Indianapolis Vocational Intervention Program: Overview

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Indianapolis Vocational Intervention Program
Overview

• Paul H. Lysaker, Ph.D.
• Roudebush VA Medical Center
• Indianapolis, IN

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Indianapolis Vocational Intervention Program
Overview

• Who When and Where
• Background mixed history of psychotherapy
• Program values and targeted outcomes
• Program structure
• Group Intervention
• Individual Intervention

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Indianapolis Vocational Intervention Program

• Paul Lysaker Ph.D. Principal Investigator
• Morris Bell Ph.D. Co-Investigator
• Gary Bryson Ph.D. Co-Investigator
• Jovier Evans Ph.D. Co-Investigator
• Gary Bond Ph.D. Co-Investigator
• Research funded by the Department of Veteran
  Affairs, Rehabilitation, Research, and
  Development Service

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The Background

• Mixed past of psychotherapy
• Blamed parents for mental illness
• Excuse for long hospitalization/incarceration
• Oppressive power relations
• Seduction of being a savior/protector
• Odd metaphysics
• tradition of understanding rather than shunning
  or seeking distance from madness/the
  disenfranchised
• Humane enterprise of persons understanding one
  another, regardless of differences

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Background

• Evidence of effectiveness
• Boston Psychotherapy Study
• The Hogarty and colleagues Study
• CBT studies
• Consumer opinion surveys
• Consumer self report and advocacy
• Case studies from re-awakening literature

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Indianapolis Vocational Intervention Program

• Program Elements
• Six month paid work placement
• Participants with schizophrenia spectrum
  disorders
• Group meeting that implement cognitive behavioral
  techniques to address work-related issues.
• Individual therapy session that implement
  cognitive behavioral techniques to address
  work-related issues.

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Indianapolis Vocational Intervention Program

• Program Values
• Facilitation of autonomy among disabled persons
• Interest in participants personal point of view
  and life narrative Listening
• Honest appraisals of the positive and negative
• An interested rather than protective or parental
  stance

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Indianapolis Vocational Intervention Program

• Desired Outcomes
• Sustained work activity
• Improved work behavior
• Correction of dysfunctional beliefs
• Symptom reduction
• Increased autonomy
• Greater narrative coherence

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Indianapolis Vocational Intervention Program

• Caveats
• No substitute for training and supervision
• Procedures may not be applicable to all clients
  or compatible with all rehabilitation programs or
  approaches
• Procedures supplement, but not replace, thorough
  assessment, case conceptualization, ongoing
  monitoring of clinical status, and clinical
  judgment.
• As knowledge evolves, it is expected that new and
  improved interventions will emerge.

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Indianapolis Vocational Intervention Program

• Time line
• Week 1 Introductory individual meeting
• Week 1 Develop placement
• Week 2 First day at work placement
• Week 2 First Group meeting
• Week 2 First Individual meeting

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Introductory Meeting

• Greeting
• Outline of Program
• Reviewing thoughts/feelings about work
• Identification of barriers to work
• Review of past work (optional)
• Intervention (if necessary)
• Identification of initial dysfunctional belief to
  be targeted

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The Weekly Group Meeting

• Combination of client discussion about work,
  planned lessons, and feedback regarding clients
  performances at their work sites.
• Planned lessons are in the form of 4 work-related
  modules
• Each module takes 2 weeks and is divided into two
  parts
• The modules repeat 3 times during the course of
  the program.

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The Weekly Group Meeting Values

• Therapy as necessarily a collaborate process
• Group member feedback is encouraged
• Immediate success is not required
• Mistakes and problems at work are acceptable
• Mental illness does mean work is impossible
• Work is an essential human activity

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CBT Principles Used in IVIP

• Therapy as necessarily a collaborate process
• Evolving formulation in cognitive terms
• A sound alliance
• Goal oriented and problem focused
• Initial emphasis on the present
• Time limited and structured
• Teaching person to identify/evaluate/respond to
• beliefs

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Group Setting

• A leader and co-facilitator attend every group.
• A private and comfortable room with table.
• Regularly scheduled meeting time and place
• Leader ideally has at least a masters degree
  Co-facilitator ideally has BA and course work
  related to mental health issues (e.g.
  psychology).
• A leader and co-facilitator receive supervision
  ideally, from experienced professionally licensed
  clinician with minimum of MA in mental health
  related field.

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A Typical 60 Minute Group Session

• Check-in clients briefly describe their weekly
  work experiences.
• Didactic Presentation group leader presents a
  planned lesson based on the manuals modules.
• Work Performance Feedback - group leader provides
  direct feedback about client strengths and
  weaknesses based on a formal assessment, the Work
  Behavior Inventory
• Wrap-up group leader addresses
  questions/comments, clients receive practice
  assignments, and clients complete post-tests.

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A Typical Check In

• Introduction of new members
• Report of hours worked
• Reinforcement for work and thinking about oneself
  in the worker role
• Free commentary about work experiences of the
  week
• Request for other agenda items

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The Didactic Portion

• Structured Portion
• Active teaching
• Application to recent experience
• Encouragement of discussion and questions

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The Didactic Portion Four modules

• Thinking errors and work
• Internal and External barriers to work
• Relationships at the workplace
• Accepting success and limitations

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Module A, Session 1 Thinking Errors and Work

• Goals
• Help participants to recognize and identify
  automatic thoughts as they occur.
• Explain negative thinking in the context of the
  cognitive triad (thoughts affect feelings affect
  actions affect thoughtsetc).
• Apply the cognitive model to examples of
  real-world work situations.

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Module A, Session 1 Thinking Errors and Work

• Discussion of types of thinking errors
• Types include all or nothing thinking,
  personalizing, magnification, jumping to
  conclusions, overgeneralization, perfectionism,
  and self-blame.
• Instances of errors in thinking may be generated
  by participants or portrayed by group leaders in
  a role play scenario.

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Module A, Session 2 Modifying Self-defeating
Thinking about Work

• Goals
• Give participants the skills needed to modify
  dysfunctional cognitions using the 4 As model.
• Use examples of thinking errors reported by
  participants or role play occurrences of thinking
  errors in order to practice applying the 4 As
  model as a means to combat thinking errors.

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Module A, Session 2 Modifying Self-defeating
Thinking about Work

• The 4 As Model
• Be aware of your thoughts. (Participants are
  encouraged to recognize automatic, negative
  thoughts about work).
• Answer inaccurate, unhelpful thoughts with more
  accurate, helpful thoughts. (Participants are
  encouraged to look for alternative ways to
  perceive situations that lead to negative
  thinking).
• Act based on more accurate, helpful thoughts.
  (Rather than acting based on dysfunctional
  thoughts).
• Accept that you will make mistakes you dont
  have to be perfect.

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Module B, Session 1 Preparing for the
Unexpected When Life Gets in the Way

• Goals
• Assist clients to identify barriers to work
  (transportation problems, illness, family
  demands, etc.) that they are currently
  encountering or anticipate encountering based on
  past experiences.
• Encourage participants to negotiate barriers
  using the problem-solving model.
• Apply the problem-solving model to real world
  examples of barriers to work.

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Module B, Session 1 Preparing for the
Unexpected When Life Gets in the Way

• The Problem-Solving Model
• Identify the problem.
• Think of a variety of solutions.
• Pick the most promising solution.
• Implement your decision.
• Evaluate the outcome. If the problem is not
  solved, implement the next most promising
  solution.

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Module B, Session 2A Managing Emotions
interfering with work Anger

• Goals
• To define anger in terms of the cognitive model
  and to teach cognitive and behavioral skills that
  clients can use to decrease their reactivity to
  anger triggers and to cope with angry feelings.
• Present step-by-step anger management techniques
  and apply them to real world examples of work
  situations that might trigger anger.

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Module B, Session 2A Managing Emotions
interfering with work Anger

• Step-by-Step Anger Management
• Calm down.
• Ask yourself Why am I angry? Am I interpreting
  the situation correctly?
• Go through the steps of problems solving.
• If you cant solve the problem, try to shake it
  offyou cant fix everything and ruminating about
  it only makes you more upset. If you solve
  itcongratulate yourself.

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Module B, Session 2B Managing Emotions
interfering with work Anxiety

• Goals
• To define anxiety/stress in terms of the
  cognitive model.
• To teach cognitive and behavioral skills that
  clients can use to decrease their baseline level
  of anxiety/stress as well as to cope with
  situations at work that provoke anxiety/stress.

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Module B, Session 2B Managing Emotions
interfering with work Anxiety

• Techniques for decreasing baseline anxiety and
  dealing with stressful situations
• Increasing pleasant activities.
• Relaxation training.
• Positive self-talk (affirmations).

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Module C, Session 1 Relationships at the
Workplace - Accepting and Learning from Feedback

• Goals
• Help clients differentiate between constructive
  (assertive) and destructive (aggressive)
  criticism and recognize the costs of
  misinterpreting feedback.
• Help clients identify how they might benefit from
  feedback.
• Teach clients a step by step process for
  responding to feedback and use real world
  examples of feedback to allow clients to practice
  responding to feedback.

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Module C, Session 1 Relationships at the
Workplace - Accepting and Learning from Feedback

• Responding to feedback from others effectively
• Dont get defensive, get into a debate, or
  counterattack.
• Ask questions to get more information so you are
  clear about the criticism and its purpose.
• Connect with what the other person is saying
  find some grain of truth in the feedback.
• Agree with the other person in some way and
  restate the feedback.
• Compromise by suggesting a behavior change that
  you can make to meet the criticism.

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Module C,Session 2Relationships at the
Workplace Effective self expression

• Goals
• Teach clients strategies for giving feedback to
  others effectively, in particular when responding
  to unwarranted or unjustified criticism given by
  a coworker or supervisor.
• Using a step by step process and real world
  examples from work, allow clients to practice
  giving effective feedback.

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Module C,Session 2Relationships at the
Workplace Effective self expression

• Giving feedback to others effectively
• Calm down first so you can speak clearly and
  firmly but not angrily.
• State the criticism in terms of your own feelings
  (not absolute facts) about the behavior.
• Request a specific behavior change, be willing to
  compromise, and start and finish on a positive
  note.

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Module D,Session 1 Self Appraisal Accepting
Accomplishments and Limitations

• Goals
• Apply the 4 As to rigid and/or extreme
  self-belief in the context of realistically
  appraising abilities/accomplishments and
  limitations.
• Discuss how to match abilities and limitations
  with a job and identify ways the work setting can
  make accommodations for limitations.

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Module D,Session 1 Self Appraisal Accepting
Accomplishments and Limitations

• Examples of issues for discussion
• Can a person be mentally ill and also work?  
• Weve talked about the 4 As, one of which is
  acceptance. Is it possible to accept that you
  have limitations at the same time as you have
  abilities that help you function well at work?
• Why would it be important to have flexible goals
  when beginning to work again after a long period
  of not working?

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Module D,Session 2 Self Appraisal Managing
Success

• Goals
• Articulate the meaning of success and failure and
  identify successes and failures related to
  clients current work placements.
• Address the negative effects of harboring
  unrealistic expectations for ones self at work.
• Discuss failure and success in the context of the
  cognitive model.

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Module D,Session 2 Self Appraisal Managing
Success

• Examples of issues for discussion
• What is success at work?
• Have your successes so far at work made you
  uncomfortable?
• Can a person be ill and succeed at work? 
• If someone succeeds in this program does this
  mean he or she could have worked all along? Does
  this mean he/she doesnt deserve disability
  income?

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Work Performance Feedback

• Biweekly feedback given in group
• Strengths are presented first and areas for
  improvement second
• Didactic materials applied
• Group problem solving
• Feedback is presented as our best estimate

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Weekly Individual Therapy Sessions

• Therapist and client address unique work-related
  needs, problems, etc.
• Didactic material from the weekly group session
  is reinforced.
• Cognitive behavior interventions
• Dysfunctional thoughts about work are recorded,
  addressed, and assessed weekly.
• Therapist is MA level and supervised by
  experienced licensed MH professional

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Weekly Individual Therapy Sessions Outline

• Initial ratings of cognitions
• Mini mental status
• Review of New and old material
• Application of didiactic material
• Cognitive interventions
• Behavioral interventions
• Re-ratings of dysfunctional cognitions and
  answering cognitions

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CBT Principles used in IVIP

• Therapy is necessarily a collaborate process
• Evolving formulation in cognitive terms
• A sound alliance
• Goal oriented and problem focused
• Initial emphasis on the present
• Time limited and structured
• Teaching person to identify evaluate - respond
  to beliefs

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Weekly Individual Therapy Initial Ratings
and conviction and impact

• Client rates conviction of belief on 1-100 scale
  with visual aid.
• Client rates impact of belief on 1-100 scale with
  visual aid.

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Weekly Individual Therapy Initial Ratings
and conviction and impact

• Conversational assessment of changes/level of
  signs and symptoms of distress/mental illness
• We use 5 component model Positive, Negative,
  Cognitive, Excitement and Emotional Discomfort
• Dangerousness
• Associated stressors

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Weekly Individual Therapy Initial New and
old material

• At clients direction new or old material is
  related
• Therapist makes sure they know link of material
  to work
• Link may be close or more distant
• Material flows by direction of client

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Weekly Individual Therapy Intervention

• Application of didactic materials by client
• Therapist as guide in application
• Identifying and challenging beliefs with
  answering belief
• Examination of the evidence for each
• Discussion of ways to get more evidence
• Behavioral interventions
• Client as scientist

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Weekly Individual Therapy Intervention

• Art of clarifying dysfunctional belief
• Belief can be outrageously implausible
• Beliefs can be approached through feelings
• Implausible beliefs can harbor more plausible
  ones
• Therapist as collaborator but nor owner of truth

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Case examples Implausible beliefs

• Obviously implausible belief I will be forced
  to be the Colts QB this weekend.
• Underlying this belief might be the belief
  People expect too much of me and I will be
  rejected when I fail to meet others expectations
  or I am too inadequate to be linked by others.
• Evidence supporting the later beliefs could
  include historical and present day experiences

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Case examples Implausible beliefs

• Obviously Implausible Belief I am related to
  Bill Gates or Roy Orbison
• Underlying this belief might be the belief
  People deny me what I need, or Ive failed
  because people get in my way, or Ive thrown
  away my life.
• Evidence supporting the later beliefs could
  include historical and present day experiences

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Case examples More plausible beliefs

• Belief My supervisor is trying to humiliate
  me.
• Supporting evidence supervisors grimace and
  feedback and past supervisors behavior
• Didactic material Accepting/ Learning from
  Feedback
• Answering belief might be this supervisor is not
  the same person as the last supervisor
• Data needed ask supervisor this week How am I
  doing?
• Relaxation at lunch time

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Case examples More plausible beliefs

• Belief I will not meet others expectations.
• Supporting evidence 2 divorces, hx of shock tx.
• Didactic material on negative thinking
• Answering belief might be I had success as a bus
  driver or My grown sons love me
• More data is needed to client will ask co-worker
  this week How am I doing?
• Positive self talk at lunch time

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Weekly Individual Therapy Session end

• Add or modify belief to be foci
• Max number of beliefs should be 3-4
• Rate conviction of dysfunctional beliefs
• Rate impact of dysfunctional beliefs
• Rate conviction of answering cognition
• Therapist as collaborator but nor owner of truth

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Therapists and group leader beliefs we
discourage

• Professionals should tell people with mental
  illness what to think
• People with mental illness need to be managed
• Listening is easy and painless
• Listening and relating to clients is not the
  major task
• There is a manual for relating to people
• At a certain level professionals do not need
  supervision

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More therapist and group leader beliefs we
discourage

• Motivation is an all or nothing phenomenon
• There is no such thing as mental illness
• The primary task of the therapist is to protect
  vulnerable people
• Socio economic changes are the hallmark of
  improvement.
• A supportive relationship has no room for
  criticism within it

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Special Problems Substance Abuse

• We dont help people work to get substances
• Referral/collaboration with SA program
• SA issues can be addressed
• SA should not be a barrier to work
• Required abstinence should be on an individual
  basis
• Passing drug test is a reality of competitive
  employment

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Special Problems Unawareness/ Denial of
illness

• We dont force people to use labels
• We encourage people to identify their own needs
  and label them as they see fit
• Stereotypic stigmatizing beliefs about the
  mentally ill can be challenged as dysfunctional
• A belief that I must have no problems or
  weaknesses or people are totally ill or totally
  not ill underlie denial