Treatment non-negotiables: How to think about them and make them work.

Transcription

1 Treatment non-negotiables: How to think about them and make them work. ANZAED 2014 Conference: Fremantle Jeremy Freeman Chris Thornton The Redleaf Practice Josie Geller University of British Columbia & St Pauls Hospital Vancouver

2 Emma Emma attends regularly for outpatient treatment, and seems to be addressing her anorexic cognitions. After several weeks of treatment her weight seems to drop. She gives understandable reasons as to why she missed her last GP visit

3 Jean Jean is a young woman who agreed to enter a day program to stop restricting, bingeing and purging. Prior to starting the program she agreed to eat all of the meals. Today, three days into the program she refuses to eat her lunch, tearfully saying that she does not like the way the food is prepared and says she will just eat more for afternoon tea to make up.

4 OUR PLAN To present a framework for conceptualising non-negotiables and how they can be implemented in a collaborative, supportive way that fosters motivation for change, particularly in situations that may engender intense emotional reactions in the client, clinician or team.

5 What are therapeutic Non-Negotiables? Limits, boundaries, rules Framework, structure of treatment, therapeutic frame Rules are not only non-negotiable and indispensable, but also constitutive of the therapeutic process (Goldberg, 2009) Positive, not negative

6 Principles of Non Negotiables. Josie Geller 1. Ensure safety 2. Fostering an environment that is conducive to change 3. Promote client self-awareness, motivation to change, self-acceptance Treatment Non-Negotiables: Why We Need Them and How to Make Them Work Geller & Srikameswaran (2006)

7 What are your therapeutic nonnegotiables? brainstorm

8 Generic non-negotiables? Confidentiality Payment, notes/medical records, other service rules Frequency of visits minimum, maximum Degree of self-disclosure of clinician Aggression, intimacy Willingness to step outside a traditional therapeutic setting, eg deciding whether to meet with a patient s partner or relative.

9 ED Non-Negotiables Medical Safety Weighing Homework, monitoring Expected rates of weight gain How and when involuntary treatment occurs Expectations of clients at meal times

10 Redleaf Non- Negotiables An outpatient example. Medical. Self Monitoring/Homework Session Boundaries cancellation and payment. Weighing. Communication between professionals. FBT Both parents attend assessment, all family members attend from session 1.

11 Role Play

12 What s more important? What are the non negotiables Or How they are implemented

13 The Tone of Non Negotiables Always delivered with an MET tone. A collaborative tone rather than a expert/directive tone. More acceptable to both patient and clinician More likely to be followed through.

14 A Motivational therapist stance is a judicious blend of empathy and firmness, of acceptance and pressure to change (Vitousek et al., 1998). Applies to how NN are presented. Tone is conveyed by. Empathy (working to stay on the patients side). Curiosity and interest promoting an experimental stance. Respect. Patience. Elicit responses Offer choices. Validate distress or confusion.

15 The Tone of MET (Collaboration)

16 Not the tone of MET (Overcontrol/Argumentative)

17 Janet Treasure Although something may be a non-negotiable matter, it is possible to manage this without resorting to confrontation or threat but in an empathic onedown position, in which the patient and the therapist are both bound by the laws of a higher authority (the laws of nature or mental health legislation) (Treasure & Schmidt, 2008).

18 Guidelines for Developing Non-Negotiables

19 Key Components of NNs 1. Clear rationale/not Arbitrary. 2. Surprises are minimised 3. Consistent/Not Inconsistent 4. Client Autonomy is maximised. Geller & Srikameswaran (2006) European Eating Disorders Review,14,

20 Implementing Non-Negotiables. (ASIA) Problem 1. Arbitrary (pyjamas) (No rationale or not explained) 2. Surprise Implementation (no advance warning) {Hospitalisation} Consequences Decreases trust Distract from Therapeutic Goals Increase pt anxiety Increase confrontations Denies pt opportunity to change behaviour Lack of clarity about bottom line is uncontaining for pt

21 Implementing Non-Negotiables. (ASIA) Problem 3. Inconsistent {between patients/between consultants/between sessions} 4. Lack of Autonomy {You must finish everything on your plate} Consequences Testing of limits Experience of favouritism Increase hostility Inconsistency creates lack of trust in therapy and therapist. Therapy becomes unsafe. Inconsistency can be schema activating Increases power struggles Decreases motivation Relapse I'm not responsible for recovery. Does not recognize self efficacy of patient.

22 Key Components of NNs 1. Clear rationale/not Arbitrary. 2. Surprises are minimised 3. Consistent/Not Inconsistent 4. Client Autonomy is maximised. Geller & Srikameswaran (2006)

23 Consequences of Non- Negotiables What might you do if the client breaks the non negotiable? Three red flags (often used in day programs) Change focus of treatment Discharge or sabbatical from treatment. Other Ideas..

24 Exercise 1 Exercise 2 Formulating Evaluating 1. Define the NN. 2. What is the rationale? 3. When and how will this be communicated to patients/to staff? 4. Can it be implemented consistently over time, clients, staff? How will you insure this? 5. How can client personal responsibility be maximized. What choices will be offered to the patient? 6. What are the consequences of the NN. 7. How will client feedback be sought? 8. What barriers do you anticipate? 1. Identify a current NN 2.Evaluate against ASIA. A. What is the rationale and how is this explained to the patient? S. When is it explained to the patient? I. How consistently is it implemented? Across staff, across patients, across sessions. A. How is patient personal responsibility is maximized? 3. Describe the barriers to this NN.

25 Implementing Non-Negotiables. (ASIA) Problem Consequences Principal 1. Arbitrary (pyjamas) (No rationale or not explained) 2. Surprise Implementation (no advance warning) {Hospitalisation} Decreases trust Distract from Therapeutic Goals Increase pt anxiety Increase confrontations Denies pt opportunity to change behaviour Lack of clarity about bottom line is uncontaining for pt Need a rationale Rationale explained to pt without discomfort. Reflect if NN is needed. As above explained early in treatment (eg in a patient/parent handbook). Client to share reactions to NN

26 Implementing Non-Negotiables. (ASIA) Problem Consequences Principal 3. Inconsistent {between patients/between consultants/between sessions} 4. Lack of Autonomy {You must finish everything on your plate} Testing of limits Experience of favouritism Increase hostility Inconsistency creates lack of trust in therapy and therapist. Therapy becomes unsafe. Inconsistency can be schema activating Increases power struggles Decreases motivation Relapse I'm not responsible for recovery. Does not recognize self efficacy of patient. All staff apply nn to all patients consistently. Can you be consistent in practical terms (eg is there a bed in hospital?) Maximise autonomy by always providing a menu of options to allow patient choice. Validate that all options are unwanted.

27 REACTIONS TO NON NEGOTIBALES

28 Client Reactions You are punishing me You are patronising me Usually a result of poorly designed NN Arbitrary, Surprising, Inconsistent, No choices. When designed well NN s are typically experienced as supportive and therapeutic.

29 Team Reactions Do all members agree on the rationale. What was the process by which the NN were arrived at. Collaborative vs non-collaborative design. (How>What). How is disagreement resolved? Decree (Power imbalance) Experiment and Review Stance (trial the NN) When well designed NN are supportive and containing for the team and their therapy. You always have a position to refer to.

30 Outpatient Teams Team Agreement on NN - Inconsistency What do we agree on - 19 year old male with HR of 37. Clin Psy has a non negotialble of you must present to ED vs GP you re fit not a problem Medical Non Negotiables not agreed.

31 Therapist Reactions. Does applying firm boundaries make you feel bad. The patient will be sad or anxious The patient will be angry with me. The patient may not come back. Patient hopelessness. Waller, Stringer & Meyer (2012) Turner, Tatham, Lant, Mountford, Waller (2014)

32 Possible Solutions to Reactions Set up and Evaluate Non Negotiables using ASIA. For All Teams Regular meetings (in person or virtual) to review NN. Documentation for patients and for team members (letter to GP s explicitly outlining your expectations).

33 For Inpatient/Daypatient Teams Whole of team commitment regardless of agreement. Awareness of Non Negotiables (and treatment philosophy) prior to employment. Non Negotiables for team behaviour.

34 Outpatient Teams Be clear about your own NN and acceptance of what you can control in others. Communicate regularly (this is a NN). Create an in-house team (where nobody can disagree with you). Can create a self sustaining system with no splitting (or other opinions). Be Socratic and motivational in tone with others I was interested in your decision to hospitalise Mary when she appeared to be making some progress. Can I get your thoughts about that.. I was hoping we could look at some other options (menu of choices) Validate Mary s understandable distress. Help Mary accept or advocate for her within the team ( Can we, as a team, discuss some concrete guidelines as to how Mary can resume exercise?

35 Therapist reactions: Possible Solutions Make sure your non negotiables are well thought through (ASIA). When applied in a toneful and consistent manner NN are typically seen as supportive and containing. In teams collaborative development of NN Be aware of your own reactions (eg conflict avoidance) Talk through you reactions in supervision.

36 In Conclusion Non Negotiables are a central tool in ED treatment. Their purpose is to keep therapy safe and help in the process of treatment. When designed well they are typically containing for clients and therapist. We hope ASIA helps in design, implementation and review of NN.

37 Treatment non-negotiables: How to think about them and make them work. Jeremy Freeman Chris Thornton The Redleaf Practice Josie Geller University of British Columbia & St Pauls Hospital Vancouver