therapeutic conversations - college · 2016-09-20 · a randomized, clinical trial of education or...

Therapeutic

Conversations:

Promoting Self-Management for Clients

with Chronic Conditions Using CBT and

Motivational Interviewing Concepts

Kyle Schalk, Ph.D, RPsych

Kimberly Price, BScOT

Listening and Letting Go of Your

Agenda

https://www.youtube.com/watch?v=-4EDhdAHrOg

Objectives

Increase knowledge of Motivational Interviewing

and application for chronic populations.

Increase understanding of psychosocial

barriers/processes connected to chronic conditions

and knowledge of CBT concepts to inform practice.

Developing strategies to assist clients in effective

and consistent self-management of chronic

conditions.

Defining the Problem

What is a Chronic condition?

“long duration and generally slow

progression” (World Health Organization)

Focus on self-management

Psychosocial Barriers

Canadians with chronic physical conditions have twice

the likelihood of also experiencing a mood or anxiety

disorder when compared to those without a chronic

physical condition. (Government of Canada, 2006)

Hopelessness/helplessness

Loss of identity/grief

Adjustment difficulty and fear

Emotional roller coaster (Bordeaux & Walters, 2013)

Cognitive Behavioral Therapy

(CBT)

Cognitive Behavioral Therapy

Traditionally focused on treatment of anxiety and

depression

In terms of chronic illness/pain CBT posits that

inaccurate cognitions and negative coping behaviors

interact with physiological and environment factors and

produce negative outcomes including pain, distress,

disability and isolation (Heapy, Stroud, Higgins, &

Sellinger, 2006).

Essentially people develop ineffective coping thoughts

and behaviors.

Cognitive Behavioral Therapy

CBT focuses in developing awareness of patterns

CBT focuses on education and intentionally

intervening/planning for more adaptive thinking and

acting

CBT is collaborative, practical, purposeful

CBT focuses on goal setting, skill acquisition and coping

strategies

Motivational Interviewing (MI)

“Motivational Interviewing is a collaborative

conversation style for strengthening a person’s own

motivation and commitment to change.” (Miller, 2000)

It is client centered approach that requires the

therapist to convey empathy, actively listen for values,

focus on the clients strengths and ensure treatment is

collaborative.

It is DIRECTIVE

Motivational Interviewing

“Spirit” of MI

Collaborative vs confrontation

Evocative rather than imposing

Autonomy vs authority

Principles

Self-efficacy

Roll with resistance

Elicit discrepancy and work with ambivalence

Differences and Integration

CBT is one of the primary methodologies used in interdisciplinary programs

MI can be supplemental despite philosophical differences

Both are collaborative with focus on promoting self-management

CBT is more useful when clients are ready to change

Research indicates strong support for MI in health care (Chen et al., 2012, Thomas, et al., 2012, Tse et al. 2013)

Stages of Change

Transtheoretical model

Prochaska, DiClemente, & Norcross (1994)

Positive behaviour changes typically follow general pattern

or “stages of change”

Understanding Change

Stage of Change : Pre-Contemplation

Mandated treatment

No show

Medically focused

Expectation of passive versus active treatment

Looking for magic cure

Attendance as a sign of willingness to change

“kernel of intent to grow”

Stage of Change : Contemplation

Profile

Ambivalence – feeling conflicted

Inconsistent engagement/behaviour

Discrepancy between values and behaviours

Lack of awareness

Examples

No work between sessions

Good dad yet dealing drugs

Stage of Change : Preparation

Profile

Client is preparing for self-management of health issues

Acceptance of responsibility

Less medically focused

Experimenting with different ideas

Open to education

Stage of Change : Action

Profile

Client is actively engaged in change

Using self-management routine

Querying feedback on strategies

Personalizing program and working intently at home

Shift in language

Personal responsibility “I know I might not be pain free but I’m

going to do the best I can to manage”

Acceptance

Creative in application in other areas of life

Stage of Change : Action

Stage of Change : Maintenance

Self-management!!!

Stage of Change : Recycling

Change Talk Strategies

Therapeutic alliance

Active listening skills (OARS)

Strategies

Establishing a Strong Treatment

Alliance

Building Rapport

Mutual goals and tasks

Trust

Humour/self-disclosure

The Importance of Language

Illicit and strengthen change talk

Client builds argument

Improves treatment effectiveness (Hall et al., 2010)

Active Listening Skills

Open-questions

Avoid “yes/no” answers with “what and how” questions

Affirmation

“It’s clear that you are really trying to change”

“I’m impressed with…”

Reflective listening

Mirror what client has said while amplifying ambivalence

“It sounds like this has been really hard for you but I’m also hearing you want to do something different”

Summarize

* Resist the righting reflex*

Strategies

Asking permission

Scaling questions (readiness/importance/confidence)

On a scale of 0 to 10 how ready/confident do you feel…

Normalizing

Strategies

Decisional balancing (pros and cons)

“What are some good things?...some things that aren’t working?”

Explore the extremes

“What‘s the worst that could happen if you don‘t change? What the best thing you can imagine if you do change“

Looking back/forward

“Remember times in the past when you were able to make change...”

Exploring vision for the future if change were to occur

Strategies

Explore goals and values

“What things are most important in your life”

Columbo approach

“Help me understand...I‘m confused”

Rolling with Resistance

Emphasizing personal choice while avoiding arguing

“I know this is hard and you may make the decision not to

change…”

Hope!

Hope plays an essential part in coping

with chronic illness (Duggleby et al.,

2012)

Helping clients find ways to have

meaningful lives despite illness

Thanks!!

References Bordeaux, T. L., & Walters, A. (2013, August). Coping with a diagnosis of chronic illness.

Retrieved September 4, 2016, from http://www.apa.org/helpcenter/chronic-illness.aspx

Chen, S. M., Creedy, D. Huey-Shyan Lin, & H. S, Wollin, J. (2012) Effects of motivational interviewing intervention on self-management, psychological and glycemic outcomes in type 2 diabetes: A randomized controlled trial. International Journal of Nursing Studies, 49, 637-644. doi: http://dx.doi.org/10.1016/j.ijnurstu.2011.11.011

Duggleby, W., Hicks D., Neokolaichuk, C., Holtslander, L., Williams A., Chambers, T. & Eby J. (2012). Hope, older adults, and chronic illness: a metasynthesis of qualitative research. Journal of Advanced Nursing, 68, 1211– 1223. doi: 10.1111/j.1365-2648.2011.05919.x

Government of Canada, (2006). The human face of mental health and mental illness in Canada (Catalogue No. HP5-19/2006E). Ottawa, ON: Minister of Public Works and Government Services Canada

Hall, A. M., Ferreira, P. H., Maher, C. G., Latimer, J., & Ferreira, M. L. (2010). The influence of the therapist-patient relationship on treatment outcome in physical rehabilitation: A systematic review. Physical Therapy, 90, 1-12. doi: http://dx.doi.org/10.2522/ptj.20090245.

Heapy, A., Stroud, M., Higgins, D., & Sellinger, J.(2006). Tailoring cognitive- behavioral therapy for chronic pain: A case example. Journal of Clinical Psychology, 62, 1345–1354.

References Miller, W. R. (2000). Motivational interviewing. (2nd ed.). New York: Guildford Press.

Noncommunicable diseases. (n.d.). Retrieved September 04, 2016, from

http://www.who.int/topics/noncommunicable_diseases/en/

Prochaska, J.O., Norcross, J.C. & DiClemente, C.C. (1994). Changing for good. New

York: Morrow.

Sawatzky, R., (2010). Motivational interviewing level I training workbook. Empowering

Change Inc.

Sawatzky, R., (2013). Motivational interviewing level II training workbook. Empowering

Change Inc.

Thomas, M.L., Elliot, J. E., Rao, S. M., Fahey, K. F., Paul, S. M. & Miaskowski, C. (2012),

A randomized, clinical trial of education or motivational-interviewing-based coaching

compared to usual care to improve cancer pain management. Oncol Nurs Forum,39, 39-

49.

Tse, M. M., Vong, S. K. & Tang, S. K. (2013), Motivational interviewing and exercise

program for community-dwelling older persons with chronic pain: a randomised

controlled study. J Clin Nurs, 22, 1843–1856. doi:10.1111/j.1365-2702.2012.04317.x