Engagement: How motivational interviewing can help? Anna Ratzliff, MD, PhD Psychiatry & Behavioral Sciences University of Washington

Transcription

1 Engagement: How motivational interviewing can help? Anna Ratzliff, MD, PhD Psychiatry & Behavioral Sciences University of Washington

2 Why is engagement important in Collaborative Care? In studies, patients with early follow up were less likely to drop out and more likely to improve (Bauer, 2011) What are your experiences with early engagement?

3 Psychotherapeutic Process Engagement Assessment Crisis management Treatment Depression Anxiety Behavioral Interventions

4 What happens when you have a patient difficult to engage? What does the patient do? What do you do in response?

5 Key #1 Quality of Alliance determines outcomes (coaching, counseling, medicine, teaching, job training) Strong alliance Good outcome Weak alliance Poor outcome

6 3 Critical elements of Alliance: (all 3 must be agreed upon by pt & prov) Tasks? Goals? Bond? Working Alliance

7 3 Critical elements of Working Alliance: what are they Bond: The connection between the patient and the provider. May need to consider both individual providers and the team of providers Goals agreed upon: Agreed on by both patient and provider(s). Start with the patient-goals Tasks agreed upon: Both provider and patient must agree on HOW to reach goal. Will need to start small

8 Alliance Reciprocal causality (everything effects everything)

9 Key #2 Not ready to change / engage? Not Ready On the Fence Ready

10 Assessing for readiness What brings you to see me? What are you expecting in this visit today? In primary care, may not understand role of behavioral health providers What are you hoping to get from your care? What would be different in your life if our work was successful? After behavioral health assessment Agree on the initial task to return for treatment Set mutual goals

11 Psychotherapeutic Process Engagement Assessment Crisis management Treatment Depression Anxiety Behavioral Interventions

12 Some Provider Potholes Question and answer trap (closed questions) Consider mix of open and closed questions Correcting wrong thoughts with rational explanations (telling them what to do) Consider acknowledging reluctance to change so the patient CAN argue for change Avoiding the patient (hiding, acquiescing with Rx) Consider discussing the engagement challenges directly

13 Good Reflections Prove You Understand Most powerful technique for preventing and dealing with tough interactions Shows nonjudgmental understanding of the patient s point of view Communicates respect and understanding of the patient s experience Does NOT mean you agree with their explanatory model nor endorse maladaptive behavior choices!

14 Rationale for Motivational Interviewing Style If not listened to: If listened to: Secretive Angry, annoyed Avoidant Oppositional Discounting Frank Understood, accepted Exploring Cooperative Concerned

15 Ambivalence Example MI Spirit My client struggles with ambivalence about change. One moment, she wants to take the plunge, and the next moment, she s stuck again. She s working hard to resolve this. MI Inconsistent She s manipulative. She tells me she wants to change, because she thinks it s what I want to hear. But she s really not motivated.

16 Reflections: Examples MI Spirit It sounds like you are feeling It sounds like you are not happy with It sounds like you are a bit uncomfortable about So you are saying that you are having trouble So you are saying that you are no so sure about You re not ready to You re having a problem with You re feeling that It s been difficult for you You re struggling with What a pisser!

17 Engagement Steps Elicit the story Understanding Summary of pros/cons to treatment Elicit treatment hopes and dreams Link to treatment Feedback = psychoeducation Barriers: practical, psychological, cultural Elicit commitment

18 Barriers Practical Psychological Cultural Take time to understand these from the patient perspective

19 When to step up engagement Lacking agreement on goals Lacking agreement on tasks Weak bond At the beginning or over time Engagement can get thwarted!

20 Psychotherapeutic Process Engagement Assessment Crisis management Treatment Depression Anxiety Behavioral Interventions

21 Engagement Steps Elicit the story Understanding Summary of pros/cons to treatment Elicit treatment hopes and dreams Link to treatment Feedback = psychoeducation Barriers: practical, psychological, cultural Elicit commitment

22 Your Questions 1. What's the best way to engage patients who may have cultural barriers to depression treatment, especially medication? 2. What are some techniques for keeping patients (both patients who are improving and not improving) engaged after 1-2 sessions? 3. Patients who feel better after 2-3 sessions are often hard to reach or schedule time with; what are some ideas for keeping patients who feel better engaged in continuing follow up with the depression care manager? Patients understand from the beginning that this is a multisession interaction with the depression care managers, but we have seen some disenrollment because the patient have felt better and don't see value in continuing with the depression care manager. 4. For patients who work, what are some ideas for keeping patients interested in CCI when some of these patients have competing priorities (work, children, grandchildren, etc.)? 5. Patients who agree to work with a depression care manager, returns for one visit, but does not return for a couple of weeks, how do we encourage the patient to follow up weekly? 6. How do you assist providers in seeing the benefits of engaging their patients and treating depression in the primary care setting?

23 Resources to help with provider engagement Making the Case for Change and Overcoming Resistance ult/files/making-case-change-overcoming- Resistance.pdf Reasons PCPs Love Collaborative Care PsLoveCC.pdf