The Use of Acceptance and Commitment Therapy with Hemodialysis Patients

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

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***  Team’s or facility’s approach causing patient resistance?

*Journal of Clinical Epidemiology, 2001 **Seminars in Dialysis, 2001 ***Nephrology Nursing Journal, 2010

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 patient’s behavior are important but secondary to primary task of dealing with condition

Causes of Patient Resistance

 Patient’s 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”  Patient’s 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)

What Can We Do?

 Patient Centered Care National Research Corporation

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

Considerations When Applying Interventions

 Patient should have a life goal  Proceed at patient’s 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

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

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

Therapeutic Goals

 Desired therapeutic outcomes were: 1) to increase hemodialysis treatment adherence to prescribed dialysis regimen 2) to increase patient’s quality of life and achievement of life goals

Acceptance and Commitment Therapy (ACT)

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

Acceptance and Commitment Therapy (ACT)

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

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

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

Mindfulness and Acceptance Processes

 Acceptance – willingness to experience any degree of psychological distress  Cognitive defusion – techniques designed to alter the context of one’s thoughts, especially those that produce harm  Self-as-context – a person’s 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

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 one’s chosen values

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

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

Interventions Cont’d

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

Interventions Cont’d

 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

Interventions Cont’d

 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)

Interventions Cont’d

 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)

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

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.

Other Uses for ACT

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

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?

 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” “I would like to go to treatment and I am feeling anxious”

Explore life goals  What type of life would you like to have?

 Goals should be specific  Measurable and include details  Within the patient’s ability  How do you know you are moving in the direction of obtaining goal?

 What’s getting in the way?

 Can you try to work towards goals while still feeling these distressful feelings?

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!!!