Poor treatment adherence is a systemic problem. It impedes treatment outcomes, complicates
treatment planning, and frustrates providers.
I have yet to meet a healthcare provider who entered the field to argue
with their patients, but I have met many passionate providers who are
frustrated with the seemingly apathetic responses of seriously ill
patients. A primary care colleague
recently commented regarding a mutual patient with a history of nonadherence
with his diabetic treatment regimen, "I have told him a thousand times. He just doesn’t care.”
The management of most chronic conditions requires behavior
change. However, patients often
underestimate their ability to modify their lifestyle and positively impact
their health status. Instead, they
expect their visit to the doctor to result in a prescribed treatment or
medication that will cure their condition or at least alleviate their symptoms. Thus, when the prescribed treatment involves
behavior change, resistance is often created.
"I have pain every day and you are telling me to exercise and eat
Prochaska and DiClemente (1984) described a model of
assessing patients’ readiness to change and tailoring interventions to enhance
patients’ willingness and ability to engage in behavior change. As healthcare providers, we are always in the
"action” stage. We assess and diagnosis
conditions and prescribe behavior change interventions to improve health
Viewing ambivalence as a normal part
of the chronic disease process allows us to treat ambivalence as a component of
However, our focus on overall
health may not be patients’ priority and patients are often not in the "action”
stage. Many of us can relate to the
patient with an A1C of 13 who wants the focus of their primary care visit to be
their back pain. It is difficult to
focus this patient on their diabetes in the context of the medical visit, much
less encourage them to leave our office and make meaningful lifestyle changes
to improve their A1C.
Too often these patients become labeled "difficult
patients,” as if something were inherently wrong with the patients. However, viewing ambivalence as a normal part
of the chronic disease process allows us to treat ambivalence as a component of
the disease. We must accept that we
cannot force our patients to change.
Rather, we must help our patients decide to engage in behavior change. Motivational Interviewing, a style of
interacting with patients developed by Miller and Rollnick (1991), addresses
this ambivalence by eliciting motivation to change from the patient through
At Cherokee Health Systems, a FQHC and CMHC with an
integrated care model that blends behavioral health and primary care where I
work as a Behavioral Health Consultant, we’ve learned that we must change our
thinking about changing our patients. We
serve a population of largely indigent patients with multifaceted behavioral
health, primary care, and social needs who present across the continuum of
readiness to change. Thus, we have
instituted brief, basic trainings in Motivational Interviewing for our primary
care providers. They are, in fact, the
gateway to behavior change in an integrated model, either through direct conversation with
patients or by "closing the sale” and facilitating a warm hand-off to a
Behavioral Health Consultant. In
implementing this training, we have learned that brief training can be
effective in equipping providers with the skills to motivate patients’ behavior
change and reducing provider frustration with "difficult patients.”
As we continue to address ambivalence as part of the chronic
disease process and work to motivate behavior change, I am continually reminded
that motivation truly is elicited and developed collaboratively in the context
of the patient-provider relationship. I recently had a patient explain, "I don’t
want to change, I just want to feel better.”
There is perhaps no better foundation on which to begin a guided
conversation about behavior change.
Suzanne Bailey, Psy.D. is a Licensed Clinical
Psychologist and Behavioral Health Consultant at Cherokee Health Systems. She earned her doctorate in Clinical
Psychology at Xavier University in Cincinnati, Ohio. Dr. Bailey practices in an integrated primary
care clinic at Cherokee Health Systems’ Center City office in downtown
Knoxville, TN, which serves a population of primarily indigent, homeless
patients. She is the Director of
Cherokee Health System’s Intensive Outpatient alcohol and drug Program and
Supervisor for Case Management Services.
This Sunday marks my tenth Mother’s Day married to the dynamic Ana
Reitz. Thus, it is also the tenth
anniversary of when I gave her a 9-inch circular saw as a Mother’s Day gift. Now, please save your maternalistic eye rolls
for another blog post. She asked for the
saw and even picked out the model for purchase.
Unfortunately, as men and their tools go, I am a disorganized wuss. My ownings are scant and strewn amongst a
number of broken-down cardboard boxes in the garage. I don’t value them enough to invest in
them. I tend to buy them at garage sales
and in bargain bins because my children break and lose them along with the rest
of their playthings.
As a result, I am often required to make suboptimal usage of the tools
I do have accessible at any one time.
For example, during spring clean-up this year, I was forced to use my
wife’s 9-inch saw to prune trees. As sap
smeared the blade and sawdust sprayed my face, I reflected on the PHQ-9. A syllogism quickly formed in my mind:
If you recently took the GRE, introduced yourself to an integrated care
referral, or pruned a tree, I’m sure this logic is readily apparent to you. To
the skilled craftsman or contractor, the 9-inch saw is of limited use. It is
only helpful for shortening lumber with quick, imprecise cuts. A professional would cry inside to see me use
it for pruning, ripping, demolishing, splitting, or chopping (all of which I
have done with my wife’s saw).
Rather than investing in a table saw, chain saw, miter saw, hack saw,
or ax, I grab the 9.
Such is the PHQ-9 in the integrated care setting. A clinician in a traditional private practice
would maintain a fully-stocked tool box of clinical assessments: Becks, GAD-7s,
Vanderbilts, Edinburghs, MDQs, OQ45s, Family Environment Scales, genograms, and an assortment of positive psychology
screens. Each tool would be closely fit to
a specific condition or patient. The
tools would provide precise diagnosis and symptom management.
Despite the myriad advantages, I rarely use the other assessment tools.
I grab the 9.
The PHQ-9 presents numerous advantages in primary care and teaching
It is unbeatably easy to take and
score—especially when paired with the PHQ-2.
Many EMR systems have
built-in smart forms that calculate the score, interpret the result,
auto-populate the HPI, and track the levels across time like a lab value.
Health systems work most efficiently when the
operations are kept simple. While I’d
love to have nurses giving GAD-7s for patients with anxiety and MDQs for
bipolar, that level of sophistication is a fantasy.
Integrated care charting is mostly a means of
communicating with other members of the primary care team. I prefer to use tools that are familiar to my
Our clinic’s experience with the Edinburgh Postnatal Depression Scale
and the "PHQ-12” provide compelling reasons for the PHQ-9 hegemony in primary
care. The Edinburgh is an excellent
depression screen that is more reliable in the pre- and post-partum periods
because it teases out the symptom overlap between pregnancy and
depression. Before going live on our EMR
it was our clinical standard to administer the Edinburgh to OB patients. However, our EMR isn’t hard-wired to easily
track and communicate the Edinburgh, so we reverted to using the PHQ-9 instead.
Regarding the "PHQ-12”, I invented it about 10 years ago while at Marillac Clinic. We were 1 of the first clinics to
widely adopt the PHQ-9. Back in the day
I noticed that the PHQ-9 and the GAD-7 had an overlap of 4 items and that by
adding the extra 3 GAD-7 items to the PHQ-9 we could create a brief screen that
gave scores for both depression and anxiety.
Many other clinics have adopted it and loved it. I loved it, too, until
we adopted the EMR. Because of the way
we needed to move the items around on the PHQ-9 to have them line up with
GAD-7, it made it much more difficult to enter the scores into the EMR’s PHQ-9
form. So, we reverted to the traditional
Who knows, maybe in a few years (after we haven’t adopted a new EMR 2
times within 1 residency cycle) I’ll up the bar and re-institute the Edinburgh and
PHQ-12 as first steps in reversing the
trend of trading precision for convenience. But, for this Mother’s Day, I’m giving all my
depressed (and anxious, grieving, and relationally conflicted) patients the
PHQ-9-Inch Circular Saw.
Shhh…don’t tell Ana, but I’ve wrapped up a miter saw for Sunday.
Reitz , PhD, LMFT is the Director of Social Media of CFHA and the Director of Behavioral
Science at St Mary’s
Family Medicine Residency in Grand Junction, CO. He and Ana Reitz have
3 children: Gabriela, Paolo, and Sofia. He posts his ideas at CFHA's Collaboblog and tweets at @reitzrandall.
Posted By Margaret Peterson,
Thursday, May 3, 2012
A month or two ago I was accompanied into a consult by a young woman who was training for a new job as a behavioral health consultant at a clinic elsewhere in the city of Philadelphia. The consult was an integrated care visit, which meant that we entered the exam room knowing nothing but the patient’s name and date of birth, and with the agenda being to explore behavioral and psychological factors that might be affecting the patient’s health: diet, exercise, substance use, depression, anxiety, trauma.
The patient was a middle-aged man who turned out to be a rather colorful character—flamboyantly gay, with a long history of polysubstance abuse and a range of other health issues including infection with HIV. He and I were quickly absorbed in conversation about his concerns and his goals for his health, some of which were more conventional (adherence to his medication routine) and some of which were less so (getting back in touch with a "hormone doctor” who had been helpful to him in the past).
the provider arrived and the consult was over. I left the room with the
woman who had been observing me, whose presence I had more or less
forgotten about in my focus on the patient. "Well, that was
interesting,” I remarked. "It certainly was,” she agreed, fervently.
Something in her tone of voice made me realize: she had been a little
startled by this patient. Her reaction shed a sudden light upon my own: I
had responded to this patient as if he were an old friend.
Every patient needs
and deserves welcome and safety, even—perhaps especially—the ones for
whom empathy might not come automatically.
Where did this come from? It came, I realized, from my experiences at the Duke University Infectious Diseases Clinic in the early 1990s. My late husband was a patient there, and practically every other patient was a flamboyantly gay man. This was back in the day when there wasn’t much of a welcome mat anywhere for people who were gay or HIV-positive, and one of the things that distinguished the Duke ID clinic was the absolutely unconditional welcome extended to people who were either or both of these.
I was extraordinarily grateful for the care that my husband and I received at the ID clinic. At the same time, it was unnerving to find myself surrounded by the clinic’s other patients, many of whom were (like my recent patient) very colorful characters with complex psychosocial histories, and (superficially, at least) not at all like me. "What on earth am I doing here?” I would think. "How is it that I belong here, in this place, with these people?” It felt like I was normal and they weren’t, and I wanted out.
What I grasped only dimly at the time was that I was no more or less unique an individual than anyone else at the clinic, and the same unconditional welcome that was extended to everyone else was extended to me. There was no comment and no criticism; only curiosity and empathy and a desire to be of help. And it changed me; and one specific way it changed me was to create in me a deep sense of kinship with individuals who (like my recent patient) remind me of the clinic and its patients.
In a broader sense, I find that experience at the Duke ID clinic informing every aspect of my new work in behavioral health. Behavioral health is all about welcoming; it is about creating a safe space in which the patient feels confident that he or she is cared for, and thus feels free to explore issues that may feel overwhelming or scary, whether those have to do with symptoms ("I’m in pain all the time”) or risk factors ("I know I need to quit smoking”) or relationships ("I’ve had so many losses in my family recently”).
Sometimes creating this safe space seems to happen very easily. The other day I entered an exam room to find a woman in her 30s who a few weeks earlier had come in complaining of severe situational stress and anxiety. The doctor had prescribed an anxiolytic and invited her to come back for a followup visit in a month. She hadn’t taken much of the medication, she reported, but she was feeling much better. "That sounds like a big change,” I said. "How has that happened?”
She wasn’t sure. Externally, things were much the same: the job, the kids, the busyness of life. "But I’m not stressing about everything,” she said. "I just let it go. And I go out with a girlfriend from work, and we go shopping.” "It sounds like the beginning of the change might have been your decision to come to the doctor,” I said. "And then the doctor responded supportively, and that was enough to help you make some different decisions about how to handle your stress.”
"Yes,” the patient said, thoughtfully. "I guess that’s exactly what happened.” As if on cue, the provider entered; I summarized our conversation and left the room. It had been a straightforward and enjoyable consult: the patient was resilient and had already reached out for and received some of what she needed and had made good use of it, she had been ready to relax into the opportunity to explore the sources of her increased well-being, and the connection between provider and patient had been enhanced.
Other times it’s not so easy. Later that same day I saw another patient, a man in his mid-twenties, at the doctor for a routine checkup. He was handsome, personable, and in apparently perfect health. He was also unemployed and uneducated beyond high school. Mostly, he just watched TV and went to the gym. "What would you identify as your primary goal for your life or health?” I asked. "Oh,” he said, "I want to have kids and grandkids, with some kind of check coming in—disability, whatever.”
"What???” I thought (but did not say). "You are smart and strong and 25 years old, and you actively aspire to be on disability? What is wrong with you?” In that moment, I was not feeling empathetic, or welcoming, either. Somehow I managed to stay with him. He wasn’t proud of his lack of ambition or accomplishment, he said; in fact, he was troubled by it. He hadn’t done anything bad with his life, but he hadn’t done anything good, either; years were going by, and he had nothing to show for them.
"If you did have an interest in something, what would it be?” I asked. His eyes lit up. "I love trains!” he said. "Not subway trains. Real trains, big ones.” And then he returned to the subject of his inertia in life. "I need a drill sergeant,” he said, fretfully. "Someone who will tell me what to do and make me do it. My mom made me work in high school, but since then I haven’t had anyone to make me do anything. I think things would be different if I had a drill sergeant.” He paused for a moment. "Or maybe if I had a father.”
All of a sudden I saw before me, not a 25-year-old man, but a six-year-old boy, a boy who loved trains, and who had no father to show him how to be a man. No wonder he had been unable to grow into adult achievements and responsibilities. No wonder he longed to be himself a father and a grandfather, yet had no idea how to integrate those roles with other aspects of an adult identity. What might help him develop into a fuller sense of himself and a greater ability to reach more of his potential?
"Have you ever had any outpatient psychotherapy?” I asked. "Do you know what psychotherapy is?” He hadn’t, and he didn’t. I offered a few words of explanation: "Children need certain things from their parents when they’re growing up, and if they don’t get those things, it can be very difficult for them to move into satisfying adult lives. Psychotherapists work with people who didn’t get what they needed when they were children, and help those individuals grow up and into more of what they want as adults. There are outpatient clinics where psychotherapy is available, and if you were ever interested in this, we would be happy to refer you.”
Before I was half done with this speech, the provider entered the room. She waited while I finished, and then I rose and took my leave. Of course I hope that this patient got some small piece of what he needed in our conversation, and that perhaps some day he will get more of what he needs in the context of some other relationship, perhaps even in therapy. What I got from our conversation, though, was a reminder: every patient needs and deserves welcome and safety, even—perhaps especially—the ones for whom empathy might not come automatically.
Peterson, PhD, is a student in the master’s program in Marriage and Family
Therapy at La Salle University in Philadelphia. She is doing an internship in
integrated behavioral health at Fairmount Primary Care Center, under the
supervision of Suzanne Daub, LCSW, Director of Behavioral Health for Delaware
Valley Community Health.
Posted By Randall Reitz and Neil Korsen,
Thursday, April 26, 2012
Narrative Means to Disastrous Ends
Randall Reitz, PhD, Family Therapist
St Mary's Family Medicine Residency
As a relative neophyte in family medicine education, I look back weeks, rather than years, to re-experience my foibles. A recent experience with my physician faculty colleagues is still poignant. My residency program director has tasked me with building a culture of introspection and feedback sharing among the faculty. Additionally, I have been introducing the physician faculty to the same therapy models that I teach residents. This led to a faculty development session during which I presented the basic concepts of narrative therapy to my colleagues.
It was a complete disaster.
To demonstrate strength-based and problem-based narratives, I shared a perceived strength and weakness from my own residency teaching. I then requested that the others do the same in a small group discussion. My colleagues struggled to grasp the concepts, were uncomfortable with the requested disclosure about their teaching, and disliked sharing the problem-based narrative second (asserting that it negated the strength-based narrative). There was not an elegant way to close the discussion and the following day a dear colleague described it using an f-word combination that I was not previously aware existed.
Here are my take home lessons from the experience:
Behavioral science faculty are trained in environments rich in collegial feedback and self-disclosure. Because the same is not always true in medical training—tread very lightly.
Clearly distinguish between education and therapy, and always choose the former over the latter in collegial settings.
When introducing new curricular elements, test-drive it with a smaller group first.
Don’t give up: seek to understand what didn’t work, apologize for unintended consequences, and then recalibrate.
On a much brighter note, last weekend was our annual residency retreat. While mountain biking in Moab (a perk of living where we do) one of the residents joked that he didn’t want to hear any medical talk or offer any medical treatments during their time-off: "If you break your arm, the only person who is going to help you is Randall”. And then a chorus of jokes gave me soothing reassurance regarding the positive impact I have had:
Resident A: "Think about a time when your broken arm wasn’t present, how was that day different?”
Resident B: "Suppose that I see you 6 months from now and your arm has healed itself, what will have happened to make that possible?”
Faculty Member C: "On a scale of 1 to 10 how much does that arm hurt? What change could make it 1 point better?”
Resident D: "Let’s suppose that when you wake up in camp tomorrow you discover that a miracle has happened and the broken arm doesn’t bother you anymore…”
Their solution-focused sarcasm was healing to my heart.
I'm a Doctor, Not a Business Expert
Neil Korsen, MD, Family Physician
Maine Medical Center
MaineHealth has had a Mental Health Integration program since 2006 and has done pilot work with several dozen practices. We have learned our share of lessons over the years by making mistakes and figuring out what doesn’t work.
One early mistake we made has to do with how we start a behavioral health clinician working in a practice. Our initial thinking was that starting with a small amount of time (1/2 day per week) minimized the financial risk and therefore should lead to the service working financially. We could then gradually grow the service as the clinician got busier.
The problem with this approach is that, if a clinician is not in the practice very often, it is hard for them to become part of the team. It is also hard for primary care providers and staff to remember when the clinician is in the practice, so they are less likely to think about referring a patient for integrated services. Given that many primary care providers work less than full time, it is possible that some will never even cross paths with the integrated clinician, making it even less likely that they will refer patients. We now believe that there is a minimum of about 16-20 hours per week needed for the integrated clinician to become a member of the team and for the primary care team to develop the new habits necessary for them to make good use of the clinician and to develop and build the integrated service.
Posted By Jennifer Hodgson and Norm Rasmussen,
Thursday, April 19, 2012
Jennifer Hodgson, PhD, Family Therapist
East Carolina University
I was setting up an integrated care clinic in a family medicine
residency setting in Florida. It took a while to earn the trust of the
residents and faculty but even harder were the nurses. They were the
gatekeepers...protectors of the providers and patients.
My students struggled
getting exam room time to see patients. The providers wanted us to see
their patients but the patients were processed so quickly. Then one day
it hit me like a brick. We were hanging out in the precepting
room joining with the providers but completely
neglected joining with the nurses.
One day, a nurse was upset about
something personal. We asked her if she way okay. She shared her
struggle and we sat with her in her pain. The next week we had received a
referral to see a patient. We were so excited. When
the behavior health provider exited the room he saw a note stuck to the
door, "Do not disturb. Therapy in Progress."The referrals started
pouring in from that point forward. We were schooled. In our haste to
join with the "physicians" we neglected the critical
role of the nurses.
I cannot imagine integrated care now without them;
except for now we prefer the note, "Therapy in progress. Please
Norm Rasmussen, EdD, Psychologist
Recently I modified my integrated behavioral healthcare
(IBH) approach for service delivery and teaching residents in my position as a
Behavioral Healthcare Provider (BHP) in the family medicine department at Mayo
Clinic. For 25 years, I used the co-located model of collaborative healthcare.
My office was in the family medicine clinic, the collaboration was called the
Psychology Preceptorship, and my office space was in general referred to
affectionately as the "annex.” I was linked to and accepted by the family
medicine staff and residents because they value collaborative care.
The recent change that I devised has been re-named as the
Main Street Model of IBH. There are two important methodological differences
between the prior approach and the new Main Street model. First, I now am physically in the office
space where the resident physicians are located and I sit at the table where
the medical preceptors reside – thus, I have migrated from the annex to main
street! Second, I now have the potential to provide a significantly increased
number of same day or virtually immediate IBH services such as curbstone
consultation, resident physician-psychologist co-visits in the patient exam
room, and "warm handoffs” from staff and resident physicians.
The first two weeks in implanting the Main Street model, I assumed the role of
sitting at the medical preceptor table but remaining quiet and waiting for an
invitation to be involved. Big mistake! I had assumed the resident physicians
and medical preceptors would know how to involve me in this new model – all
they had to do was ask! Indeed I was
"invited” one or two times per a four hour block. This was not working as I had
envisioned. Thus, I decided to move my
chair into close physical proximity of the resident physician-medical preceptor
discussion to form a triad. Immediately
the requests tripled for either a curbstone consultation, warm handoff, or
invitation to accompany the resident physician back to the exam room to either
do a brief and focused IBH intervention for the resident to observe or to
observe and train the resident doing an intervention that they were learning in
the didactic work that I was doing with them. The message was clear: BHP
proximity and visibility were critical but insufficient. In this new model, I needed to "move in
closer” and reconfirm my role as the BHP on the healthcare team. Don’t expect
family physicians to find you – rather find them and show your interest and
enthusiasm in being a member of the collaborative healthcare team. As we all know, one can never be too experienced,
not just early in one’s career, to make a mistake involving foresight or
Posted By JoEllen Patterson and David Clarke,
Thursday, April 12, 2012
JoEllen Patterson PhD, Family Therapist
University of San Diego
Several years ago, I was working with an elderly cancer
patient and her husband. They had been
referred to me by a wonderful physician in my collaborative care setting. The
wife had received grueling chemotherapy and radiation. Her prognosis was bleak.
I knew the physician
to be conscientious, kind, and exceptionally thorough. The physician eventually told the couple that
there were no further treatments available to treat the patient’s cancer. The couple was furious at the doctor "for
giving up” and spent their next therapy session criticizing the physician’s
heartless care. They hoped that I "would be more caring than the physician.” I
was unsure how to respond. Eventually, they
implied that "we” had failed them. They
did not schedule another session with me.
I wrote a brief note in the chart but failed to discuss the
session with the physician. I also realized later that I had not known how to
respond quickly to being triangulated into the conflict between the physician
and the couple. The physician eventually
learned that the couple sought alternative treatments in Mexico, and the women
died a painful death in a Tijuana clinic.
When I eventually told the physician about the session, he said he had
no idea that they were so angry with him.
Why hadn’t I told him?
I thought about this case for a long time and what I might
have done differently. Here are some of
I wish I had viewed the doctor-couple
relationship as my patient, at least briefly.
I would have encouraged the couple to talk to the physician about their
feelings of abandonment instead of simply ruminating about his "indifference”.
I could have even offered to facilitate the discussion.
I was sometimes too concerned about interrupting
the overwhelmed physicians to talk about an individual patient. So, I would write a note in the chart instead
of taking their time. In some cases, I
should have "interrupted” the busy physician to talk about a specific patient
situation. This was one of those times.
I wish I had found more ways to gradually give
the couple "hope” even when the clinic could not offer them a cure. I think I was too focused on the medical
prognosis to move the conversation to an emotional/spiritual prognosis.
David Clarke MD, Gastroenterologist
Oregon Health and Science University
I met Catherine thirty years ago during my Gastroenterology Fellowship
at Harbor/UCLA. We spent only an hour together, but the encounter completely
changed my career. In her mid-thirties
she developed severe constipation, largely unchanged even with simultaneous
administration of four different laxatives at double the usual doses. Diagnostic evaluation over two years by her
family doctor and two universities was unrevealing.
When I asked if she had been under a lot of stress recently, as other
doctors had asked her, Catherine shrugged and replied, "Just the stress from
My next question was: "Were you under any stress earlier?” I was
wondering if she had experienced a specific stress when her illness began two
years before. She interpreted the question to mean the more remote past.
"Yes,” she replied calmly and
with little hesitation. "My father molested me.”
This was the first time anyone had made this revelation to me and I had
no idea how to respond. Without any childhood stress of my own to recall, or
any medical training about how to relate this information to her illness, I was
at a loss for words.
She went on to say her earliest memory of her father molesting her was
at age four. The molestation continued regularly for the next eight years. When
she began menstruating, he stopped. There were no other incidents of abuse or
personal trauma in her life.
I was aware of a psychiatrist on our faculty, Harriet Kaplan, MD, who
was also an internist with expertise in mind-body medicine and requested a
consultation. Four months later, I ran
into Dr. Kaplan in an elevator and asked how Catherine was doing. "Well, I
haven’t seen her in over a month, Dave,” she replied. "Her bowels are working
just fine now.” She had even stopped taking the medicines I had recommended.
I was shocked at the concept of
alleviating a serious physical condition solely by a few months of counseling.
Over the next few years, I learned everything I could from Dr. Kaplan and
during 25 years of practice treated over 7000 such patients myself.
Dr. Clarke invites you to find out more about psychophysiologic disorders and an upcoming conference at www.ppdassociation.org and www.stressillness.com.
Posted By Susan McDaniel and Andrew Pomerantz,
Thursday, April 5, 2012
Susan McDaniel PhD, Family Psychologist
University of Rochester
One of my first medical referrals was from an obstetrician on faculty in Family Medicine . He requested a "psychological evaluation" of a thirty-nine-year old single female patient who presented for donor insemination to have her first child. The obstetrician said he always asked any single OB patients to see a therapist, both for his own protection and for the patient and her family to have the opportunity to discuss the request and its likely consequences.
I thought this a fairly simple, straightforward request and scheduled a session with the patient, her mother, and her sister to discuss the procedure. I asked to see the patient only for the first half of the session. It quickly became clear that she was quite ambivalent about the procedure and more interested in proving to her family that she was an "adult” than she was in actually raising a child. In the second half of the session, the woman told her mother and sister that she did not want to proceed with the insemination and the family ended by agreeing to open more communication and contact among themselves. It seemed a good use of 50 minutes. However, when I reported this outcome back to the referring physician, he became angry, saying I "talked this woman out of her last chance to have a baby."
Like a bolt from the blue, I realized that I had not explored this physician's view of the problem when he made the referral. It was several years before I saw another patient of his. One of those lessons I had to learn again: to spend time early soliciting the physician's view and discussing the possible outcomes of a consultation.
Andrew Pomerantz MD, Psychiatrist
Veterans Health Administration
second attempt at integrated care took place at the White River
Junction VA medical center in Vermont in 1989 (the first was in 1974
when I was still a Primary Care physician in the community). A
psychologist and I opened an office in the primary care clinic and told
everyone we were there to bring mental health care to primary care so we
could reduce stigma. For a month or so, we sat there one afternoon
every week reading journals (and probably some magazines as well).
Finally a patient with PTSD and alcohol dependence was deposited on our
doorstep. We double-teamed him weekly for a month, after which time he
asked us why he couldn’t just go see us in the mental health clinic
where it was quieter. We said it was because we were trying out a new
way to provide care. A month later he moved to Montana. By that time
primary care needed the space back and we folded our tent and moved back
upstairs. I did hear from him a few years later when he returned to
Vermont with end stage lung cancer. We had a few visits – in the mental
often said that a plan without action is a daydream and an action
without a plan is a nightmare. In this case, all I knew what that I
wanted to provide mental health services in primary care, so I put out
my shingle and waited for them to come. I had no plan, just a dream
that ran afoul of the details. Though it did not turn out to be a
nightmare, it taught lesson one: Integrated care is not just about
co-location. It is a different paradigm. It also requires education of
the customers (in the commercial world, that’s called marketing). In
this case the main customers were the primary care staff.
Over the next
15 years, I tried many different approaches, each building on the
experiences of the previous one. Finally, a concerted planning effort
that involved primary care leadership and all of our mental health
clinicians fulfilled the dream and the program unveiled in 2004 soon
became the gold standard for co-located collaborative care in the
Veterans Health Administration and, more recently, a core component of
the Patient Aligned Care Team, the VA version of the Patient Centered
Posted By Randall Reitz and Leslie Lieberman,
Thursday, March 29, 2012
ACE in the Hole
or Futile Fact?
At this point in my education I am not easily awed, much less shocked. Discovering the Adverse Childhood Experience research was a shock and awe campaign to my clinical sensibilities.
For the uninitiated, the ACE study was n=17,000 research sponsored by the CDC. It looks at the effects of childhood trauma on adult health and behavior. Each research participant completed a 10-item childhood trauma screen. They also provided a thorough health and behavior history. The participants were stratified by trauma history ("ACE Score”) to assess whether it was predictive of health outcomes. Their data proved statistically significant to a degree rarely seen in the human sciences.
In each of the graphs below the numbers on the X-axis are ACE Scores (i.e. how many of the 10 traumas the person endured as a child) and the Y-axis is the percentage of participants with a particular health outcome as an adult. I apologize for the low quality of the graphs.
Negative early childhood experiences, especially those involving family members and other caregivers, have a profoundly detrimental effect on adult health.
People with low ACE scores are amazingly free of these problems.
No, that's a poor word choice. It is not fine, it's horrible.
Let's try that again, inspired from a song my kids love, but I hate: "whatever, it doesn't matter, oh well”.
No, that's not right either. It does matter. It matters deeply. BUT, as it relates to my adult patients who are already demonstrating the health sequelae of childhood traumas, I haven't been able to identify anything I can do with these data.
Knowing the fact that horrible parenting or a chaotic childhood placed the patient on a nearly inexorable path toward health destruction is diagnostic, but not therapeutic.
How do I intervene?
How do I make it better?
How do I advise my medical and nursing colleagues?
I have attempted 3 (inadequate) responses so that at least I feel like I'm not being callous:
1. Normalize their Experience: I can say: "I'm sorry, you've been through horrible experiences in your life, and unfortunately, science and my own clinical practice has shown us that these experiences help to explain many of your health problems”. This might assist the patient in piecing together a different health narrative, and the empathy that it implies might fortify our therapeutic relationship. But, I've never seen it go very far.
2. Protect the Innocent: I haven't had occasion to do so, but I've often imagined that a reasonable MedFT intervention would be to go through the ACE research with an abusive parent. These data might be the missing piece to dissuading him from passing along this horrible family legacy to his children. After all, this is exactly what we do with pre-contemplative smokers (i.e. "Were you aware that 2nd-hand smoke can cause more frequent illness, asthma episodes, and perhaps even lung cancer in your children?"). So, yes, this might help the next generation, but it doesn't turn back the clock for the abusive parent in the room who is already addled with her own health problems from her parents' abuse.
3. Educate the Clinicians: Patients who were traumatized as children are some of the least rewarding for healthcare providers. They come to the room with intractable health problems and behavior which looks like an Axis 2 diagnosis. These are the patients who quickly get labeled and often get fired from a practice. Perhaps having the patient complete an ACE screen will assist the clinician in having more compassion and in passing less judgment to the patient. If so, that would be wonderful.
OK, there might be some clinical advantage to screening for childhood traumas. However, I remain unconvinced that it is a clinically relevant tool. The ACE score should NOT be the 6th vital sign (or the 7th or 8th, or however many there are now that we therapists keep adding our soft scales to the hard science of checking patients-in). Perhaps I will continue to bust out an ACE 1-2 times per year, but it's not about to join the PHQ9, GAD7, and Vanderbilt in the pantheon of primary care screens.
Embracing the ACES and Trauma Informed Care: The Time is Now
Randall, I am very pleased that you raise awareness of the importance of the
Adverse Childhood Experiences (ACES) research. However, I beg to differ
with your conclusion that there is no place for translating the significance of
the ACES findings into the design and provision of collaborative healthcare
To recap, the ACE study surveyed more than 17,000 mid-life adults about 10
categories of adverse childhood experiences (all forms of abuse, witnessing
violence, parental absence, incarceration, mental illness and substance abuse)
then linked their responses and health histories. Key findings included: 1) a high prevalence
of ACES – only 1/3 of those surveyed reported NO ACES - and 16%
reported 4 or more ACES; 2) a very strong correlation between ACES and numerous
health and behavioral health diagnoses, as well as high risk behaviors
associated with poor health outcomes; and 3) a cumulative effect, four or more
ACES translated into significantly higher rates of morbidity and mortality.
Results of the ACE study were first published
in 1998 and there have been numerous replications since then. Additionally over the last 20 years there has
been a plethora of neuro-scientific studies demonstrating the negative impact
of toxic stress, trauma and adversity on health and development. In spite of this, few health and human
services organizations, CFHA among them, actively advocate to integrate this
research into practice. Trauma informed care (TIC) is an approach which both
acknowledges the importance of the ACES and provides a framework for how
organizations and systems must change in light of this knowledge. Fourteen
years is long enough - it is imperative that all health and human services
systems, including collaborative care models, become trauma informed now.
The concept of trauma informed care, first introduced by Fallot and
Harris in 2001, requires that all services designed to assist vulnerable
populations (health, behavioral health, education, housing, welfare etc…)
acknowledge the prevalence of and pervasive impact that violence and
victimization play in the lives of many consumers and recognize the presence of
behaviors and symptoms associated with trauma. This understanding must
then drive the design of services to validate trauma survivors, promote their resiliency
and recovery, and reduce and eliminate policies and practices that may be
traumatizing or re-traumatizing.
To promote trauma informed care, a number of individuals and organizations
have defined core principles and developed models of TIC (Sandra Bloom, Sanctuary Model,Community Connections, The National Child Traumatic Stress Network to
name a few) All have at their core safety first and safety for all (consumers,
family members, employees). Additionally
most advocate the importance of establishing cultures where collaboration,
democracy, consumer choice and control, and establishing positive relationships
CFHA is in an excellent position to be a strong advocate for trauma informed
care. The core principles of TIC are embedded in the organization's self
description which states: collaboration isn’t just a word in our name;
it defines who we are, how we interact with each other and other organizations.
We believe deeply that collaboration is an essential element necessary for
re-visioning healthcare, specifically, and society, generally. And echoed
in its mission to
promote comprehensive, cost-effective integrated health care and achieves this
mission through education,training,partnering,
consultation,research and advocacy.
Randall your "shock and awe" in response to learning about the ACE
research is noteworthy, yet your follow-up statement that you don’t know how to
use the information is dismaying.You suggest that perhaps the ACES can be
used to: 1) to normalize the trauma experience,
2) protect the innocent (prevent the transmission of trauma to the next
generation), and 3) educate providers.
These ideas are a good start toward becoming trauma informed, but much more
needs to happen and CFHA can take a leadership role in ensuring that it does.
With CFHA's urging, ALL collaborative care
providers and organizations can be sensitized to the prevalence and impact of
violence and trauma, not only in consumers/patients but among providers/staff;
they can learn to address secondary traumatic stress (the impact of exposure to
traumatic material from consumers/patients); they can provide
psycho-educational materials about trauma and toxic stress; they can integrate
routine screening for trauma exposure and trauma symptoms; they can identify, refer to, and integrate evidence based trauma-focused treatment; they can closely
and deeply examine and change their policies, protocols, standards and
practices to ensure that they do not re-traumatize, and they can involve trauma
survivors in the process of transforming services. Above all, each CFHA member can use his or
her sphere of influence to be a champion for trauma informed care. Together we can shift the fundamental
question that still permeates far too much of the health/behavioral health care
services system from: What's
wrong with you?" to "What has happened to you?" – the ACE study data
make it clear why we must do this now.
Posted By James B. Anderson and Jodi Polaha,
Thursday, March 22, 2012
James B. Anderson
1:the imaginative projection of a subjective state into an object so that the object appears to be infused with it.
2:the action of understanding, being aware of, being sensitive to, and vicariously experiencing the feelings, thoughts, and experience of another of either the past or present without having the feelings, thoughts, and experience fully communicated in an objectively explicit manner;also: the capacity for this.
The importance of the relationship between therapist and client has long been recognized as a key to successful intervention. In his landmark work in developing his style of psychotherapy, Carl Rogers advocated a humanistic, client-centered approach to therapy. Central to Rogers' approach was the creation of the relationship between therapist and client. According to Rogers (1946):
If the counselor can create a relationship permeated by warmth, understanding, safety from any type of attack, no matter how trivial, and basic acceptance of the person as he is, then the client will drop his natural defensiveness and use the situation (p. 419).
Since Rogers' work, a strong therapeutic alliance has been reliably demonstrated to be associated with positive therapeutic outcome, regardless of type of therapy. Recognizing the importance of such a relationship, many clinicians have made the assumption that empathy is an essential component of effective therapy. Explicitly or implicitly, it seems that many assume that empathy serves as a mediating variable to achieve the coveted alliance so valuable to positive therapeutic outcome.
A prime example of this assumption can be found within Motivational Interviewing (MI). MI is a contemporary therapeutic approach that has been demonstrated to be efficacious when used to help patients make behavioral changes for a variety of health concerns (smoking, weight loss, diabetes, etc.). While certainly not a magic bullet approach (it's not a "panacea,” as founders William Miller and Stephen Rollnick repeatedly remind us), it is very clearly a very important approach to clinical care that has the potential to make primary care interventions more effective. Listed first amongst principles for an MI approach to talking with patients is the expression of empathy from the therapist towards the patient. While it is clear that therapeutic alliance is important to therapeutic outcome generally, and that expression of empathy may be an important path to such an alliance, I argue that it is the former component ("expression”) that is more vital than the latter ("empathy”).
What is vital to what happens in therapy is a result of what happens in therapy—that is, outcome is related to actions, not a hypothetical construct felt inside of the therapist. Certainly the relationship between the patient and the provider is important, as has been repeatedly demonstrated, but that relationship is an interaction of behaviors that have symbiotic influence on one another. When the construct of therapeutic alliance has been evaluated empirically, a number of variables that influence outcome and treatment retention have been identified, ranging from agreement between patient and clinician about treatment tasks, to level of patient arousal (energy and alertness) to the bond between clinician and patient as characterized by expressions of acceptance and confidence.
While one could argue that it is helpful for a therapist to truly have a subjective sense of what life feels like in his or her patient's shoes in order to exude behaviors typically interpreted by patients (or observers) as representative of clinician empathy, it is not necessary. In fact, a clinician might be able to effectively articulate his or her difficulty understanding a patient's motivations or circumstance to help the patient clarify values, recognize possible dissonance between actions and values, and assert and strengthen autonomy to make decisions even if they are not completely understood by another. The bottom line is that while a good working relationship is important (and perhaps vital) to successful treatment, the way that the therapist feels is not essential to creating such a relationship. It is the interplay of behaviors between individuals involved in this complex interaction is important, and ultimately the way that the patient thinks and feels as a result of the interaction is much more important to therapeutic outcome than the feelings of the therapist.
Does the therapeutic alliance (with or without empathy included) predict positive outcomes in therapy? I called my good friend Trent Codd, III, Cognitive Behavior Therapist Extraordinaire, about the empathy issue. He pointed me to studies by DeRubeis and Feeley (1990) and Feeley, DeRubeis, & Gelfand (1999), examining early and late measurement of process variables, including factors specific to CBT as well as therapeutic alliance/facilitative conditions. The findings of these studies showed that "common factors” including alliance did not affect depression early in treatment (CBT factors did), but were, instead, the consequence of change. Since these common factors were traditionally evaluated at a point when a great deal of symptom change had already occurred they could not be considered causal. These results suggest the field needs to go back and redesign its studies, taking temporal factors into account. In the process, researchers could examine the definition of "alliance,” better operationalize "empathy,” and try to unbundle these to identify which elements have greatest impact (or, the MINC, Minimum Intervention Needed for Change) just like we are doing with multi-component evidence based interventions.
Is empathy relevant? It is an empirical question, which is the easy "out” for any academic with a full in-box. Therapists' assumption that empathy is effective or necessary might be driven by a history of real-world observations; the stuff upon which relevant science is based.
Still, when placing this question in the context of a field working to implement and disseminate our science in new and changing paradigms driven by a new group of consumers, I'm having a hard time empathizing with the issue as a whole. What is the place of empathy or even therapeutic alliance in integrated care? What about in mHealth or eHealth interventions, which are gaining popularity and an evidence base? Treatment in these contexts bears little resemblance to the kind of therapy upon which these concepts of empathy and alliance were originally conceived. Perhaps, for the readers engaged here, it's time to exnovate some of the research targets that made sense in days gone by and consider innovating fresh and relevant targets.
James is a second-year UMass Fellow of Clinical Health Psychology in Primary Care. He received his BA from the University of Wisconsin- Eau Claire, research training from the Neuropsychiatric Institute of UCLA, and his PhD in Clinical Psychology at Western Michigan University.
Jodi is an Associate Professor in the Department of Psychology at East Tennessee State University where her primary professional interest is research, training, and workforce development in rural integrated practice.
Posted By Peter Fifield and Randall Reitz,
Friday, March 16, 2012
A KISS to Make it Better: A Two Step Model of Behavior Change
Why is it the more educated we become the more complicated we make things?
I was facilitating a Motivational Interviewing [MI] group the other day and during a discussion on the 5A's, the topic of Prochaska and DiClemente's Transtheoretical model [TTM] came up; specifically the stages of change. This got the entire group thinking about the complexities of behavior change and the most prolific model we use to describe it.
Since the 1980s when the TTM debuted, the stages of change have become the most widely used approach to explaining behavior change; thus it is the model most professionals [working on any sort of change process] have become familiar with. The substance abuse and medical worlds have been two sectors that have relied heavily on use of this model. Since its inception the TTM has been heralded as the kissing cousin of Motivational Interviewing [MI]. In all actuality, however, one of the originators of MI, William Miller, clarified in an article dubbed Ten Things that MI is Not , that the stages of change where originally associated with MI only because, they provided a logical way of seeing how MI fits into the clinical process, but in the end, the stages of change model is not MI.
For substance abuse treatment, the TTM allowed for a fresh new look into addiction and allowed us to see how individuals made their way through phases regarding change behavior. One pivotal discovery birthed by this model was that patients needed motivational enhancement towards change more than they needed blame for their existing situation. Look at any substance abuse counseling program curriculum [and even some medical school curricula] and you are bound to find a class that mentions the TTM and its role in behavior modification. The insight that the TTM gave treatment professionals is absolutely extraordinary and subsequently the prevention world has coveted the TTM like a golden calf.
Leanardo Da Vinci has a famous quote that states "simplicity is the ultimate sophistication”. To me the TTM lacks this ultimate sophistication. Some may argue that you could not get a simpler model than one that has managed to reduce the complex nature of behavior change down to a mere five step process. However, I feel that the TTM is in need of one more round of distillation. According to the stages of change, people make their way from a precontemplative state, to contemplative, to preparation, then to action and after that they maintain: Then the cycle repeats [see below].
TTM Stages of Change Model
What this says to me is that what kind of Inaction the patient is in somehow matters more than the inaction itself. We are in constant flux and eternally making our way in and out of readiness regarding any behavior and quite simply it seems unnecessary to complicate the matter anymore than it needs to be. A simpler more therapeutically helpful perspective is that people are either in action or in ambivalence; nothing more.
Maybe it is we the therapist that is assisted most by the stages of change; not in that it teaches us more about the patient, but more about ourselves. Knowing that the patient is contemplative, in preparation or any other phase of the stage of change model may just be a way to help us feel better about the unknown nature of the situation. We resource the stages of change algorithm, place the patient in precontemplation and then [according to one manual] "encourage them to become more mindful of their decision making and more conscious of the multiple benefits of changing an unhealthy behavior”. This is stated like patient behavior is a forecastable action.
What we typically find is that in action is not where we find most of our patients. I’d venture in saying that only about 10% of patients are in action mode; leaving 90% in ambivalence. For this 90% of the population we rely on motivational interviewing to work through the ambivalence, roll with the resistance and navigate a next step that derives from the patients wants and needs at that time. We don’t educate, advise or assist, we just sit there in the ambivalence with them, negotiating this unknown territory as if it were our own journey. We save the rest of the five A’s [Advice, Agree, Assist and Arrange] for the action phase: the other ten percent—a very small portion.
I once read, when people are in ambivalence it is like Linus without his blanket, we have nothing to hold on to. So we ourselves reach for something to grab hold of, to stabilize the spin. I think the complexity of the TTM merely gives providers a blanket to hold on to. It is an ameliorating agent for us; something to ground us as we flounder around looking for a way to help the patient out of their current predicament. What is a bit more difficult to master yet profoundly more therapeutic is to fully embrace that we are only accountable for the interaction with and not the outcome of the situation. In doing so we are able to commit to the patient without any expectation of an outcome and thus we can be more comfortable with their ambivalence. We then know that the best thing we can do is sit in the unknowness with the patient, experiencing the moment with them and not try to fix or right the situation.
The stages of change are very useful, but only if you use them cautiously. The problem that I have discovered is that they can facilitate an assumptive pattern, pigeonholing people into a mold that which we think they fit. This is done with such subtlety that we ourselves don’t even see it happening. Rechecking the manual I see that the patient is now contemplative so I must "encourage them to reduce their harmful behaviors and look for change within the next six months”. If this were true, my life would be quite boring, but a heck of a lot easier.
In the vein of Keeping It So Simple [KISS] I often think back to a childhood movie when Yoda explained to Luke one fateful day in the swamp. He said: "Do or do not, there is no try”. I think lil’ man Yoda may be on to something.
I Beg to Differ
Wow Pete, please take off your shoes when you address the Trans-Theoretical Model. It is a sacred calf and when you approach it you are standing on holy ground. Your heresy is that by dropping from 5 levels of readiness to 2, you are also dropping the model’s 2 greatest strengths: Hope and Change.
Hope. As astutely posited in your essay and supporting literature, MI is an evidence-based practice, but readiness assessment through the TTM is not. Fair enough, but how do you separate the 2 since they have been co-mingled since birth? How do you separate the science supporting MI from the science of TTM since most clinicians choose their MI interventions on how they gauge their client’s place on the TTM scale?
When you collapse the levels of TTM, you’re left with just 2 levels: abstinent or not. In the process you also take MI from a harm reduction model to an abstinence model. Yes, there is simplicity in this, but there is no hope. Once you carve out contemplation, preparation, and maintenance, clinicians will start turning Okham’s Razor on their own wrists in desperation. We need degrees of change to give us hope. We want morbidity and mortality. Imagine dropping all A1c values except a 7.0 for diabetes. Imagine dropping the quantitative PHQ9 and only keeping the binary PHQ2.
This is especially true with the dreary art of behavior modification. It is often cited that it takes the average person 7 smoking cessation attempts to actually quit the habit for good. Then, you tack on to this the much larger percentage of patients that I see every day who are not ready to attempt smoking cessation. My guess is that, as a result, only about 2-3% of the smokers I see in counseling will actually quit smoking in a given year and that only about 10-15% I see for tobacco specifically will be fully successful. With those difficult odds, if I had a binary approach I would feel quite depressed. If I keep the 5 levels alive then I can at least take comfort in the fact that a smoker moved from precontemplation to contemplation. This allows me to believe that I am the Johnny Appleseed of a tobacco-free world—planting seeds that I won’t harvest. Don’t kill Johnny.
Change. Prochaska and Diclemente’s "Stages of Change” model has brought change to medicine. The model fundamentally change is how clinicians consider their patients. Before 1990 was there a field that hated their clients more than the addictions field? The lingua franca that joined clinicians and clients was all about "drunks, alkies, boozers, winos, and junkies”. In using TTM, we remove the focus from pathologizing a person to describing their desire and readiness. I’d much rather be labeled as a "contemplator” (it’s so zen!) than a drunk. Who wouldn’t prefer to be a "preparer” than a junkie?
And, this is more than mere semantics. This language can saturate a clinical setting and reverse patient hating. It adds a narrative sense to the way clinicians describe their substance using patients. It challenges simple stigma and replaces it with a story of resilience and everyday heroics. It provides an arc with a beginning point (addiction) and an endpoint (harm reduction). It prevents us from viewing patients and the change process in black/white terms. In a circular way, this change instills more hope in both patients and providers and keeps them engaged in the process.
In conclusion, I like Yoda. Compared to other wizened pond frogs, he is incredibly wise. However, one of his axioms seems especially glib: "Size matters not. Look at me. Judge me by my size, do you?” Size does matter. In basketball, bed, and behavior modification a "5” will always be better than a "2”.
Peter and Randall have been close friends and collaborators since 2006 when Peter was "Data Dude" and Randall was "El Jefe" at the Summit Community Care Clinic in Frisco, CO.
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