new york state brief behavioral inteventions aug...
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New York State Collaborative Care Initiative
Evidence‐based Psychotherapeutic Interventions for Primary Care
August 29, 2013
Anna Ratzliff, MD, PhDAssociate Director of Education
Division of Integrated Care and Public Health University of Washington
Presenter
Building on 25 years of Research and Practice in Integrated Mental Health Care
http://uwaims.org
Why brief behavioral interventions?
Feel Bad
Do Less
Behavioral Activation
set of strategies at the beginning of CBT treatment
Cognitivedysfunctional cognitions
or “automatic thoughts” increase flexibility and
decrease depressed way the thoughts function
Good evidence for C, B, and C+BBA: Cuijpers et al 2007, Ekers et al 2008, Mazzucchelli et al 2009;listed as an evidence‐based treatment for depression by the National Institute for Health and Clinical Excellence (2009)
Good evidence for C, B, and C+BBA: Cuijpers et al 2007, Ekers et al 2008, Mazzucchelli et al 2009;listed as an evidence‐based treatment for depression by the National Institute for Health and Clinical Excellence (2009)
CBTFirst line depression treatment
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Case example: RB30 y/o Caucasian woman, mother of 2 (ages 8 and 2), 2nd marriage, unemployed since pain began, some college
Lifetime pattern of depressive episodes starting as a teenager, baseline PHQ‐9 23 (severe) & GAD‐7 11 (moderate), average pain rating 5/10
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Increase adaptive activities,
preferably for mastery and pleasure
Decrease activities that maintain depression
Problem solve
barriers to rewarding things
3 Goals of Behavioral Activation
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Doing BA in Primary Care
Explain the model
Ask lots of questions until you have a good formulation
Select BA targets
Follow‐up
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stay home, stay in bed, watch TV,
withdraw from social
contacts, ruminate, etc.
sad, tired,
worthless, indifferent,
etc.
Explaining the Model: How depression happens
Life Events
loss offriendships, conflict with supervisor at
work, financial stress, poor health,
etc.University of Washington ©
2012
Case example: RB
30 y/o Caucasian woman, mother of 2 (ages 8 and 2), 2nd marriage, unemployed since pain began, some college
Lifetime pattern of depressive episodes starting as a teenager, baseline PHQ‐9 23 (severe) & GAD‐7 11 (moderate), average pain rating 5/10
Key complaints: my neck hurts; my arm is screwed up; what is wrong with me?; the pain is ruining my life and ability to care for my children
1‐2 years of worsening neck pain and tingling, numbness, weakness in left lower extremity; MRI evidence of disk degeneration in C5‐6
Course of tx in the Center for Pain Relief:– Increase sertraline to 100mg– gabapentin 900mg– trigger point injections – no pain reduction– nortriptyline 10mg at bedtime– baclofen– brief cognitive behavior therapy
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Staying in bed, napping, shutting down
emotionally with kids and
husband
Guilty, ashamed, frustrated,
angry, scared, helpless
RB: Pitching the model
loss ofmarital intimacy, loss of fun activities with kids,
loss of sense of self efficacy with marriage
and mothering
Divorce, pain onset, unemployment,
child with learning disability, marital
conflict
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Formulation
• What are the avoidance patterns?• How can we interrupt the avoidance and/or switch to approach rather than avoidance?
• How can we build mastery and pleasure?
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Staying in bed, napping, shutting down
emotionally with kids and
husband
Guilty, ashamed, frustrated,
angry, scared, helpless
RB
loss ofmarital intimacy, loss of fun activities with kids,
loss of sense of self efficacy with marriage
and mothering
Divorce, pain onset, unemployment,
child with learning disability, marital
conflict
What is sheAvoiding???
University of Washington © 2012
Staying in bed, napping, shutting down
emotionally with kids and
husband
Guilty, ashamed, frustrated,
angry, scared, helpless
RB
loss ofmarital intimacy, loss of fun activities with kids,
loss of sense of self efficacy with marriage
and mothering
Divorce, pain onset, unemployment,
child with learning disability, marital
conflict
She’s avoiding:Emotional
expression, engaging kids, acknowledging
her positives
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Mastery and pleasure targets:
Parenting and Marriage
Decrease activities that
maintain depression:Napping and
emotional disengagement
Problem solve barriers:
communica-tion skills,
activity pacing, relaxation training
3 Goals of BA
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Selecting RB’s BA targets:
• What she worked on…Won’t talk to husband,
avoiding emotional expression with her
partner
• Talk to husband about frustrations
• Take timeouts but plan when you will re-engage when fights happen
• Try reflective listening• Increase physical
intimacy
Stopped activities with kids
• Pace activities with kids• Dance with them,
moving her neck especially; reduce guarding activity
Won’t acknowledge her accomplishments
• Internal validations for her motherhood and accomplishments
• She chose to:• Organize and
decorate her house• Improve her attire, put
on make-up, do her hair
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RB’s symptoms: 8 visits over 4 mos
0
5
10
15
20
25
1/22/2010 2/22/2010 3/22/2010 4/22/2010
PHQ-9
GAD-7
Pain
Pain Interference
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Typically we think of acting from the “inside out”
(e.g., we wait to feel motivated before completing tasks)
In BA, we ask people to act according to a plan or goal rather than a
feeling or internal state
Approach: Outside In
Avoiding the Mount Everest:Selecting the BA Targets
Complex tasks
Simple tasks
Assign increasingly more difficult tasks to move toward full participation in
activities
• Help break tasks down into manageable tasks• Mastery and success of one small
task will increase likelihood of completing other tasks
• Have them tell you what and how they’ll do the task (Details! Details! Details! Have them walk you through it)• Help problem solve and ask how
likely it is they will do it.• If it seems too challenging, it is! Break
it down further.
Follow‐up
ALWAYS ask about the target behavior the next time you see the patient
Expect them to not do the activity and don’t punish
If goal was not accomplished, ask 3 questions:
Do they have buy in to the treatment?
Did they simply forget?
Was it a Mt Everest?
Problem-Solving Treatment (PST):
FAST
• Engage patient in what they care most about
FOCUS ATTENTION
• Training brain to solve problems
Problem‐Solving Process
UNIVERSE OF PROBLEMS
Problem Definition
Realistic Patient Goal
Brainstorming
Pros and Cons
Choosing a Solution
Action Plan
Outcome Evaluation
How is PST Different from What I Already Do?
• BUT: picks up where MI endsLike MI
• BUT: focuses on life problemsLike BA
• BUT: Patient learns to personalize the plans on their own
Like Case or Self Management
• BUT: emphasis is on patient developing their OWN strategies Like CBT
What you need to do
• Educate and socialize the patient to the treatment
• Create a problem list• Teach the patient the 7‐step process• Use the worksheet as a guide to PST• Create an action plan• Schedule in pleasant/valued activities
Therapeutic Frame
• 6‐10 sessions at place they feel most comfortable (in person or by phone)
• You work on problems EVERY SESSION
• They need to solve problems between sessions
• Eventually the patient should be able to problem solve on their own
Educate Patient About PST Process
• What PST is or is not: – not life review therapy– not psychodynamic analysis– not *just* supportive therapy/case management– action focused on immediate issues causing depression
Problem ListIf you’re not having a problem, you’re missing a chance to grow. – anon.
• Domains– Financial– Housing– Medical– Social– Family
• Organize in a hierarchy
• Start with easiest problem
Problem DefinitionA problem well‐stated is a problem half solved. – Kettering
• Concrete and specific terms
• Assumptions versus facts
• Details
• Breaking down problems
Realistic Goal SettingGoals are dreams we convert to plans and take action to fulfill. – Zig Ziglar
• Specific• Attainable• Realistic• Measureable
BrainstormingDon’t put all your eggs in one basket – anon.
• All ideas that come to mind
• Withhold judgment• Be detailed• Generate five
Decision Making
• Weighing the pros and cons
• Does it meet immediate goal?
• Does it meet long term goal?
• Does it create other problems?
• Is it feasible?
Again and again, the impossible problem is solved when we see that the problem is only a tough decision waiting to be made. – Robert H. Schuller
Selecting the SolutionYou are the sum total of all your choices up to now. – Dr. Wayne Dyer
• One with the most pros and least cons
• Most feasible
• Less amount of effort
Solution Implementation
• Steps to implementation
• Specify when will do (earlier the better)
• Delegate
• When to check in
• Do you need other people to help?
Even if you are on the right track, you’ll get run over if you just sit there. – Will Rogers
Solution EvaluationWhen you lose, do not lose the lesson. – The 14th Dalai Lama
• Did it work?– If so, why?
• Would you do anything differently?
• Will you use this solution again?
• If not why?– What did you learn?
• Does the problem need to be redefined?
Rewards and ActivitiesOne joy scatters a hundred griefs. – Chinese proverb
• Make sure includes pleasant activities
• Include a reward for hard work
• Reinforce patient efforts at change
Brief Psychotherapy Skills• Evidence based psychotherapies can be adapted to primary
care• Brief psychotherapy requires specific skills
• Takes time and Practice• Systematic feedback on performance / skill coaching
• Strategies to improve skills:• Need basic training in specific skills• Network with other clinicians with experience for skills coaching• Bring in expert trainer to strengthen practice• Pay attention to patients when you are effective you will see
results; if patients are not improving, revisit skills used and need for additional training
Where to get more information
• Behavioral Activation– http://uwaims.org/webinars/slides/AIMS_MHIP_Behavioral_Activatio
n.Slides_040510.pdf
• IMPACT‐PST– http://uwaims.org/tools/clinicalskills.html#pst
• Pat Areán’s PST Training website– http://pstnetwork.ucsf.edu/
Acknowledgements
Behavioral Activation•Kari A. Stephens, PhD•Christopher Martell, PhD
Problem Solving Therapy• Pat Arean, PhD