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Illinois Psychiatric Rehabilitation Training Institute

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Outline some nuts and bolts. Exercise for Practitioners. During Training ... Diet. Exercise. Daily Maintenance Plan. Daily routines that contribute to well-being ... – PowerPoint PPT presentation

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Title: Illinois Psychiatric Rehabilitation Training Institute


1
Illinois Psychiatric Rehabilitation Training
Institute
  • Illness Management
  • and Recovery
  • Gary Bond
  • October 2002

2
Learning Objectives
  • Explain illness management and recovery
  • Identify key concepts
  • Illustrate with concrete examples
  • Summarize the research
  • Outline some nuts and bolts

3
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

4
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?

5
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

6
Roots of Illness Management and Recovery (IMR)
  • Consumerism/self-help in health care field
  • Mental health consumer movement
  • Literature on psychotherapy techniques

7
Influence of Consumerism in Health Care Field on
IMR
  • Doctors dont have all the answers
  • Norman Cousins Laugh therapy
  • Maxwell Moltz Psychocybernetics

8
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).

9
  • 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)

10
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

11
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

12
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).

13
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

14
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

15
Examples of Illness Self-Management Packages
  • Wellness Recovery Action Plan (WRAP) (Copeland)
  • Recovery Workbook (Spaniol)
  • Mental Health through Will-Training (Low)
  • GROW manual

16
WRAP
  • Integrated package of techniques
  • Simple and clear
  • Provides instructions for planning your life

17
Components of WRAP
  • Wellness toolbox
  • Daily maintenance plan
  • Triggers
  • Early warning signs
  • Crisis plan
  • Post crisis plan

18
Wellness ToolboxThings you do to feel better
  • Talking to a friend
  • Journaling
  • Relaxation
  • Diet
  • Exercise

19
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

20
TriggersExternal events that may lead to relapse
  • Family friction
  • Work stress
  • Anniversaries
  • Financial problems

21
Early Warning SignsInternal events signaling
possible deterioration
  • Sleeping too much
  • Sleeping too little
  • Change in eating pattern
  • Growing a beard
  • Nonstop talking

22
Herz and Melville (1985)Warning Signs of Relapse
23
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

24
Post Crisis Plan
  • Returning after a hospitalization can be
    devastating
  • Have a plan to help during that transition

25
Influence of Psychotherapy on IMR
  • Techniques borrowed and adapted from related
    fields
  • Skills training
  • Cognitive-behavioral therapy
  • Stress management

26
Skills Training
  • These social learning principles used to teach
    skills
  • Modeling
  • Role playing
  • Positive and corrective feedback
  • Homework
  • Generalizing skills

27
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

28
Who Benefits from Skills Training?
  • Individuals with cognitive impairment learn
    skills more slowly
  • Most research limited to schizophrenia

29
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

30
Similarities Between IMR and Illness
Self-Management
  • Same goals
  • Similar rationale
  • Overlap in methods and techniques
  • Borrow from much of the same literature

31
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

32
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

33
One Further Difference Between IMR and Some
Illness Self-Management Approaches
  • Illness self-management often limited to
    educational programs
  • IMR emphasizes cognitive-behavioral techniques

34
Illness Management and Recovery
  • Research Evidence

35
Facets of Illness Management and Recovery
  • Psychoeducation
  • Strategies to facilitate taking medication as
    prescribed
  • Relapse prevention
  • Teaching strategies for coping with symptoms

36
Psychoeducation
  • What is it?
  • Is it effective?

37
What Is Psychoeducation?
  • Term used in many ways
  • Definition used here
  • Providing consumers with practical information on
    their illness and recovery

38
Psychoeducation Format
  • Typically given in groups
  • Can be provided individually

39
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

40
Types of Psychoeducation Groups
  • General psychoeducation
  • Medication education
  • Other specialty groups (e.g., substance abuse)

41
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

42
Resources for Psychoeducation
  • Many different workbooks and handouts available
  • Liberman medication and symptom management
    videotapes
  • Thresholds videotapes

43
Research on Psychoeducation
  • 4 studies of psychoeducation on illness
    management
  • 8 studies specifically on medication education

44
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

45
Psychoeducation Bottom Line
  • Psychoeducation is necessary but not sufficient
    for illness management
  • Giving people information is not enough to change
    behavior

46
Strategies to Increases Taking Medications as
Prescribed
  • What are they?
  • Are compatible with IMR?
  • Are they effective?

47
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

48
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

49
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

50
Taking Medications as Prescribed
Behavioral/Motivational Strategies
  • Behavioral tailoring
  • Simplifying regimen
  • Motivational interviewing/ CBT

51
Behavioral Tailoring
  • Developing strategies for incorporating
    medication into daily routine
  • Example Place meds next to toothbrush as
    reminder

52
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

53
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

54
Principles of Motivational Interviewing
  • Express empathy
  • Develop discrepancy
  • Avoid argumentation
  • Roll with resistance
  • Support self-efficacy

55
Research on Taking Medications as Prescribed
  • Behavioral Tailoring
  • Simplifying Regimen
  • Motivational Interviewing/ CBT
  • Controlled Studies
  • 4/4 effective
  • 1/1 effective
  • 2/2 effective

56
ConclusionsTaking Medications as Prescribed
  • Evidence Strong for behavioral tailoring, weak
    for other areas
  • Motivational interviewing used for consumers not
    fully accepting
  • Meds ? Recovery

57
Relapse Prevention
  • What is it?
  • Is it effective?

58
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

59
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

60
Teaching Strategies for Coping with Symptoms
  • What is it?
  • Is it effective?

61
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

62
Coping Strategies Used Intuitively by Many
Consumers
  • Best strategy often idiosyncratic
  • Whatever works for you
  • (Breier Strauss)

63
Coping Model (Adapted from Lazarus)

Symptoms
Perceived Efficacy
Appraisal of symptom
COPING
Functioning
64
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

65
Teaching Coping Skills Typical Components
  • Psychoeducation
  • Personalizing to individual
  • Brainstorming
  • Systematic selection of coping strategies
  • Behavioral rehearsal

66
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

67
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

68
Nuts and BoltsWhat Does IMR Look Like?
  • From IMR
  • Implementation Resource Kit
  • (Mueser Gingerich)

69
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

70
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

71
Session Format
  • Can be individual or group
  • Structured, predictable sessions are recommended
  • Typically 45 -60 minutes (but shorter if
    appropriate)
  • Take breaks if necessary

72
Typical Session Format
73
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

74
Educational Handouts
  • Simple language
  • Summary boxes
  • Probe questions
  • Checklists
  • Planning sheets
  • Success stories

75
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

76
Sample Checklist
77
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?

78
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.

79
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

80
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)

81
Practitioner Qualifications
  • Warm, kind, empathic
  • Teaching skills
  • Ability to take shaping approach to knowledge
    Give feedback for small successes

82
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
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