New York State Brief Behavioral Inteventions Aug...

New York State Collaborative Care Initiative

Evidence‐based Psychotherapeutic Interventions for Primary Care

August 29, 2013

Anna Ratzliff, MD, PhDAssociate Director of Education

Division of Integrated Care and Public Health University of Washington

Presenter

Building on 25 years of Research and Practice in Integrated Mental Health Care

http://uwaims.org

Why brief behavioral interventions?

Feel Bad

Do Less

Behavioral Activation

set of strategies at the beginning of CBT treatment

Cognitivedysfunctional cognitions

or “automatic thoughts” increase flexibility and

decrease depressed way the thoughts function

Good evidence for C, B, and C+BBA: Cuijpers et al 2007, Ekers et al 2008, Mazzucchelli et al 2009;listed as an evidence‐based treatment for depression by the National Institute for Health and Clinical Excellence (2009)

Good evidence for C, B, and C+BBA: Cuijpers et al 2007, Ekers et al 2008, Mazzucchelli et al 2009;listed as an evidence‐based treatment for depression by the National Institute for Health and Clinical Excellence (2009)

CBTFirst line depression treatment

University of Washington © 2012

Case example: RB30 y/o Caucasian woman, mother of 2 (ages 8 and 2), 2nd marriage, unemployed since pain began, some college

Lifetime pattern of depressive episodes starting as a teenager, baseline PHQ‐9 23 (severe) & GAD‐7 11 (moderate), average pain rating 5/10


Increase adaptive activities,

preferably for mastery and pleasure

Decrease activities that maintain depression

Problem solve

barriers to rewarding things

3 Goals of Behavioral Activation


Doing BA in Primary Care

Explain the model

Ask lots of questions until you have a good formulation

Select BA targets

Follow‐up


stay home, stay in bed, watch TV,

withdraw from social

contacts, ruminate, etc.

sad, tired,

worthless, indifferent,

etc.

Explaining the Model: How depression happens

Life Events

loss offriendships, conflict with supervisor at

work, financial stress, poor health,

etc.University of Washington ©

2012

Case example: RB

30 y/o Caucasian woman, mother of 2 (ages 8 and 2), 2nd marriage, unemployed since pain began, some college

Lifetime pattern of depressive episodes starting as a teenager, baseline PHQ‐9 23 (severe) & GAD‐7 11 (moderate), average pain rating 5/10

Key complaints: my neck hurts; my arm is screwed up; what is wrong with me?; the pain is ruining my life and ability to care for my children

1‐2 years of worsening neck pain and tingling, numbness, weakness in left lower extremity; MRI evidence of disk degeneration in C5‐6

Course of tx in the Center for Pain Relief:– Increase sertraline to 100mg– gabapentin 900mg– trigger point injections – no pain reduction– nortriptyline 10mg at bedtime– baclofen– brief cognitive behavior therapy


Staying in bed, napping, shutting down

emotionally with kids and

husband

Guilty, ashamed, frustrated,

angry, scared, helpless

RB: Pitching the model

loss ofmarital intimacy, loss of fun activities with kids,

loss of sense of self efficacy with marriage

and mothering

Divorce, pain onset, unemployment,

child with learning disability, marital

conflict


Formulation

• What are the avoidance patterns?• How can we interrupt the avoidance and/or switch to approach rather than avoidance?

• How can we build mastery and pleasure?




husband



RB



and mothering



conflict

What is sheAvoiding???




husband



RB



and mothering



conflict

She’s avoiding:Emotional

expression, engaging kids, acknowledging

her positives


Mastery and pleasure targets:

Parenting and Marriage

Decrease activities that

maintain depression:Napping and

emotional disengagement

Problem solve barriers:

communica-tion skills,

activity pacing, relaxation training

3 Goals of BA


Selecting RB’s BA targets:

• What she worked on…Won’t talk to husband,

avoiding emotional expression with her

partner

• Talk to husband about frustrations

• Take timeouts but plan when you will re-engage when fights happen

• Try reflective listening• Increase physical

intimacy

Stopped activities with kids

• Pace activities with kids• Dance with them,

moving her neck especially; reduce guarding activity

Won’t acknowledge her accomplishments

• Internal validations for her motherhood and accomplishments

• She chose to:• Organize and

decorate her house• Improve her attire, put

on make-up, do her hair


RB’s symptoms: 8 visits over 4 mos

0

5

10

15

20

25

1/22/2010 2/22/2010 3/22/2010 4/22/2010

PHQ-9

GAD-7

Pain

Pain Interference


Typically we think of acting from the “inside out”

(e.g., we wait to feel motivated before completing tasks)

In BA, we ask people to act according to a plan or goal rather than a

feeling or internal state

Approach: Outside In

Avoiding the Mount Everest:Selecting the BA Targets

Complex tasks

Simple tasks

Assign increasingly more difficult tasks to move toward full participation in

activities

• Help break tasks down into manageable tasks• Mastery and success of one small

task will increase likelihood of completing other tasks

• Have them tell you what and how they’ll do the task (Details! Details! Details! Have them walk you through it)• Help problem solve and ask how

likely it is they will do it.• If it seems too challenging, it is! Break

it down further.

Follow‐up

ALWAYS ask about the target behavior the next time you see the patient

Expect them to not do the activity and don’t punish

If goal was not accomplished, ask 3 questions:

Do they have buy in to the treatment?

Did they simply forget?

Was it a Mt Everest?

Problem-Solving Treatment (PST):

FAST

• Engage patient in what they care most about

FOCUS ATTENTION

• Training brain to solve problems

Problem‐Solving Process

UNIVERSE OF PROBLEMS

Problem Definition

Realistic Patient Goal

Brainstorming

Pros and Cons

Choosing a Solution

Action Plan

Outcome Evaluation

How is PST Different from What I Already Do?

• BUT: picks up where MI endsLike MI

• BUT: focuses on life problemsLike BA

• BUT: Patient learns to personalize the plans on their own

Like Case or Self Management

• BUT: emphasis is on patient developing their OWN strategies Like CBT

What you need to do

• Educate and socialize the patient to the treatment

• Create a problem list• Teach the patient the 7‐step process• Use the worksheet as a guide to PST• Create an action plan• Schedule in pleasant/valued activities

Therapeutic Frame

• 6‐10 sessions at place they feel most comfortable (in person or by phone)

• You work on problems EVERY SESSION

• They need to solve problems between sessions

• Eventually the patient should be able to problem solve on their own

Educate Patient About PST Process

• What PST is or is not: – not life review therapy– not psychodynamic analysis– not *just* supportive therapy/case management– action focused on immediate issues causing depression

Problem ListIf you’re not having a problem, you’re missing a chance to grow. – anon.

• Domains– Financial– Housing– Medical– Social– Family

• Organize in a hierarchy

• Start with easiest problem

Problem DefinitionA problem well‐stated is a problem half solved. – Kettering

• Concrete and specific terms

• Assumptions versus facts

• Details

• Breaking down problems

Realistic Goal SettingGoals are dreams we convert to plans and take action to fulfill. – Zig Ziglar

• Specific• Attainable• Realistic• Measureable

BrainstormingDon’t put all your eggs in one basket – anon.

• All ideas that come to mind

• Withhold judgment• Be detailed• Generate five

Decision Making

• Weighing the pros and cons

• Does it meet immediate goal?

• Does it meet long term goal?

• Does it create other problems?

• Is it feasible?

Again and again, the impossible problem is solved when we see that the problem is only a tough decision waiting to be made. – Robert H. Schuller

Selecting the SolutionYou are the sum total of all your choices up to now. – Dr. Wayne Dyer

• One with the most pros and least cons

• Most feasible

• Less amount of effort

Solution Implementation

• Steps to implementation

• Specify when will do (earlier the better)

• Delegate

• When to check in

• Do you need other people to help?

Even if you are on the right track, you’ll get run over if you just sit there. – Will Rogers

Solution EvaluationWhen you lose, do not lose the lesson. – The 14th Dalai Lama

• Did it work?– If so, why?

• Would you do anything differently?

• Will you use this solution again?

• If not why?– What did you learn?

• Does the problem need to be redefined?

Rewards and ActivitiesOne joy scatters a hundred griefs. – Chinese proverb

• Make sure includes pleasant activities

• Include a reward for hard work

• Reinforce patient efforts at change

Brief Psychotherapy Skills• Evidence based psychotherapies can be adapted to primary

care• Brief psychotherapy requires specific skills

• Takes time and Practice• Systematic feedback on performance / skill coaching

• Strategies to improve skills:• Need basic training in specific skills• Network with other clinicians with experience for skills coaching• Bring in expert trainer to strengthen practice• Pay attention to patients when you are effective you will see

results; if patients are not improving, revisit skills used and need for additional training

Where to get more information

• Behavioral Activation– http://uwaims.org/webinars/slides/AIMS_MHIP_Behavioral_Activatio

n.Slides_040510.pdf

• IMPACT‐PST– http://uwaims.org/tools/clinicalskills.html#pst

• Pat Areán’s PST Training website– http://pstnetwork.ucsf.edu/

Acknowledgements

Behavioral Activation•Kari A. Stephens, PhD•Christopher Martell, PhD

Problem Solving Therapy• Pat Arean, PhD

New York State Brief Behavioral Inteventions Aug...

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