI - Ignore

G Get a ClueN Now What?I I am Ready!T Try It!E - Encourage

Four Underlying Principles of Motivational InterviewingExpress empathyDevelop DiscrepancyRoll with resistanceSupport self-efficacy

*See Miller & Rollnick, 2002Empathic AffirmationEmpathic 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 SolutionsEmpathyReturning the Focus to the ParentAmplifying Solution TalkDifference QuestionsAmplifying Solution TalkEncouraging 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 TrustPotential Blind SpotsListening to each family member.Demonstrating respect for family members.Developing an understanding of the familys past experiences, current situation, concerns, and strengths.Responding to concrete needs quickly.Establishing the purpose of involvement with the family.Being aware of ones own biases and prejudices.Validating the participatory role of the family.Being consistent, reliable, and honest.Engaging and involving fathers and paternal family membersEngaging ParentsTuning into self and othersFocused listeningClarification of role and purposeRespectClear and accurate response to parent questionsHonestyDependabilityIdentification and support of parents strengthsThe Pennsylvania Child Welfare Training ProgramEngaging ParentsSeeking to understand the parents point of viewCulturally sensitive practiceConnecting agency goals with parent goalsInvestment in parent successOutcomes-oriented practiceRegular feedbackConfrontationDemand for workThe Pennsylvania Child Welfare Training ProgramReturning the Focus to the ParentParents 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 StrategiesIdentifying 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 ProgramSolution-Building QuestionsTell 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 ProgramHow to Gain TrustPotential Blind SpotsListening to each family member.Demonstrating respect for family members.Developing an understanding of the familys past experiences, current situation, concerns, and strengths.Responding to concrete needs quickly.Establishing the purpose of involvement with the family.Being aware of ones own biases and prejudices.Validating the participatory role of the family.Being consistent, reliable, and honest.Engaging and involving fathers and paternal family membersImpact & Effectiveness of EducationOral 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 agendas that may be in the room. Myths about Child TherapySome argue that family therapy will fail to attend to the childs own symptoms.Family therapists argue that childs 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 & BriefBegins 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 ChangeThoughts on the Therapeutic ProcessAgain, keep a developmental perspective.

Winnicott (1971): One must have in ones bones a theory of the emotional development of the child and the relationship of the child to the environmental factors.Make use of not knowingTalked of a holding environment.Made use of the Squiggle Game.

Post-modern therapist.Reflection-in-action vs Reflection-on-action

Deeper StrategiesInstilling 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 ResilienceBeing 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, 2001Building 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, 2001ToolsGain understanding Watch & listenAlways modeling 3rd eyeNon-verbals are keyUse what you haveProps & metaphorsSee pt in context family, community, schoolKeep your eye on the pt

Hope TheoryHope 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 ChangeAccentuating 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 BondingBuilding 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 ContinuedBuilding 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 EnhancingStrategies 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-PowerGWhat is the characters goal?PWhich pathways does the character identify to use to move toward stated goal?OWhat obstacles lay in the pathway?WWhat source of willpower is keeping the character energized?EWhich pathway did the character elect to follow?RRethink the process would you have made the same decisions and choices?

Pedrotti, Lopez, & Krieshok, 2000Hope RemindingIt is the strategy of encouraging pts to become their own hope-enhancing agents.The strengthening of ones ability to daily identify goal thoughts and barrier thoughts increasing self-monitoring.Development of mini interventions in strengthening hope.Theory of Personal ControlLearned Helplessness: The giving-up reaction, the quitting response that follows from the belief that whatever you do doesnt 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 - SeligmanGuidelines for Using OptimismUse 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 - SeligmanGuidelines for Using OptimismDo 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 - SeligmanKey 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 - SeligmanFrom Pessimism to OptimismAdversityBeliefsDistractionDisputationDistancingConsequences

Arguing with yourselfEvidenceAlternativesImplicationsUsefulness

Learned Optimism: How to Change Your Mind and Your Life - SeligmanDeveloping Capable IndividualsSeven SkillsIdentification 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 IndividualsSeven SkillsAdequate development of interpersonal skills.Well-developed situational skills.Adequate developed judgmental skills.Glen & Warner, 1982Like 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 CareBHC 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 patients presenting complaints or are adversely impacting the response to treatmentBHC Points of ContactWell visitsConsultationsFollow-upCurb-side interactions

Integration in ContextFull IntegrationPatientBehavioral Health ClinicianPhysicianSupports cultural competency among staffShared/coordinated responsibility of careTo the patient it feels like primary care.Charting in one chart/one formatCreates seamless spectrum of care

The Primary Care Team6161Active MomentsConsultation & Collaboration

Participation in EVERY Well Child Exam - Peds

Creation of Developmental Services

Building of treatment guidelines

Develop group approaches to bridge servicesLevel I: ScreeningInfant Development ReviewChild Development ReviewModified Checklist for Autism in Toddlers (M-CHAT)Pediatric Symptom ChecklistEdinburgh Postnatal Depression Scale (EPDS)Kindergarten Readiness.Substance Abuse Behavioral IntakeLevels II and III: Management and ReferralTennessee 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 issueAppropriate 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 ClinicTraditional 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 assessmentsHealth Condition AssessmentsOutcomes Research

6767BHC CollaborationMake and coordinate referrals/follow-upAssist 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 servicesMaintain open communication with schools

BHC Interventions

Focused Client InterventionsLimit 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

7070Health Condition Management

ObesityBrief solution focused interventions May use classes and group care clinicsAssessmentBehavioral Assessment System for Children, Piers-Harris 2 Self-Concept Scale, Childrens Eating Behavior Inventory, Childrens Depression Inventory Dietary habits, activity level, parental attitudes toward food and activityReadiness to change (Prochaskas model)Metabolic measuresADHDParent and child education groupsAssessmentBehavioral Assessment System for Children, Parenting Stress Index, ADHD Symptom Checklist-4

7171

Only those who look with the eyes of children can lose themselves in the object of their wonderEberhard Arnold