Behavioral Interventions to Improve Health and Wellness MODERATOR: - - PowerPoint PPT Presentation

Behavioral Interventions to Improve Health and Wellness

MODERATOR: TERRI FLINT PHD, LCSW PRESENTERS: MATT MACKAY, PSYD LORI NEELEMAN, PHD KEN WEIGAND, PSYD

Objectives

• Discuss behavioral interventions to improve the health

and wellness of patients and providers.

– Identify provider burnout and how to prevent it using appropriate self-care strategies. – Increase familiarity with cognitive behavioral therapy for insomnia. – Learn the benefits of using behavioral health handouts as an effective intervention for your MHI role in a medical clinic.

“Helping People Live the Healthiest Lives Possible”

Provider Self-Care, Finding Balance to Avoid Burnout

HOW TO PRACTICE WHAT WE PREACH

What is Burnout?

signs and symptoms

• Feeling less effective or useless
• Lack of or decline in empathy
• Lack of enthusiasm or motivation at work
• Feeling board, tired, or even daydreaming during sessions
• Increased irritability, sarcasm, or passive-aggressive

behavior with others (both in and out of work)

• Job dissatisfaction
• Self-medicating

Causes of Burnout

• Prolonged exposure to stress in the work environment
• Professional isolation
• Real or perceived Lack of support/resources/availability
• Disproportionate number of high risk/difficult patients
• Lack of training or competency
• Vicarious Traumatization
• Self-sacrifice own needs (self-care) for patients/job
• Lack of appropriate self-care, Life not balanced

Consequences of burnout

• Overall decline in emotional, mental, physical and

spiritual health/wellness

• Increased stress at home and on the family
• Impaired social relationships
• Decreased professional efficiency

Professional and Ethical Obligations Regarding Burnout and Self-Care

Do No Harm

Self-care

• Physical
• Mental
• Emotional
• Personal
• Spiritual
• Professional

Intentional actions taken to achieve overall wellness in all areas of self

The art of balance and self-care

• Disproportionate time and effort on one area of self for

prolonged periods of time can lead to imbalance and the beginning of stress and burnout. All areas are equally important

• Watch (and listen) for warning signs
• “How do you feel?”
• Learn to Compromise (look for the gray areas)

Coping with and preventing burnout

• Focus on physical wellness
• Developing Self-Awareness
• “Me time,” focus on relaxation and “Let it go”
• “What is mine, what is not?”
• Develop/modify coping strategies
• Coming up with a support system/network
• Be involved with non-professional activities/interests
• Seek personal therapy if/when needed
• Organize your week to include other areas of self-care

Burnout Prevention

• Maintain realistic expectations
• Maintaining 70/30 model
• Establish and maintain boundaries
• Hold difficult case discussions or clinical case

conference (seek consultation)

• Develop a support network
• Seek additional training/education
• Be organized
• Take a break
• Know your limits
• Leave work at work

Work environment considerations

Burnout Prevention

• Zero Harm

– Open communication with staff – Daily huddles

• Review schedules and case load
• Risk management
• Debriefing

Work environment considerations

Cognitive Behavioral Therapy for Insomnia

PRACTICE TIPS YOU CAN USE

CBT-I As First Line Treatment The American Academy of Sleep Medicine & American College of Physicians recommend

CBT-I as the first line treatment for chronic insomnia.

Scenarios Reported by Patients

Patient: “I can’t sleep...” Provider: “Welcome to the club.” Patient: “I can’t sleep….” Provider: “This should help.”

Insomnia Disorder

• Trouble falling asleep, staying asleep or waking too early with

the inability to return to sleep.

• Causes clinically significant distress or impairment in important

areas of functioning.

• At least 3 nights per week.
• Present for at least 3 months.
• Not better explained by another sleep disorder.
• Not attributable to physiological effects of a substance.
• Coexisting mental disorders and medical conditions do not

adequately explain the predominant complaint of insomnia.

• May be episodic, persistent, or recurrent

Spielman 3 (4)-P Model

Predisposing Precipitating Perpetuating- Acute Perpetuating Chronic

Insomnia Threshold

Adapted from Spielman, A.J. & Glovinsky, P. (1991)

CBT-I in a Nutshell

• Behavioral Strategies

– Stimulus control – Sleep compression/sleep restriction – Sleep hygiene

• Cognitive Strategies

– Challenge dysfunctional thoughts associated with sleep and excessive sleep effort/safety behaviors.

• Arousal

– Relaxation – Sleep hygiene

Behavioral Strategies

• Stimulus control: Goal is to strengthen the association

between the bed and sleep. – Reserve the bed for sleep and sex only. – It’s better to be awake and frustrated on the couch than it is in bed (get out of bed if you can’t sleep after 15-20 min). – Wait until you are sleepy to go to bed. – Get up at the same time each day. – Only sleep in your bed.

Behavioral Strategies

• Sleep compression/sleep restriction: Goal is to

increase sleepiness by reducing sleep opportunity. – Reduce sleep opportunity to the number of hours the patient is sleeping + 15-30 min as indicated on their 2- week sleep log. Not less than 5 ½ hours. – Seek to improve sleep efficiency:

• SE=Time asleep/Time in bed.

– When sleep efficiency is >90%, increase sleep

• pportunity by 15 min and continue to until sleep need

is met and sleep efficiency is >85%. – Be careful with potential sleep apnea patients.

Behavioral Strategies (2)

• Sleep hygiene

– Avoid screens at least 2 hours before bed (blue light blocking glasses, apps/programs for computer and tablets). – Avoid caffeine 8 hours before bed – Dim lights in the evening – Adequate bright light (outdoor light) exposure during the day – Include an hour of wind-down time – Avoid big meals before bed – Exercise most days but not too close to bed time (usually at least a 2- 3 hour window). – Avoid nicotine at least 3 hours before bedtime – Avoid alcohol 4-5 hours before bedtime. Make sure you ask about using alcohol for sleep. – Be aware of stimulating medications taken at bedtime – Avoid naps or keep them early (before 2 pm) and short (<30 min).

Cognitive Strategies

• Avoid excessive sleep effort.

– Paradoxical intention (passively try to stay awake)

• Avoid excessive worry about sleep.

– Take frustration/worry to the couch. – Have some enjoyable relaxing things to do if not able to sleep. – Go to bed when sleepy/don’t try to force it.

• Challenge dysfunctional thoughts about sleep.

– I have to get 8 hours of sleep. – I will feel terrible tomorrow if I don’t get enough sleep (behavioral experiments).

Arousal Factors

• Relaxation before bed

– Handouts – Apps – Downloads – CDs and cassette tapes

• Start to wind down an hour before bed
• Sleep hygiene

– Avoid overly stimulating activities before bed (unique to the individual).

Patient Resources

• Apps

– Relaxation

• CBT-I Coach
• Stress Free
• Headspace

– Information

• CBT-I Coach
• Nova Sleep Coach
• Online CBT-I

– Shuti – Sleepio – Go! To sleep

Patient Resources (2)

• Books:

– Goodnight Mind by Colleen Carney and Rachel Mandber – No More Sleepless Nights by Peter Hauri

• Books focused on sleep for kids and teens:

– Snooze or Lose: 10 No-war ways to Improve Your Teen’s Sleep Habits by Helene Emsellem and Carol Whiteley – Take Charge of Your Child’s Sleep: The All-in-One Resource for Solving Sleep Problems in Kids and Teens by Judith Owens and Jodi Mindell.

Provider Resources

• Cognitive Behavioral Treatment of Insomnia: A Session-by-

Session Guide. Michael Perlis, et al. 2008

• Insomnia: A Clinical Guide to Assessment and Treatment.

Charles Morin and Colin Espie. 2003.

• Treatment Plans and Interventions for Insomnia: A case

formulation approach. Mandber and Carney. 2015.

• Cognitive Behavioral Therapy for Insomnia

– Continuing education credits through HealthForumOnline.com (2 credits $50)

• CBT-I training offered at UPENN in the fall of each year

through PESI (3 day training $549).

– DVD of the training for the previous year (2015 - 22.5 credits $299.00)

Behavioral Health Handouts & Anxiety Interventions

Behavioral Health Handout Benefits

 Integration includes adapting to medical time.

• Medical follow up appointments – 10 to 20 minutes
• Mental Health follow up appointments – 45 to 50 minutes

 Envision yourself conducting a 25 minute behavioral health

• consult. It could be an efficient “tool in your toolbox.”

 Envision 3 to 6 total appointments for most medical referrals.  Handouts can serve as treatment plans.  Handouts can serve as ready made homework assignments.

Behavioral Health Handout Benefits

 Handouts are updatable as your knowledge, skills and style grow.  Handouts can easily contain up-to-date, effective standards of care (i.e., evidence-based interventions).  Useful for very talkative patients.  Quiet patients welcome the structure handouts can provide.  They can allow for more “therapeutic alliance” time.  Consider growing an individual library for yourself, starting with the most common conditions you see to least common conditions.

Behavioral Health Handouts Benefits

 Group share with co-workers or clinic.  Handouts reduce “therapeutic drift” over time.  It’s possible for medical or clinic staff to initially distribute a handout as a preview of likely treatment approaches for the new MHI referral.  Patients can choose to share handouts with supportive persons in their daily life who can remind them of coping skills and home work.  Handouts provide a tangible option for patients to answer spouse or family questions, “What happened in your appointment? What did you guys talk about?”

Behavioral Health Handouts Are Not…

 … a cookie cutter, or one size fits all, approach.  … a substitute for interpersonal factors.  … always a good fit between clinicians, so clinicians are encouraged to edit and customize a handout for themselves when needed.  …a useful intervention when new or emotionally loaded patients are wanting or expecting to vent, and mostly need active listening.

Sample Behavioral Health Patient Handouts

Take Away Points

 Behavioral health handouts can be efficient use of time.  They can serve as treatment plans containing high standards of care.  Behavioral health handouts allow more time for relationship building.  Try writing one for yourself in an area you already know well.  Established treatment for anxiety includes a mix of CBT and psychoeducational interventions, which might well overlap with Mindfulness and ACT interventions.

Thank you

Discussion/Questions:

• How can you utilize staff/team huddles to help you with self-care?
• What would your ideal huddle look like?
• What operational support do you need to make huddles happen?
• What do you do when a patient comes in seeking sleep medication for their

insomnia and isn’t interested in CBT-I?

• When using behavioral health handouts, how do you personalize interventions

so the patient doesn't feel like a part on an assembly line?