The Use of Acceptance and Commitment Therapy with Hemodialysis Patients

1
The Use of Acceptance and Commitment Therapy
with Hemodialysis Patients

• Mary Rzeszut, MSW, LCSW
• Winthrop University Hospital
• Mineola, New York

2
Can We Do Something Different?

• 60 of patients with chronic disorders adhere
  poorly to treatment regimen
• Estimated that 50 of dialysis patients do not
  adhere to at least part of their treatment
• Depressive symptoms are present in 30 of
  dialysis patients
• Teams or facilitys approach causing patient
  resistance?
• Journal of Clinical Epidemiology, 2001
• Seminars in Dialysis, 2001
• Nephrology Nursing Journal, 2010

3
Expectation of Medical Model

• Educating patient increases understanding and
  reduces anxiety
• Health care team leads patient toward taking
  correct action with regard to treatment and
  disease management
• Patient will want to take correct action in order
  to produce good outcomes
• Psychological factors and patients behavior are
  important but secondary to primary task of
  dealing with condition

4
Causes of Patient Resistance

• Patients self-blame and guilt if belief illness
  was self induced
• Denial- talking about illness makes it real
• Expect to find a cure Receive a transplant
  soon
• Patients sense of being labeled or judged by
  team
• (difficult, angry, non-compliant,
  depressed)
• Clinical urges to fix, to reassure" or to
  advise patient
• Feelings of anxiety, shame, and vulnerability
• during every treatment (whether expressed or
  not)

5
(No Transcript)
6
What Can We Do?

• Patient Centered Care
• National Research Corporation

7
Psychosocial Interventions Maybe Helpful

• Difficulty coping with adjustment to disease
• Anger displayed through acting out behavior,
  self-medication with drugs or alcohol, or
• non-adherence
• Tool to assist in breaking through resistance
• To meet demands of CMS to regulate and control
  hospitalizations and medical outcomes

8
Considerations When Applying Interventions

• Patient should have a life goal
• Proceed at patients pace, avoid persuasion.
• Education of medical condition important but
  often insufficient for behavioral change.
• Need constant support due to complications from
  illness
• Expect relapse or setback

9
Overview of Case Study

• Patient is a 49 year old single male
• Abandoned by his biological mother at birth and
  adopted at the age of 13
• Never married and has limited support network
• Suffered from two major losses, his father and
  fiancé
• Lives alone and works part time
• History of drug and alcohol abuse and has been
• incarcerated for dwi and assault
• Still drinks occasionally and smokes marijuana
  

10
Overview of Case Study

• Had an acute diagnosis of ESRD
• From onset of hemodialysis treatment was
  non-adherent
• Missing on average 2-4 treatments a month, one
  month missing 7 treatments
• Displayed constant anger towards unit staff
• Displayed feelings of hopelessness towards life

11
Therapeutic Goals

• Desired therapeutic outcomes were
• 1) to increase hemodialysis treatment
  adherence to prescribed dialysis regimen
• 2) to increase patients quality of life and
  achievement of life goals

12
Acceptance and Commitment Therapy (ACT)

• Considered a third world modern cognitive
  behavioral therapy(CBT)
• Contrary to traditional CBT
• Mindfulness-based, values-oriented behavioral
  therapy

13
Acceptance and Commitment Therapy (ACT)

• Teaches mindfulness skills to address
• painful thoughts and feelings effectively
• To have less impact and influence
• Clarify whats important and meaningful
• To inspire and motivate to set goals
• Take action that enriches life

14
Acceptance and Commitment Therapy (ACT)

• ACT has two therapeutic goals
• Accept what is out of our personal control
• Commit to taking action that enriches life

15
Acceptance and Commitment Therapy (ACT)

• ACT consists of six core processes that are
  divided into two main components
• Mindfulness and acceptance processes
• Commitment and behavior changes

16
Mindfulness and Acceptance Processes

• Acceptance willingness to experience any degree
  
• of psychological distress
• Cognitive defusion techniques designed to alter
  the
• context of ones thoughts, especially those
  that
• produce harm
• Self-as-context a persons view of themselves
  based on what they are currently thinking and
  feeling
• These three processes help transform the
  cognitive and
• emotional barriers that stand in the way of
  obtaining a value driven life

17
Commitment and Behavior Changes

• Contact with the present moment closely
  monitoring how one is effectively or
  ineffectively behaving in the present moment
• Values verbal statements of what an individual
  desires to experience throughout his life
• Commitment - action towards achieving ones
  chosen values

18
How Was ACT Implementated

• Assessment
• Patient described problematic issues
• Illness and hemodialysis treatment
• Described feelings regarding issue
• feelings of distress, frustration and anger
• Discussed behaviors when experiencing these
  feelings
• (avoidance behaviors)
• Avoidant behaviors excessive drinking, drug use,
  behaviors that cause physical harm,
  procrastination and avoidance of conflict
• Skips treatment
• Drinks excessive fluids
• Takes anger out on others

19
Interventions

• Discussion if avoidant behaviors were adapted to
  avoid distressful emotions
• Patient explored present strategies/behaviors
  when dealing with problematic issue and evaluated
  if they were effective (anger, leaving dialysis
  unit and skipping treatment)
• Patient reflection, no suggestions are given
• May take more than one discussion for patient to
  see that current avoidant strategies are
  problematic

20
Interventions Contd

• Once patient saw avoidant strategies/behaviors as
  problematic
• Discussed what losses occur from this behavior in
  terms of patients emotional energy, and health

21
Interventions Contd

• Discussed how negative thoughts and feeling have
  effect on living a more meaningful life.
• nothing in life was worthwhile
• Felt less than
• Discussion on avoiding negative feelings creates
  behavior that is detrimental to well-being and
  quality of life.
• Avoidance and control of these distressing
  emotions
• are the problem not dialysis

22
Interventions Contd

• Acceptance
• The willingness to experience distressing
  emotions
• To be mindful of emotions and choose the solution
• that benefits his health
• Exposure exercise Patient asked to monitor
  behavior in the present moment and choose
  alternative solution
• (choose different approach if wait times are
  excessive at unit)
• (to think about if skipping treatment will
  benefit long term
• goals)

23
Interventions Contd

• Established Life Goals
• Discussed life goals
• (kidney transplant, relationship, purchasing a
  car,
• going on vacation)
• Commitment/Maintenance
• Develop plan of action to reach life goals
• Support when complications arose
• (environmental stressors or medical
  complications)
• 
  

24
Case Study Results

• Treatment adherence improved after 15 sessions
• Since July 2011, continues with 100 compliance
  or missing only one treatment
• Improvement in mood and affect
• Self report of awareness of behavior
• Responsibility for actions

25
Case Study Results

• Decrease in hospitalizations
• 2011 - 8 admissions
• 2012 2 admissions
• Improvement seen in KDQOL scores for mental
  function and effect/burden of disease
• Achieving life goals presently in relationship,
  on transplant list.

26
Other Uses for ACT

• Adherence issues to diet and fluid restriction
• Anxiety/Needle Phobia
• Depression

27
How to Apply ACT

• Have patient discuss problematic issue
• Explore present coping strategies
• What have you tried?
• Reflect on outcome and create awareness of
  behavior
• Do you feel this strategy is working?
• Is it giving you the outcome you want in terms
  of your health?
• Is there something you can do differently in
  this
• situation?

28

• Explore the negative feelings/thoughts associated
  
• with issue/problem
• Have you thought about how this problem
• makes you feel?
• Is the thought true?
• Replace but statements with and statements
• I would like to go to treatment but it makes me
  feel anxious

29

• Explore life goals
• What type of life would you like to have?
• Goals should be specific
• Measurable and include details
• Within the patients ability
• How do you know you are moving in the direction
  of obtaining goal?
• Whats getting in the way?
• Can you try to work towards goals while still
  feeling these distressful feelings?

30
Intervention Has Been Successful

• Patient takes responsibility for behavior
• Small behavioral change (adherence, diet or
  treatment)
• Affect or mood change (less angry)
• Therapeutic interventions are not about what
  the clinician values but what matters to the
  patient!!!