Dorothy Trevino, Ph.D. Catalina Triana, M.D. A Skills-Based Behavioral Medicine Rotation: Lowering Resistance, Keeping it Relevant and Fun Dorothy Trevino, Ph.D. Catalina Triana, M.D.

Rolling with resistance Evaluation Credibility/ Relevance Content Teaching Strategies

Background Family Physicians are often the only resource for behavioral health counseling services. Family Medicine residents need the skills to provide time-efficient, evidence-based, brief counseling services to their patients.

Program Description Four-week mandatory rotation Second-year residents Skills-based, highly interactive curriculum Focus on relevance and application to clinical practice

Educational Strategies Interactional presentations on: Basic counseling skills Difficult encounters Motivational Interviewing Counseling for depression Counseling for anxiety Role modeling of skills Role play practice

Real Play

Standardized Patient Practice Three cases were developed to provide longitudinal practice opportunity Each case’s counseling needs match the topic of the week Every resident interviews two patients with direct observation and feedback from faculty and patient

SP Practice

Direct Supervision in the Clinic A behavioral medicine faculty checks each resident’s skills proficiency in their own clinic.

CONTENT & EVALUATION Week 1 Basic Counseling Skills Open-ended questions Affirmations Repeating words Rephrasing words Empathic reflections Feeling reflections Reflective listening Containment Elicit – Provide – Elicit (E-P-E) Assess stress, context, coping skills and resources (BPS)

CONTENT & EVALUATION Week 1 Offering Advice Model Ask permission, then offer advice Emphasize choice Elicit response Difficult Encounters Acknowledge/reflect feeling Self-reflection/internal check Reflective listening Elicit patient’s perspective Empathy “Tell me more”

CONTENT & EVALUATION Week 2 Motivational Interviewing Assessment of importance and confidence Reflective listening Scaling questions Explore costs & benefits of change Evocative questions Giving clinical feedback

CONTENT & EVALUATION Week 2 (continued) Motivational Interviewing Circle chart Simple reflection Amplified reflection Double-sided reflection Shifting focus Reframing Emphasizing personal control Siding with the negative End with a positive Use “and” instead of “but”

CONTENT & EVALUATION Week 3 Depression Screening and diagnosis of depression Psychoeducation on depression, E-P-E BPS model of disease Normalize Validate feelings Address feelings, & concerns Brief advice Cognitive Behavioral Therapy Education on CBT Automatic thoughts Thought challenging Pleasure list Offer psychotherapy & antidepressants

CONTENT & EVALUATION Week 4 Anxiety Screening for anxiety Diagnosis of anxiety Differential diagnosis of Substance Abuse Psychoeducation on anxiety, E-P-E Cognitive Behavioral Therapy Education on CBT Automatic thoughts Thought challenging Deep breathing Muscle relaxation Safe place

“305.00 ALCOHOL ABUSE – UNSPECIFIED TRANSLATION INTO PRACTICE Quotes from residents’ assessments and plans in the Electronic Medical Record Motivational Interviewing “305.00 ALCOHOL ABUSE – UNSPECIFIED Motivational interviewing with the patient in pre-contemplative state over alcohol and contemplative state on tobacco.” “Tobacco Abuse: Discussed benefits of cessation and he understands, however currently in pre-contemplative phase”

“V25.9 CONTRACEPTIVE MANAGEMENT NOS (primary encounter diagnosis) I counseled patient using motivational interviewing skills re: contraception, safe sex behavior, risks & benefits and side effects from OCP. “ “It is not necessary that patient be accompanied by her husband, however, his participation in her care and weight-loss efforts will increase her compliance.”

TRANSLATION INTO PRACTICE Counseling for Depression “250.02 DIABETES MELLITUS TYPE II UNCONTR UNCOMPL Comment: uncontrolled. Patient seems to have a problem with compliance. Will stop SSI and Glyburide and will start adjusting Lantus. Patient will need to be screened for depression on her next clinic visit to address her noncompliance.”

TRANSLATION INTO PRACTICE Counseling for Anxiety “308.4 STRESS REACT, MIXED DIS Comment: pt was given counseling and instruction on breathing techniques. Plan: 30 mins of this encounter was spent on counseling and deep breathing exercise, with instruction of coping skills.”

MI Principles   Interpersonal style: motivation—and resistance—is powerfully influenced by the interpersonal style of the helping professional (Motivational Interviewing: Miller and Rollnick, 1991, 2002)