1. Real Behavior Change in Primary Care: Improving Patient Outcomes Patricia J. Robinson PhD patti1510@msn.com Mountainview Consulting Group, Inc. patriciarobinsonphd.com Healthcare Consultant and Trainer, Yakima, WA Debra A. Gould MD, MPH deb.gould@commhealthcw.org Central Washington Family Medicine Residency Program, Yakima, Washington Associate Clinical Professor, University of Washington, Seattle Collaborative Family Healthcare Association 13 th Annual Conference October 27-29, 2011 Philadelphia, Pennsylvania U.S.A. Session #: G1a October 28, 2011 1

2. Faculty Disclosure We currently have the following relevant financial relationships during the past 12 months: New Harbinger Publications – Co-Authors 2

3. Need/Practice Gap & Supporting Resources What is the scientific basis for this talk? New CBT contextual behavioral interventions, such as ACT, are useful to primary care providers and patients (particularly to primary care patients with poor outcomes such as those with diabetes, tobacco use, chronic pain, depression, and anxiety). Gregg, Callaghan, Hayes, & Glenn-Lawson, 2007; Gifford, Kohlenberg, Hayes, Antonuccio, Piasecki, et al., 2004; McCracken & Eccleston, 2003; Dahl, Wilson, & Nilsson, 2004; Lundgren, Dahl, Yardi, & Melin, 2008); Zettle & Hayes, 1986; Hayes, Wilson, Gifford, Bissett, Piasecki, et al., 2004; Hayes, Luoma, Bond, Masuda, & Lillis, 2006 3

4. Objectives Introduce the “Love, Work, Play and Health” interview as a tool for obtaining an understanding of a a patient’s life context Introduce the “Three Ts & Workability” interview as a tool for obtaining an understanding of a target problem Introduce six core processes of psychological flexibility and the “Core Process Assessment Tool” (a case formulation tool) Introduce the “Real Behavior Change Pocket Guide” (a tool for rapid identification of an experiential or psycho-educational intervention 4

5. Expected Outcome By learning about the availability of interview, case formulation, and intervention tools, provider interest in learning to apply these tools will increase. With increased awareness of a platform for using contextual behavioral (ACT) interventions amenable to team-based support, primary care clinicians and provider interest in learning and applying these newer interventions as a team will increase. 5

6. Learning Assessment A learning assessment is required for CE credit. 1.Rate your level of awareness of tools for obtaining an understanding of a patient’s life context and a completing a brief functional analysis of a target problem in 15 minutes. (1 = not aware; 10 = very aware) 2.Rate your current level of awareness of contextual behavioral interventions, such as ACT, and their applicability to primary care behavioral health (1 = not aware; 10 = highly aware). 3.Rate your current interest in learning contextual behavioral interventions, such as ACT, and their applicability to primary care behavioral health (1 = low interest; 10 = high interest). 4.Rate your current intention to learn contextual behavioral interventions, such as ACT, and their applicability to primary care behavioral health (1 = low intention; 10 = high intention). 6

7. Experiential Avoidance Behavioral Avoidance

8. Psychological Flexibility (Model of Acceptance and Commitment Therapy) Pain is inevitable, suffering isn’t! 8

9. Psychological Flexibility Learning to be aware and accepting of the pain that comes into our lives while continuing to pursue what we value. Action & Acceptance Questionnaire II 9

10. How Can I Be More Psychologically Flexible? How Can I Help Patients Become More Psychologically Flexible? 10

11. 11 TEAMS (Our Private Experience) Sensations Thoughts EmotionsAssociations Memories

12. 6 Core Processes – Psychological Flexibility Experience Present Moment Accept TEAMSConnection with Values Step back from Value Consistent TEAMS (Defusion) Action Use Observer Self To See Limiting Self-stories Flexibility 12

13. Step Back from TEAMS and Unworkable Rules (Defusion) 13

14. Therapist / Provider: Start with Focus, Return to Focus Breath, Form, Depth Settling (throughout the practice day) One in the beginning and one in the end Letting go Half Smile Treating with intention 14

15. Focused Interviewing: The Love, Work, Play & Health Questions Love Where do you live? With whom? How long have you been there? Are things okay at your home? Do you have loving relationships with your family or friends? Work Do you work? Study? If yes, what is your work? Do you enjoy it? If no, are you looking for work? If no, how do your support yourself? Play What do you do for fun? For relaxation? For connecting with people in your neighborhood or community? Health Do you use tobacco products, alcohol, illegal drugs? Do you exercise on a regular basis for your health? Do you eat well? Sleep well? 15

16. Focused Interviewing: The Three Ts & Workability Questions Time When did this start? How often does it happen? Does it happen at a particular time? What happens just before the problem? Immediately after the problem? Trigger What do you think is causing the problem? Is there anything or anyone that seems to set it off? Trajectory What’s this problem been like over time? Have there been times when it was less of a concern? More of a concern? What have you tried in the past? Workability How have the things you’ve tried worked in the short run? In the long run or in the sense of being consistent with what really matters to you? 16

17. Focused Intervening: Case Formulation and Mindful Intervention The Core Process Assessment Tool: – Selection of a target process to enhance flexibility The “Real Behavior Change Pocket Guide” – Rapid identification of experiential and/or psycho- educational interventions The Bulls Eyes Plan – Development of an on-going intervention amenable to PC team support 17

18. For Free All Real Behavior Change in Primary Care Tools http://www.newharbingeronline.com/real- behavior-change-in-primary-care.html 18

19. REAL Behavior Change in Primary Care: Tools and Strategies for Improving Patient Outcomes and Job Satisfaction Robinson, Gould, & Strosahl December 2011 Oakland, CA: New Harbinger SEE Patriciarobinsonphd.com for updates 19

20. ACT in PC Resources “Association for Contextual Behavioral Science” http://www.contextualpsychology.org/ http://www.contextualpsychology.org/ http://www.newharbingeronline.com/real-behavior-change-in-primary-care.html

21. Learning Assessment A learning assessment is required for CE credit. 1.Rate your level of awareness of tools for obtaining an understanding of a patient’s life context and a completing a brief functional analysis of a target problem in 15 minutes. (1 = not aware; 10 = very aware) 2.Rate your current level of awareness of contextual behavioral interventions, such as ACT, and their applicability to primary care behavioral health (1 = not aware; 10 = highly aware). 3.Rate your current interest in learning contextual behavioral interventions, such as ACT, and their applicability to primary care behavioral health (1 = low interest; 10 = high interest). 4.Rate your current intention to learn contextual behavioral interventions, such as ACT, and their applicability to primary care behavioral health (1 = low intention; 10 = high intention). 21

22. Session Evaluation Please complete and return the evaluation form to the classroom monitor before leaving this session. Thank you! 22