Understanding and Changing Avoidance Behaviors Key to Care for Complex Patients, UH Pilot Project Shows
November 02, 2022
UH Clinical Update | November 2022
Every primary care provider has patients who seem to stall out on making progress on their health issues, whether it’s losing weight or taking better control of COPD or Type 2 diabetes. It can be hard to know what to try next. However, a new approach to care being piloted in the UH Employee Accountable Care Organization (ACO) seeks to understand these patients through the lens of complexity – and to address the social and emotional issues that may be standing in the way of their overall health. Already, the approach has been shown to significantly lower health care costs for these “complex” patients.
“You might look at their chart and say that the person has only a couple of medical issues going on,” says Trygve Dolber, MD, a UH internal medicine physician and psychiatrist who is leading the new UH Complex Care initiative. “But if they're not doing well with those things, we might look a little bit closely and see that there are emotional and social issues that are pretty significant. When you're able to step back and see the big picture, you'll see how all those problems are networked together.”
Intervention for Complex Patients
The UH Complex Care intervention team includes Dr. Dolber, a dietitian, a licensed professional clinical counselor and a social worker. Before approaching any patient, the team reaches out to the primary care providers of patients who are good candidates for the program to offer their collaboration and assistance.
“We are a consult team,” Dr. Dolber says. “We're not taking over care of patients. We're supporting the primary care team or specialist team, whoever the patient is engaging with most. Our goal is to support them and the patient to get their care to a stable level. As soon as we see things going in that direction, we start to take a step back.”
How It Works
The Complex Care intervention begins for the patient with an hour-long intake interview with Dr. Dolber, relying on his expertise in both internal medicine and psychiatry. A technique called Acceptance and Commitment Therapy (ACT) plays a key role. Its goal is to help patients overcome the many maladaptive strategies they’ve used in their lives for avoiding the emotional distress they feel.
These “emotional avoidance behaviors,” Dr. Dolber says, can include worrying excessively, disengaging with life, overeating, abusing drugs or alcohol, engaging in risky sexual behavior or simply suppressing the distress they feel – all of which can interfere with the patient’s ability to manage their health. In fact, he says, insomnia, depression, generalized anxiety disorder, panic attacks, obesity and alcoholism or other substance abuse disorders can all be linked to emotional avoidance and create issues of medical complexity that make care improvements difficult.
ACT aims to short-circuit this process, Dr. Dolber says.
“It's really designed around avoidance and emotional avoidance in particular,” Dr. Dolber says. “People might have an emptiness in their life, don’t like it and want it to go away. They ask themselves what they can do to make it stop.”
Dr. Dolber gives the example of a person who eats chocolate as a means of coping with emotional upset. Eating the chocolate provides short-term and partial relief from the person’s emotional distress – a “dopamine spritz,” he says, to the reward pathway of the brain that sets the stage for the behavior to be repeated over and over, as detailed in Judson Brewer’s book “The Craving Mind.” Other maladaptive behaviors follow the same pattern.
“We all have little ways we avoid,” he says. “These are ways of avoiding the underlying emotional distress rather than opening up to it, being curious about it. With ACT, we’re trying to help people be aware of it, just see how it feels to let that feeling of emptiness be there, explore it, observe it, be curious about it, notice it. Then the goal is show them it’s actually not as bad as they thought when they actually pay attention to it. In addition to that, we ask them whether that empty feeling is there for a reason. What are the thoughts and emotions that come up when I notice that? And what are those telling me about? Is there something that's absent from my life that I that I would like to have in my life, something that I would like to be doing differently than that it is now? From that, people can take a wise action and do something that's in accordance with their values. This is about who the person wants to be.”
Dr. Dolber says that complex patients undergoing ACT can make progress in just a matter of weeks or months. It helps, he says, that he and the Complex Care team have the time within patient visits to delve deeply into a patient’s emotional and social issues – time other providers just don’t have in their schedules.
“You can even fit this whole process into a single visit,” he says. “We can help patients start to identify some of the things that they're doing, their avoidance behaviors, and how they may not have been consciously aware of them. You can do that within the frame of mindfulness within a few minutes. You'd be surprised. It feels like it's taking a long time, and then you look at your watch, and only a few minutes have gone by. When you're doing a mindfulness intervention with someone like that, they start to really connect with those emotions that they're having. When you can walk through that with someone in a really skillful way, you can do that with someone in 30 minutes.”
Already, the pilot program has been shown to lower health care costs for participating UH employees. At the individual level, the results are in some cases dramatic – and are being achieved without a lot of “nagging,” Dr. Dolber says.
What I've noticed is changes can tend to come in almost like a step-wise fashion,” he says. “Someone will quit drinking, just simply saying, ‘I'm not going to drink anymore.’ I thought that was going to be a process. The power of these interventions, I think, is people. When you empower people to understand how their own mind works and guide them through how they want to make their own changes, they start to make their own changes. You don't have to push them. It's really been quite liberating. I used to feel a lot of pressure to try and force the needle on some things. But if you just trust the patient and give them the understanding, they will understand, and they will go in the right direction.”