Tag Archive: stages of change

On this day in 1904 Pavlov made his acceptance Nobel prize speech.

In his own words:

“Essentially only one thing in life interests us: our psychical constitution, the mechanism of which was and is wrapped in darkness. All human resources, art, religion, literature, philosophy and historical sciences, all of them join in bringing light in this darkness. But man has still another powerful resource: natural science with its strictly objective methods. This science, as we all know, is making huge progress every day.”

From Nobel Lectures, Physiology or Medicine 1901-1921, Elsevier Publishing Company, Amsterdam, 1967

107 years later we are still finding our way out of darkness. Pavlov’s theory remains as solid today as back then and over time came to ciment the foundation of experimental behaviorism. While no longer popular with philosophers, behaviorism remains strong in modern counseling, as seen in the evidence about the efficacy of cognitive-behavioral therapy in a variety of mind-brain conditions.

Using a CBT framework, you might think of symptoms, including Axis I symptoms or personality traits, as habits or, in pavlovian terms, conditioned reflexes. The treatment needs to extinguish undesirable behaviors, while creating “better” conditioned behaviors.

How do you do it?

Lack of practice results in extinction.

Lots of practice results in new habits.

Certainly true but easier said than done.

The essential ingredient that is missing in the above picture is will. Which the behavioralist can think of just another behavior that needs to be modified. However, how can this be done in a world that banishes behavior modification based on the preeminence of free will?

Solution: you need to find a way to convince your patient to go on your hand, i.e. abandon free will till recovery. Which is a risky proposal. Strong handed approaches or advice giving are unlikely to work. Alternatively, you need to find a way to engage, motivate, or persuade your patient about the right course of action.

In other words, if you are to be an effective behavioral therapist you need to first master the skills of motivational enhancement.

Past Psychiatric History

There are many things you can ask but here is a minimalistic list of informative data:

1. How many visits to a psychiatric ER?

Too many to count“: usually indicates a severe Axis  I disorder (psychotic or affective), personality disorder, moderate (or more) panic disorder, somatization disorder, or secondary gain (which can also be part of a personality disorder). Very few or none (esp. in an older patient) usually rule out Axis II.

2. How many of the above (ER visits) were followed by hospitalization?

Most of them“. Balance tilts toward Axis I. Most of them were not: balance tilts toward Axis II.

3. How many psychiatric hospitalizations total?

Too many to count: reserved prognosis (due to chronicity, dual diagnosis or Axis II comorbidity). Consider non-compliance and dual diagnosis. Just a few/none: good prognosis.

4. What was the chief complaint/reason for most of the hospitalizations/ER visits?

Great screening question. Voices or paranoia versus depression with suicidal ideation will greatly focus further inquiry.

5. What was the longest hospitalization?

I started to appreciate this question after one patient told me his been hospitalized only twice before. I was puzzled and had a difficult time understanding the mismatch between his level of dysfunction (which was pretty significant) and the very low number of hospitalizations. It turned out that his second hospitalization was 12 years long, in one of the state forensic facilities. So, while the total number of hospitalizations is informative, what really matters (when it comes to prognosis and understanding dysfunction is the total duration of the time one spend inpatient).

6. What medication(s) worked the best/was the worst?

Good question to further narrow the differential. Also, it will save you time to cross off the list ineffective/poorly tolerated medications. Futher, usually there is no need to reinvent the wheel: if a specific intervention worked once, change is that it will work again (the exceptions here is a medication tachyphylaxis reaction, more commonly known as “poop out” phenomenon, where a medication that is effective stops working)

7. Is there a history of noncompliance? Why?

Two benefits: 1. Gives a good measure of the patient’s insight. 2. Places the patient on the stages of change continuum and thus allows you to tailor your intervention accordingly.

8. Were you using drugs around the times when you got hospitalized?

If the answer is”yes, time and again” you should re-asses what’s primary versus secondary.

9. Tell me what’s the most violent you’d ever been.

Open ended increases the chance to get a valid answer.

10.  Did you ever find yourself wishing to be dead?

Suicidality is a sensitive topic. Go straight for a past history of attempts you might put the patient off. Also, your range is too narrow. Start with a broad question and follow up with more specific questions (use a concentric approach) and you will get more honest and comprehensive (thus also more valid) answers.

Stages of Change

I find Prochaska and Di Clemente’s model of change a very useful guide for my first encounter with a new patient.

We see people who have issues.

The important question is: on the change continuum, where does your patient place himself regarding his ability to engage in change work? A practical question as the answer will inform your intervention as much as current Axis I symptoms and personality dimensions.

Case and point:

Approaching an already committed to change patient with an educational agenda is poorly timed at best, and, at worst, unproductive and even irritating to the patient. It is an equal waste of time to approach a precontemplator with a list of change promoting interventions (which would be much better suited for patients already are in a preparation or action stage).

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