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 Intentional actions taken to achieve overall wellness in all areas of self • Physical • Mental • Emotional • Personal • Spiritual • Professional
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
Maintain realistic expectations • Maintaining 70/30 model • Establish and maintain boundaries • Hold difficult case discussions or clinical case • Burnout Prevention conference (seek consultation) Work environment Develop a support network considerations • Seek additional training/education • Be organized • Take a break • Know your limits • Leave work at work •
Burnout Prevention Work environment considerations Zero Harm • – Open communication with staff – Daily huddles • Review schedules and case load • Risk management • Debriefing
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 Insomnia Threshold Predisposing Precipitating Perpetuating- Perpetuating Acute Chronic 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 opportunity 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.
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