laura heesacker, lcsw behavioral health innovaon ... · laura heesacker, lcsw behavioral health...
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Conversa)onsAsMedicineCompassion-BasedDifficultConversa)ons
LauraHeesacker,LCSWBehavioralHealth
Innova)[email protected]
IHAVENOTHINGTODECLAREINREGARDS
CONFLICTSOFINTEREST
IWORKWITHJCCANDHOLDA
CONTRACTW/THESTATEOFOREGON-PDO-CDCGRANT
Iwanttothankthepar)cipantsforaFendingandCentralOregonforInvi)ngme
GeneralObjec)ves
1) Suggest4trapsaprovidercanfallintowhilehavinga“difficultconversa)on”
2) Offer4guidelinestoapplywhilehavinga“difficultconversa)on”
3) Offer4toolsthatcanbeusedduringa“difficultconversa)on”
ThePowerof4
• 4Traps• 4Guidelines• 4Tools
Doesiteverfeellikeyouhavesteppedintoatrap?
InspiredbyBradAnderson,MDKeiser
”GivenallthatIhavebeenthrough…youjustwantmetosuffer?”(CompassionTrap)
“IfyoucutmeoffIwillloosemyjobandbecome
homeless!”(AllorNothingTrap)
“Areyouaccusingmeofbeinganaddict?”
(Addic)onLabeling/GuiltTrap)
“Don’tbotherwithanyothermeds,I’lljustkill
myself.”(Desperate/Threatening
Trap)
Whatisgoingon?????• About1in4misusingandabout1in10aredeliberatelyusinginawaythatmightresultinharm-KevinE.Vowles,UofNM
• About1in4pa)entsreceivinglong-termopioidtherapyinaprimarycaresebngstruggleswithopioid-CDC
• Powerof1/3rds-(Recep)ve,Ambivalent,Resistant)-M.Parchman-MacCallCenterandanecdotalexperience
ThePowerof4
• 4Traps• 4Guidelines• 4Tools
4Guidelines1) Reframemanipula)on/Aggression(It’saboutsurvival)
2) ConfidenceinyourselfandyourPt(Mantra-”Icandothiswithcompassionandgrace”)
3) ExpectaPonsneedtoberealis)c(AgreeingtoDisagree,mostptsleaveunhappyatfirst)
4) Safetyisjob#1(StayCalmandTaketheReigns,theseptsareyourcharges)
Beitfear,addic)on,dependence...Thebrainseestheopioidassomethingnecessary
forsurvival
Whyisitseenasthis?It’snotpersonal.
TrueorFalse? Someone who is
drowning is a personality disordered manipulative jerk who is trying to hurt you?
False
ThePowerof4
• 4Traps• 4Guidelines• 4Tools
GripeandTreasureHunt!
ListeningandValida)onvs.
ProblemSolving
“ListeningisDoingSomething…Theopiumhazegraduallydrawsback.Itbecomeslesslikeaninterveningbarrierandmoreandmorelikeanauraemana)ngfromthepa)ent.”
SeeingthePaPentThroughanOpiumHazeBalintGroups-2016
JohnMuench,MD,MPHDeptofFamilyMedicine-OHSU
4Toolsforthe-“DifficultConversaPon”
Ac#vate
VEMA
PsychologicalFlexibility
VEMA
Inspired by Anthony J. Mariano, PhD-VA Health System-Clinical Director Pain Clinic
Valida)onintheExamRoom
• “YouaretellingmethatyourpainisreallyterribleandIhearyouand…”
• “Ibelieveyourpainisrealandthisisareallyhardsitua)onand...”
• “IpromiseIwills)ckbyyoursideand...”• “NothinghasworkedinthepastexceptRxopioidsand...”
“Iputmyhandovermyheart,Ileanin,andsay,“Icareaboutyouandthisisaboutyour
safety,weneedtomakesome
changes”
Thiscanbeveryhardwork!
81%ofprescriberssaidtheydon’tenjoyworkingwiththispopula)on
77%saidtheydon’thavetheskillsneeded!
Valida)onmustbeauthen)candgenuine.
Valida)onisnot
synonymouswithapproval,agreement,orsympathy.
• Disbeliefthat“my”pa)entismisusing/abusing• ReducedPtsa)sfac)on(pricetag)• Theseconversa)onstakemore)me(pricetag)• Notenoughteamsupport• Notenoughnon-opioidtxop)ons• Ptwon’tagreetonon-opioidtx• Providerdoesn’t“buy”thescience• Discomfortwithexpressedemo)ons/guilt/shame• Itishardtobeinthefaceofsufferingandfeelhelpless
Validatethen…Educate
“Thescienceofopioidsforchronicpainisclear:forthevastmajorityofpa#ents,theknown,serious,andtoo-o>en-fatalrisksfaroutweightheunprovenandtransientbenefits.”
March15,2016
TheU.S.SurgeonGeneralTakethePledgeturnthe)derx.org
ASHEALTHCAREPROFESSIONALS,WEBELIEVEWEHAVETHEUNIQUEPOWERTOENDTHEOPIOIDCRISIS.WEPLEDGETO:1. Educateourselvestotreatpainsafelyand
effec)vely.2. Screenourpa)entsforopioidusedisorderand
provideorconnectthemwithevidence-basedtreatment.
3. Talkaboutandtreataddic)onasachronicillness,notamoralfailing.
6thAnnualPainConferenceMay4,5,and6,2017
• Free-XWaiverCMEbyOHSU• DayofDifficultConversa)onsWkShops• BehavioralMedicine-CBTandMindfulness• CommunityForum-forthepublic• Dr.DanielClauw-CentralSensi)za)on• WorkshopsbyleadingexpertsintheNa)onNewAshlandVenue-Shakespeare-Winery's,etc.
[email protected]/OregonPainGuidance.com
Whenyouchangethewayyoulookatthings…
thethingsyoulookatchange.
TheLateDr.WayneDyer
Conversa)onsasMedicine
Theparadigmshia
7thAnnualPainConferenceinAshlandonMay4,5,and6,2017-Oregonpainguidence.com
CompassionTraps• Pa)ent: “Doyouwantmetolosemyjob,doyouwantmetobeonthestreet?”
• Provider: Iwantyoutohavesafeandeffec6vepaincontrolanditismymedicalopinionthatyourcurrentmedicinewon’tgiveyouthat.
• Pa)ent: “Doyouhavepain?”• Provider: Iwanttouseeveryminuteofour6metodaytotalkaboutyourpainmanagementplan.
• Pa)ent: “Iwishyoucouldfeelmypain.”• Provider: Iknowyou’resufferingandI’msurethatwecanworktogethertoreducepain,soyoudon’thavetosuffer.
AllorNothingTraps• PaPent: “Soyou’regoingtodonothingformethen?”• Provider: “Iamconfidentthattogetherwewillfindsafe
andeffecPveopPons”• Pa)ent:“You’recubngmeoffandIhavetolivewithmy
pain?”• Provider: Therearemany,manythingsthatpeoplewith
chronicpaincandootherthanopiatestomanagetheirpain.Wouldyouliketohearaboutthem?
• Pa)ent:“I’vetriedallofthatstuff,noneofitworks.”• Provider: Iwanttohearwhatyou’vetriedsowecanfind
awayforittobemorehelpfulthis6me.
AddicPonLabelingTraps:• Pa)ent:“Areyouaccusingmeofbeinganaddict?”• Provider: Ihaveneveraccusedanyoneofdiabetesbut
I’vediagnosedhimorherwithitandthatiswhatIamtryingtonow,diagnose.
• Pa)ent:“Don’tlabelmeasadruggie”• Provider: Ihavenointerestinlabelsatall;Iam
interestedinhelpingpeoplewhoarestrugglingwithmedicalproblems.
• Pa)ent:“Soyou’rebasicallysayingthatI’majunkie.”• Provider: I’msayingthataddic6onisamedicalproblem
thatrespondstotreatmentnotaproblemofbadmoralsorbehavior.
DesperateandThreateningTraps• Pa)ent: “Iheardit’sillegalforyoutoletmegointowithdrawal.”• Provider: Withdrawalisuncomfortablebutnotlife-threatening,Ican
prescribeyoumedicinestohelpwiththewithdrawalsymptoms.• Pa)ent: “I’lljustgoanduseheroin.”• Provider: IfthereisanypossibilityofthatIwouldliketotakeaminuteand
exploreyourrela6onshipwithopioids…doyoucurretnlyuseherioin,haveyouuseditinthepast,doyouhaveaccesstoit?”
• Pa)ent: “Don’tbotherwithanyothermeds,I’lljustkillmyself.”• Provider: Ineedtoaskyousomemoreques6onsaboutyourthoughts
aboutsuicide.• Pa)ent: “I’mgebngalawyer(themedicalboard,yourboss,etc..”• Provider: Youdowhatyoufeelisright,ofcourse.That’swhatI’mdoingfor
you,too.• Pa)ent: “Iamgoingtofindoutwhoyoulovemostintheworld,killthem
andthenkillmyself”• Provider: Pickupyourcellphoneandcallthe911,withaslidleemoPonas
possible.
Endgame• Pa)ent:Behaviorisangry,despondent,avoidant,etc…• Provider:“Atthispoint,Isuggestweagreetodisagree,
whatIhavelaidoutiswhatIbelievetobethesafestandmosteffec)vecourseofac)onrightnow.Now,howdoyouwanttospendtherestofour)me?”
• Pa)ent:“Ihateyou,Iamleaving,yousuck,etc.”• Provider:Itisunderstandablethatyouareupset,itismy
jobtokeepyousafeandIcareaboutyou.Youarefreetogoany)me,IwillbehavingmyMedicalAssistantcallyouinthenextcoupleofdaystocheckonyouandinviteyoutocomebackintotalktoaboutnextsteps.
7thAnnualPainConferenceinAshlandonMay4,5,and6,2017-Oregonpainguidence.com
“Confidenceandbeliefare#1”MichelleMarikos,PLCP,PeerSpecialistExtraordinaire
ConfidenceandBeliefs
BELIEFinyourpa)ent’sability
toliveopioidfree
BELIEFinnon-opioid
managementstrategies
BELIEFinyourabilitytohavethisconversa)on
CONFIDENCEinpartnershipwith
yourpa)ent
CONFIDENCETocon)nuecaringfor
yourpa)ent
CONFIDENCEtotaperwithyourpa)ent
“It’sNotLikelyWeWillBeSibngAround
SingingKumbaya”
HaveRealis)cExpecta)onsofaposi)veoutcome
ReframingSuccess
AgreeingtoDisagree
• LayingtheGroundworkforfutureappointments,whenyoudon’tgetbuyin
• Tellthepa)entyouwillbehavingyourMAcallinthenextfewdays
• Invitethepa)enttocon)nuetobeyourpa)enteveniftheyfireyou
AVaria)on
FindaPartner(youdon’tknow)
PersonA:Yourpartnerhas“thekey”youneed,useaformofthe“CompassionTrap”toaFempttogetit.PersonB:Youhold“akey”anditisnotsafetogiveittoyourpartner,use:• Valida)on• Safetyis#1• Createamantra
WordsMaFerJANINEBERA,MD,,KAISERPERMANENTEWhenItalkwithmypa)entsaboutopioids,I’vefoundthatwordsreallycount.Howwetalkaboutopioidsaffectsthewaythatpa)entsunderstandtherisksandbenefits.Butusingtherightwordsisalsoaboutconveyingempathyandshowingthatmypa)entandIareworkingtogethertowardsthepa)ent’sgoal.Thegoalisprobablynotaboutbeingpainfree,butabouthelpingthepa)entdothethingstheywanttodoevenifpainispresent.Forexample,whendiscussingtaperingoffopioidsinmyownprac)ce,I’vebeenusingtheword“habituated”–andit’sbeenworkingmuchbeFerthan“addictedoroverusing.”Thishelpstokeepmypa)entlisteningandopentoop)ons.Theydon’tfeelshamefulorlikeadrugaddicttheyhaveseenonTV.Ithelpsthemtounderstandthatthereasontheyareusinghigherdosesmaybebecauseofthewaythedrugworksintheirbodyandnotthattheyaregebngintoxicated.Sayingtheyarehabituatedalsohelpsthemtounderstandwithdrawalandtoprepareforit.
Avoid “hot” phrases (6 of 6)
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BlindSpots/Triggers
Thesubstance(andassociatedcontextsandbehaviors)becomeserroneouslyvalued(rewardedandremembered)aswouldsomethingnecessary
forsurvival.
DifficultConversa)onYouTubesPosiPveUDS-Version1hFps://www.youtube.com/watch?v=Yua_g587x8(2.23min.)Contractviola)on,earlyrefiland+THC-PCPConfron)vePosiPveUDS-Version2hFps://youtu.be/_-U-McHl_EY(4:22Min)Contractviola)on,earlyrefiland+THC-PCPCompassionateDetachmentDiversionhFps://www.youtube.com/watch?v=qsVmetxWWIM&feature=youtu.be(3.10min)-UnexpectedUDS(nega)veforRxopioids)DifficultconversaPons(Erin’sscenario)hFps://www.youtube.com/watch?v=WMASyreKIIc&feature=youtu.be(5min)E.Krebs-QualityofLife,Value-DrivenChangestoRx(tapering)
GuidingPrincipals-ErinKrebs
• KeeptheprimaryfocusonoutcomespaPentscareabout
• RedirecttheconversaPontofocusonwhatpaPentscandotoimprovetheirqualityoflife.
• Whendiscussingrisk,focusonthedrugsandtheharms/sideeffectsopioidscancause.
• AvoidbackingthepaPentintoacornerandusedshareddecision-makingtoaddresspaPentconcerns
• BeyourpaPent’sallybyexpressingempathyandsupportfortheirconcernsanduncertainPes.
ParallelProcess/Countertransference
“Neitheroneofuscouldstandtobewiththehorrific
emo)onalpainshelivedwitheveryday!”