Therapeutic Conversations: Promoting Self-Management for Clients with Chronic Conditions Using CBT and Motivational Interviewing Concepts Kyle Schalk, Ph.D, RPsych Kimberly Price, BScOT
Listening and Letting Go of Your Agenda https://www.youtube.com/watch?v=-4edhdahrog
Objectives Increase knowledge of Motivational Interviewing and application for chronic populations. Increase understanding of psychosocial barriers/processes connected to chronic conditions and knowledge of CBT concepts to inform practice. Developing strategies to assist clients in effective and consistent self-management of chronic conditions.
Defining the Problem What is a Chronic condition? long duration and generally slow progression (World Health Organization) Focus on self-management
Psychosocial Barriers Canadians with chronic physical conditions have twice the likelihood of also experiencing a mood or anxiety disorder when compared to those without a chronic physical condition. (Government of Canada, 2006) Hopelessness/helplessness Loss of identity/grief Adjustment difficulty and fear Emotional roller coaster (Bordeaux & Walters, 2013)
Cognitive Behavioral Therapy (CBT)
Cognitive Behavioral Therapy Traditionally focused on treatment of anxiety and depression In terms of chronic illness/pain CBT posits that inaccurate cognitions and negative coping behaviors interact with physiological and environment factors and produce negative outcomes including pain, distress, disability and isolation (Heapy, Stroud, Higgins, & Sellinger, 2006). Essentially people develop ineffective coping thoughts and behaviors.
Cognitive Behavioral Therapy CBT focuses in developing awareness of patterns CBT focuses on education and intentionally intervening/planning for more adaptive thinking and acting CBT is collaborative, practical, purposeful CBT focuses on goal setting, skill acquisition and coping strategies
Motivational Interviewing (MI) Motivational Interviewing is a collaborative conversation style for strengthening a person s own motivation and commitment to change. (Miller, 2000) It is client centered approach that requires the therapist to convey empathy, actively listen for values, focus on the clients strengths and ensure treatment is collaborative. It is DIRECTIVE
Motivational Interviewing Spirit of MI Collaborative vs confrontation Evocative rather than imposing Autonomy vs authority Principles Self-efficacy Roll with resistance Elicit discrepancy and work with ambivalence
Differences and Integration CBT is one of the primary methodologies used in interdisciplinary programs MI can be supplemental despite philosophical differences Both are collaborative with focus on promoting selfmanagement CBT is more useful when clients are ready to change Research indicates strong support for MI in health care (Chen et al., 2012, Thomas, et al., 2012, Tse et al. 2013)
Stages of Change Transtheoretical model Prochaska, DiClemente, & Norcross (1994) Positive behaviour changes typically follow general pattern or stages of change
Understanding Change
Stage of Change : Pre-Contemplation Mandated treatment No show Medically focused Expectation of passive versus active treatment Looking for magic cure Attendance as a sign of willingness to change kernel of intent to grow
Stage of Change : Contemplation Profile Ambivalence feeling conflicted Inconsistent engagement/behaviour Discrepancy between values and behaviours Lack of awareness Examples No work between sessions Good dad yet dealing drugs
Stage of Change : Preparation Profile Client is preparing for self-management of health issues Acceptance of responsibility Less medically focused Experimenting with different ideas Open to education
Stage of Change : Action Profile Client is actively engaged in change Using self-management routine Querying feedback on strategies Personalizing program and working intently at home Shift in language Personal responsibility I know I might not be pain free but I m going to do the best I can to manage Acceptance Creative in application in other areas of life
Stage of Change : Action
Stage of Change : Maintenance Self-management!!!
Stage of Change : Recycling
Change Talk Strategies Therapeutic alliance Active listening skills (OARS) Strategies
Establishing a Strong Treatment Alliance Building Rapport Mutual goals and tasks Trust Humour/self-disclosure The Importance of Language Illicit and strengthen change talk Client builds argument Improves treatment effectiveness (Hall et al., 2010)
Active Listening Skills Open-questions Avoid yes/no answers with what and how questions Affirmation It s clear that you are really trying to change I m impressed with Reflective listening Mirror what client has said while amplifying ambivalence It sounds like this has been really hard for you but I m also hearing you want to do something different Summarize * Resist the righting reflex*
Strategies Asking permission Scaling questions (readiness/importance/confidence) On a scale of 0 to 10 how ready/confident do you feel Normalizing
Strategies Decisional balancing (pros and cons) What are some good things?...some things that aren t working? Explore the extremes What s the worst that could happen if you don t change? What the best thing you can imagine if you do change Looking back/forward Remember times in the past when you were able to make change... Exploring vision for the future if change were to occur
Strategies Explore goals and values What things are most important in your life Columbo approach Help me understand...i m confused Rolling with Resistance Emphasizing personal choice while avoiding arguing I know this is hard and you may make the decision not to change
Hope! Hope plays an essential part in coping with chronic illness (Duggleby et al., 2012) Helping clients find ways to have meaningful lives despite illness
Thanks!!
References Bordeaux, T. L., & Walters, A. (2013, August). Coping with a diagnosis of chronic illness. Retrieved September 4, 2016, from http://www.apa.org/helpcenter/chronic-illness.aspx Chen, S. M., Creedy, D. Huey-Shyan Lin, & H. S, Wollin, J. (2012) Effects of motivational interviewing intervention on self-management, psychological and glycemic outcomes in type 2 diabetes: A randomized controlled trial. International Journal of Nursing Studies, 49, 637-644. doi: http://dx.doi.org/10.1016/j.ijnurstu.2011.11.011 Duggleby, W., Hicks D., Neokolaichuk, C., Holtslander, L., Williams A., Chambers, T. & Eby J. (2012). Hope, older adults, and chronic illness: a metasynthesis of qualitative research. Journal of Advanced Nursing, 68, 1211 1223. doi: 10.1111/j.1365-2648.2011.05919.x Government of Canada, (2006). The human face of mental health and mental illness in Canada (Catalogue No. HP5-19/2006E). Ottawa, ON: Minister of Public Works and Government Services Canada Hall, A. M., Ferreira, P. H., Maher, C. G., Latimer, J., & Ferreira, M. L. (2010). The influence of the therapist-patient relationship on treatment outcome in physical rehabilitation: A systematic review. Physical Therapy, 90, 1-12. doi: http://dx.doi.org/10.2522/ptj.20090245. Heapy, A., Stroud, M., Higgins, D., & Sellinger, J.(2006). Tailoring cognitive- behavioral therapy for chronic pain: A case example. Journal of Clinical Psychology, 62, 1345 1354.
References Miller, W. R. (2000). Motivational interviewing. (2 nd ed.). New York: Guildford Press. Noncommunicable diseases. (n.d.). Retrieved September 04, 2016, from http://www.who.int/topics/noncommunicable_diseases/en/ Prochaska, J.O., Norcross, J.C. & DiClemente, C.C. (1994). Changing for good. New York: Morrow. Sawatzky, R., (2010). Motivational interviewing level I training workbook. Empowering Change Inc. Sawatzky, R., (2013). Motivational interviewing level II training workbook. Empowering Change Inc. Thomas, M.L., Elliot, J. E., Rao, S. M., Fahey, K. F., Paul, S. M. & Miaskowski, C. (2012), A randomized, clinical trial of education or motivational-interviewing-based coaching compared to usual care to improve cancer pain management. Oncol Nurs Forum,39, 39-49. Tse, M. M., Vong, S. K. & Tang, S. K. (2013), Motivational interviewing and exercise program for community-dwelling older persons with chronic pain: a randomised controlled study. J Clin Nurs, 22, 1843 1856. doi:10.1111/j.1365-2702.2012.04317.x