Chronic Disease Self-Management: Helping clients help themselves -Treatment Adherence: Factors, challenges, and solutions Paul R. Swaim; MEd, ALC

Why is this even being discussed with this group? New Years’ resolutions Antibiotics Communication with family (Arguing) Speeding tickets The more included the patient feels, the more they will progress, the less they will rely on more intense services, the more likely the overall cost of care will be reduced

Defending the need for care Nearly one out of two adults is living with a chronic illness, according to the Centers for Disease Control (2010) High blood pressure Heart disease Diabetes 5-11% of hospitalizations are due to medication 60% poor adherence 29-59%

Open ended statement Share the main goal for your patients. “We work in a strange field. It’s almost our job to try and work our way out of having a job” We have to be mindful not to lead people to the goal before they are ready

Rules of thumb Exploring and Resolving Ambivalence Center on the patients’ individual motivational processes to facilitate change Do not impose change Congruent with Patient’s Values

In essence It’s all about THE PATIENT’S goals, not OUR goals For those who like a more concrete definition: [Treatment] is “a collaborative, person-centered form of guiding to elicit and strengthen motivation for change.” - MIA:STEP, 2009

3 key elements Collaboration (v. Confrontation) Evocation (v. Imposing Ideas) Autonomy (v. Authority) Initiative v. Structure

Collaboration Partnerships- build rapport, facilitate trust Focus on mutual understanding Not the treatment professional being right Meet in the middle We are the experts in treatment Patients are the experts on themselves

Evocation Draw out the patient’s thoughts and ideas Don’t impose your own Lasting change is more likely to occur when the patient discovers his or her own reasons and determinations to change.

Autonomy Power for change rests within the patient It’s up to the patient to make the change Remember, there are multiple ways that change can occur.

Why is it difficult for patients to identify this on their own? Self-esteem Upbringing Experiences Societal values Poverty Lack of resources

Emotional Reactions Anxiety- apprehension in the absence of a specific danger Difficult to specify what is causing the feeling Existential anxiety Unfounded rumor Fear of the unknown Fear of death

The presence of others in uncertain situations Comforting Reassuring Empathy vs. sympathy Difficult Fear of suffering and pain Depression Anger and hostility

Self-efficacy Focus on previous successes Highlight skills and strengths Remember, there is no “good/bad” there is only what works and what doesn’t Identifying a behavior provides more support and motivation than encouragement does

Identifying examples It seems you’ve been working hard to quit smoking. That is different from before. How have you been able to do that? So, even though you have not been taking your medicine every day, you have taken it more often this week than last. How were you able to do that? After asking about changes patients have made, it is important to follow-up with a question about how patients feel or what patients think about the changes they made

Rolling with resistance Conflict between view of problem and solution Experiences loss of freedom or Autonomy being infringed upon Too much us and they will shut down

Severe disequilibrium Demands many readjustments as you react to constantly changing events Illness becomes the central focus around which the family organizes itself and its activities Emotional demands such as setting priorities so that the ill and the healthy all get their needs met

More about resistance Do not confront the patient when resistance occurs De-escalate or avoid negative interactions Patient remains in control Define problem Develop solution  little resistance to change

Develop Discrepancy Change occurs when there is a mismatch Where they are Where they want to be Encourage the patient to identify this fact Can’t Should Will

Strategies for evoking change talk Ask evocative questions Open ended questions elicit change talk Explore decisional balance Pros and cons of staying the same Look back As about before the target behavior emerged Use change rulers On a scale of 1-10, how important is it to you to change (target behavior) Why are you at __ and not __ What might move you from __ to __ Come alongside Reverse psychology/ therapeutic paradox Explicitly side with negative Perhaps __ is so important to you that you won’t give it up, no matter what the cost.

Examples What would you like to see different about your current situation? What makes you think you need to change? What will happen if you don’t change? What will be different if you (behavior)? What would your life be like 3 years from now if you changed you (risky behavior)? Why do you think others are concerned about (behavior)?

Signs of readiness for change Decreased resistance Decreased discussion Resolve Direct statements about desire Questions about change Envisioning Experimenting

When applying this information, remember “I can” Indicate this is a summary and include: Change talk Ambivalence Next step

Application We’ve been together for a lot of time know. What is it that you’re taking from this? What was said early about why we were discussing this information? Suppose you don’t apply any of this information to your patients. What is the worst thing that might happen? How are you apply what you’ve said you understand?