Transcript Session 3: Motivating Families to Address Mental Health Concerns

Eleanor Mackey, Ph.D.
Gail Avent
Lakeshia Lewis
Disclosures
 No relevant disclosures.
 No relevant conflicts of interest.
 There will be no discussion of off-label use of
medications.
Learning Objectives
 To recognize barriers to following referrals for mental
health services
 To learn some Motivational Interviewing techniques to
improve follow-through
 To learn ways to educate families about mental health
care
Overview
 Barriers to following mental health recommendations
 Use of brief education
 Use of Motivational Interviewing
 Patient Examples
Why is this relevant?
 Pediatricians see many children with emotional and
behavioral difficulties which impact their functioning
 Mental and behavioral health services can deliver
treatments that work
 No-show rates for initial treatment sessions range from
48-62%!
 How can pediatricians help families follow through?
Potential Barriers
 Family feels judged
 Concern “physical” problems not taken seriously
 Misunderstand recommendation or purpose of referral/Do not
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understand what mental health services can do for them
Do not agree that this is a problem/May not want to believe their child
has a mental health concern
May not want to “stigmatize” or label by seeing a mental health
professional
May not believe in benefit of mental health services
Competing stressors/priorities
May have difficulty getting to or affording weekly therapy sessions
Example
 Example of barriers from Lakeshia
Motivational Interviewing
 The first step is to help the parent/child see how
making a change (with the help of a professional) can
improve their lives.
 Motivational Interviewing a helpful tool
 Quick
 High Impact
 Culturally sensitive
Example
 Joe is a 7 year old boy who comes in reporting frequent
stomachaches. It becomes clear that he is very fearful,
has trouble sleeping on his own, is scared to go to
school, and is having difficulty making friends.
 Other relevant information is that he lives with a
single mom with 3 other children. They do not own a
car and financial resources are tight.
Start with Motivational
Interviewing
 Goal is for the family to identify that they believe life
would be better for Joe to have less anxiety and feel
motivated to treat it
 Can get there by guiding them to identify that these
behaviors could change and, if so, could improve life
for Joe and his family
Questions to improve motivation
 What are your hopes for Joe in terms of how he feels about
going to school or separating from you or making friends?
 How do you think Joe’s life would be different if these
things were easier for him?
 What are some of your goals for Joe?
 Joe, if you woke up tomorrow and these things, like going
to school or talking to other kids, didn’t bother you so
much, what would it be like?
Questions, continued
 Other questions to the child:
 If you had a magic wand and could use it to make three
wishes to change something about your life, what would
they be?
 If you woke up tomorrow and those things were
changed, what would that be like for you?
Questions for the parent
 I imagine it is not easy to manage getting to appointments
with your job and childcare. You are here today, which is
great – how were you able to manage it today?
 Are there resources you have that help you for coming to
see me that you could use to help get Joe to other
appointments as well?
 What do you need to support your efforts to help your
child?
 Goal is to help the parent feel like a partner and the most
important team member in helping their child
Examples: Gail
 My son was diagnosed with Oppositional Behavior
Disorder at the age of 9 years old. I was very reluctant
to believe my child was not normal. He had suffered
trauma during a very difficult divorce.
 After my son returned home, I began to notice lots of
negative behavior in the home and school. I took him
to Children’s for help after he cut superficial wounds
on his wrist.
Examples
 The pediatrician carefully listened as I explained my son’s
behavioral history and gave me a referral to a therapist. It was
very difficult to acknowledge my son had mental health issues.
 The difference for me was when the pediatrician said to me, “I
don’t know where this is going to lead you, (in terms of
treatment) but stick with him because he is going to need you.”
So, I did just that. I attended sessions with my son and began to
read everything I could about his diagnoses and other mental
health illnesses.
Examples
 Over the years, I reflect back to the pediatrician’s statement
and am glad I did not give up on my son.
 For a lot of parents who learn that their child has mental
health challenges, they (the parent) need to feel empowered
with information and supported by professionals and others.
 Parents can accept responsibility better when they believe that
whatever the situation is about their child, it will be objectively
viewed without blaming and shaming. Parents want to be
partners to help you help their children.
Education
 Second step is brief education
 Once you have the family motivated that changes
would be important, tell them how a mental health
professional can help
 Parent and child need to understand what a
mental/behavioral specialist is and does and how this
is relevant to their concerns
Follow-up Education Statements
 Thoughts and feelings like the one Joe is having are not
uncommon, but it sounds like they are making life difficult
for him and you both would like for them to improve.
 In addition to making sure that we understand his stomach
pains and that we are managing those, it may be helpful for
him to see a professional who has expertise in helping
children with the worries Joe is having.
Follow up Education Statements
 I would like to refer you to a specialist to help Joe.
Would you be willing to try, since it sounds like both of
you would like to see improvement?
 Like coming to see any doctor, this specialist would get
more information about when, where, and what
happens. They will use well-known treatments to help
him feel better by learning new skills and ways to
manage his body’s response to worry.
Follow up statements
 Behavioral health specialists usually see kids once a
week for a few months. This allows them to truly teach
kids how to use and practice new skills that can help.
 Remember, that the brain is the most powerful part of
the body and works like a muscle. A behavioral health
specialist works like a coach and teaches you new skills
and then helps you practice them so you can get good
at them.
Follow up statements
 As Joe’s parent, the therapist will also be able to help you learn
ways to help Joe. He can practice during each appointment, but
as his parent, you will be able to help him the most each day, so
you will also be part of the process. You may find that these skills
you learn help your other children too!
 You will be the most important team member for your child. You
know him/her best and are the one on the ground able to help in
real world situations. A behavioral health specialist will be able
to support you in this role as well.
Wrap up
 At this point, provide some referrals. Make sure, if possible, to refer to
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places nearby the family and with convenient hours in order to reduce
barriers to attendance.
Ask if the family has any questions or concerns. Be particularly aware of
the fact that they might have questions about what caused this
problem for their child. They may need you to be optimistic and
realistic about likelihood of success in treatment.
Ask when they will call to set up an appointment.
Remind them that they may have to call a few places before they get an
opening.
Always tell them that they have to feel comfortable with a provider, so
if they start somewhere and after a few appointments don’t feel it is
helpful, don’t give up, but try another resource on the list.
Summary
 Keep in mind barriers family might be experiencing
 Use motivational interviewing questions for a quick
way to get families to buy into need for services
 Once you have buy in, give some education about what
mental health specialists do and why it is useful