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TRANSCRIPT
Treatment with
Brief InterventionsPresenter - Gina Pate-Terry, LSCW, LAC,
June 26, 2018
Treatment Referral
Now What?
American Society of
Addiction Medicine (ASAM)
An addiction medicine professional society representing over 5,000 physicians, clinicians and associated professionals with a focus on addiction and its treatment. ASAM is dedicated to increasing access and improving the quality of addiction treatment, educating physicians and the public, supporting research and prevention, and promoting the appropriate role of physicians in the care of patients with addiction.
Northwest Addiction Medicine Chapter
Why do we treat them?
Why Behavioral Health in
Primary Care?
Primary care settings have become the gateway to
the behavioral health system.
Why Integrated Treatment?
Because Referrals
Don’t Work Well.
Referrals are often
sporadic and poorly
coordinated
Scarcity of mental
health consultants
Patients simply “fell
through the
cracks.”
The window of
opportunity is gone
Why in Primary Care?
Ground Zero
Where most people with substance use
issues present
Nine times greater risk of congestive
heart failure
12 times greater risk of liver cirrhosis
12 times greater risk of developing
pneumonia
Complicates the management of other
chronic illnesses
They Seek Their Primary Care
From Us
• Adults with serious mental illnesses
and substance use disorders also have
higher rates of chronic physical
illnesses and die earlier than the
general population. (Untreated or
undertreated mental illnesses have
serious consequences. People with
severe mental illness often die 13-30
years earlier than the general
population from medical conditions that
could have been treated by a primary
care provider) (NIH)
They Are Us
Population of US is over 300 million
Around 50% will experience a diagnosable
disorder at some time in life (Kessler,
Demlet, et al., 2005)
Only 20% will receive care from specialty
MH or substance use clinic
21% will be treated in PC
59% will receive no care
Most people with problems seek no care;
few will ever see a therapist’s couch
Treatment Works in Primary Care
Greater improvement in anxiety, depression,
and quality of care (Bradford, et al., 2011;
Roy-Byrne, et al., 2010; Lang, 2003)
Reduction of panic attacks in COPD patients
(Livermore, Sharpe, & McKenzie, 2010)
Improving treatment access for patients with
PTSD (Possemato, 2011)
Reduction in symptoms of insomnia (Buysse,
et al., 2011)
Improving treatment adherence for patients
with comorbid diabetes and depression
(Lamers, Jonkers, Bosma, Knottnerus, & Van Eijk, 2011; Osborn, et al., 2010)©
Lives are Saved in Primary
Care?
Increased self-management skills (Battersby, et al., 2010; Damush et al., 2008; Kroenke et al., 2009)
Improved quality of life for patients with chronic cardiopulmonary conditions (Cully, et al., 2010).
Reduction of substance abuse (Whitlock, et al., 2004)
Earlier of identification and intervention for pediatric behavior problems (Berkovits, O’Brien, Carter, & Eyberg, 2010; Laukkanenet al., 2010)
Reduction of somatization (Escobar, et al., 2007; Kroenke & Swindle, 2000)
Our Challenges
Challenges
Well-supported evidence shows that:
The current SUD workforce does not have
the capacity to meet the existing need for
integrated health care
The general health care workforce is
undertrained to deal with SUD related
problems.
Stigma
Work Force/Education
A national survey conducted by the National Center on Addiction and Substance Abuse at Columbia University of 648 primary care physicians and of 510 adults receiving treatment for substance use in 10 treatment programs highlighted some troubling findings. More than 50% of patients reported that their primary care physician did not address their substance abuse. More than 40% of patients stated that their physician missed the diagnosis of a substance use disorder, and only 25% were involved in their decision to seek treatment..
Work Force/Education
Less than 20% of primary care physicians
considered themselves “very prepared to
identify alcohol or drug dependence.” This
contrasts with more than 80% feeling very
comfortable diagnosing hypertension and
diabetes
Why Offer Brief Therapy?
Why Brief Therapy?
Access
One hour to you….
Research
Why?...Research
In a naturalistic study of over 9,000
patients seeking therapy, the modal
number of psychotherapy visits was one
(Brown & Jones, 2004)
Clients seek treatment when
psychological distress is high and stop
coming when distress level drops; for
most this is within 5 visits (Brown &
Jones, 2004)
Why?...Research
Research shows 40-45 percent of
depressed patients have large gains
within the first two to four sessions
(Doane, Feeny, & Zoellner, 2010)
30 to 40 percent drop out of treatment
without consulting their therapist
(Talmon, 1990, Olfson et.al., 2009) *
Features of Effective Brief
Interventions
Clearly defined goals that are related to
specific behavior change
Active and empathetic therapeutic style
Patients values and beliefs are incorporated
into the intervention
Measurable outcomes (utilizes rating systems)
Enhance patient’s self efficacy
Responsibility for change is with the patient
Brief Therapy Models
Motivational Interviewing (MI)
Problem Solving Treatment (PST)
Focused Acceptance Commitment Therapy
(FACT)
Motivational
Interviewing
Strong Research Support
Over 200 Clinical Trials and Over
400 Outcome Studies
ASAMAmerican Society of
Addiction Medicine
“Specific attention is given…to motivational and
engagement strategies, which are used in
preference to confrontational approaches”
Research has shown that
change…
Is a natural process
Can be facilitated or sped up with
relatively brief interventions
Can be significant within a single session
Occurs early on
The Therapist Stance- MI
Must have at least a willingness to
suspend an authoritarian role
Explore client capacity rather than
incapacity
Have a genuine interest in the client’s
experience and perspective
The Principles of Motivational
Interviewing
Express Empathy
Support Self--‐Efficacy
Roll with Resistance
Develop Discrepancy
Directives - MI
OARS
O = Open-Ended
Question
A = Affirm
R = Reflect
S = Summary
DARN-C
D = Desire
A = Ability
R = Reason
N = Need
C = Commitment
Level
MI Utilize Rating Scales
Focused Acceptance and
Commitment Therapy
(FACT)
A New Model of Brief Therapy that is a
Highly Condensed Version of Acceptance
and Commitment Therapy.
Acceptance and Commitment
Therapy
“A core conception of ACT is that
psychological suffering is usually caused
by avoidance and cognitive entanglement
and rigidity that leads to a failure to take
needed behavioral steps that are in
accord with core values.”
FACT…helps the patient…
Focus on unworkable results of avoidance
Accept the presence of distressing,
unwanted
private experiences
Choose a life path based in personal
values
Take actions which propel the them down
that path
First Session is Important.
Perfect the First 2 Minutes
Hi: My name and (discipline)
• My Job: To help you solve problems in living that happen to all of us
• In this visit: Get a snapshot of your life and see what’s working and not working; work together to come up with a plan to make your life better.
• After today: You may implement the plan and find that things change enough; or you might return to learn more.
• Assessment: Today and at every visit, to plan ways to make the most of our time together, to make every session count. (Rating Problem Severity, Confidence and Helpfulness)
Work with your other health care providers
Use rating scales: Problem severity, confidence, helpfulness
Love
Where do you live? With
whom?
How long have you been there?
Are things okay at your home?
Do you have loving
relationships with your family
or friends?
Work
Do you work? Study? If yes,
what is your work?
Do you enjoy it? If no, are you
looking for work?
If no, how do your support
yourself?
Play
What do you do for fun? For
relaxation?
For connecting with people in
your neighborhood or
community?
Health
Do you use tobacco products,
alcohol, illegal drugs?
Do you exercise on a regular
basis for your health?
Do you eat well? Sleep well?
FACT Assessment
FACT- Directives
Validation of emotions; validation of
behaviors
• Understand and acknowledge function of
the
problem
• Connect pain and values
• Create new relationship to symptoms
importance, usefulness
True North Worksheet
What are your values?
What are your current strategies and are
they working?
What skills will you need to make the
journey?
Problem Solving
Therapy (PST)A form of brief psychotherapy where patients
are taught a structured approach to recognizing
problems and finding workable solutions
Problem Solving Therapy in
Primary Care
Research has shown that minor life events
or problems are strongly associated with
psychological symptoms, in particular
depression, possibly even more so than
major life events (Nezu, 1987).
Problems are defined as any situation in
which an immediate and easily
recognizable solution is not apparent
Core Principles - PST
EFFECTIVE PROBLEM- SOLVING RESULTS
IN REDUCED SYMPTOMS
INEFFECTIVE PROBLEM-SOLVING
RESULTS IN INCREASED SYMPTOMS
Research
PST‐PC is a brief treatment, it can be as brief as 4 sessions and as many as 12 sessions.
Research shows that the smallest effective dose of PST‐PC is 4 sessions, offered over an 8‐week period of time.
9 sessions seems to be the PST‐PC sweet spot for most patients.
Each session is 30 minutes in primary care medicine.
PST-PC First Session is
Important
Develop as much trust and engagement as possible within
the first session. If by the end of the first session the
patient is not convinced that you or the model will be
helpful, therapists will find themselves struggling to get
patients to use the model in subsequent sessions and in the
homework assignments.
Careful attention must be paid to the first visit so that the
patient does not leave the session confused or unconvinced
about the efficacy of PST
Present a confident, knowledgeable, and professional image
and maintain appropriate professional boundaries
Explain the basic framework for treatment
Establish that symptoms are related to their diagnosis
Problem Solving Treatment
PST‐PC is divided into three phases:
Introduction/Education, Training, and Prevention phases. The first 1‐2 PST‐PC sessions is spent getting to know the patient, creating a problem list and how their symptoms interfere with daily activities.
Middle sessions are spent encouraging the use of the PST‐PC skills.
The last session or two is spent helping patients develop a relapse prevention plan based on the PSTPC format.
Seven Stages - PST
(1) Selecting and defining the problem
(2) Establishing realistic and achievable
goals
(3) Generating alternative solutions
(4) Implementing decision making
guidelines,
(5) Evaluating and choosing solutions
(6) Implementing the preferred solution
(7) Evaluating the outcome.
Worksheet - PSTReview of progress during previous week:
Rate how Satisfied you feel with your effort (0 – 10) (0 = Not at all; 10 = Super): ___
Mood (0-10): _____
1. Problem:
2. Goal:
3. Options/Solutions: 4. Pros versus Cons (Effort, Time, Money, Emotional Impact,
Involving Others)
a) a) Pros (+) What
makes this a
good choice?
a) Cons
b) b) Pros (+) What
makes this a
good choice?
b) Cons
c) c) Pros (+) What
makes this a
good choice?
c) Cons
d) d) Pros (+) What
makes this a
good choice?
d) Cons
Harm Reduction
Strategies for Cutting Down
Resources Strosahl, Robinson & Gustavsson. (2012) Brief Interventions for
Radical Change: Principles & Practice of Focused Acceptance &
Commitment Therapy. New Harbinger Publications, Inc.
Miller &Rollnick. (2002) Motivational Interviewing: Preparing
People for Change. The Guilford Press.
Robinson &Y Reiter. (2016) Behavioral Consultation and Primary
Care: A Guide to Integrating Services. Springer International
Publishing
Burdick, D. (2013). Mindfulness Skills Workbook for Clinicians and
Clients: 111 tools, techniques activities and worksheets. Pesi
Publishing & Media
Burdick, D. (2013). Mindfulness Skills Workbook for Clinicians and
Clients: 111 tools, techniques activities and worksheets. Pesi
Publishing & Media
Bourne, E. (1990). The Anxiety & Phobia Workbook. New Harbinger
Publications, Inc.