Beruflich Dokumente
Kultur Dokumente
Emily
Your having a busy day at your Family practice, you are seeing Emily, who is now 22 years old, but you have not seen her since she was 12 years. You remember many visits form her mother with concerns about her daughters oppositional behavior. Emily is here for a physical exam, she has come to you because she is now living with her 3 year old son at her parents and she feels her primary care should be with her childhood Family MD rather than the street youth clinic she used to go to. Emily is on a Methadone Maintenance Treatment (MMT) program. She has a history of street involvement, IV heroin use, and intermittent homelessness between the ages 14- 19. She went onto MMT when she was pregnant. She had a relapse 1 year ago after leaving MMT, but has now returned to care. She requests if you will be the Family doc for her son too.
Julianna
For one year, you have been providing primary care support, through your Family practice, to the local detox in your small town Today you are seeing Julianna who is 28 years old, she needs a check for STDs, because during intake at the detox she revealed that she had unprotected sex Julianna is a petite woman, who appears guarded, but speaks forthrightly, immediately stating her distrust of doctors and their drugs The detox told you this is the first time this patient has sought their services for her polysubstance abuse and they would like to engage her in addictions treatment
Bill
Bill is a 44 year old long standing patient to you.He requests appointments almost monthly, when you see him, you usually find that he has minor or vague symptom complaints. You have discussed anxiety symptoms with Bill before, and you have started him on an SSRI, which he reports is somewhat helpful. Although he accepted the pharmacotherapy, he has always avoided answering any questions about his worries or sources of anxiety. He states that his difficulties with people and worrying is why he does not work, has few friends, lives with his mother. His mother, also your patient, has booked an appointment, for him, with you, for an AHEx. She wants you to talk to him about the health effects of sitting at the computer all day long. On your systemic review for his AHEx, Bill revealed he drinks alcohol nightly for sleep and to deal with his day. Upon further enquiry using the CAGE Questionnaire, you realize he may have a problematic use of alcohol.
Meredith
Meredith is a 44 year old relatively new patient to you. You have done an intake history and noted her cycles of depression. She was told you do some GP Psychotherapy and you agreed, to her request, and the hallway referral from your older colleague, for regular counseling. You usually book Thursday afternoons for 20 minute therapy sessions. You provide counseling for patients from your own and your colleagues practices for mood disorders and situational emotional stressors. Within your first two sessions with Meredith, you learn that she has had multiple suicide attempts and visits to the Emergency Department when she was younger. She has attended many individual counseling and group therapy programs. She willingly admits that she uses cannabis to self medicate her symptoms of stress and insomnia. As she is relaying this history, your mind wanders from her narrative and you notice her arms have multiple old and healed cuts across the volar surface.
Perception that providing care to patients with SUD is repetitive and detracts from the care of others Satisfaction achieved in caring for alcohol and substance abusing patients diminished over the years of training
Physician-in-training attitudes toward caring for and working with alcohol and drug abuse diagnoses. Southern Medical Journal 2006
20% of GPs said no alcohol misusing patients in their practice, 62% reported not seeing drug misusing patients Although GPs surveyed had strong negative perceptions and attitudes about alcohol and drug misusing patients, 61% felt the primary care setting was an appropriate place to treat alcohol problems, and only 6% felt the same for drug using patients
Addictions:Therapeutic Responses
Screening and identification Empathic attunement: authentic and responsive Therapeutic alliance: the relationship is the healer Motivational Enhancement: a relational approach to challenge and help the patient to change Environmental adaptations: a team approach Tools and resources: feeling prepared Self awareness and self care Collegial support: MMAP
a directive, client-centered counseling style for eliciting behavior change by helping people to explore and resolve ambivalence Working with ambivalence is working with the heart of the problem Intervention is matched to the readiness to change
Maintenance
Action
Precontemplation
No intention to change behavior in the foreseeable future Unaware or underaware of their problem Families, friends , and coworkers are often aware that the precontemplation has problems May even demonstrate change, but only as long as the pressure is on They may wish to change, but not planning to change
Contemplation
Ambivalent about change Both considers change and rejects it Can stay stuck here for long periods Open to information and decisional balance considerations
Preparation
Prepare to make a specific change Taking small, tentative steps in getting ready to make change Intend to take action soon
Action
Engaging in particular actions intended to bring about change Making the change
Spiral of Change
MAINTENANCE relapse action relapse action relapse action precontemplation contemplation preparation
Contemplation
Raise doubt- increase the patients perception of the risks and problems with current behavior Tip the balance- evoke reasons to change, risks of not changing; strengthen the patients self efficacy to change
Preparation
Action Maintenance Relapse
Help the patient to determine the best course of action to take in seeking change Help the patient to take steps toward change
Help the patient to identify and use strategies to prevent relapse Support the patient through renewal
The Opening
Raising the issue of Substance Abuse Avoid labeling, confrontation, and giving advice Proceed at the clients own speed Establish rapport Use open-ended questions Find a way in Tell me, where does your use of cocaine fit into all of this?
Opening Strategies
Ask Open-Ended Questions Listen Reflectively Affirm Summarize Elicit Self-Motivational Statements
Getting Going
Exploring Concerns and Options for Change Ask about substance use in more detail Ask about a typical day of use Ask about lifestyle and stresses Ask about health, then substance use Ask about good things, then less good things Ask about substance use in the past and now
CONTEMPLATION
Goal: patient will examine benefits and barriers to change Why do you want to change at this time? What are your reasons for not changing? What would keep you from changing at this time? What might help you with that aspect? What things have helped in the past to change?
READINESS TO CHANGE
On a scale of 1 to 10 where 1 is where you are only willing to hope and pray that things improve and 10 is where you are willing to do anything to change, how ready are you to make changes?
What would help to move you from a 6 to an 8? What would have to happen to make you more ready?
CONFIDENCE TO CHANGE
Ability to change depends on ones confidence in ones ability= self efficacy On a scale of 1 to 10 how confident are you that you will be able to make these changes? 1=not all confident 10= fully confident What would help you to move from a 3 to a 6?
Summarize
Key Questions What would be some of the good things about making a change? What do you think has to change? What are your options? It sounds like things cant stay the way that they are now, what are you going to do? How would you like for things to turn out for you, ideally?