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8/14/2017COACHING AND ENGAGINGCLIENTS WITH MENTAL HEALTH NEEDSHealth Home Care Coordinators and Allied StaffAugust 10, 2017Today’s PresenterTony O’Leary, LMHC– DSHS/Behavioral Health Administration– 360 725-1039– [email protected]

8/14/2017Objectives Key questions for assessing the client, theirenvironment and behaviors Fundamentals of an effective behavioralsupport plan Strategies for supporting behavioral change Promoting collaboration to support behavioralchange3BEHAVIORAL HEALTH CLIENTS IN PRIMARYCARE SETTINGS“Psychological Masquerade:” Behavioral health conditions superimposed onmedical conditions Medical conditions superimposed onbehavioral health conditions Presenting medical complaints with behavioralhealth basis42

8/14/2017BARRIERS TO CLIENTS RECEIVING SERVICES Lack of motivation (often mistaken for otherbarriers) Inability/unwillingness to recognize the problem Cultural barriers Difficulty with transportation Estrangement from family/natural supports Economic problems Social isolation5ENGAGEMENT, TREATMENT AND RECOVERY Client engagement is essential in any treatmentmodel The longer clients are engaged in treatment, themore successful the outcome Clients who perceive a working alliance with theirprovider are more likely to remain in treatment63

8/14/2017INITIAL ENGAGEMENT Identify the client (who has the problem?) Define an outcome from the client’s perspective Assessment tools won’t tell you what the clientwants Identify strengths7KEEPING CLIENTS ENGAGED Welcoming atmosphere Personal qualities (empathy, warmth andgenuineness) Respect for cultural differences Family/collateral involvement Maintaining clients’ right to self determination Peer support (“recovery coaches”) Meet clients where they are84

8/14/2017STAGE BASED INTERVENTIONS Precontemplation stage. At this stage the client is notconsidering the possibility of change. The client is unaware ofhaving a problem or needing to make a change. Contemplation stage. Awareness of the problem has arisen,and the client is ambivalent about making a change. Determination stage. The client is motivated to do somethingabout the problem and has not yet taken the initiative. Action stage. The client engages in action for the purpose ofbringing about change. Maintenance stage. The client engages in behavior to sustainthe change.9STAGE BASED INTERVENTION TIPS Minimize confrontationMutual treatment planningHumorAvoid power strugglesAvoid labelingAsk permissionAwareness of countertransferenceOpen to a variety of approaches105

8/14/2017SYSTEMIC STRATEGIES Partnerships between behavioral healthproviders and medical clinics Co-located professionals Behavioral health screening and referral Partnerships between local Behavioral HealthOrganizations and county health departments11First Rule of Managing BehaviorFor the care provider, the behavior isthe problem .BUTFor the individual, something else isthe problem and the behavior isthe solution.126

8/14/2017Second Rule of Managing BehaviorIf the behavior is going to change, thecare provider and the individual mustreach a common understanding ofwhat the problem is.13Third Rule of Managing BehaviorBefore attempting to change anindividual’s behavior, the careprovider(s) often must first changetheir own.147

8/14/2017Common Deficits in Individuals withChallenging BehaviorA “challenging behavior” is likely to involve adeficit in one or more of these areas: CommunicationProblem SolvingSocial SkillsSelf ManagementImpulse Control15Key Questions Before attempting to address an individual’sbehavior, there are some things you’ll need toknow about the individual, the environment,the care provider(s) and the situation. These questions will help you get theinformation you need to develop an effectivebehavioral support plan.168

8/14/2017Key Questions cont.Is the behavior new?17Key Questions cont.If the behavior is new, when didit start?189

8/14/2017Key Questions cont.If the behavior is not new, why isthe care provider asking forhelp now?19Key Questions cont.How is the behavior different fromthe individual’s baselinefunctioning?2010

8/14/2017Key Questions cont.Is the behavior random orsituational?21Key Questions cont.When and where is the behaviormost/least likely to occur?2211

8/14/2017Key Questions cont.Does the individual appear to havecognitive and/or volitional controlof the behavior?23Key Questions cont.What are the individual’s cognitiveand/or sensory challenges?2412

8/14/2017Key Questions cont.Has there been a change in theindividual’s mental status ororientation?25Key Questions cont.Has there been a change in theindividual’s medical condition?2613

8/14/2017Key Questions cont.Is the individual in pain?27Key Questions cont.Is the individual in a newenvironment, and/or has therebeen a change in theenvironment?2814

8/14/2017Key Questions cont.Has there been a recent loss?29Key Questions cont.Have there been any knowntraumatic events in theindividual’s history?3015

8/14/2017Key Questions cont.What are the individual’s culturalnorms?31Key Questions cont.What is keeping the behaviorfrom getting worse?3216

8/14/2017Key Questions cont.What are the individual’sstrengths and capabilities?33Key Questions cont.Has there been a change inothers’ tolerance of thebehavior?3417

8/14/2017Key Questions cont.Who is the one with the problem(or, who is really your client)?35Systemic vs. Linear ApproachA linear approach addressesbehavior as an event.3618

8/14/2017Systemic vs. Linear Approach cont.A systemic approach addresses behavior aspart of a process: What was going on prior to the behavior (the“Antecedent”)?The event itself (the “Behavior”).What happened following the behavior (the“consequence”)?37Systemic vs. Linear Approach cont.How can this information help indeveloping a more effectivebehavioral support plan?3819

8/14/2017Fundamentals of a BehavioralSupport PlanAn effective behavioral support planshould be able to be “stuck on therefrigerator” and frequently referred toas a guide for both the individual and thecare provider.39Fundamentals of a BehavioralSupport Plan cont.Clearly identify the individual’scognitive and sensory capabilities4020

8/14/2017Fundamentals of a BehavioralSupport Plan cont.Clearly identify the problem anddesired outcomes41Fundamentals of a BehavioralSupport Plan cont.State the problem and desiredoutcomes in terms that arebehaviorally specific4221

8/14/2017Fundamentals of a BehavioralSupport Plan cont.State the problem and desiredoutcomes in terms that aremeasureable43Fundamentals of a BehavioralSupport Plan cont.State the problem and desiredoutcomes in terms that everyoneinvolved can understand4422

8/14/2017Fundamentals of a BehavioralSupport Plan cont.State how everyone will know ifthe plan is working45Case Example Bobby Smith’s HAP– Long term goal: gain better control of hisbreathing by getting routine medical and mentalhealth care– Short term goal: get a doctor (primary carephysician) Note: many of the action steps are completed by theCare Coordinator and Peer Support Specialist– Bobby is a Level 1 according to his responses to the PatientActivation Measure (PAM)4623

8/14/2017Strategies to Support BehavioralChangeModifying the environment,antecedents to behavior orroutine47Strategies to Support BehavioralChange cont.Providing an alternative to thechallenging behavior to obtainthe desired outcome4824

8/14/2017Strategies to Support BehavioralChange cont.Tactical ignoring of the challengingbehavior49Strategies to Support BehavioralChange cont.Distracting the individual5025

8/14/2017Strategies to Support BehavioralChange cont.Changing expectations anddemands placed upon theindividual51Strategies to Support BehavioralChange cont.Teaching the individual new skillsto manage their own behavior5226

8/14/2017Strategies to Support BehavioralChange cont.Introducing natural consequences tothe individual’s behavior (taking intoconsideration the individual’s abilityto understand cause-and-effect)53Strategies to Support BehavioralChange cont.Changing how people around theindividual react to the challengingbehavior5427

8/14/2017Promoting Collaboration toSupport Behavioral ChangeBehavioral support planning involves designinginterventions based on an understanding ofthe circumstances affecting an individual’sbehavior and implementing thoseinterventions in the context of the individual’sregular routines and environments.55Promoting Collaboration toSupport Behavioral Change cont.People with whom the individual interactson a regular basis are an essential featureof the environment and thecircumstances affecting their behavior,both positive and challenging.5628

8/14/2017Promoting Collaboration toSupport Behavioral Change cont.Collaboration means that a team, made upof the individual, their family and friends,and collaterals from various disciplinesand environments, are engaged in allaspects of the behavioral supportprocess.57Promoting Collaboration toSupport Behavioral Change cont.Collaboration requires that systemssupport creative, cooperative activitiesrather than hierarchical structures, andextending participation in team activitiesbeyond typical roles and responsibilities.5829

8/14/2017Promoting Collaboration toSupport Behavioral Change cont.Collaboration often involves overcomingattitudinal barriers and extendingparticipation in team activities beyondtypical roles and responsibilities.59ResourcesBehavioral Health Administration ioral-health-andrecovery6030

8/14/2017Resources cont.See the handout for links to Behavioral HealthOrganizations (BHOs) and Early Adopters in Clarkand Skamania counties The DSHS BHO Development web -organizations The HCA’s Behavioral Health and Covered Services web vioral-health#coveredservices61Resources cont.Low cost storeus/browse/Social-WorkWashington/ /N8cnsul?p 1&pageSize 126231

8/14/2017Resources cont.Translations of the PHQ-9 and GAD-7The websiteis sponsoredby Pfizerhttp://www.phqscreeners.comWashington State Action Plan on OlderAdult Falls PreventionThe Department of Health is in the process of developing our first-everWashington State Action Plan on Older Adult Falls Prevention, and anessential component of this process is the Older Adult Falls PreventionSurvey. This online survey will close on August 31st. The purpose of thesurvey is to gather input from individuals across Washington State ontheir attitudes and ideas regarding falls prevention. Informationgathered through the survey will be utilized to define priorities andrecommendations in the Action Plan.Survey Link: https://fortress.wa.gov/doh/opinio/s?s 115366432