MATCP When the Severity of Symptoms Interferes with Progress

Transcription

1 MATCP 2017 When the Severity of Symptoms Interferes with Progress 1

2 Overview Stages of Change, or Readiness for Change Changing Behavior Medication Adherence Disruptive Behaviors Level of Care Tools including Substance Use Disorders 2

3 Changing Behavior 3

4 Stages of Change RELAPSE Slide back into old behavior PRE- CONTEMPLATION No intention of changing behavior MAINTENANCE Sustained change CONTEMPLATION Aware of problem, no commitment to change ACTION Active behavior PREPARATION Plan for action 4

5 Stage of Change Precontemplation Contemplation Preparation Action Maintenance Relapse Ignorance, Denial Strategies: Build rapport and trust Educate Express concern Raise doubt Aware of pros and cons but ambivalent Strategies: Weigh pros and cons Extrinsic to intrinsic motivation Personal values Explore expectations and ideas of self-efficacy Decided to change, plan steps Strategies Clarify their goals Offer options Identify barriers and supports What has worked in the past. Trying new behaviors, direct actions Strategies: Experiment with small steps Reward successes Learn new reinforcers Build social supports Maintain new behaviors, avoid old temptations Strategies: Affirm commitment and self-efficacy Identify new reinforces Practice new coping skills Recurrence of behavior, frustration, shame Strategies: Help re-enter the cycle of change Identify what triggered the relapse Identify new barriers Re-commit Improve reinforcements and supports 5

6 Changing Behavior Punishment Purpose is to decrease the likelihood of a behavior Most effective when applied immediately after a behavior Results in extinction when not consistently applied Reinforcement To strengthen Purpose is to increase the likelihood of a behavior More powerful than punishment 6

7 Positive vs Negative Negative Something is taken away Punishment: Take away the PlayStation to decrease hitting Reinforcement: Release from jail to increase following rules Positive Something is added Punishment: add something to decrease likelihood of behavior. E.g. Spanking to decrease hitting sibling, jail to decrease thefts. Reinforcement: add to increase likelihood of behavior. E.g. Allow extra PlayStation time for playing peacefully, add privileges to reinforce good behavior. 7

8 Punish or Reinforce Positive reinforcement, applied on a variable schedule, is more powerful than punishment or negative reinforcement, in changing behavior in a lasting way. 8

9 Medication Adherence 9

10 Medication Adherence Predictors for Adult schizophrenia Cognitive functioning is not predictive Drug Attitudes Inventory 10 moderately predictive. Best indicator of compliance for hospitalized adults. Patients taking second generation antipsychotics more likely to have positive attitudes than those on first generation antipsychotics. Key questions for adults: I feel more normal on medication I am happier, feel better, when taking medication. 10

11 Medication Adherence Adolescents Study used the DAI 30 for adults but used Likert scale rather than T/F Diagnoses were bipolar and major depressive disorders, attention deficit/hyperactivity disorder Key questions were: My thoughts are clearer on medication. I am in better control of myself on medication. 11

12 Medication Adherence DAI-10 Response Score Response Score 1 For me, good things about medication outweigh the bad. F -1 T +1 2 I feel weird, like a zombie, on medication. F +1 T -1 3 I take medication of my own free choice. F -1 T +1 4 Medications make me feel more relaxed. F -1 T +1 5 Medication makes me feel tired and sluggish. F +1 T -1 6 I take medication only when I feel sick. F +1 T -1 7 I feel more normal on medication. F -1 T +1 8 It is unnatural for my mind and body to be controlled by medications. F +1 T -1 9 My thoughts are clearer on medication. F -1 T By staying on medications, I can prevent getting sick. F -1 T +1 12

13 Medication Adherence Co-morbidity increases risk for poor adherence Adolescents with conduct disorder and depression, or oppositional defiant disorder with substance abuse Medication characteristics Formulation Daily oral meds vs monthly injections Dosage Once a day Side effects Cost 13

14 Medication Adherence Choose medications with proof Injectable medications Medications that have standards for blood levels. What do you do if the DAI is negative? Address the attitudes that create barriers Use pre-contemplation and contemplation strategies Understand that poor insight, judgement and motivation are SYMPTOMS Use reinforcers that are meaningful to the consumer What IS the consumer looking for? E.g. relief from insomnia AOT may be a reinforcer. 14

15 Disruptive Behaviors 15

16 Suicide-Threat to Self Causes: Mood or psychotic disorder Need to treat the disorder Adjustment disorder Response to financial situation, grief, rejection Borderline Personality Disorder Early life trauma such as sexual abuse Self-harm and suicide Instability of emotion, relationships, self-image 16

17 QPR Ask the Question Direct: Are you thinking about hurting or killing yourself? Indirect: People who are going through what you are going through sometimes think about suicide. Are you? How not to ask: You re not thinking about suicide are you? Be genuine in your concern 17

18 Question Thinking about death vs. suicide or self-harm Assess the risk Intention Plan Means 18

19 Persuade Start with establishing a positive relationship Active listening Give hope The intent is not to solve problems, but to commit to working together for a period of time to get past this difficult moment. Most people you encounter are early in their contemplation of suicide and will responds to sincere interest, concern and active listening. 19

20 Refer Start with an agreement that the person considering suicide needs help. If you can t get there, then 911 Hand-delivery to referral is best Know your community resources, or refer to someone who does. 20

21 What to expect from the Referral Mood or psychotic disorder Adjust medications or therapy Use of objective tools such as PHQ9 or PHQ4 Adjustment Disorder Coping skills Case management to resolve the stressor Borderline Personality Disorder Dialectical Behavior Therapy (DBT) Mindfulness, Distress Tolerance, Emotion Regulation and Interpersonal Effective Skills 21

22 DBT-Interpersonal Effectiveness Describe- specific words what you want Express- facial expressions, tone, gestures Assert- matter of fact, not aggressive Reinforce- why they should respond to your request Mindful (Stay)- broken record, don t be distracted Appear Confident- practice self-validation Negotiate- win-win 22

23 Threats to Others Mood Disorders Depression: agitated or anxious Bipolar Disorder: agitated or grandiose Psychotic Disorders High expressed emotion Excess stimulation Substance Use Disorders In withdrawal or intoxicated? Personality Disorders Reinforcers 23

24 Response to Threat Assess risk. If acute, high risk then 911 and security protocols Verbal De-escalation Be calm and confident Facial expression, body language and tone of voice Ask/use name, introduce self Ask how you can help What and we Empathy (match tone) Startle to break behavior 24

25 Helpful Tools 25

26 Level of Care Tools Purpose of these tools is to assess the needs of the consumer=medical necessity Many of these tools then match the needs to the appropriate level in an array of services Often these tools also allow for quantification of severity May be useful as screening and/or monitoring tools 26

27 LOCUS Level of Care Utilization System Copyrighted tool by the AACP Adults with mental health and addictions Used to: Assess immediate service needs Plan resource needs over time Monitor changes, progress 27

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29 Patient Health Questionnaire Self-report inventory for mental health: Depression, anxiety, alcohol, eating and somatoform disorders. Version of the Primary Care Evaluation of Mental Disorders (PRIME-MD). Both a screening and diagnostic tool Effective for monitoring progress as well. 29

30 PHQ9 for Depression Over the past 2 weeks, how often have you been bothered by: Little interest or pleasure in doing things Feeling down, depressed or hopeless Trouble falling asleep, staying asleep, or sleeping too much Feeling tired or having little energy Poor appetite or overeating Feeling bad about yourself-or that you re a failure or have let yourself or your family down Trouble concentrating on things Moving or speaking so slowly that others have noticed. Or, the opposite- being so fidgety or restless that you have been moving around a lot more than usual Thoughts that you would be better off dead or of hurting yourself in some way. 30

31 American Society of Addiction Medicine (ASAM) 31

32 American Society of Addiction Medicine (ASAM) 32

33 ASAM Criteria Early Intervention Level 0.5 Outpatient Treatment Level 1 <6hrs/wk Intensive Outpatient Treatment (IOP) Level hrs/wk Partial Hospitalization Level hrs/wk Dimension 1 Intoxication and/or withdrawal potential None None Mild or is at risk of withdrawal Mild or is at risk of withdrawal Dimension 2 Biomedical Conditions or complications Dimension 3 Emotional, Behavioral, or Cognitive Conditions or complications None or Mild None or Mild None or Mild Distracts from treatment in a lower level of care None or Mild Distracts from treatment in a lower level of care None or Mild One or more One or more One or more a)dangerousness - None Mild Safe between sessions b)interference with Addiction Recovery Efforts Mild Safe overnight - Mild Mild Moderate c)social Functioning - None to Mild Mild to Mod Moderate d)ability for Self-Care - Mild Mild to Mod Moderate e)course of Illness - Mild Moderate Moderate 33

34 Tools Crisis Residential Crisis Stabilization Assertive Community Treatment Teams Clubhouse and Drop-In Centers Vivitrol 34

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