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Treatment with

Brief InterventionsPresenter - Gina Pate-Terry, LSCW, LAC,

gpate-terry@mtpca.org

June 26, 2018

Treatment Referral

Now What?

American Society of

Addiction Medicine (ASAM)

An addiction medicine professional society representing over 5,000 physicians, clinicians and associated professionals with a focus on addiction and its treatment. ASAM is dedicated to increasing access and improving the quality of addiction treatment, educating physicians and the public, supporting research and prevention, and promoting the appropriate role of physicians in the care of patients with addiction.

Northwest Addiction Medicine Chapter

Why do we treat them?

Why Behavioral Health in

Primary Care?

Primary care settings have become the gateway to

the behavioral health system.

Why Integrated Treatment?

Because Referrals

Don’t Work Well.

Referrals are often

sporadic and poorly

coordinated

Scarcity of mental

health consultants

Patients simply “fell

through the

cracks.”

The window of

opportunity is gone

Why in Primary Care?

Ground Zero

Where most people with substance use

issues present

Nine times greater risk of congestive

heart failure

12 times greater risk of liver cirrhosis

12 times greater risk of developing

pneumonia

Complicates the management of other

chronic illnesses

They Seek Their Primary Care

From Us

• Adults with serious mental illnesses

and substance use disorders also have

higher rates of chronic physical

illnesses and die earlier than the

general population. (Untreated or

undertreated mental illnesses have

serious consequences. People with

severe mental illness often die 13-30

years earlier than the general

population from medical conditions that

could have been treated by a primary

care provider) (NIH)

They Are Us

Population of US is over 300 million

Around 50% will experience a diagnosable

disorder at some time in life (Kessler,

Demlet, et al., 2005)

Only 20% will receive care from specialty

MH or substance use clinic

21% will be treated in PC

59% will receive no care

Most people with problems seek no care;

few will ever see a therapist’s couch

Treatment Works in Primary Care

Greater improvement in anxiety, depression,

and quality of care (Bradford, et al., 2011;

Roy-Byrne, et al., 2010; Lang, 2003)

Reduction of panic attacks in COPD patients

(Livermore, Sharpe, & McKenzie, 2010)

Improving treatment access for patients with

PTSD (Possemato, 2011)

Reduction in symptoms of insomnia (Buysse,

et al., 2011)

Improving treatment adherence for patients

with comorbid diabetes and depression

(Lamers, Jonkers, Bosma, Knottnerus, & Van Eijk, 2011; Osborn, et al., 2010)©

Lives are Saved in Primary

Care?

Increased self-management skills (Battersby, et al., 2010; Damush et al., 2008; Kroenke et al., 2009)

Improved quality of life for patients with chronic cardiopulmonary conditions (Cully, et al., 2010).

Reduction of substance abuse (Whitlock, et al., 2004)

Earlier of identification and intervention for pediatric behavior problems (Berkovits, O’Brien, Carter, & Eyberg, 2010; Laukkanenet al., 2010)

Reduction of somatization (Escobar, et al., 2007; Kroenke & Swindle, 2000)

Our Challenges

Challenges

Well-supported evidence shows that:

The current SUD workforce does not have

the capacity to meet the existing need for

integrated health care

The general health care workforce is

undertrained to deal with SUD related

problems.

Stigma

Work Force/Education

A national survey conducted by the National Center on Addiction and Substance Abuse at Columbia University of 648 primary care physicians and of 510 adults receiving treatment for substance use in 10 treatment programs highlighted some troubling findings. More than 50% of patients reported that their primary care physician did not address their substance abuse. More than 40% of patients stated that their physician missed the diagnosis of a substance use disorder, and only 25% were involved in their decision to seek treatment..

Work Force/Education

Less than 20% of primary care physicians

considered themselves “very prepared to

identify alcohol or drug dependence.” This

contrasts with more than 80% feeling very

comfortable diagnosing hypertension and

diabetes

Why Offer Brief Therapy?

Why Brief Therapy?

Access

One hour to you….

Research

Why?...Research

In a naturalistic study of over 9,000

patients seeking therapy, the modal

number of psychotherapy visits was one

(Brown & Jones, 2004)

Clients seek treatment when

psychological distress is high and stop

coming when distress level drops; for

most this is within 5 visits (Brown &

Jones, 2004)

Why?...Research

Research shows 40-45 percent of

depressed patients have large gains

within the first two to four sessions

(Doane, Feeny, & Zoellner, 2010)

30 to 40 percent drop out of treatment

without consulting their therapist

(Talmon, 1990, Olfson et.al., 2009) *

Features of Effective Brief

Interventions

Clearly defined goals that are related to

specific behavior change

Active and empathetic therapeutic style

Patients values and beliefs are incorporated

into the intervention

Measurable outcomes (utilizes rating systems)

Enhance patient’s self efficacy

Responsibility for change is with the patient

Brief Therapy Models

Motivational Interviewing (MI)

Problem Solving Treatment (PST)

Focused Acceptance Commitment Therapy

(FACT)

Motivational

Interviewing

Strong Research Support

Over 200 Clinical Trials and Over

400 Outcome Studies

ASAMAmerican Society of

Addiction Medicine

“Specific attention is given…to motivational and

engagement strategies, which are used in

preference to confrontational approaches”

Research has shown that

change…

Is a natural process

Can be facilitated or sped up with

relatively brief interventions

Can be significant within a single session

Occurs early on

The Therapist Stance- MI

Must have at least a willingness to

suspend an authoritarian role

Explore client capacity rather than

incapacity

Have a genuine interest in the client’s

experience and perspective

The Principles of Motivational

Interviewing

Express Empathy

Support Self--‐Efficacy

Roll with Resistance

Develop Discrepancy

Directives - MI

OARS

O = Open-Ended

Question

A = Affirm

R = Reflect

S = Summary

DARN-C

D = Desire

A = Ability

R = Reason

N = Need

C = Commitment

Level

MI Utilize Rating Scales

Focused Acceptance and

Commitment Therapy

(FACT)

A New Model of Brief Therapy that is a

Highly Condensed Version of Acceptance

and Commitment Therapy.

Acceptance and Commitment

Therapy

“A core conception of ACT is that

psychological suffering is usually caused

by avoidance and cognitive entanglement

and rigidity that leads to a failure to take

needed behavioral steps that are in

accord with core values.”

FACT…helps the patient…

Focus on unworkable results of avoidance

Accept the presence of distressing,

unwanted

private experiences

Choose a life path based in personal

values

Take actions which propel the them down

that path

First Session is Important.

Perfect the First 2 Minutes

Hi: My name and (discipline)

• My Job: To help you solve problems in living that happen to all of us

• In this visit: Get a snapshot of your life and see what’s working and not working; work together to come up with a plan to make your life better.

• After today: You may implement the plan and find that things change enough; or you might return to learn more.

• Assessment: Today and at every visit, to plan ways to make the most of our time together, to make every session count. (Rating Problem Severity, Confidence and Helpfulness)

Work with your other health care providers

Use rating scales: Problem severity, confidence, helpfulness

Love

Where do you live? With

whom?

How long have you been there?

Are things okay at your home?

Do you have loving

relationships with your family

or friends?

Work

Do you work? Study? If yes,

what is your work?

Do you enjoy it? If no, are you

looking for work?

If no, how do your support

yourself?

Play

What do you do for fun? For

relaxation?

For connecting with people in

your neighborhood or

community?

Health

Do you use tobacco products,

alcohol, illegal drugs?

Do you exercise on a regular

basis for your health?

Do you eat well? Sleep well?

FACT Assessment

FACT- Directives

Validation of emotions; validation of

behaviors

• Understand and acknowledge function of

the

problem

• Connect pain and values

• Create new relationship to symptoms

importance, usefulness

True North Worksheet

What are your values?

What are your current strategies and are

they working?

What skills will you need to make the

journey?

Problem Solving

Therapy (PST)A form of brief psychotherapy where patients

are taught a structured approach to recognizing

problems and finding workable solutions

Problem Solving Therapy in

Primary Care

Research has shown that minor life events

or problems are strongly associated with

psychological symptoms, in particular

depression, possibly even more so than

major life events (Nezu, 1987).

Problems are defined as any situation in

which an immediate and easily

recognizable solution is not apparent

Core Principles - PST

EFFECTIVE PROBLEM- SOLVING RESULTS

IN REDUCED SYMPTOMS

INEFFECTIVE PROBLEM-SOLVING

RESULTS IN INCREASED SYMPTOMS

Research

PST‐PC is a brief treatment, it can be as brief as 4 sessions and as many as 12 sessions.

Research shows that the smallest effective dose of PST‐PC is 4 sessions, offered over an 8‐week period of time.

9 sessions seems to be the PST‐PC sweet spot for most patients.

Each session is 30 minutes in primary care medicine.

PST-PC First Session is

Important

Develop as much trust and engagement as possible within

the first session. If by the end of the first session the

patient is not convinced that you or the model will be

helpful, therapists will find themselves struggling to get

patients to use the model in subsequent sessions and in the

homework assignments.

Careful attention must be paid to the first visit so that the

patient does not leave the session confused or unconvinced

about the efficacy of PST

Present a confident, knowledgeable, and professional image

and maintain appropriate professional boundaries

Explain the basic framework for treatment

Establish that symptoms are related to their diagnosis

Problem Solving Treatment

PST‐PC is divided into three phases:

Introduction/Education, Training, and Prevention phases. The first 1‐2 PST‐PC sessions is spent getting to know the patient, creating a problem list and how their symptoms interfere with daily activities.

Middle sessions are spent encouraging the use of the PST‐PC skills.

The last session or two is spent helping patients develop a relapse prevention plan based on the PSTPC format.

Seven Stages - PST

(1) Selecting and defining the problem

(2) Establishing realistic and achievable

goals

(3) Generating alternative solutions

(4) Implementing decision making

guidelines,

(5) Evaluating and choosing solutions

(6) Implementing the preferred solution

(7) Evaluating the outcome.

Worksheet - PSTReview of progress during previous week:

Rate how Satisfied you feel with your effort (0 – 10) (0 = Not at all; 10 = Super): ___

Mood (0-10): _____

1. Problem:

2. Goal:

3. Options/Solutions: 4. Pros versus Cons (Effort, Time, Money, Emotional Impact,

Involving Others)

a) a) Pros (+) What

makes this a

good choice?

a) Cons

b) b) Pros (+) What

makes this a

good choice?

b) Cons

c) c) Pros (+) What

makes this a

good choice?

c) Cons

d) d) Pros (+) What

makes this a

good choice?

d) Cons

Harm Reduction

Strategies for Cutting Down

Thank You!Contact Information

gpate-terry@mtpca.org

406-491-1418

Resources Strosahl, Robinson & Gustavsson. (2012) Brief Interventions for

Radical Change: Principles & Practice of Focused Acceptance &

Commitment Therapy. New Harbinger Publications, Inc.

Miller &Rollnick. (2002) Motivational Interviewing: Preparing

People for Change. The Guilford Press.

Robinson &Y Reiter. (2016) Behavioral Consultation and Primary

Care: A Guide to Integrating Services. Springer International

Publishing

Burdick, D. (2013). Mindfulness Skills Workbook for Clinicians and

Clients: 111 tools, techniques activities and worksheets. Pesi

Publishing & Media

Burdick, D. (2013). Mindfulness Skills Workbook for Clinicians and

Clients: 111 tools, techniques activities and worksheets. Pesi

Publishing & Media

Bourne, E. (1990). The Anxiety & Phobia Workbook. New Harbinger

Publications, Inc.