The Overarching Approach The patient must… The patient must feel there is hope and benefit in doing a good job (GOALS) BELIEVE SELF-MANAGEMENT IS WORTHWHILE: The patient must feel there is hope and benefit in doing a good job (GOALS) The patient must have a clear and achievable plan for self-management (ACTION PLANS) KNOW WHAT TO DO: The patient must have a clear and achievable plan for self-management (ACTION PLANS)
Persuasion Techniques Agree that patient should make the change Agree that patient should make the change Explain why the change is important Explain why the change is important Warn of consequences of not changing Warn of consequences of not changing Advise how to change Advise patient how to change Reassure patient that change is possible Reassure patient that change is possible Disagree if patient argues against change Disagree if patient argues against change Tell the patient what to do Tell the patient what to do Give examples of others (other patients, peers, celebrities) who have made similar healthy changes Give examples of others (other patients, peers, celebrities) who have made similar healthy changes
The Overarching Approach GOALS: BELIEVE SELF-MANAGEMENT IS WORTHWHILE: The patient must feel there is hope and benefit in doing a good job.
FACTS AND FICTIONS 1.Diabetes is the leading cause of adult blindness, amputations and kidney failure. True or false? ________________________________________ A.. A. False. Poorly controlled diabetes is the leading cause of adult blindness, amputations and kidney failure.
Feelings Can Fuel Change What are the patient ’ s feelings? Think of a patient you ’ ve seen recently Have you ever asked how he/she feels about his/her diabetes? What “ bugs ” that person the most about his/her diabetes??? What is working for that person in their current lifestyle? ( what is the function in the “ dysfunction ” ) ASK! (then listen)
Behavior Change Strategies 1.Begin with your patient’s interests Agenda must be personally meaningful for the patient Start with questions, not information: “What questions should we make sure to address today?” “What’s been driving you crazy about your chronic condition?”
1.Begin with your patient’s interests 2.Believe that your patient is motivated to live a long, healthy life You are both on the same side Behavior Change Strategies
The “ Journalist ” Intervention 1. Zero in on an area for behavior change 2. Get the details Be a journalist, listen carefully, limit questions 3. Explore relevant beliefs (4 “ importance ” questions) “ Your current score? Why not lower? Why not higher? How to bump it up? ” 4. Summarize and feed back the total story DO NOT OFFER ANY HELP OR ADVICE
Importance “ How do you feel about exercise now? If ‘ 0 ’ was not important, and ‘ 10 ” was very important, what number would you give yourself? ” 0_________________________________10 0_________________________________10 not importantvery important “ You rated exercise importance at 4. ” Why isn ’ t it a 3? (listen for the benefits) “ And what would it take to make it a 7 (listen for ideas to overcome barriers)a 6 or 7? ” (listen for the obstacles) Rollnick et al, 1999
Listen Well and Summarize “ It sounds like you ’ re inclined in two different directions. On the one hand, you ’ re somewhat worried about the possible long-term effects of your illness if you don ’ t manage it well – it’s pretty scary to think about such things. On the other hand, you ’ re young and you feel fairly healthy most of the time. You enjoy doing what you like to do, eat what you like to eat, and the long-term consequences seem far away. You ’ re concerned, and at the same time you ’ re not concerned. ”
1.Begin with your patient’s interests 2.Believe that your patient is motivated to live a long, healthy life 3.Help your patient determine exactly what they might want to change Behavior Change Strategies
The Overarching Approach BELIEVE SELF-MANAGEMENT IS WORTHWHILE: The patient must feel there is hope and benefit in doing a good job. KNOW WHAT TO DO. The patient must have a clear and achievable plan for self-management
Behavior Change Strategies 1.Begin with your patient’s interests 2.Believe that your patient is motivated to live a long, healthy life 3.Help your patient determine exactly what they might want to change Identify and respect ambivalence Present the bouquet 4.Develop a reasonable, detailed action plan
The “ Action Plan ” Intervention 1. Don ’ t tell patients what to do 2. Negotiate what changes to focus on blending your expertise and patients ’ desires 3. Focus on 1 – 2 concrete actions to start Not attitudes, numbers, or actions to stop Not “ lose 5 pounds in 2 weeks ” Instead… ” Walk briskly 20 minutes 3 x/ week, Monday, Wednesday and Friday after lunch ”
The “ Action Plan ” Intervention 4. 4. Start with changes that are achievable even if “ physiologically silly ” 5.Selected actions must be personally meaningful 6.Do the first step right away “ What does this mean you ’ ll do tomorrow AM? ”
Behavior Change Strategies 1.Begin with your patient’s interests 2.Believe that your patient is motivated to live a long, healthy life 3.Help your patient determine exactly what they might want to change 4.Develop a reasonable, detailed action plan 5.Stay alert for common obstacles
Social devastation (poverty, homelessness, lack of access to health care services, etc) Lack of information Cultural disconnect Low functional health literacy Relative lack of life skills Anxiety/disease-specific distress/depression Patient Self-Management Barriers
Address Health Literacy Assess patients ’ recall or comprehension of recommendations (aka “close the loop”) D. "So... let's make sure. What medications are we going to change?" P. "I think we're going to stop this one (is it metformin?)... and I'm going to take glipizide twice a day... I think that's the green one. “ Develop strategies to overcome this barrier (case management, phone contacts, etc) Schillinger et al, 2003
Depression “Depression significantly increases the overall burden of illness in patients with chronic medical conditions… depression is associated with a 50-100% increase in health services use and cost.” Simon, Gregory E. “Treating Depression in Patients With Chronic Disease”. Western Journal of Medicine 2001:175:292-293
PHQ-9 1-4 normal – repeat PHQ 2 annually + PHQ-9 if 2 question screen positive 5-9 minimal symptoms of mood disorder/disease-specific distress – group visits/chronic disease self-management program (CDSMP) if applicable; counseling if worsening
PHQ-9 10-15 dysthymia/disease specific distress – counseling + group visits/CDSMP if applicable >15 major depressive disorder – medication + counseling + CDSMP when improvement seen; close follow-up >20 severe depression —high risk for hospitalization/suicidality - medication + counseling (+ psychiatric evaluation if not rapidly improving)
Sources of Mood Disorders Spiritual/Emotional Crossroads (Existential Crisis) Behavioral Model: Learned Behavior(s) Biochemical: NT imbalance Unresolved Trauma(s) or trauma(s)
Risk Factors: Obesity “Recent research indicated that obese individuals have a significantly increased risk for developing a mood, anxiety, personality, and alcohol risk disorder. In this survey of 41,000 adults, the elevated risk applied to both men and women. In turn, individuals who are depressed may be more likely to become obese or have other poor health outcomes. ” http://www.surgeongeneral.gov/library/publichealthreports/sgp124- 2.pdf
The Often Hidden Driver: Adverse Childhood Events ACE Score = 1 point each for positive responses to 10 questions inquiring about exposure to: Physical abuse Emotional abuse Sexual abuse Physical neglect Emotional neglect Divorce/separation Domestic violence in the home Parent that used drugs or alcohol Parent that was incarcerated Parent that was mentally ill From: www.acestudy.org
ACE Events Please take the ACE privately, and add up your “yes” answers to determine your score.
How do ACE play out later in life? Increased smoking: – Greater the likelihood of current smoking COPD: – ACE score of 4; 2.6 x more likely to have COPD than a person with an ACE score of 0 Hepatitis: – ACE score of 4: 2.4 x more likely to have hepatitis than a person with an ACE score of 0
How do ACE play out in later life? Depression: – ACE score of 4: 4.6 x more likely to have depression than a person with an ACE score of 0 Suicide: – There was a 12.2 x increase in attempted suicide between these two groups – Between 66-80% of all attempted suicides could be attributed to ACE
Trauma “Adverse Childhood Experiences (ACE) are common, destructive, and have an effect that often lasts for a lifetime. They are the most important determinant of the health and well-being of our nation.” --Vincent Felitti, MD, co-chair of study
The Patient is a Whole Human Being, Seeking Balance
Trauma Informed Care: EMDR Eye Movement Desensitization and Reprocessing (EMDR) – developed in the mid-1980’s by Francine Shapiro, Ph.D. “EMDR is a complex, eight-phase method of treatment for individuals who have undergone Traumas/ traumas.”
Consensus on EMDR World Health Organization (2013). Guidelines for the Management of Conditions That are Specifically Related to Stress. Geneva, WHO. “Trauma-focused CBT and EMDR are the only psychotherapies recommended for children, adolescents and adults with PTSD.”
Consensus on EMDR American Psychiatric Association (2004). Practice Guideline for the Treatment of Patients with Acute Stress Disorder and Post-traumatic Stress Disorder. Arlington, VA: American Psychiatric Association Practice Guidelines. “EMDR therapy was determined to be an effective treatment of trauma.”
Consensus on EMDR Department of Veterans Affairs and Department of Defense (2004, 2010). VA/DoD Clinical Practice Guideline for the Management of Post-Traumatic Stress. Washington, DC. “EMDR therapy was placed in the "A" category as “strongly recommended” for the treatment of trauma.”
What EMDR Seems To Do Being an essentially non-verbal therapy, patients don’t have to talk about their trauma in order to heal Speeds processing of the unconscious and conscious material, integrating the trauma with current awareness It takes away the pain but not the content
49 year old divorced, morbidly obese (274#) woman who is diabetic with complications, smokes, and has had major depression most of her life. Baseline status: – ACE score of 8 – PAM: Level 3 – PHQ-9: 17 on SSRI – A1C: 9.5 Hadn’t checked her own glucose in 2 years Case Study
Case Study (Continued ) Current status: February 2014 PAM: Level 4 PHQ-9: 5 Weight: 259 A1c: 8.2 What made the difference? The patient has worked on the trauma of losing her father and is working on the physical abuse she suffered at the hands of her mother.
Ambivalence to Action Plan The healing is done within the context of a relationship Patient worked with everyone on the SCC team except for the physical therapist It’s not been easy for her—she threw up, twice, in admitting that she’d been physically abused by her mother.
Ambivalence to Action Plan Examining and helping the patient to change his/her self-talk, particularly negative cognitions, is the key to motivational change. Leading a “life worth living” is what traumatized people can only dream about. They often don’t see a future for themselves. Why take care of their health?
Ambivalence to Action Plan Use small, incremental steps Meet the patient where he/she is at Be respectful of how the “status quo” has been protecting them, sometimes for years, whether it be excess weight, non-compliance with medical care, smoking, etc. Do not try to take away their defenses. They may not return.
“...and the time came when the risk it took to remain in a tightly closed bud became infinitely more painful than the risk it took to blossom.” Anaïs Nin (1903 - 1977)
Take-Home Messages Almost everyone would prefer to live a long, healthy life Our patients are not unmotivated to self- manage effectively The problem is that self-care is tough Our patients face many obstacles to good self-care Simple behavior change strategies are likely to help for many “Stuck” patients may be victims of their early experiences which need to be addressed to sustain improvement
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