Understanding and treatment of clients as a whole, not the sum of their parts.

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Francis Tucker
5 years ago
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Andrea Cuc, MSW LCSW Mayo Clinic Department

1 Understanding and treatment of clients as a whole, not the sum of their parts. Andrea Cuc, MSW LCSW Mayo Clinic Department of Psychology and Psychiatry Spiritual Psychological Psychological Social Experiences Subjective (Subjective Experiences Objective) Biological Environmental Today s outline: Mind/body interaction. CBT 5 area model. DSM: Mental health classification and symptoms. Discussion of patient s/client s mood and how it may show up in the physical therapy room. Motivation and goal setting. Know your limits. When to refer? 1

*Scan for bathroom Anxiety and GI issues 5 Area Model (feedback loop) (Belief or Thought): What if there is no bathroom?

2 A-B-C and 5 area model A (Activating Event): C (Behavior Action) B (Belief or Thought): C (physiological) C (emotion): (Activating Event): GI issues (diarrhea) (Behavior): *Avoid leaving the house. *Don t eat before leaving the house. *Scan for bathroom Anxiety and GI issues 5 Area Model (feedback loop) (Belief or Thought): What if there is no bathroom? What if there is a line? What if I don t make it there in time? (Physical Sensations): *Tense Body *Increased heart rate *Breathing changes *Stomach tension (Emotion): Anxiety Can you spot anxiety and depression? 2

3 Anxiety Disorders: Generalized anxiety Panic disorder Phobias (ex. social phobia, agoraphobia, specific phobias) Obsessive compulsive disorder (OCD) Post traumatic stress disorder (PTSD) and acute stress disorder. Anxiety NOS Anxiety due to medical condition Separation anxiety Selective mutism Adjustment disorder (mixed or with anxiety) Somatoform disorders (ex. illness anxiety disorder (hypochondriasis), conversion disorder (functional neurological symptom disorder), somatic symptom disorder, body dysmorphic disorder, factitious disorders, psychological factors affecting physical condition) Features of Anxiety: Thoughts: What if. If only. Should s The worst possible scenario is going to happen. (catastrophic thoughts) I won t be able to cope! I need to take action! Protect self and others! I m in danger! Feelings: Fear Frustration Dread Disappointment Anger Sadness Overwhelmed Physical symptoms/sensations: Racing heart Breathing changes Tense muscles, Shaking GI issues (nausea, stomach ache, diarrhea) Dizziness Sweat Behaviors: Avoid (people, places, thoughts etc.). Push self to get it done. Jump from one task to another. Future thinking (not present). Human do-er vs. human be-ing Decreased memory/concentration. Decreased socialization/activity. Increased activity. Sleep problems (decreased sleep). Fatigue. Ruminate Hypervigilant What anxiety may look like in the physical therapy room: Difficulty sitting still/fidgeting. Mind wandering. Difficulty staying task focused. Fearful of moving their body a certain way because what if it hurts or it makes it worse? Overachieving. Doing too much. Difficulty pacing themselves. Procrastinating. I can t do it, unless I do it right. I m overwhelmed. Human do-er vs. human be-ing. Double checking that they are doing it correctly. They may want detailed instructions (and get too caught up in the details). Fatigue (from doing too much, not enough sleep, mind racing etc.). With social anxiety, they may miss/cancel appointments. They may be so anxious they can t hear what they are being told. 3

4 Case example: functional neurological symptoms 35 year old female with hemiplegic migraine, psychogenic movement, facial droop/pulling/tightening History: Hemiplegic migraine event followed by a 14 day hospitalization (where she was diagnosed with migraine). Hospitalized two more times, second time at Mayo Clinic. Neurology felt movement was functional. Patient in a wheelchair and not able to work. She has a stressful job (works from home, long hours), has 4 kids, sudden onset of hemiplegic migraine (thought she was having a stroke). A few days later she had another episode in her closet and she crumpled/fainted to the floor (last thing she remembered was her 4 y/o dtr saying mommy are you okay. ) She feared having migraine, and now feared going into her closet because it reminded her of pain. Interventions: Neurology interventions: Botox and nerve blocks Physical therapy helped with walking. Patient out of wheelchair, used walker, and now walks independently. Patient weaned off narcotics and felt better emotionally and physically. Work with me to learn skills on how to work with pain and anxiety. She also feared pain, so pain memory triggered anxiety and functional neurological symptoms. Mood: anxious Therapy: CBT, EMDR, ACT, mindfulness skills. During EMDR her face started to pull again while talking about her closet experience (migraine pain and her little daughter). End result: Decreased/no anxiety and migraine pain (she has skills she can use if these were to increase). She is able to walk into her closet. She is a stay at home mom and enjoying it. Depressive Disorders: Major depression Depression NOS Adjustment disorder (mixed or with depressed mood) Persistent depressive disorder (dysthymia) Bipolar depression Features of Depression: Thoughts: It will never get better. What s the point of living? It s all my fault. I don t feel like doing it. Who cares? Hopeless. Helpless. Worthlessness. Suicidal thoughts Feelings: Sad Overwhelmed Irritable Guilt Physical symptoms: Empty Heavy Fatigue/tired Aches/pains. Behaviors: Tearful Avoid/disconnect Decreased activity (procrastinate, don t start, sedentary, can t break down tasks) Stop doing enjoyable activities Eat too much/too little Sleep too much/too little Difficulty concentrating Decreased memory and concentration. Suicide attempts/gestures 4

5 What depression may look like in the physical therapy room: *Difficulty following instructions. *Overwhelmed. *Difficulty having the energy and motivation to do the PT exercises at home. *Non-compliance. *Reduced flexibility during movement. *Decreased energy/stamina. *May want to quit sooner. *Argumentative. *Negative view about their abilities and/or physical appearance. 5

6 Schizophrenia Spectrum and other Psychotic Disorders: Schizophrenia (subtypes: paranoid, disorganized, catatonic, undifferentiated, and residual) Unspecified schizophrenia Schizoaffective Schizophreniform Delusional disorder Brief psychotic disorder Psychosis (associated with substance use or medical conditions) Features of schizophrenia and other psychotic disorders. Delusions Hallucinations Speech that is incoherent or has loose associations. Disorganized or catatonic behavior. Negative features (flat affect, apathy, anhedonia, attentional impairment) Positive features (hallucinations, delusions, bizarre behavior, thought disorder, insomnia) The primary goal is not to treat the mental health issue directly, but to help with comorbidities. Help them release muscle tension in their body. Help with posturing/walking etc. The ways they hold themselves. Help with proper movement and motor control. Help them pacing/modify activities. Help with an exercise plan to increase physical activity (how to safely move their body, in their space, with their emotional state, and with the resources they have to work with). *In the process, these interventions may also help improve their emotional state. *When people feel better in the body, they feel better in their mind (and vice versa). 6

Working with client s PTSD: *Ask permission before you

Mental health history and current mood state.

planning What are they willing/not willing to do?

7 Working with client s PTSD: *Ask permission before you touch. *Let them know where you are. Motivation! Is your client ready for change? Know your client: Health history. Mental health history and current mood state. Experiences and beliefs. What is their goal? Compromise What is their current pace? Case example: patient with depression and activity planning What are they willing/not willing to do? Are there barriers? (physical, emotional, environmental, relationship, time, financial, past experiences etc.) What does/doesn t motivate them? 7

Motivational Interviewing by William Miller and Stephen Rollnick It s a collaborative, person-centered, partnership and conversation that helps elicit and strengthen a client s own motivation for

*True power for change rests within the client (autonomy). *Role with resistance. Dance don t wrestle with the client. UNDERSTAND their motivation.

8 Motivational Interviewing by William Miller and Stephen Rollnick It s a collaborative, person-centered, partnership and conversation that helps elicit and strengthen a client s own motivation for change, and their commitment to change. The process honors the client s autonomy. R U RESIST telling them what to do. *Autonomy vs. authority. *True power for change rests within the client (autonomy). *Role with resistance. Dance don t wrestle with the client. UNDERSTAND their motivation. *Seek to understand their values, needs, abilities, motivations and potential barriers to changing behaviors. L E LISTEN with empathy. *Seek to understand their values, needs, abilities, motivations and potential barriers to changing behaviors. EMPOWER them. *To set achievable goals. *Identify ways to overcome barriers. Change Talk: Ask for pros and cons for both changing and staying the same. Ask about the positives and negatives of the target behavior. Miracle question: If you were 100% successful in making the changes you want, what would be different? Scale: On a scale of 1-10, how important is it to you to change X behavior? What would happen if you moved to a higher number? Scale: On a scale of 1-10, how confident are you that you can make X change if you decided to do it? Ask what their goals and/or guiding values are. What do they want out of life and how will this help keep them on that path? Come along side them. Emotionally validate them for X behavior and it s importance for them. Does their behavior serve a function (helpful or unhelpful), and therefore that is why they are unwilling to change it? Is there an alternative way to view it/approach it? 8

9 Motivation: Emotion after motion. Willingness. 10 minute rule. You don t have to like it, you just have to do it. Action Planning: Feeding the good wolf. Actions/goals in direction of values. Anticipate road blocks and set backs and problem solve them. A goal without a plan and action, is just a wish. 9

*When patients/clients are asking for help. Know your limits!

10 When to refer patients/clients for psychotherapy? *When anxiety, depression, trauma etc. starts to affect PT progress. *When patients/clients are asking for help. Know your limits! Refer out and/or seek Consultation. Check in with your client s experience, and pace yourself with them. Thank you for all that you do! 10

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