Illinois Psychiatric Rehabilitation Training Institute

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Illinois Psychiatric Rehabilitation Training
Institute

• Illness Management
• and Recovery
• Gary Bond
• October 2002

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Learning Objectives

• Explain illness management and recovery
• Identify key concepts
• Illustrate with concrete examples
• Summarize the research
• Outline some nuts and bolts

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Exercise for PractitionersDuring Training

• Think about some consumer you are currently
  working with who has one or more of the following
  issues
• Feels hopeless
• Has symptoms that are bothering them
• Is not taking medications as prescribed
• Is at risk for relapse

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What is Illness Management and Recovery (IMR)?

• Where did it come from?
• How does it compare to consumer-developed
  approaches, such as Wellness Recovery Action Plan?

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Definition of Illness Management(Mueser et al.,
2002)

• Broad set of strategies to help consumers
• Collaborate with professionals to manage mental
  illness
• Reduce effects of illness
• Reduce susceptibility to relapses
• Cope with symptoms
• Discover (or rediscover) strengths

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Roots of Illness Management and Recovery (IMR)

• Consumerism/self-help in health care field
• Mental health consumer movement
• Literature on psychotherapy techniques

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Influence of Consumerism in Health Care Field on
IMR

• Doctors dont have all the answers
• Norman Cousins Laugh therapy
• Maxwell Moltz Psychocybernetics

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Some Common Attitudes Among Patients with Medical
Problems

• Just give me a pill, doctor.
• I dont need treatment, I feel fine (e.g.,
  someone with high blood pressure).

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• In chronic illnesses (diabetes, arthritis,
  obesity, cardiac disorders, stroke, cancer)
• Patients who take an active role in
• Understanding their illness
• Making informed treatment choices
• Being persistent in self-care
• Have better outcomes
• (Wennberg, Dartmouth)

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Implications of Health Care Findings

• Patients should be educated regarding treatment
  choices, warning signs, lifestyle changes, etc.
• Practitioners should be trained in methods to
  ensure patient participation in treatment
  choices

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Influence of Mental Health Consumer Movement on
IMR

• Recovery stories (first person accounts)
• Spread of self-help organizations
• Manuals and workbooks originating in
  consumer/self-help movement
• These approaches sometimes called illness
  self-management

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Definition of Recovery

• Recovery involves the development of new meaning
  and purpose in ones life as one grows beyond the
  catastrophic effects of mental illness (Anthony,
  1993).

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Characteristics of Recovery

• Unique to each person
• Defined and accomplished by consumer
• Both process and outcome
• Personal and social success
• Universal human experience
• Themes of hope, self-confidence, enjoyment,
  well-being, and optimism

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Relationship of Illness Management to Recovery

• Regain mastery over ones life
• Move from hierarchical to collaborative
  relationships with treatment providers
• Learn how to direct ones treatment
• Spend less time on illness More time
  pursing personal goals

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Examples of Illness Self-Management Packages

• Wellness Recovery Action Plan (WRAP) (Copeland)
• Recovery Workbook (Spaniol)
• Mental Health through Will-Training (Low)
• GROW manual

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WRAP

• Integrated package of techniques
• Simple and clear
• Provides instructions for planning your life

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Components of WRAP

• Wellness toolbox
• Daily maintenance plan
• Triggers
• Early warning signs
• Crisis plan
• Post crisis plan

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Wellness ToolboxThings you do to feel better

• Talking to a friend
• Journaling
• Relaxation
• Diet
• Exercise

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Daily Maintenance Plan

• Daily routines that contribute to well-being
• For me
• A cup of coffee and newspaper in the morning
• Go jogging at 11 pm

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TriggersExternal events that may lead to relapse

• Family friction
• Work stress
• Anniversaries
• Financial problems

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Early Warning SignsInternal events signaling
possible deterioration

• Sleeping too much
• Sleeping too little
• Change in eating pattern
• Growing a beard
• Nonstop talking

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Herz and Melville (1985)Warning Signs of Relapse
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Crisis Plan Template for indicating what to do
when consumer is in crisis

• Written when consumer is thinking clearly
• Identifies 5 support people
• Gives specific instructions
• Indicates which treatments consumer wants and
  doesnt want
• Identifies people consumer wants and doesnt want
  to help and how

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Post Crisis Plan

• Returning after a hospitalization can be
  devastating
• Have a plan to help during that transition

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Influence of Psychotherapy on IMR

• Techniques borrowed and adapted from related
  fields
• Skills training
• Cognitive-behavioral therapy
• Stress management

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Skills Training

• These social learning principles used to teach
  skills
• Modeling
• Role playing
• Positive and corrective feedback
• Homework
• Generalizing skills

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Important Step Often Omitted Generalizing Skills
to Real World

• Teach skills at the point they are relevant!
• Teach skills in settings where skills are used
• Build in reminders
• Build in rewards
• Get family and friends to support changes

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Who Benefits from Skills Training?

• Individuals with cognitive impairment learn
  skills more slowly
• Most research limited to schizophrenia

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Some Principles of Cognitive-Behavioral Therapy

• Form collaborative partnership with client
• Give rationale for treatment
• Suggest alternative interpretations for
  irrational thoughts
• Remain non-confrontational
• Suggest behavioral tests Try this out, see if
  your theory is correct

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Similarities Between IMR and Illness
Self-Management

• Same goals
• Similar rationale
• Overlap in methods and techniques
• Borrow from much of the same literature

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Some Goals of IMR

• Instill hope
• Develop treatment team collaboration
• Help people establish personally meaningful goals
• Give information about mental illness
• Develop skills for reducing relapses
• Provide information about resources
• Help enhance support system

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Differences Between IMR and Illness
Self-Management

• IMR
• Based on quantitative studies ? Evidence-based
• Stresses collaboration with professionals
• Includes strong emphasis on using medications

• Illness Self-Management
• Based on personal success stories, no rigorous
  studies
• Stresses self-help and peer support

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One Further Difference Between IMR and Some
Illness Self-Management Approaches

• Illness self-management often limited to
  educational programs
• IMR emphasizes cognitive-behavioral techniques

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Illness Management and Recovery

• Research Evidence

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Facets of Illness Management and Recovery

• Psychoeducation
• Strategies to facilitate taking medication as
  prescribed
• Relapse prevention
• Teaching strategies for coping with symptoms

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Psychoeducation

• What is it?
• Is it effective?

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What Is Psychoeducation?

• Term used in many ways
• Definition used here
• Providing consumers with practical information on
  their illness and recovery

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Psychoeducation Format

• Typically given in groups
• Can be provided individually

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Strategies to Maximize Effectiveness

• Provide to consumers who ask for it
• Give explanations that consumers understand
• Use interactive teaching
• Dont overload with too much information in a
  single session
• Show personal relevance to each consumers goals

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Types of Psychoeducation Groups

• General psychoeducation
• Medication education
• Other specialty groups (e.g., substance abuse)

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Psychoeducation Comprehensive Curriculum

• Using medication
• Alcohol and drugs
• Preventing relapse
• Stress management
• Coping with symptoms
• Mental health system

• Recovery strategies
• Mental health facts
• Stress-vulnerability model
• Social support
• Treatment choices

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Resources for Psychoeducation

• Many different workbooks and handouts available
• Liberman medication and symptom management
  videotapes
• Thresholds videotapes

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Research on Psychoeducation

• 4 studies of psychoeducation on illness
  management
• 8 studies specifically on medication education

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Psychoeducation Research Findings

• Clearly better than discussion group
• Increases knowledge
• Little or no impact on behavior
• No effects on taking medication as prescribed
• No effects on symptoms, social functioning, or
  rehospitalization

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Psychoeducation Bottom Line

• Psychoeducation is necessary but not sufficient
  for illness management
• Giving people information is not enough to change
  behavior

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Strategies to Increases Taking Medications as
Prescribed

• What are they?
• Are compatible with IMR?
• Are they effective?

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Rationale for Including Medication Use as Part of
IMR

• Medications Sensitive topic with some consumers
• Forced taking of meds Antithetical to consumer
  choice and to recovery
• Not taking meds For many consumers,
  incompatible with recovery

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Effectiveness of Antipsychotics

• Reduce relapse rates compared to no medications
  (Shown in 200 studies)
• Reduce positive symptoms
• About 70 of individuals with schizophrenia have
  improved symptom control on antipsychotics,
  compared to controls receiving placebo

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Medications and Recovery

• Medications are clearly a mixed blessing
• critical to find best meds and best dose
• Without meds, the research evidence clearly shows
  illness management is often more difficult

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Taking Medications as Prescribed
Behavioral/Motivational Strategies

• Behavioral tailoring
• Simplifying regimen
• Motivational interviewing/ CBT

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Behavioral Tailoring

• Developing strategies for incorporating
  medication into daily routine
• Example Place meds next to toothbrush as
  reminder

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Simplifying Regimen

• Definition Reducing number and frequency of
  medications
• Rationale It is easier to get into a routine
  that is simple than one that is complex
• May be especially important if consumer has
  cognitive impairments

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What is Motivational Interviewing?

• It is a set of strategies
• Supportive, not argumentative
• Timing plays a crucial role
• Emphasis is on the reasons to change, rather than
  on how to change

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Principles of Motivational Interviewing

• Express empathy
• Develop discrepancy
• Avoid argumentation
• Roll with resistance
• Support self-efficacy

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Research on Taking Medications as Prescribed

• Behavioral Tailoring
• Simplifying Regimen
• Motivational Interviewing/ CBT

• Controlled Studies
• 4/4 effective
• 1/1 effective
• 2/2 effective

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ConclusionsTaking Medications as Prescribed

• Evidence Strong for behavioral tailoring, weak
  for other areas
• Motivational interviewing used for consumers not
  fully accepting
• Meds ? Recovery

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Relapse Prevention

• What is it?
• Is it effective?

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Relapse Prevention Components

• Psychoeducation
• Identify environmental triggers
• Identify warning signs
• Develop coping strategies
• Continuously monitor for warning signs
• Rapid intervention when indicated
• Stress management training
• Involve relatives in program

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Relapse Prevention Research Evidence

• 5/5 controlled studies showed decreases in
  relapses and rehospitalization
• 3 of studies also found improvements in social
  functioning and other outcomes

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Teaching Strategies for Coping with Symptoms

• What is it?
• Is it effective?

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Rationale for Teaching Coping Skills

• Persistent psychotic symptoms present in 25-40
  of persons with schizophrenia
• Psychotic symptoms predict relapses and
  rehospitalizations
• Consumers distressed by persistent psychotic
  symptoms

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Coping Strategies Used Intuitively by Many
Consumers

• Best strategy often idiosyncratic
• Whatever works for you
• (Breier Strauss)

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Coping Model (Adapted from Lazarus)

Symptoms
Perceived Efficacy
Appraisal of symptom
COPING
Functioning
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Teaching Coping Skills

• Use of cognitive-behavioral strategies
• Assessment of coping
• In-session and out-of-session practice
• Target positive, negative, and affective symptoms
  and other sources of stress

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Teaching Coping Skills Typical Components

• Psychoeducation
• Personalizing to individual
• Brainstorming
• Systematic selection of coping strategies
• Behavioral rehearsal

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Research on Teaching Coping Skills

• 4 controlled studies
• All studies show decreases in symptom severity
• Some studies also indicate less distress and
  lower rates of rehospitalization

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IMR Research Summary

• Psychoeducation improves knowledge, but not other
  outcomes
• Behavioral tailoring increases taking medication
  as prescribed
• Relapse prevention training reduces relapses and
  rehospitalizations
• Teaching coping reduces symptoms and distress

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Nuts and BoltsWhat Does IMR Look Like?

• From IMR
• Implementation Resource Kit
• (Mueser Gingerich)

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Selection of Participants for IMR

• Can be offered to anyone who experiences
  psychiatric symptoms
• Educational handouts available for schizophrenia,
  bipolar disorder, and major depression
• May be preferable to wait if someone is currently
  under extreme stress

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Is Illness Management for Everyone?

• Does participation in illness management assume
  that consumer is already highly motivated?
• IMR research Studies may be selecting a special
  subgroup
• Dropout rates 22 55 in psychoeducation
  studies

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Session Format

• Can be individual or group
• Structured, predictable sessions are recommended
• Typically 45 -60 minutes (but shorter if
  appropriate)
• Take breaks if necessary

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Typical Session Format
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Location of IMR Training

• Sessions can be held anywhere home or public
  setting (coffee shop) may be OK
• Ample lighting, comfortable seating, some privacy
• Quiet, free of distractions

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Educational Handouts

• Simple language
• Summary boxes
• Probe questions
• Checklists
• Planning sheets
• Success stories

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Summary BoxStrategies for Recovery

• self-help programs
• staying active
• developing a support system
• maintaining physical health
• being aware of the environment

• making time for recreation
• expressing creativity
• seeking out spirituality
• following through with treatment choices

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Sample Checklist
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Probe Questions(Identifying what you would like
to improve in your life will help you set goals)

• What two areas of your life are you not satisfied
  with and would like to improve?
• What goals would you like to set for yourself in
  these areas?

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Example from Handout Choosing Treatments

• I have chosen treatment that includes a
  self-help group, a part-time job, and taking
  medication. I like to be pro-active. Following
  through with those things makes me feel strong,
  like I can handle my daily challenges.

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Use of Educational Handouts

• Review the contents
• Help consumer personalize content
• Assign homework assignments based on handouts
• Ask consumer to share handouts with family
  members

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Involvement of Significant Others

• Keep them informed
• Practice skills with them
• In some instances, involve them in training
  sessions (especially in developing relapse
  prevention plan)

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Practitioner Qualifications

• Warm, kind, empathic
• Teaching skills
• Ability to take shaping approach to knowledge
  Give feedback for small successes

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Core Values of IMR

• Hope is the key ingredient
• Person is expert on own experience of mental
  illness
• Personal choice is paramount
• Practitioners are collaborators
• Practitioners must demonstrate respect