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

PerpetuatingChronic

InsomniaThreshold

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.

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?