engaging difficult patients & families

Engaging Difficult Patients & Families

Thomas W. Bishop, PsyDDepartment of Family

Medicine

Finding Change with Primary Care

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.

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.

The Engagement Level of Intervention

Specific Interventions

Engagement of Pt’s & Families in Participating in Interventions

The Practice of Family Systems

Family Staff

ChildCommon Tasks (Family & Staff) Soothe Develop Trust Manage Conflict

Consultation Directives Join Focus Promote Competence Collaborate

Interviewing Strategy

Behavioral Health Issues

Developmental Functioning

Family Context

Physical Limitations

Practice Constraints

Engaging Challenging Patients

Communication Skills Reflection Respect Listening Collaboration Compassion

– Verbal & nonverbal

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.

Nonverbal cues in expressing warmth

Tone of voice Facial expression Posture Eye contact Touching Gestures Physical proximity Synchrony of behavior with

patient Energy level

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

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

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

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

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.

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

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

Strategies for Change Precontemplation Contemplation Preparation Action Maintenance

Consciousness RaisingSocial LiberationHelping Relationships Emotional

ArousalSelf-Evaluation Commitme

nt Environmental ControlRewardCountering

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.

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.

Changing Stripes…Beginning Adventures

I - Ignore

G – Get a Clue

N – Now What?

I – I am Ready!

T – Try It!

E - Encourage

Four Underlying Principles of Motivational

Interviewing Express empathy Develop

Discrepancy Roll with

resistance Support self-

efficacy*See Miller & Rollnick, 2002

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?”

Key Tools in Seeking Solutions

Empathy Returning the Focus to the

Parent Amplifying Solution Talk…

Difference Questions

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.

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

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

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

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?

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

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

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

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)

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.

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.

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, 1997. Solution-Focused Therapy with Children: Harnessing Family Strengths for Systemic Change

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

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

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

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

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

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).

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 FindingHope BondingHope EnhancingHope reminding

Hope FindingThere 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.

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).

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.

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)

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

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.

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

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

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

Key to Optimism UseAsk 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

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

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

Developing Capable Individuals…Seven Skills

Adequate development of interpersonal skills.

Well-developed situational skills. Adequate developed judgmental

skills.

Glen & Warner, 1982

“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.

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

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

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

Integration in Context…Full Integration

Patient

Behavioral Health

ClinicianPhysician

• 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

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

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

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 resourcesBehavioral health care/SA treatment for

parent or family memberSchool psychologists/psychoeducational

evaluation

Passive MomentsGroup office including BHC,

pediatrician, call nurse, and studentsConsultation occurs within Pediatric

Clinic“Traditional” Therapy on-siteDevelopmental Services on-siteChild Psychiatry Available Coordinated assessmentsTeaching atmosphereMaintaining a developmental & stages

of change perspective

BHC Consultation/Liaison Services

Can occur with or without patient presentCan include mental health and/or physical concernsAssist with diagnostic assessments

Health Condition AssessmentsOutcomes Research

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

BHC Interventions…Focused Client Interventions

Limit session time to 15-20 minutesLimit number of sessions Focus on specific concernsProvide parent trainingRisk factor reductionHealth Condition Management (e.g., obesity)

Crisis InterventionAssess crisis and needsEstablish a crisis planCoordinate immediate care

Training and Supervision

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–Assessment

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

Only those who look with the eyes of children can lose themselves in the

object of their wonderEberhard Arnold