Posts Tagged ‘integrated healthcare’

I’d been meaning for a while to write about my experiences with motivational interviewing, and specifically the aspect of non-judgment in it, at my job but I guess I haven’t done that yet.

I was reminded of this recently though when I had some personal training sessions at my new gym. Which left me thinking that boy, personal training certifications should also come with motivational interviewing training!

Of course, I always think everyone in the world would benefit from a little social work training, so I’m a bit bias of course.

Let me back up first though and talk a bit about my experiences with this at work. Motivational interviewing is a method of brief intervention that is meant to help motivate people to change, but it does so in ways that are not pushy and never judgmental. Many of the underlying principles of motivational interviewing come out of person centered therapy as developed by Carl Rogers. I, myself, am a huge Rogers fan. His theory for psychotherapy is that change for people comes through unconditional acceptance and positive relationships, and so that is the primary purpose of a psychotherapist- to provide that unconditional positive regard and warm relationship.

Motivational interviewing comes primarily from the substance abuse field. It is a method of working with someone who maybe is starting to see the problems with their substance use but often are not ready to make changes yet. We call this the contemplation stage. And the idea is first off, that you go with what they say and accept it without judgment. There is not judgment about their use, their reasons for use, or their reasons for not wanting to become sober. Of course the motivational interviewing part comes in with emphasizes the change statements they themselves make in order to help them move toward wanting to make changes. But it is NEVER directive. A therapist using motivational interviewing will never direct a client that they need to abstain from substances, or tell them that they are wrong for their reasons for using or the things they like about it or why they don’t see it as a problem. (ie “I don’t want to stop using because I will lose my friends”, “well those people aren’t really your friends then”- this is not motivational interviewing. Motivational interviewing would explore what this means for the client and accept without judgment that they fear losing meaningful relationships to them if they quit using).

Right now I am working in integrated healthcare. So I work with folks with physical health, mental health, and/or substance abuse disorders. A lot of what I do with this is actually applying the concepts of motivational interviewing to physical health disorders. A big one I work with is diabetes. And boy, have I noticed what a huge difference it makes in folks that they are not being judged! If I talk to someone with diabetes that is not well controlled about their diet, often they first thing they say is “I know, I know, I need to stop eating/drinking X” or something like that. They know. They have gotten the lecture many times from doctors and nurses. And those lectures don’t work. The tone completely changes though when I don’t respond by telling them what they have to do, or warning them of all the dangers of not doing what I tell them (the most common approach taken by doctors). From there, they often start talking about their own ideas for how they can make changes that make sense for them.

“I know, I shouldn’t put sugar in my coffee because of my blood sugar. I just can’t stand black coffee and I can’t get going in the morning without my coffee.”

“That makes sense, you need that boost of energy from coffee in the morning but you don’t like the taste of black coffee. And that would be a huge change to go from that much sugar to just black coffee.”

“Yeah, exactly. Though I think I could maybe cut down on the sugar a little bit”

“Yeah, cutting down a little bit would help and it would probably be less harsh of a difference than just trying to drink coffee black when you aren’t used to that.”

And then we explore more about how they feel about this and what their thoughts and plans are. They are used to being told though that they just shouldn’t put sugar in their coffee and that’s not a change that they are ready or willing to make. So they sit through the lectures and don’t do anything differently after.

 

I was reminded of this when I went through personal training at the gym because the trainer I worked with was very directive. And that did not work with me either. I like working out, but personal training made me feel like I was taking a class, with directions I had to follow whether they were what I wanted or not, and with homework and scolding if I didn’t follow directions or didn’t do the homework. (ok, so “scolding” might be a drastic way of phrasing it, but still, it was that feeling of having to do what you are told and if not you are “in trouble” in some sense.)

There were of course a few specific issues I had too. I told her early one what my goal in joining the gym was- about my current limitations, but how I want to regain the former activity and strength I had.

She accepted my comment that I was not trying to focus on weight loss, only to turn around and tell me how I needed to focus on fat loss. As though rephrasing it that way made it different.

Even though my focus was activity she also made nutrition the focus, telling me how I had to stop intermittent fasting. She also claimed this was both the reason I am fatigued all the time (not my illnesses!) and also why I’m fat. I do not react well to people who do not have the same health issues trying to explain to me the right way to deal with fatigue or the magic cure for it. Even someone who also struggles with chronic illness and fatigue, doesn’t mean their experiences are the same as mine.

The thing is, these topics probably could have been covered a lot better using a more motivational interviewing method. First off, motivational interviewing, if I say I am focused on activity more than nutrition we would focus there, not try to keep redirecting me back to nutrition. Advice would never be directive or one size fits all. She could have asked me how to I feel about intermittent fasting, how it works for me, if I want to change it (the answers would be that I feel better eating this way and no I do not want to change that). She could have asked if there were things I wanted to change, what they were, what my barriers to change are, how things might be different without those barriers, how to address those barriers, whatever. I’m not saying my diet is perfect all the time or that I couldn’t eat in a way that is healthier for me sometimes, including eating in ways that help me manage my illness better. I’ve written here before about the struggles of my illness making eating well more difficult, and yet when I don’t it can make my illness worse. It’s a bit of a catch 22 at times, because if I don’t have the spoons to cook, I don’t have the soons to cook. That’s how spoons work.

 

And I don’t mean to sound that mean toward her or anything because I could go through a lot of things I think she also did well working with me! And the reason I didn’t continue with the personal training was mostly financial (and in a related sense spiritual). My point was more so that being on the receiving end of that really had me thinking how much better (in my opinion) things like personal training could be if they utilized more motivational interviewing skills.

So I think I mentioned before that my new job is working in integrated healthcare- integrated physical, mental, and substance abuse healthcare.

And so at work there is a lot of talk about people dealing with chronic physical illnesses, and also mental illnesses. Both of which I fall under, and feel a little awkward at times about because I’ve never had cause to mention these factors at work, and particularly when talking about people with them it brings to mind my typical awkward feelings around the fact that coworkers looking at me would likely assume such things don’t apply to me.

In a recent training we talked about this 4 quadrant model for physical health and mental health.

(phrasing here is all mine, so I may be off in terms of what the official terminology is meant to be)

Quadrant 1 is people with low physical health problems and low mental health problems- someone who is generally healthy but may need to see a doctor for an injury, acute illness, and may see a therapist to deal with depression or stress during times of particular upset in their lives but does not have a severe and persistent mental illness.

Quadrant 2 is people with low physical health problems but high mental health problems.

Quadrant 3 is people with high physical health problems, but low mental health problems.

Quadrant 4 is people with high physical health problems, and high mental health problems.

As we are talking about this, and the trainer makes a comment how we may be people who fall in quadrant 1 and how that is a very different experience with the healthcare system than someone in quadrant 4… and I’m like, actually I would say I alternate between Quadrant 3 and Quadrant 4 as my depression is somewhat intermittent (typically dependent on how my physical health is), but certainly at times quite severe.

Which is also interesting to me, in mental health there are positions for peer specialists, and in my required trainings when I started the job there was a lot of talk about how peer specialists were created to recognize the benefits consumers bring to the table, and having someone who understands these experiences. Now, I wouldn’t fit the role of a peer specialist in a community mental health setting because I’ve never been a community mental health patient/consumer/client. But one thing that stands out to me in how this is talked about is there seems to be this idea that people are either mental health professionals with advanced degrees and licensing, or people with mental illnesses (or in integrated care, you could say physical illnesses as well). There still doesn’t seem to be any recognition that the people with degrees, and professional licenses, may also themselves have chronic illnesses.

And while I’ve never talked about it at work, I do think I have a benefit in this work being someone who has chronic illnesses, not struggled with not being able to afford care for them as well. Many of the things I’m told about what clients may do are things I’ve been through too. I understand all too well when you decide you just aren’t seeing a doctor anymore for your chronic illnesses because they never seem to help and the only thing you see from it is less money in your wallet/bank account. I’ve not had prescriptions filled or been inconsistent in taking them because I couldn’t afford them. Et cerera, et cetera. And I think really understanding that situation is a benefit, compared to someone whose never been through that.

Random closing thought though, whenever I think about this topic, I also think about my pill organizers, and so I have to say, for anyone who takes a lot of medication- especially if some are rather large- I highly recommend these 7 day organizers.

My 7 day 4 compartment pill organizers after my weekly pill prep

These are the ones I have, which have 4 sections each day. They also have ones with 3 sections, or 2 sections for each day. For the record, I am not being paid or asked to promote these by the company, though if they would like to pay me for promoting their products I would be totally amendable to that. But this is just my own love for these containers, and wanting to let other people who may benefit from them know about them.

What I like them are that each day is separate and so I can carry just one day with me in my purse, compared to most weekly pill organizers you see. I’ve had people recommend those really big organizer that are one big thing with 7 days in the week and 4 times slots for each day- but that’s only really convenient if you are home all day to take them. And it may be the best option if you are, but for someone like me- I’m often out of my house at times I need to take my meds, and I can’t carry around that big, whole week organizer with me! Also most pill organizers have small compartments! Which is fine if you take a few small pills, but if you are taking pills that are large (as I do) they don’t all fit in those typical small pill organizers. These are an inch deep and really do hold a significant amount of pills for each time slot. Also they are colorful and that’s always fun 🙂 Oh, and they are easy to fill. You can pull the plastic tops off completely to fill them.

Unfortunately they don’t have any for over 4 times a day- which is something that is really lacking in pill organizing products. My grandmother used to have to take medicine 6 times a day and I remember what they did for her was use one of those week organizers and just relabeled each compartment for a time instead of a day and had to set it up for the next day each night.