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20 WAYS TO OVERCOME BARRIERS TO RECOVERY

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Title: SIXTEEN CRITICAL QUESTIONS Author: Brooke Wingate Harding Last modified by: Courtenay Created Date: 3/19/2002 2:47:59 PM Document presentation format – PowerPoint PPT presentation

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Title: 20 WAYS TO OVERCOME BARRIERS TO RECOVERY


1
20 WAYS TO OVERCOME BARRIERS TO RECOVERY
  • Prof. Courtenay M. Harding
  • Professor of Psychiatry and Director,
  • Center for Rehabilitation and Recovery
  • The Coalition of Behavioral Health Agencies - NYC

2
(No Transcript)
3
Good Morning!
  • OVERALL GENERAL INFORMATION FOR TODAY
  • Whats in the folders?
  • How to work with this information
  • Take a break for phone bathroom
  • Ask questions as we go along
  • Evaluations and Certificates at end

4
THE PRESENTATION PLAN
  • Review 20 obstacles with strategies to get some
    answers or how to better understand the
    complications. Lots of resources!

5
(No Transcript)
6
IF RECOVERY AND SIGNIFICANT IMPROVEMENT ARE
POSSIBLE.
  • THEN WHY ARE SO MANY PARTICIPANTS NOT GETTING
    BETTER?
  • 2.5 5 MILLION PEOPLE LANGUISHING IN US ALONE

7
ACKNOWLEDGMENT APPRECIATION
  • TO ALL THE CLINICIANS FAMILIES
  • WHO CARE
  • WHO SPEND TIME PROBLEM SOLVING
  • WHO CHALLENGE THE STATUS QUO
  • WHO SPEND TIME GOING THE EXTRA MILE

8
HOWEVER..
  • If your participant seems to be stuck on the
    path to recovery lets look at some possible
    reasons and ways to change the Individual
    Recovery Plan (IRP)

9
Learning to play a detective !
10
(No Transcript)
11
LOOKING FOR THE PERSON UNDER THE DISORDER
  • COMPREHENSIVE RE-EVALUATION NEEDED (based on
    history, careful interview, lab findings
    physical exam)
  • BIO-PSYCHO-SOCIAL-SPIRITUAL APPROACH
  • SYSTEMATIC MULTIDISCIPLINARY

12
YOU NEED TO LOOK AT A PERSON TWICE once with
your heart and then with your head..
  • FIRST TO SEE THE SIMILARITIES
  • AND ONLY THEN CAN YOU APPRECIATE THE DIFFERENCES

13
QUESTION 1
  • HAVE OTHER POSSIBLE CAUSES OF SYMPTOMS AND
    BEHAVIORS BEEN ELIMINATED?

14
(No Transcript)
15
DIAGNOSIS OF EXCLUSION (especially schizophrenia)
  • 26 other disorders (medical, neurological, and
    psychiatric) that masquerade with
    schizophrenia-like symptoms !

16
DIAGNOSIS OF EXCLUSION (schizophrenia)
  • Autism (esp. Aspergers Syndrome)
  • Temporal Lobe Epilepsy
  • Tumor
  • Stroke

17
MORE THINGS TO EXCLUDE
  • Brain Trauma
  • Endocrine Metabolic Disorders (e.g. acute
    intermittent porphyria (liver enzyme)
  • Homocystinuria (a disorder of amino acid
    metabolism)

18
MORE THINGS TO EXCLUDE
  • Vitamin Deficiency (e.g. B 12)
  • Central Nervous System Infectious Processes (e.g.
    AIDS, neurosyphilis, or herpes encephalitis)
  • Autoimmune Disorders (systemic lupus erthymatosa)
  • Heavy Metal Toxicity (e.g. Wilsons Disease too
    much copper)

19
EVEN MORE TO EXCLUDE
  • Some Drug Induced States (e.g. amphetamines,
    barbiturate withdrawal, cocaine, digitalis,
    disulfram)
  • Mood disorders, schizoaffective disorder,
  • Personality disorders,
  • Brief Reactive Psychosis,
  • OCD

20
Differential Diagnoses for Mood D/O (based on
history, careful interview, lab findings
physical exam)
  • Multiple Sclerosis
  • Stroke
  • Hyper Hypothyroidism
  • Bereavement
  • Dementia
  • Cancer (esp. of Pancreas)
  • Spinal Cord Injury
  • Peptic Ulcer
  • Mononucleosis
  • Huntingtons Disease
  • AIDS
  • End-stage Renal Disease
  • Head Injury
  • Parkinsons Disease
  • Lupus
  • Hyper Hypo parathyroidism
  • Hepatitis

21
SUGGESTED INSTRUMENT
  • Basis-24
  • a leading behavioral health assessment
  • Comprehensive
  • Cuts across diagnostic categories
  • Provides weighted average
  • Overall score plus 6 subscales
  • (sub abuse, symptoms and functioning,
    relationships, self harm, emotional liability,
    psychosis, and depression)

22
SUGGESTED INSTRUMENT
  • SCID THE STRUCTURED CLINICAL INTERVIEW FOR
    DSM-IV TR
  • CLINICAL VERSION

23
HOW TO DO BETTER
  • Take the time get triangulated information
  • Get the lab tests done
  • Reassess over time
  • Pay attention to comorbid d/o

24
Treat or refer other diagnoses
  • Establish links and a little black book with
    other medical colleagues across the local
    community
  • Work with your colleagues in other fields to
    understand what happened and how to understand
    your participant who may still appear to them to
    have a psychiatric disorder
  • Health Homes are coming as networks of
    partnerships treating person in a holistic way
  • Partners include hospital, primary care docs,
    mental health and addiction services

25
OR IF PSYCHIATRIC DIAGOSIS IS RE-ESTABLISHED
  • All diagnosis are cross-sectional working
    hypotheses
  • Not lifetime labels
  • Not able to predict long-term outcome
  • Write enough evidence to convict person of the
    diagnosis into the case record

26
REMEMBER TO LOOK FOR RECORD STRENGTHS
  • Strengths of your participant ( e.g. insight?
    Manage meds? Manage S/S ? Uses strategies to
    recognize oncoming prodrôme? Uses coping to
    reduce anxiety? Computer skills? Has drivers
    license? ETC
  • Working with the strengths rather than deficits,
    problems and disabilities that is what helps
    people get better

27
EBPWELLNESS MANAGEMENT AND RECOVERY PROGRAM-1
  • CLINICIAN BENEFITS
  • A comprehensive step by step approach
  • Ready-to-use materials
  • Skills is using motivational , cognitive
    behavioral and educational strategies
  • ? Satisfaction to see ? outcomes

28
EBP WELLNESS MANAGEMENT AND RECOVERY PROGRAM-2
  • CLINICIANS RECEIVE
  • guide with practical tips
  • handouts, checklists, planning sheets
  • intro video
  • info brochures
  • fidelity scale
  • outcome measures

29
EBP WELLNESS MANAGEMENT AND RECOVERY PROGRAM-3
  • reducing
  • relapses
  • using meds
  • effectively
  • coping with
  • stress
  • coping with
  • problems symptoms
  • getting your
  • needs met in the mh system
  • Recovery strategies
  • Practical facts about mi
  • Stress-Vulnerability treatment strategies
  • Building social supports

30
EBP ILLNESS (WELLNESS) MANAGEMENT AND RECOVERY
PROGRAM-4
  • RESOURCES
  • Wellness Self-Management Plus by Columbia
    University Paul Margolies and Tony Salerno
  • http//www,mentalhealth.samhsa.gov/cmhs/communitys
    upport/toolkit
  • http//www.mentalhealthpractices.org/imr_mlpl.
  • html
  • Liberman RL et al, describing UCLA Models,
    Innovations Research, Vol2(2), 1993
  • P.A. Garrety et al , Schiz Bull, 2000

31
QUESTION 2
  • Is there an additional neurological impairment?

32
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33
THE DEFICIT SYNDRÔME
  • /- S/S of Schizophrenia Come and Go (esp.
    symptoms)
  • Attempts to find primary, enduring stable
    negative symptoms
  • Subtype or Additional D/O
  • Neurological Impairments ( sensory integration,
    stereognosis, graphesthesia, right-left
    confusion, the face-hand test, audiovisual
    integration)

34
THE DEFICIT SYNDRÔME - 2
  • Poor premorbid social functioning
  • Reduced glucose uptake in the frontal cortex,
    parietal thalamic areas on PET scans
  • Increased anhedonia and fewer psychotic events
  • Earlier onset, seems to be unremitting, suffer
    spontaneous movement d/o, severe cognitive
    impairments

35
THE DEFICIT SYNDRÔME - 3
  • Deficit PARTICIPANTs in comparison to NonDeficit
  • PARTICIPANTs show
  • Equal positive symptoms (hallucinations,
    delusions, and formal thought d/o)
  • Less severe dysphoric symptoms (e.g. depressive
    mood, anxiety, guilt, hostility)
  • Less severity of suspiciousness
  • Similar duration of illness
  • Brain architecture seems to be more intact in
    some areas

36
THE DEFICIT SYNDRÔME - 4
  • Need longitudinal information
  • Use SDS or PDS Criteria
  • Exclude drug effect demoralization
  • Need 2 of of the following for more than a year
  • restricted affect,
  • diminished emotional range,
  • poverty of speech,
  • curbing of interests,
  • diminished sense of purpose and social drive

37
THE DEFICIT SYNDRÔME - 5
  • USE SCREENING TOOL THE Neurological Evaluation
    Scale (NES)
  • TRY
  • Atypical Neuroleptics
  • Cognitive Remediation
  • Other Aggressive Rehab

38
Some Resources
  • Brian Kirkpatrick et al, 1989, (SDS -The Schedule
    for the Deficit Syndrome), 1993, 2001
  • PDS Proxy for Deficit Syndrome Kirkpatrick 1996
    (core deficit no dysphoria)
  • Robert W. Buchanan et al, 1990, 1993,1994, 1996

39
QUESTION 3
  • DOES THIS PERSON HAVE OTHER MEDICAL PROBLEMS
    ABOUT WHICH TO WORRY?

40
(No Transcript)
41
OVERVIEW OF SITUATION
  • 40-60 with medical co-morbidity
  • Not recognized nor treated
  • Participants get turfed back to psychiatry or
    not referred at all
  • Need primary care, eye hearing exams, OB etc
  • Need physical by nurse practitioner, a health
    history questionnaire and basic lab tests

42
LABORATORY TESTS TO ORDER
  • BIOCHEM 23
  • TOX SCREEN
  • COMPLETE BLOOD COUNT
  • URINALYSIS
  • THYROID FUNCTION TESTS (T4 TSH)
  • B-12
  • FOLATE
  • VDRL (for syphilis)
  • HIV
  • _______________
  • CT or
  • MRI (if indicated)

43
Some Suggested Strategies
  • Collaboration and linkages
  • Have a case manager or other person who knows
    person well go armed with information and written
    questions and take notes
  • Rescheduling missed appt.s
  • Get outside prescriptions into record

44
Medical Algorithm for Detecting Physical Disease
in Psychiatric Patients
  • Harold C. Sox, Jr. et al Hospital and Community
    Psychiatry, vol.40 (12) 1270-1276

45
Some Suggested Strategies
  • Offer preventive programs e.g. Weight Watchers,
    Jazzercise, other exercise programs, nutrition,
    cooking and grocery shopping skills, meditation,
    other relaxation techniques, walking, blood
    pressure and diabetes monitoring.
  • Health and Wellness Education Classes

46
PAYING ATTENTION GETS
  • Finding strengths in self care management
  • Healthier people
  • Reduced mortality rates
  • Avoids confounding diagnosis
  • And contraindicated medications

47
QUESTION 4
  • WHO IS THIS PERSON UNDER A COAT OF ILLNESS?

48
(No Transcript)
49
ASSESSMENT OF ADULT DEVELOPMENT
  • PSYCHIATRIC PROBLEMS DISRUPT A LIFE
  • NEED TO GRIEVE FOR LOSS OF TIME AND OPPORTUNITIES
  • THE REHABILITATION CRISIS (McCRORY, 1982)
  • ASSESSMENT OF PREMORBID LEVELS OF FUNCTIONING
    (PEER RELATIONS, SCHOOL PERFORMANCE AND DATING
    etc)

50
What to do when people deny they have an illness?
  • Can get better without any insight or admission
    that they have a diagnosis
  • Usually aware that something is holding them back
    from getting a life they want
  • If want to recapture their dreams and accept some
    kind of help from others or
  • Focus on what the person thinks is distressing or
    getting in the way of dream
  • Listening and engaging
  • L. Davidson, 2012

51
Question 5
  • WHAT OTHER THINGS HELP OR HINDER PROGRESS?

52
(No Transcript)
53
Assessment of THINGS THAT GET IN THE WAY OF
RECOVERY PROCESS
  • NEED TO ASSESS SOCIALIZATION INTO PARTICIPANT
    ROLE
  • LIMITED ECONOMIC OPPORTUNITIES
  • MEDICATION SIDE EFFECTS, LACK OF REHABILITATION,
    EXTREME VIRULENCE OF ILLNESS, LACK OF STAFF
    EXPECTATIONS, LOSS OF HOPE

54
ASSESSMENT OF CHARACTERLOGICAL TRAITS
  • Can get in the way or aid progress
  • How did the person respond to crises before
    mental illness?
  • Is the schizophrenia gone but not the personality
    ?
  • Look for problem-solving, a sense of humor, a
    philosophical approach, optimism, persistence and
    strengths in functioning

55
QUESTION 6
  • ARE THERE SPECIFIC NEUROCOGNITIVE DEFICITS BEING
    COPED WITH BY THIS PERSON?

56
SCHIZOPHRENIA NEUROCOGNITIVE DEFICITS
  • Attention
  • Vigilance
  • Executive functioning (reasoning, judgment,
    problem-solving, anticipation, planning,
    decision-making)
  • Learning
  • Memory
  • Ability to read affect on faces
  • Find cognitive strengths

57
MUTLIMODAL APPROACH
  • Tests of laterality- prefrontal, frontal,
    parietal, temporal functioning
  • Semantic, episodic working memory
  • Expressive receptive language
  • Constructional skills

58
MUTLIMODAL APPROACH -2
  • NEW COGNITIVE RETRAINING EFFORTS
  • VIDEO CUE TRAINING
  • GOAL IS TO MATCH REHAB TYPE AND INTENSITY TO
    NEEDS

59
SOME RESOURCES
  • G.E. Hogarty - Cognitive Enhancement Therapy
    2002- Guilford Press
  • G.E. Hogarty S. Flescher (1999)
  • H.D. Brenner et al Hografe Huber Toronto, 1994
  • W. Spaulding et al BJP, 1989
  • Michael F. Green AJP, 1996
  • MATRICS new 60 minute battery
  • Harding - A Classical but short battery

60
QUESTION 7
  • ARE THE MEDICATIONS REALLY WORTH THE TRADE-OFF?

61
(No Transcript)
62
ASSESSMENT OF NEED FOR, RESPONSE TO, AND SIDE
EFFECTS FROM MEDICATION
  • TAKE A THOROUGH HISTORY
  • GET OLD RECORDS
  • TALK TO OTHERS WHO KNOW PERSON
  • COLLABORATE, COLLABORATE, COLLABORATE, COLLABORATE

63
CAUSES OF MISINTERPRETATION
  • MUST LISTEN TO THE WAY MEDS MAKE PEOPLE FEEL FROM
    THE INSIDE OUT
  • SOMETIMES CLIENTS CANT DESCRIBE SUBTLE FEELINGS
  • E.g. Side Effect of Akathisia- being compelled to
    be in motion- pacing, rocking, etc thought to be
    agitation, elopement, need for seclusion, acting
    out, and left untreated.
  • USE AIMS EPS EXAM q.6 MOS

64
MORE ON SIDE EFFECTS
  • 20-30 OTHER SIDE EFFECTS e.g. DYSKINESIAS,
    DYSTONIAS, PARKINSONISM
  • EVEN NEW ATYPICALS CAN HAVE SIDE EFFECTS DOSE
    DEPENDENT
  • NEED TO SYSTEMATICALLY CHECKED q.6 MOS WITH
    INSTRUMENTS
  • TRAIN PARTICIPANTS TO SELF-MONITOR
  • ATTEND TO SEX DIFFERENCES

65
DEFINITION OF THE WORD COMPLIANCE
  • GIVING IN TO A REQUEST, DEMAND, WISH
    ACQUIESENCE A TENDENCY TO GIVE IN TO OTHERS

66
vs ADHERENCE
  • TO STICK FAST
  • TO BECOME ATTACHED
  • TO GIVE ALLEGIANCE TO
  • TO GIVE DEVOTION OR SUPPORT

67
MORE ADVICE
  • nothing in the literature that says everyone
    needs meds for a lifetime only maybe a small
    group
  • taper, taper very very slowly if on for a long
    time

68
EBP- MedMAP MEDICATION MANAGEMENT APPROACHES IN
PSCYHIATRY
  • Provides a systematic structured plan for med
    management
  • Documentation is clearer and more concise
  • Objective measures of outcome
  • Shared decision-making

69
EBP- MedMAP MEDICATION MANAGEMENT APPROACHES IN
PSCYHIATRY - 2
  • New developments in antipsychotic therapy - an
    interesting discussion report of a group of
    psychopharmacologists J. Clin Psych Nov 2003
  • CATIE Clinical Antipsychotic Trials of
    Intervention Effectiveness
  • CATIE Results underscore need for access to
    full range of medications in www.szdigest.com
    and also NEJM Sept 22, 2005 J. Lieberman et al

70
Morbidity Mortality
71
MORBIDITY AND MORTALITY
  • The Metabolic Syndrome
  • Abdominal obesity (excessive fat tissue in and
    around the abdomen)
  • Atherogenic dyslipidemia (blood fat disorders
     high triglycerides, low HDL cholesterol and
    high LDL cholesterol that foster plaque
    buildups in artery walls)
  • Elevated blood pressure

72
MORBIDITY AND MORTALITY-2
  • More of The Metabolic Syndrome
  • Insulin resistance or glucose intolerance (the
    body cant properly use insulin or blood sugar)
  • Prothrombotic state (e.g., high fibrinogen or
    plasminogen activator inhibitor1 in the blood)
  • Proinflammatory state (e.g., elevated C-Reactive
    Protein in the blood)

73
MORBIDITY AND MORTALITY-3
  • Increased risks of
  • Coronary heart disease
  • Stroke
  • Peripheral vascular disease
  • Type 2 Diabetes
  • Physical inactivity
  • Hormonal Imbalance
  • Expression of familial genetic profile

74
MORBIDITY AND MORTALITY-4
  • Graded relationship between number of
    neuroleptics taken and mortality
  • (even after adjusting for known risk factors of
    premature death such as smoking, lack of
    exercise, BMI, B/P, serum total and HDL
    cholesterol).

75
MORTALITY-5
  • Graded relationship between number of
    neuroleptics taken and mortality and dosage
    levels with
  • Fatal arrhythmias
  • Sudden cardiac deaths
  • Venus thrombosis
  • Pulmonary embolism
  • Asthma deaths

76
MORBIDITY AND MORTALITY-6
  • On 1st Generation drugs mortality risk 2.84 and
    was just slightly reduced to 2.25 after adjusting
    for other factors such as somatic diseases, BMI,
    exercise, B/P, BMI, alcohol intake and education.
  • Relative risk for each new drug added 2.50
    additional risk.
  • Joukamaa et al, 2006
  • Similar Findings for Atypicals and for
    Antidepressants (both SSRIs and Tricyclics)

77
(No Transcript)
78
New Considerations for optimization of medications
  • Some people seem to need no medications
  • Some people seem to need medications for a short
    while
  • A few people seem to need medication for a longer
    period.

79
Support for optimization of medications.
  • Literature says that 1st episode participants may
    need little or no medications
  • Nothing in the literature that says everyone
    needs meds for a lifetime only maybe a small
    group
  • Taper, taper very very slowly if on for a long
    time

80
More Resources
  • Personal Therapy GE Hogarty et al 1997 helps
    adherence
  • W. Fenton Psych Times 2006 Combined therapy
  • MedMAP http//www.mentalhealth.SAMHSA.org
  • APA 2004 Practice Guidelines
  • Texas Medication Algorithm No!

81
QUESTION 8
  • WHY IS THIS PERSON TAKING STREET DRUGS IN PLACE
    OF OR IN ADDITION TO PRESCRIPTIONS ?

82
(No Transcript)
83
INFO ON USING STREET DRUGS
  • At least 47 co-occurring disorders
  • Most costly to treat
  • IS PERSON TREATING DEPRESSIONS OR MEDICATION SIDE
    EFFECTS (e.g. Akinesia) or to ameliorate lack of
    motivation and pleasure or to combat loneliness
    or to get a social group ?

84
INFO ON USING STREET DRUGS -2
  • MAKES INITIAL DIAGNOSIS DIFFICULT
  • USE OF STRUCTURED INTERVIEWS HELPFUL (SCID OR
    ASI)
  • INFO ON STREET DRUG OF CHOICE MAY BE HELPFUL TO
    ADD INTO DIAGNOSTIC PROCESS
  • STANDARD CONFRONTATIONAL MODELS MIGHT NOT WORK
    FOR PEOPLE WITH SCHIZOPHRENIA
  • BLENDED FUNDING STREAMS AND INTEGRATED CARE MORE
    HELPFUL

85
Co-Occurring or Dual Dx D/O can lead to
  • Symptom
  • Relapses
  • hospitalization
  • financial and family problems
  • homelessness
  • suicide
  • Violence,
  • Sexual and physical victimization,
  • Incarceration,
  • HIV,
  • Hepatitis B and C
  • and early death.

86
EBP Integrated Dual Disorders Treantment (IDDT)
  • Services provided concurrently
  • Individualized assessment and treatment planning
    in heavy collaboration
  • Use SCID-SA Screener

87
EBP Integrated Dual Disorders Treatment
  • DUAL DISORDERS TREATMENT IMPLEMENTATION RESOURCE
    KIT
  • Information
  • Training Materials
  • Annotated Bibbs
  • Refs
  • http//www.mentalhealthpractices.org

88
EBP Integrated Dual Disorders Treatment
  • Blending
  • Stage-wise Treatment
  • Motivational Treatment
  • Substance Abuse Counseling
  • Involving all stakeholders
  • 4 basic skills for clinicians
  • Knowledge of substances how they affect MI
  • Assessment skills
  • Motivational interviewing skills
  • SA Counseling skills

89
QUESTION 9
  • WHAT ARE THE RELEVANT SEX DIFFERENCES?

90
(No Transcript)
91
SEX DIFFERENCES ACROSS THE LIFE SPAN
  • NEURAL DEVELOPMENTAL GROWTH
  • BIRTH COMPLICATIONS
  • PEDIATRIC INJURIES
  • PUBERTY AND HORMONES
  • METABOLIC DIFFERENCES
  • MENOPAUSE
  • PRESCRIBING PRACTICES ARE DIFFERENT

92
QUESTION 10
  • WHERE IS THIS PERSON IN THE COURSE OF ILLNESS?

93
(No Transcript)
94
COURSE INFORMATION
  • Schizophrenia is virulent early and tapers off
    later
  • Like other general medical disorders
  • Mother nature is trying to help
  • BURNT OUT vs. The phoenix

95
MORE ON COURSE
  • ALSO COURSE OF LIFE, ITSELF
  • USE A LIFELINE OR LIFE HISTORY
  • MUTUAL PARTICIPATION MODEL
  • LONGITUDINAL PATTERNS AND TRENDS
  • DIFFERENT USES OF SOCIAL RELATIONSHIPS
  • BUILD THERAPEUTIC RELATIONSHIPS

96
QUESTION 11
  • WHAT MYTHS AND MISINFORMATION ARE STRESSING THE
    PERSON?

97
(No Transcript)
98
ASSESSMENT OF UNDERSTANDING THE ILLNESS AND
MEDICATIONS
  • Knowledge is power
  • Collaboration and education
  • Helps change the stressful valence can reduce
    relapse rates
  • Teaches how to manage symptoms
  • Promotes competency and empowers
  • Increases self-esteem

99
QUESTION 12
  • WHO DEPENDS ON THE CLIENT FOR HELP?

100
(No Transcript)
101
SOCIAL SUPPORTS
  • CONNECTION BETWEEN KIND AND AMOUNT OF SOCIAL
    SUPPORTS AND RECOVERY FROM AND PREVENTION OF
    ILLNESS OF ALL KINDS
  • NETWORKS TYPE, AMOUNT, DENSITY, SIZE, DEGREE
    OF INTERDEPENDENCE, CLUSTERING, DEGREE OF INTIMACY

102
SOCIAL SUPPORTS - 2
  • Social Skills Training (Promising Rehab Practice)
  • Reading social cues
  • Acting appropriately
  • Practicing acceptable social behaviors
  • (e.g. eye contact, small talk etc)
  • Decrease loneliness
  • Increase possibility of finding friends and
    significant others.

103
More resources
  • Robert Libermans Social Independent Living
    Skills Modules at UCLA
  • See Innovations Research
  • Vol2 (2) 1993
  • Hardings Star Chart (Social Network) Harding
    Keller, 1998

104
QUESTION 13
  • WHAT IS THE PERSONS WORLD VIEW?

105
(No Transcript)
106
CULTURAL SENSITIVITY
  • ONLY RECENTLY APPRECIATED
  • DIVERSITY IS HALLMARK OF WORLD
  • NEED TO UNDERSTAND AT INTAKE ONWARD
  • WHAT IS IMPORTANCE OF RELIGIOUS THINKING versus
    RELIGIOSITY?
  • SENSE OF TIME?
  • DISPLAYED AFFECT?

107
CULTURAL SENSITIVITY-2
  • Disorganized sounding speech - a linguistic
    variation?
  • Importance of family, community and church?
  • Is the interpreter asking the same questions you
    are? (see Utah DMH video)

108
CULTURAL SENSITIVITY-2
  • WWW.WICHE.EDU/MENTALHEALTH
  • SAMHSAs only approved standards for anything
  • Benchmarks
  • Guidelines
  • Outcome Measures
  • Lit Review
  • For everyone and for the core 4 minority groups

109
Question 15
  • IS THERE ANY COHESION IN THE SYSTEM OF CARE?

110
(No Transcript)
111
LINKAGES - 1
  • Coordination and linkage between all the players
    are critical
  • Need semi-permeable membranes for information
    sharing, flexibility, coordination, continuity
    and integration
  • Clear and consistent policies from the top down
  • The more we have our act together the better the
    participants become

112
LINKAGES - 2
  • Clear and consistent policies from the top down
  • Use community resource checklist (cmhcs,
    extension serv, consumer groups, nat support)
  • The more we have our act together the better the
    participants become

113
QUESTION 14 RISK MANAGEMENT - 2
  • Research has found the following risk factors for
    minor and serious violence
  • PERSECUTORY IDEATION
  • SUBSTANCE ABUSE
  • CHILDHOOD CONDUCT D/O
  • VICTIMIZATION

114
14 WHAT TO DO WITH AN OUT OF CONTROL PERSON?
115
(No Transcript)
116
RISK MANAGEMENT
  • Relapse Prevention Strategies
  • Try Paul and Lentz Social Learning Environments
    (behavioral)
  • Tony Mendittos program for forensic participants
  • Individualized Token Behavioral Programs which
    tend to generalize to other environments
  • Reduce Restraint and Seclusion with other
    psychological strategies first

117
QUESTION 16
  • WHERE DO THE CLINICIAN AND CONSUMER BEGIN TO
    START BUILDING THE RECOVERY PROCESS?

118
(No Transcript)
119
ASSESSMENT OF STRENGTHS
  • REHAB IS BUILT ON STRENGTHS NOT PROBLEMS OR
    DEFICITS
  • STRENGTHS OF PERSON, SYSTEM OF CARE, FAMILY,
    CASE MANAGER, THE DOC ETC
  • SENSE OF HUMOR, DRIVERS LICENSE, COMPUTER SKILLS,
    CARE OF OTHERS, WATERING PLANTS AND EVEN THE
    MANIPULATION OF SYSTEMS

120
New questions
  • 17) AT SOME POINT WE NEED TO FIND OUT ABOUT
    PREVIOUS TRAUMATIC EXPERIENCES
  • Avoidance, hypervigilance, emotional
    difficulties, and recall behaviors, anxiety,
    depression, probs sleeping, and sometimes
    hopeless
  • Use SCID-D for assessment

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17 WHAT ABOUT TRAUMA?
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Predictors of the Emergence of PTSD
  • LACK OF SOCIAL SUPPORT
  • LACK OF EDUCATION
  • TOUGH FAMILY BACKGROUND
  • PRIOR PSYCHIATRIC HISTORY
  • DISSOCIATIVE REACTION
  • (Berwin et al 2000, Ozer et al, 2003)

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Some Trauma Studies
  • 50-60 of US have a traumatic experience
  • 10 - 17 Chronic PTSD (Galea et al, 2002)
  • In community 1 in 10 women/girls and 1 in 20
    men/boys have PTSD (Kessler et al, 1995)
  • Most do not. Not pathological! (Bonanno et al,
    2002)

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Psychophysiological Sequelae of Stress and Trauma
  • Psychogenic Stress of all kinds can be Genotoxic
    in Cellular Structures
  • Changes in both internal and external
    environments can lead to changes in gene
    structures
  • The Brain is a Plastic Organ as well
  • Healing is possible

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Mnemonic for PTSD
  • FEARS
  • Fears
  • Ego construction (numbing withdrawal)
  • Anger
  • Repetition (Flashbacks nightmares)
  • Sleep disturbance
  • Jean Goodwin

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Mnemonic for COMPLEX PTSD
  • FEARS
  • Fugue Other Dissociative states
  • Ego fragmentation
  • Antisocial Behaviors
  • Re-enactment
  • Suicidality Somatitization
  • Jean Goodwin

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18 CAN THIS PERSON READ?
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Assessment of the level of functional literacy
  • Realizing that admitting you cant read is more
    embarrassing to a person than talking about
    symptoms!
  • Receiving information in the way a person can
    understand
  • Learning to read might improve self-esteem and
    reduce symptoms
  • Helps close the gap in healthcare disparities

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REALM-R Rapid Estimate of Adult Literacy in
Medicine, Revised
  • (a 5 minute 11 word list for English speakers
    which provides a quick measure of
    literacy) Bass et al 2003

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Ways to enhance understanding in persons with low
level literacy-1
  • Slow down speech fluency
  • Use living room language instead of medical
    terminology
  • Show or draw pictures to enhance understanding
    and subsequent recall

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Ways to enhance understanding in persons with low
level literacy-2
  • Limit amount of information given at each
    interaction and repeat instructions
  • Use a teach back or show me approach to
    confirm understanding
  • Be respectful, caring, and sensitive thereby
    empowering people to participate in their own
    health care.
  • Williams, Davis, Parker Weiss. Fam Med. 2002,
    34387)

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19 Does this person believe in something
bigger than self?
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USE OF SPIRITUALITY
  • Research shows that about half of every sample
    relies on some sort of faith (Western formal,
    informal, nature, Eastern, personal) to provide
    help and supports
  • Need to ask and talk about it if person is
    interested

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AND 20) WHAT DOES THE PERSON THINK HE OR SHE IS
RECOVERING FROM?
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CHERYL GAGNES LIST from peers Loss of self,
connection, hope Loss of roles and
opportunities devaluing and disempowering
programs, practices, and environments Prejudice
and discrimination in society Internalized
oppression and shame
  • !

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WHAT MADE THE DIFFERENCE ACCORDING TO THOSE
INTERVIEWED?
  • Decent food, clothing and housing
  • People with whom to be
  • A way to be productive
  • A way to manage s/s and meds
  • Individualized rx
  • Case management
  • Psycho-education
  • Integrated back into the community

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WHAT DID THE VERMONTERS SAY MADE THE DIFFERENCE?
  • Hope!
  • Someone believed in me
  • Someone told me i had a chance to get better
  • My own persistence
  • Hope connects with natural self-healing capacities

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HOPE CAN ARRIVE ONLY WHEN YOU RECOGNIZE THAT
THERE ARE REAL OPTIONS AND THAT YOU HAVE GENUINE
CHOICES. Jerome Groopman, MD (2004)
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To hope under the most extreme circumstances is
an act of defiance that.permits a person to live
his her life on his her own terms. It is the
part of the human spirit to endure and give a
miracle a chance to happen. Jerome Groopman, MD
(2004)
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BEING SYSTEMATIC CREATIVE, STRUCTURED IN YOUR
APPROACH
  • YOURSELF AND YOUR RELATIONSHIP ARE THE BEST TOOLS
    IN YOUR KIT BAG

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SHOW ME THE EVIDENCE AND MANY THANKS FOR COMING!
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