Workshop 3: One Step Closer to Self-Management. Mr Yap Chee Khong Psychologist Clinical Services National Healthcare Group Polyclinics

Transcription

1 Workshop 3: One Step Closer to Self-Management Mr Yap Chee Khong Psychologist Clinical Services National Healthcare Group Polyclinics

2 Acknowledgement Facilitators & Contributors Mr Loke Keng Choong Mr Mah Siew Chung Mr Ooi Say Leong Ms Serena Ho Dr Wong Mei Yin Ms Zeng Weiting Psychologist Psychologist Psychologist Psychologist Principal Psychologist Psychologist

3 Case Study

4 Mr. L Age: 57 Race: Chinese Gender: Male Height: 1.65m Weight: 78kg BMI: 28.7

5 Presenting Problem Over snacking Excessive supper

6 History of Presenting Problem Type 2 diabetes mellitus Diagnosed in December 2013 HbA1c = 13 Family history of diabetes Mother and 3 maternal uncles Feels tired almost every day Feels hungry easily Thinks that he is useless, and feels guilty that he is not working Not adherent to medications

7 Family Lives with Wife (age 46, restaurant helper) 2 sons (age 15 and 13 respectively) 1 daughter (age 9) Wife is the sole breadwinner in the family Good relationship with family members Wife is supportive, cares about him and she is concerned about his dietary

8 Work Currently unemployed Previously worked as machinist Resigned after few months being diagnosed with diabetes due to fatigue and difficulty to maintain concentration at work

9 Daily Activities / Lifestyle Sends daughter to school in the morning, picks up daughter from school in the afternoon Lies in bed and sits on sofa most of the time Feels too tired to increase physical activities

10 Dietary Food Item Quantity Calories (kcal) Breakfast Fried mee 1 plate 693 Siew mai, steamed 3 pieces 315 Soya bean milk, sweetened 1 cup 163

11 Dietary Rice + Dessert + Beverage Food Item Quantity Calories (kcal) Lunch Chicken rice 1 plate 618 Rice with soya sauce chicken 1 plate 551 Rice with duck 1 cup 706 Kway chap 1 serving 646 Bubur cha cha 1 bowl 390 Red bean soup 1 bowl 408 Ice kachang 1 bowl 257 Orange 1 43 Barley water 1 glass 55 Coffee with condensed milk 1 cup 113

12 Dietary Rice dishes Food Item Quantity Calories (kcal) Dinner White rice Fried rice 1 portion 511 Steamed egg with minced pork ½ portion 88 Curry chicken ¼ portion 113 Luncheon meat ¼ can 311 Fish head soup ¼ portion 53 Kangkong with shrimp paste ¼ portion 85 Mixed vegetables ¼ portion 29

13 Dietary 2-3 items + 3-in-1 coffee Food Item Quantity Calories (kcal) Supper Char kway teow 1 plate 744 Fishball noodles (soup) 1 bowl 329 Hokkien noodles 1 plate 617 Wanton noodles (dry) 1 plate 407 Lor mai kai 1 bowl 324 Roti prata with egg 2 pieces 578 Charsiew pow Sausage bun in-1 coffee 1 cup 62

14 Dietary 2-3 items in the list below Food Item Quantity Calories (kcal) Snacks Kuih lapis 4 pieces 588 Egg tart 4 pieces 712 Chicken nugget (deep fried) 10 pieces 588 Curry puff (deep fried) 4 pieces 1416 Kaya toast 4 pieces 1272 Bak Kwa 4 pieces 912 Ang koo kuih 4 pieces 444 Digestive biscuit 10 pieces 670

15 One Step Closer to Self-Management

16 Barriers to Lifestyle Change We already taught them many times, they don t listen, they don t do! They are so stubborn!

17 Barriers to Lifestyle Change There are so many things I need to focus on. This is not my priority. It s too hard for me to change. I don t think it helps. This is just a small issue. They are exaggerating it. Okay, I ll try.

18 Aims To facilitate healthcare providers start doing one thing different at the next consult To facilitate patients take ONE new and different step towards self management Do ONE thing different. A baby step at a time.

19 Behavior Change Assumptions We cannot change patients, they can only change themselves Let patients choose Facilitate, not tell Every patient has unique strengths and resources to help themselves Focus on positives, not negatives Nothing is all negative Focus on successes (no matter how small), not failures

20 Behavior Change Assumptions There is no such thing as resistance Find the right strategy (i.e., way-power, not just willpower ) Focus on what to do vs. what not to do A small change can lead to a big difference Set a specific action goal (DO something different) Write step by step action plans when patient is ready

21 Step 1: Clarify Patient s Goal Mr. L, what would you like to discuss today?

22 Step 1: Clarify Patient s Goal I don t know.

23 Step 1: Clarify Patient s Goal I haven t seen you since 3 months ago. What has changed since you last came?

24 Step 1: Clarify Patient s Goal Nothing. I m still the same. My diabetes doesn t improve.

25 Step 1: Clarify Patient s Goal How does diabetes affect you?

26 Step 1: Clarify Patient s Goal I feel tired all the time. I have to keep snacking to energize myself. My wife complained that I ve spent too much buying too much food.

27 Step 1: Clarify Patient s Goal Is this something you want to discuss today? How does not buying too much affect you?

28 Step 1: Clarify Patient s Goal Yes. I suppose I should just stop buying snacks. It s too hard. It s too hard. I suppose I should just stop buying snacks.

29 Step 1: Clarify Patient s Goal Yes, it is so difficult to make the change. On the one hand you need to keep snacking as you feel tired; on the other hand you know snacking contributes to diabetes.

30 Step 1: Clarify Patient s Goal You are also aware that snacking doesn t just affect diabetes, it may affect your relationship with your wife.

31 Step 1: Clarify Patient s Goal Exactly.

32 Step 2: Ask the Miracle Question Just now you mentioned that you should just stop buying snacks. When you are able to do it, what will your life be like?

33 Step 2: Ask the Miracle Question I will not eat snack. My wife will stop nagging about my snacks.

34 Step 2: Ask the Miracle Question How will you feel about yourself when you are not snacking?

35 Step 2: Ask the Miracle Question I don t know maybe less guilty.

36 Step 2: Ask the Miracle Question When you are feeling less guilty, what will you be doing?

37 Step 2: Ask the Miracle Question I don t know.

38 Step 3: Ask the Scaling Question I see. Let s say, on a scale where 10 stands for no more snacking, and 0 stands for snacking 24/7. Where would you put yourself on this scale?

39 Step 3: Ask the Scaling Question Snacking 24/7 No snacking at all 0 10

40 Step 3: Ask the Scaling Question 4 Snacking 24/7 No snacking at all 0 10 It s not that I really eat snacks 24/7. I would put myself at a 4.

41 Step 3: Ask the Scaling Question 4 5 Snacking 24/7 No snacking at all 0 10 Let s review your snacks. What will be different when you are at a 5?

42 Dietary 2-3 items in the list below Food Item Quantity Calories (kcal) Snacks Kuih lapis 4 pieces 588 Egg tart 4 pieces 712 Chicken nugget (deep fried) 10 pieces 588 Curry puff (deep fried) 4 pieces 1416 Kaya toast 4 pieces 1272 Bak Kwa 4 pieces 912 Ang koo kuih 4 pieces 444 Digestive biscuit 10 pieces 670

43 Step 3: Ask the Scaling Question 4 5 Snacking 24/7 No snacking at all 0 10 I eat less snacks Maybe, 2 instead of 4 curry puffs But I will still be eating Bak Kwa, kaya toast

44 Step 3: Ask the Scaling Question 4 5 Snacking 24/7 No snacking at all 0 10 How will you get to a 5?

45 Step 3: Ask the Scaling Question 4 5 Snacking 24/7 No snacking at all 0 10 I will buy 2 curry puffs.

46 Step 3: Ask the Scaling Question 4 5 Snacking 24/7 No snacking at all 0 10 What else would be helpful?

47 Step 3: Ask the Scaling Question 4 5 Snacking 24/7 No snacking at all 0 10 I will let my wife know that I will eat 2 curry puffs instead Just to stop her nagging.

48 Step 3: Ask the Scaling Question 4 5 Snacking 24/7 No snacking at all 0 10 What else?

49 Step 3: Ask the Scaling Question 4 5 Snacking 24/7 No snacking at all 0 10 I don t know.

50 Step 4: Ask the Exception Question Just now you mentioned that you don t eat snacks 24/7. What are you doing when you are not snacking?

51 Step 4: Ask the Exception Question I take nap Do laundry, clean my house, read newspaper

52 Step 4: Ask the Exception Question What else are you doing when you are not snacking?

53 Step 4: Ask the Exception Question I bring my daughter to school in the morning and bring her back in the afternoon

54 Step 4: Ask the Exception Question Sounds like you keep yourself active / do activities / have other activities other than snacking

55 Step 4: Ask the Exception Question Yes.

56 Step 4: Ask the Exception Question Snacking 24/7 4 5 No snacking at all 0 10 Would you consider engaging in extra light and simple activities to move yourself from 4 to 5?

57 Step 4: Ask the Exception Question Hmm I m not sure You know, I will feel too tired I don t think so.

58 Step 5: Compliment the Patient Mr. L, I m impressed by your willingness to cut down on the curry puff. Sounds good that you will cut down to 2. Just take a small step at a time.

59 Step 6: Assess Challenges What difficulties might you face to make the change?

60 Step 6: Assess Challenges I don t know.

61 Step 6: Assess Challenges What needs to happen for it to work?

62 Step 6: Assess Challenges I will share the other 2 with my sons or wife.

63 Step 7: End the Session Mr. L, I look forward to see you in next session. We can talk about how it goes the next time.

64 Next Session Mr. L, any changes since the last time we met?

65 Next Session It s too hard to change. I m still eating 4 curry puffs sometimes but compared to last time, I eat less.

66 Next Session That s great! You manages to eat less! Let s say, on a scale where 10 stands for no more snacking, and 0 stands for snacking 24/7. Where would you put yourself right now?

67 Next Session Snacking 24/7 No snacking at all 0 10

68 Next Session 4.5 Snacking 24/7 No snacking at all 0 10 I would put myself at 4.5

69 Next Session You have improved 0.5, what did you do to make it happen?

70 Next Session Was that anything different your wife / sons / daughter do that make it happen?

71 Next Session My wife bought me 4 curry puffs, I didn t want to waste the other 2

72 Next Session What could you have done differently?

73 Summary Clarify patient s goal Ask the miracle question Ask the scaling question Ask the exception question Compliment the patient Assess challenges End the session Follow-up in next session

74 Role Play

75 Mr. L I have to eat my supper before sleep, or else I will feel very dizzy when I wake up. My wife complained that I eat too much. She doesn t understand that if I don t eat, I will faint. Two years ago, I fainted because of low sugar level in the morning. We quarrel many times because of this issue.

76 Role Play Get into groups of 20 Get a partner in your group 1 of you will play Healthcare Provider Asks questions based on handout provided (Facilitating Behavior Change) 1 of you will play Mentor & Scribe Supports Healthcare Provider with interviewing the patient Writes down every question asked by your partner playing Healthcare Provider

77 Dietary 2-3 items + 3-in-1 coffee Food Item Quantity Calories (kcal) Supper Char kway teow 1 plate 744 Fishball noodles (soup) 1 bowl 329 Hokkien noodles 1 plate 617 Wanton noodles (dry) 1 plate 407 Lor mai kai 1 bowl 324 Roti prata with egg 2 pieces 578 Charsiew pow Sausage bun in-1 coffee 1 cup 62

78 Discussion

79 Discussion How did your practice go? What worked? What didn t work? What have you learned today that is different from what you are doing? What are the 3 new take-away questions or strategies you can integrate in your next consult?