Care Manager Skills IV Chapter 12: Talking to Patients and Caregivers Working With Patients with Bipolar Disorder or PTSD This chapter provides an introduction to working with patients who are suffering from bipolar disorder or PTSD. In order to help empower each patient to be an active participant in his/her treatment, the establishment of a good working relationship with the patient is very important. People with bipolar disorder or PTSD often feel isolated, avoid contact with other people, or do not have the energy to seek help. The effect of having someone seek them out, explore with them their symptoms and their attempts to cope, offer help, and encourage them to pursue effective treatment can be quite powerful. Through the relationship with the patient, the CM does more than coordinate appointments and assess needs. He or she provides a crucial and therapeutic force in a patient s ongoing treatment. During the initial contacts, the CM should communicate his or her enthusiasm and interest in the patient s wellbeing. In the initial session, the patient should begin to understand that the CM is someone with whom he or she will be in ongoing contact. This person will know the particulars of the patient s situation and can help access resources provided within the Collaborative Care model and communicate with the rest of the care team. It is very important to establish oneself as an empathic person who is trustworthy and capable and who works collaboratively with the patient s PCP and the rest of the treatment team. Empathic encouragement can make a difference in getting a patient through rough spots such as being discouraged by the slowness of medication effects. The CM can help the patient stay clear about what the goals are and support the patient s efforts to reach them. It is very important to understand each patient s perspective. Creating a good fit between clinician and patient understanding of the patient s condition (bipolar disorder, PTSD) is essential for treatment success. Try to listen and talk with the patient in uncomplicated and non-judgmental terms. Attempt to understand the patient s explanatory model (i.e., his or her perspective on the cause of the disorder, expected evaluation and treatment, benefits of various treatments, risks and harms associated with treating or not treating the disorder). This will allow the patient to feel part of the treatment team and increase his or her likelihood of treatment adherence. In discussing patients conditions, it can be helpful to mention that: - bipolar disorder and PTSD are common - bipolar disorder and PTSD can cause a wide spectrum of symptoms including physical symptoms such as restlessness, poor sleep, and changes in appetite - bipolar disorder and PTSD affect our body, our behaviors, and our thoughts - bipolar disorder and PTSD are a medical illnesses, not character defect or weakness. The symptoms are not in one s head but real physical experiences - the good news is that bipolar disorder and PTSD can almost always be treated either with medications or with psychotherapy - patients can learn skills to cope with their conditions - physical activity / exercise are often helpful, but patients are often afraid that such activities may cause injury or pain - minor tranquilizers (such as benzodiazepines), drugs, and alcohol can make bipolar disorder and PTSD worse
2 Difficult patient encounters At times, the CM may find that he or she does not feel as effective as he or she would like to be or may find it difficult to work with certain patients. The CM should discuss these concerns during weekly team meetings in order to get support and to avoid negative outcomes for either the CM or the patient. Usually, having a chance to explore one s own reactions with a skilled colleague can help future interactions with the patient go more smoothly. Working Effectively With Patients People with bipolar disorder or PTSD may have a hard time keeping focused, and can often use up time answering your questions by telling you long stories about their lives. While the social support they gain from your listening to their story is helpful to them, it is only helpful in the short run and prevents you from truly helping them learn about their condition and the various ways they can treat their disorder. There are three basic strategies that you can employ to help you make the most of the limited time you have with your patient. Setting the agenda Whenever you meet with your patient, whether it is by phone or in person, you should always begin the meeting by informing the patient about the time limit for the meeting, and what you both should cover during the time you have. Always start by telling them how much time you have to meet and the things you would like to cover. Then ask them what questions or topics they want to discuss. After getting that information, assign approximate times limits to each topic ( How about we spend about five minutes talking about the side effects you mentioned and then ten minutes talking about how your medication works ). This strategy not only focuses the patient, but also allows you to use your time efficiently. If you don t cover everything, you can then add the topics you did not cover to your agenda for the next visit, making the patient feel that you will address all their issues. Repetition and writing A good rule of thumb in teaching your patients new information is to tell them the new information a couple of times and in different ways. For instance, when educating a patient about their condition, break down the information into small sections. After discussing one section, summarize what you have just told them, and ask them questions about the information you just taught them. Also, have the patient write down what you are telling them, either on the materials you hand them or in a notebook. This procedure helps them focus on the content of what you are telling them and increases the likelihood they will remember the information. At the end of each meeting, review the topics you discussed and the solutions developed, so that they have yet another chance to hear what you want to tell them. Refocusing One of the hardest things to do is interrupt people in the middle of their stories. It is very common to feel like you are their only source of support and that it is disrespectful to interrupt. In truth, you do your patients a greater disservice by not refocusing them. A patient could potentially take up a majority of the meeting time, leaving you very little time to go over the education you need to provide. Reminding patients of the time limits you have, setting an agenda early in the meeting, and gently interrupting patients are useful refocusing tools.
3 Working with Older Adults Age combined with mental health issues can take a toll on the patient s ability to process new information. It is estimated that it takes nearly twice as long to educate an elderly patient about mental illness as it does to educate a younger patient. One way for the care manager to cope with this challenge is to use repetition during the education segment of the encounter. Try to repeat the information in several different forms so that the patient has a better chance of learning the information. When scheduling appointments, the care manager may want to allow extra time for encounters with elderly patients. Providing Culturally-Appropriate Care When working with your patients, always be mindful of that person s cultural background. Being familiar with a patient s cultural beliefs about medicine and mental illness will help you to communicate with your patient and will increase the probability your patients will adhere to treatment. While it is impossible to know all the nuances of each culture, there are still overarching themes you can keep in mind with patients from many racial/ethnic backgrounds. These are respect, family support, mistrust of white organizations, stigma, spirituality, access barriers, and acculturation. Respect In many ethnic communities, adults are seen as sources of wisdom, teachers and moral examples. Because of this perception, it can be very difficult for adults, particularly older adults to discuss problems or mental health symptoms with you, for fear of losing your and their family s respect. You can engage patients in treatment by discussing how their symptoms have impacted their relationship with the community and their family, and by helping them understand that treating their condition will help them to be there for their children, grandchildren and community. The concept of respect can also be a deterrent to treatment. Sometimes, patients will try to be respectful of their doctor and will not complain to you about medication side effects or lack of effectiveness of treatment. They may see any complaints about their physician s recommendations as being disrespectful. It is therefore important to align yourself with the primary care provider and explain that you are asking questions about side effects and response to help the doctor treat the patient s condition. It is also important to say the doctor wants to know about any problems because s/he knows that these treatments sometimes need to be adjusted or changed. This information will help the patient feel less anxious about being disrespectful. Family support In many families, when the identified patient cannot take care of him or herself, or the family suspects the patient needs help with medical care, there will be an identified family member who will usually make all the patient s appointments, will want to sit in on the visits, and will be responsible for making sure the patient adheres to treatment recommendations. This person will also function as the patient s gatekeeper, screening all research-related issues. When this is the case, this person must be involved in all aspects of the patient s care. This person will most likely be the family member who accompanies the patient to the first visit, but you should always make sure by asking the patient Is this the person who handles all your appointments and medicines? Because of the reasons discussed in the respect section above, you should
4 always explain to the family member that you would like to spend a few moments alone with your patient to get to know him or her. This allows the patient some private time to talk about any problems s/he does not want the family to know about. Mistrust It can sometimes take a long time to establish a relationship with patients from underserved communities, particularly if you are seen as part of a research project, rather than the treatment team. African Americans have often been used as subjects in studies to push the concept of racial inferiority, and have been mistreated in medical studies. It is important to be mindful of patients potential anxiety in working with you. Stigma It is important to discuss patients beliefs and attitudes about bipolar disorder or PTSD and any fears they may have about people in their community finding out they are in treatment. Much of the cultural stigma can be addressed through the use of psychoeducational materials. However, do not simply hand the patient or the family member the materials and expect them to read it. Go over all the information in the office and discuss any questions. For those patients who are fearful of losing respect, offer to hold the materials for them so that they can read them over at each visit. The use of overly processed or glossy materials can make the patient feel the treatment is impersonal. You can personalize the materials for them by writing on the pamphlets and highlighting the points in the materials the patient feels were important to learn. Spirituality Religion and spirituality are often very important components of the culture. For many patients, a good way to assess for improvement or worsening of bipolar disorder or PTSD is to assess the patient s level of activity in the church community. The use of prayer is often a very important coping mechanism and can be encouraged when patients indicate they are no longer employing this practice. Spirituality may also involve the use of healing herbs or other complementary therapies. When asking about medicines the patient is taking, it is also important to ask about the use of other herbal remedies. It is also important to respect the use of these herbs. If you try to get a patient to choose between a psychotropic medication and the herb, the medication will always lose. Access barriers Many patients have trouble making regular appointments because of the many demands on their time, such as work, taking care of children, spouses, or extended family. Many people will often put the needs of their family before their own needs. Time then is important, and as a provider you must remain flexible, but also encourage the patient to look after himself or herself. A helpful technique in getting patients to attend to their own needs is to educate them about how spending time on themselves makes them stronger and more able to manage their family demands. You can t fill someone else s cup unless your cup is full. Other access barriers include transportation and finances. In considering the frequency of treatment visits, you should also assess how long it takes patients to get to the clinic and how difficult it would be to arrange transportation. Cost of care is also important to consider since patients are often on fixed incomes and will not adhere to treatment if the most expensive medication on their list is for their mental health condition.
5 Acculturation It can be helpful to determine how acculturated racial/ethnic minority patients are and to what degree they feel connected to their ethnic community. Before assuming that any of the issues discussed above is true for your patient, get to know the person first. If he or she was never religious, recommending prayer will only offend the patient. Make sure you spend some time talking to the patient about the issues discussed above, so that you can deliver culturally appropriate care. Working with family members and significant others In many cases, it will be very helpful for the CM to involve family members or significant others in the treatment. The CM should always discuss with the patient how family members and significant others will feel about the patient s diagnosis and any proposed treatments. The CM may encourage the patient to share educational materials with significant others or suggest talking to or meeting with important family members to do some education about the patient s condition, and to ask them to support the patient s treatment plan. This could include help with adherence to medications or with plans made during BA training. See also the section on family support (above).