CHICAGO – Both the psychiatric patient and the medical patient with comorbid psychiatric conditions can be treated with a technique known as behavioral action communication.
"The challenge is ... to immerse the patient in a rich, evidence-based milieu that reinforces goal-directed behavior," said Jacqueline Gollan, Ph.D., director of the Translational Stress and Depression Laboratory at Northwestern University. The concept of behavioral activation is complex, said Dr. Gollan, but broadly invites the patient to reflect on her own behavior or inactivity in various contexts and to reinforce active, positive behaviors. On seeing the latter, "The staff can turn to the patient and say, ‘That’s great. Let’s see if you can do that again.’ "
The goals are to accelerate recovery, independence, and functionality, Dr. Gollan said at a seminar, "Reinventing Inpatient Psychiatry." In a well-controlled context, inpatients can actually learn how to manage their illnesses.
Passivity and avoidance are prevalent in psychiatric conditions, and this behavioral strategy is designed to reduce them, and to improve the quality and acceptability of care, she said.
Theoretically, overall health outcomes will also be improved. The psychiatric concept of avoidance has been linked in the literature to increased hypertension and cardiovascular mortality and diminished immunity, as well as substance abuse, depressive symptoms, overall lower quality of life, and increased mortality, she said.
Northwestern Memorial Hospital integrates behavioral action communication throughout the psychiatric unit, employing it in group meetings, education, nursing care, physician inquiry, discharge plans, and social work. A manual on the subject is given to each patient’s family members so they can reinforce goals at home, helping the individual to identify and reduce passivity and avoidance, and to understand that all behaviors have a purpose or goal. The intent is to teach the patient to connect context, behavior, and mood.
In the clinic, the first step in teaching the psychiatric patient to monitor his or her behavior is a self-reported instrument called the Checklist of Unit Behaviors, or CUB. This checklist assesses the patient’s activation (activities that create positive changes in symptoms or function) in two dimensions: approach and avoidance. The patient and staff members track progress each day with an item-by-item discussion that focuses on the patient’s successes. The conversations emphasize the context and function of behavior; avoidance behaviors are associated with negative affect.
"Every morning, they fill out a CUB," Dr. Gollan said. "It truly reflects what they’re doing. The patient reports being high or low on avoidance or approach. A set of avoidance behaviors is associated with negative affect. On intake you see high levels of avoidance ... then there’s feathering out."
The psychometric properties of the CUB allow clinicians to implement a treatment plan that increases positive affect, ultimately to help the patient have a greater interest in taking care of himself, said Dr. Gollan.
An experiment comparing the behavioral action communication (BAC) unit with the Treatment as Usual (TAU) unit reinforced this finding. Outcome measures were the Brief Symptom Inventory, Positive and Negative Affect Schedule (PANAS), Behavioral Inhibition/Activation Scale (BIS/BAS), and CUB.
The sample (n = 149) was divided between the BAC unit (72 patients) and TAU unit (77 patients), with the TAU acting as the control. No significant differences were found in patient age (mean = 38.7 years) or gender (49% male). A One-Sample T test did not reveal significant differences across psychiatric disorders using Brief Symptom Inventory for each unit at admission (P = .30). These disorders/behaviors included depression, anxiety, hostility, somatization, obsessive-compulsive, interpersonal sensitivity, phobic anxiety, paranoid ideation, and psychoticism.
The study found that increase in positive affect from admission to discharge was higher for those in the BAC unit. Patients in the BAC unit with elevated major depressive disorder reported improved positive affect at discharge, compared with those in the TAU unit. BAC unit patients also reported significantly higher approach behaviors at discharge than did TAU unit patients. BAC and TAU unit patients showed major reduction of avoidance equivalent across units at intake and discharge.
Overall, patients’ assessments of behavioral activation communication were positive. Their comments included: "It helps me visualize what’s going on," "It helps me to write things down instead of just thinking about them," and "It’s nice to know that someone is checking up on you and monitoring your progress."
A member of the audience asked whether the hospital had seen any change in repeat admissions. Dr. Gollan said data on repeat admissions were not yet available.
Dr. Gollan disclosed no relevant conflicts of interest.