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

2. 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.

3. 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.

4. The Engagement Level of Intervention
Engagement of Pt’s & Families in Participating in Interventions
Specific Interventions

5. The Practice of Family Systems
Staff
Common Tasks (Family & Staff)
Soothe
Develop Trust
Manage Conflict
Consultation Directives
Join
Focus
Promote Competence
Collaborate
Child

6. Engaging Challenging Patients
Developmental Functioning
Behavioral Health Issues
Interviewing Strategy
Physical Limitations
Family Context
Practice Constraints

7. Communication Skills Reflection Respect Listening Collaboration
Compassion
Verbal & nonverbal

8. 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.

9. Nonverbal cues in expressing warmth
Tone of voice
Facial expression
Posture
Eye contact
Touching
Gestures
Physical proximity
Synchrony of behavior with patient
Energy level

10. 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

11. 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

12. 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

13. 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

14. 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.

15. 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

16. 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

17. Strategies for Change Precontemplation Contemplation Preparation
Action
Maintenance
Consciousness Raising
Social Liberation
Helping Relationships
Emotional Arousal
Self-Evaluation
Commitment
Environmental Control
Reward
Countering

18. 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.

19. 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.

20. Changing Stripes…Beginning Adventures
I - Ignore
G – Get a Clue
N – Now What?
I – I am Ready!
T – Try It!
E - Encourage

21. Four Underlying Principles of Motivational Interviewing
Express empathy
Develop Discrepancy
Roll with resistance
Support self-efficacy
*See Miller & Rollnick, 2002

22. 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?”

23. Key Tools in Seeking Solutions
Empathy
Returning the Focus to the Parent
Amplifying Solution Talk…Difference Questions

24. 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.

25. 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

26. The Pennsylvania Child Welfare Training Program
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

27. 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

28. 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?

29. 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

30. 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

31. 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

32. 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)

33. 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.

34. 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.

35. 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, Solution-Focused Therapy with Children: Harnessing Family Strengths for Systemic Change

36. 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

37. 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

38. 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

39. 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

40. 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

41. 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).

42. 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 Finding
Hope Bonding
Hope Enhancing
Hope reminding

43. Hope Finding There 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.

44. 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).

45. 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.

46. 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)

47. 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

48. 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.

49. 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

50. 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

51. 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

52. Key to Optimism Use
Ask 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

53. 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

54. 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

55. Developing Capable Individuals…Seven Skills
Adequate development of interpersonal skills.
Well-developed situational skills.
Adequate developed judgmental skills.
Glen & Warner, 1982

56. “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.

57. 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

58. 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

59. BHC Points of Contact Well visits Consultations Follow-up
Curb-side interactions

61. Integration in Context… Full Integration
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
Patient
Behavioral Health Clinician
Physician 61

62. 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

63. 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

64. 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 resources
Behavioral health care/SA treatment for parent or family member
School psychologists/psychoeducational evaluation

65. Passive Moments
Group office including BHC, pediatrician, call nurse, and students
Consultation occurs within Pediatric Clinic
“Traditional” Therapy on-site
Developmental Services on-site
Child Psychiatry Available
Coordinated assessments
Teaching atmosphere
Maintaining a developmental & stages of change perspective

67. BHC Consultation/Liaison Services
Can occur with or without patient present
Can include mental health and/or physical concerns
Assist with diagnostic assessments
Health Condition Assessments
Outcomes Research 67

68. 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

70. BHC Interventions… Focused Client Interventions
Limit session time to minutes
Limit number of sessions
Focus on specific concerns
Provide parent training
Risk factor reduction
Health Condition Management (e.g., obesity)
Crisis Intervention
Assess crisis and needs
Establish a crisis plan
Coordinate immediate care
Training and Supervision 70

71. 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
Behavioral Assessment System for Children, Parenting Stress Index, ADHD Symptom Checklist-4 71

72. Only those who look with the eyes of children can lose themselves in the object of their wonder
Eberhard Arnold