Advanced Clinical Social Work
Practice in Integrated Behavioral
Healthcare
Module 11
Interventions in Integrated Healthcare
Mo Yee Lee, PhD
College of Social Work
The Ohio State University
Module 11
Interventions in Integrated Health: Outline
Develop knowledge of intervention models used in integrated health
Brief intervention1
Patient Activation2
Behavioral Activation3
IMPACT model4
SBIRT model5
Develop knowledge of an overview of evidence-informed treatments
Develop knowledge on the principles in adapting ESTs in integrated
health
Develop skills in a solution-focused approach to intervention
Components of Recovery6
Self-Direction
Individualized and Person-Centered
Empowerment
Holistic
Non-Linear
Strengths-Based
Peer Support
Respect
Responsibility
Hope
Models in Integrated Health
Brief Intervention
Patient Activation
Behavioral Activation
IMPACT Model
SBIRT
Brief Intervention7
Intervention principles based on “Concept of Effective
Parsimony”:
Least disruptive treatment for positive outcomes
Least extensive treatment for positive outcomes
Least intensive treatment for positive outcomes
Least expensive treatment for positive outcomes
Least expensive training of professionals to provide effective
treatment
Brief Interventions: Stepped Care8
Intensity of treatment is based on problem severity and
client’s response:
Minimal educational efforts and information sharing
Psycho-educational interventions
Provide illness/diagnoses-specific behavioral interventions
If no improvement, refer to specialty mental health system
Patient Activation9
A patient-oriented care with patients and their families integrated as
members of the care team:
• Collaborative definition of problems attending to both patient-
defined and medical problems diagnosed by physicians
• Targeting, goal setting, and planning, in which patients and
providers focus on a specific problem, set realistic objectives, and
develop an action plan for attaining those objectives in the context
of patient preferences and readiness
• Creation of a continuum of self-management training and support
services, in which patients have access to services that teach
skills needed to carry out medical regimens, guide health behavior
changes, and provide emotional support
• Active and sustained follow-up, in which patients are contacted at
specified intervals to monitor health status, identify potential
complications, and check and reinforce progress in implementing
the care plan.
Behavioral Activation10
Activating clients for targeted, desirable behaviors
Monitor ongoing avoidance patterns
Behavioral activation techniques
• Scheduling behavioral activities
• Graded homework assignments
• In-session rehearsal and role playing of targeted behaviors
• Therapist modeling of targeted behaviors
• Managing situational contingencies to facilitate initiation and
successful completion of targeted behavior more likely
• Problem solving to identify specific behavioral targets
• Training to overcome skills deficits that interfere with initiation and
maintenance of targeted behaviors
Monitor Avoidance Behavior by
ACTION11
• Assess how this behavior serves you
• Choose either to avoid or activate
• Try out whatever behavior has been chosen
• Integrate any new behaviors into a routine
• Observe the outcome
• Never give up
Monitoring Avoidance: TRAP Vs
TRAC
Teach clients to identify TRAP
• Trigger
• Response
• Avoidance Pattern
Replace by TRAC
• Trigger
• Response
• Alternate Coping behaviors
IMPACT Model12
Improving Mood-Promoting Access to Collaborative
Treatment (IMPACT)
Collaborative Care Model
Onsite depression treatment in a primary care facility
Stepped Treatment
According to outcomes and evidence-based methods
50% symptom reduction in 10-12 weeks
If no improvement, change in treatment plan
IMPACT Model
Primary
Care
Provider
Patient/
Client
Behavioral
Health Psychiatrist
Consultant
IMPACT Model (Cont’d)
Behavioral Health Consultant
Depression education
Medication therapy support
Behavioral activation
Brief counseling course
Monitors symptoms and measures outcomes using a validated tool
Relapse Prevention
Primary Care provider
Works with behavioral health consultant
Consults psychiatrist if needed
Designated psychiatrist
Works with other two on patients who do not improve
SBIRT Model13
Screening, Brief Intervention, and Referral to Treatment
(SBIRT)
Substance abuse care model
Easily used in primary care settings
Attempts to screen for those who may not be seeking help
SBIRT Model
Screening
Find those at risk of substance abuse
Use a quick 1-3 question screen
Use a standardized risk assessment tool if screen is positive
Brief Intervention
Increase insight and awareness of substance abuse
5-30 min discussion regarding substance abuse
Referral to Treatment
Refer to specialized addiction treatments
Assist patients with navigation of barriers
– Financial
– Transportation
Examples of Evidence-Informed Treatments
Behavior therapy
Cognitive-behavior therapy
E.g. for treating trauma (Trauma-focused CBT), depression, anxiety
Exposure therapy
Brief dynamic psychotherapy
Interpersonal therapy
Solution-focused brief therapy
Dialectical Behavioral therapy
EMDR
Emotional-focused therapy
Family treatment approaches:
Multisystemic (MST)
Integrative Family and Systems Treatment (I-FAST)
Brief Strategic Family Therapy
Multi-dimensional Family Therapy
Principles for adapting ESTs for Primary
Care14
Embrace the Primary Care philosophy
Treat more people with less intensity
Expand the population to be served
Study/treat patients with
– other disorders (co-morbidity)
– sub-threshold symptoms
– alcohol and drug usage
Plan for cultural, linguistic, and medical diversity
Principles for adapting ESTs for Primary
Care15
Use a patient-centered approach
Deliver services in multiple formats
– Individual, group, as well as telephone sessions
Reduce treatment length and Intensity
– Use home materials and telephone consultation as well
Convert to a Patient Education Model
– Help patients to manage symptoms through education
Principles for adapting ESTs for Primary
Care15 (Cont’d)
Adopt a Relapse Prevention Focus
Protocols for detecting at-risk patients
Schedule of “booster” contacts
Team-based Intervention
Physicians, nurses, etc. manage mental health alongside
behavioral health providers
Increased communication
FLAIR Model: Selecting interventions
A process to select appropriate ESTs:
• Formulate an empirically relevant question answerable
by data (e.g., “Why do members of X racial group often
drop out of treatment?”)
• Locate the best available evidence
• Assess the quality of the evidence
• Integrate the best available evidence with professional
judgment, client factors, and social context
• Review how treatment went
A Solution-Focused
Approach
to Integrated Health
Resilience and Strengths
Change is
Non-Problem state Constant
Exceptions
Problem
Strengths
Resilience
Goal of Treatment Consumer’s Constructio
What is noticed becomes reality, and what is unnoticed does not
exist16
Power of Language
Language and reality
Reality is co-constructed through therapeutic conversation
What is noticed becomes reality and what is unnoticed does
not exist17
Pre-suppositional language: Expectation of change
Social construction
Problem and solution as client’s construction
Constructing useful questions
Constructing useful evaluative questions: Self-initiated
feedback
if it is your idea, it is not their idea
Empowerment
Initiate a process of self-assessment
Self-evaluative Questions for Initiating Change18
Exploring questions
Difference questions
Planning questions
Effect questions
Indicator questions
Exception questions
Outcome questions
Self-Evaluative Questions for Initiating Change19
Helpfulness questions
Feasibility questions
Resilience/Coping questions
Meaning questions
Past successes
Relationship questions
Scaling questions
Identifying exceptions to initiate the change process:
The Miracle Question20
Suppose that after our meeting today, you go home, do your things and go to
bed. While you are sleeping, a miracle happens and the problem that
brought you here is suddenly solved, like magic. The problem is gone.
Because you were sleeping, you don’t know that a miracle happened, but
when you wake up tomorrow morning, you will be different. How will you
know a miracle has happened? What will be the first small sign that tells
you that the problem is resolved? How will your spouse, you child (any
significant others) know that something is different?
What do you think have to be different for the miracle to start happening?
Are there times when that already happen a little bit? How come? What's
different?
What will have to happen for that to happen more often?
Treatment process that builds
exceptions and creates change
Notice
Elicit
Amplify
Reinforce
Remember and consolidate
The devil is in the details
Deciding when to focus on exceptions
Patients/clients are able to identify exceptions and the
professional is able to help them develop useful treatment
directions and goals based on this line of therapeutic dialogue
The professional observes that patients/clients are energized by
these questioning sequences and becomes more hopeful and
engaged in treatment
A process of change is triggered by this line of therapeutic
dialogues as evident by positive, specific, and behavioral
changes in the problem pattern
Identifying exceptions and use of
language21
Do use language that
implies the patient/client wants to change
implies that the patient/client is capable of change
implies change has occurred or is occurring
implies that the changes are meaningful
encourages the patient/client to explore possibilities for change
suggests that the patient/client can be creative and playful about life.
conveys recognition of the families’ evolution of their personal story.
Limit energy expended in unproductive areas such as negative,
blaming, self-defeating descriptions
Solution-Focused Tasks
Out-of-session tasks that allows people to further explore
solutions
Do more of what works
Observation Tasks
Do Something Different
Pretending task
Solution Focused tasks suggest change has already
occurred but has gone unrecognized.
Tasks are then arranged around looking for evidence of
change (looking for exceptions).
Utilizing Strengths and The Use of Tasks
There is no failure, just experimentation
Make use of whatever response the patient/client gives to
a task
Professional suggests ideas for the task, but
patients/clients must ultimately decide on a task for
themselves
Noticing and amplifying positive changes:
Go for DETAILS
What’s better
How questions
How are you able to do that?
How did you make this happen?
What questions
What have you done to make this happen?
Difference questions
Effect questions
Relationship questions
Scaling questions
Compliment change efforts
Tracking Change: Self-Evaluative Questions for
Consolidating and Sustaining Change22
Connection questions: The mechanism of change
Choice questions: Personal agency
Comparison questions: Knowing the difference
Meaning questions
Ownership questions: Personal agency
Relationship questions
Scaling questions
Compliments: Motivation and hope
Give Patient/Client Credit
The patient/client must understand change as coming
from his or her actions
Make comprehensive lists of what the patient/client did to
create change
Indicators of the presence of “Black Holes”
Blaming talk
Repetition of ideas that amplify or maintain the problem
patterns
An individual working much harder than another with no
apparent benefit, particularly if this person is the
therapist
Decreased energy of the patients/clients involved and/or
service providers
How to Respond to “black holes”
Stop whatever you are doing
Consider doing something different
Engage in the opposite of what you are currently doing,
therefore, redirecting energy to other potentially
beneficial activities that have been neglected
Principles of solution-focused therapy23
If it works, don't fix it. Do more of it.
If it doesn't work, do something different--even if
it seems illogical or crazy.
There is no failure, only feedback
Case Discussion
Maria is a 32-year-old Latino female who is currently living with her
husband (Jay, M/32) and her 2-year-old son, Kurt. Maria was diagnosed
with breast cancer three months after she gave birth to Kurt, which took the
whole family in shock. Maria went through chemo and drug treatment and
now is considered recovered. However, Maria continues experiencing
frequent headaches and sleepless nights, which seems to get worse recently.
Maria shares with her doctor that she constantly feels anxious, worry, and
unsettled during the recent follow-up check up. Maria and Jay have a
supportive relationship and Jay has a stable, well-paid job as a computer
engineer. Maria has a close relationship with her mother and 2 sisters
although she does not have an active social life and spends most of her time
at home.
Discussion questions
• Who would you collaborate in the treatment process (including
both family members and professionals)?
• What are the factors that will need to be considered in treatment?
• What is the presenting problem and from whom’s perspectives?
• What is the identified problem pattern and what are the exceptions
to the problem?
• How would you help Maria and the family to develop a useful and
attainable goal for treatment?
• Suppose you are using SFBT, what would be some helpful
intervention steps and procedures?
• Pick an integrated healthcare intervention model and propose
some potential helpful intervention steps and procedures.
References
1. Munger & Curtis. (2012) Brief treatment: A model for clinical guidelines to integrated care. in
Curtis, R. & Christian, E. Integrated care: Applying theory to practice. New York: Taylor &
Francis.
2. Von Korff, M., Gruman, J., Schaefer, J., Curry, S. J., & Wagner, E. H. (1997). Collaborative
management of chronic illness. Annals of Internal Medicine, 127 (12), 1097-1102.
3. Martell, C. R., Addis, M. E., & Jacobson, N. S. (2001). Depression in context: Strategies for
guided action. New York: W. W. Norton.
4. Mauer, B. J. (April 2009). Behavioral Health/primary care integration and the person-centered
healthcare home. Washington, DC: National Council for community Behavioral Healthcare.
5. Madras, B. K., Compton, W. M., Avula, D. et al., (2009). Screening, brief interventions, referral
to treatment (SBIRT) for illicit drug and alcohol use at multiple healthcare sites: Comparison at
intake and six months later. Drug and Alcohol Dependence, 99, 280-295.
6. SAMHSA (Feb 2006). National consensus statement on mental health recovery. SAMHSA,
CMHS.
7. Munger & Curtis. (2012) Brief treatment: A model for clinical guidelines to integrated care. in
Curtis, R. & Christian, E. Integrated care: Applying theory to practice. New York: Taylor &
Francis.
8. Munger & Curtis. (2012) Brief treatment: A model for clinical guidelines to integrated care. in
Curtis, R. & Christian, E. Integrated care: Applying theory to practice. New York: Taylor &
Francis.
9. Von Korff, M., Gruman, J., Schaefer, J., Curry, S. J., & Wagner, E. H. (1997). Collaborative
management of chronic illness. Annals of Internal Medicine, 127 (12), 1097-1102.
References (Cont’d)
10. Martell, C. R., Addis, M. E., & Jacobson, N. S. (2001). Depression in context: Strategies for
guided action. New York: W. W. Norton.
11. Martell, C. R., Addis, M. E., & Jacobson, N. S. (2001). Depression in context: Strategies for
guided action. New York: W. W. Norton.
12. Mauer, B. J. (April 2009). Behavioral Health/primary care integration and the person-centered
healthcare home. Washington, DC: National Council for community Behavioral Healthcare.
13. Madras, B. K., Compton, W. M., Avula, D. et al., (2009). Screening, brief interventions, referral
to treatment (SBIRT) for illicit drug and alcohol use at multiple healthcare sites: Comparison at
intake and six months later. Drug and Alcohol Dependence, 99, 280-295.
14. O’Donohoe, W., Cummings, N., Byrd, M., & Henderson, D. (Eds.) (In Press). Behavioral
integrative care: Treatments that work in the primary care setting. New York: Brunner-
Routledge.
15. O’Donohoe, W., Cummings, N., Byrd, M., & Henderson, D. (Eds.) (In Press). Behavioral
integrative care: Treatments that work in the primary care setting. New York: Brunner-
Routledge.
16. Lee, M. Y., Sebold, J., Uken, A. (2003). Solution-focused treatment with domestic violence
offenders: Accountability for change. New York: Oxford University Press.
17. Lee, M. Y., Sebold, J., Uken, A. (2003). Solution-focused treatment with domestic violence
offenders: Accountability for change. New York: Oxford University Press.
18. Lee, M. Y., Sebold, J., Uken, A. (2003). Solution-focused treatment with domestic violence
offenders: Accountability for change. New York: Oxford University Press.
References (Cont’d - 2)
19. Lee, M. Y., Sebold, J., Uken, A. (2003). Solution-focused treatment with domestic violence
offenders: Accountability for change. New York: Oxford University Press.
20. Berg, I. K. & Miller, S.D. (1992). Working with the problem drinker: A solution-focused
approach. New York: W.W. Norton & Co.
21. Lee, M. Y., Sebold, J., Uken, A. (2003). Solution-focused treatment with domestic violence
offenders: Accountability for change. New York: Oxford University Press.
22. Lee, M. Y., Sebold, J., Uken, A. (2003). Solution-focused treatment with domestic violence
offenders: Accountability for change. New York: Oxford University Press.
23. de Shazer, S. (1988). Clues: Investigating solutions in brief therapy. New York: W. W. Norton.
