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Title: 20 WAYS TO OVERCOME BARRIERS TO RECOVERY (20th Revision) 2012


1
20 WAYS TO OVERCOME BARRIERS TO RECOVERY(20th
Revision)2012
  • Prof. Courtenay M. Harding

2
Good Morning!
  • OVERALL GENERAL INFORMATION FOR TODAY
  • Whats in the folders?
  • How to work with this information
  • Breaks for lunch, phone bathroom
  • Ask questions as we go along
  • Evaluations and Certificates at end

3
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4
THE PRESENTATION PLAN
  • Review 20 obstacles with strategies to get some
    answers or how to better understand the
    complications. Lots of resources!

5
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

6
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7
MORE STUDIES USING WIDER DIAGNOSTIC CRITERIA
  • STUDY Av. Years
  • Year Place of Ss
    length improvement
  • _______________________________________or
    recovery
  • HINTERHUBER 157 30 74.8
  • 1973 AUSTRIA
  • KREDITOR 115 20.2 84
  • 1977 LITHUANIA
  • MARINOW 280 20 75
  • 1986 BULGARIA

8
THESE PROJECTS HAVE STUDIED..
  • 2400 plus people
  • Across 2-3 decades after first admission
  • In intact samples
  • Found surprising confluence of findings

9
FINDINGS
  • 46-68 OF EACH COHORT SIGNIFICANTLY IMPROVED
    AND/OR RECOVERED
  • Recovered means
  • No enduring symptoms,
  • No odd behaviors,
  • No further medication,
  • Living in the community,
  • Working, and relating well to others
  • Significantly improved means
  • Recovered in all areas but one
  • Harding et al, 1987

10
Resources with More of the Evidence
  • Harding, C.M. Changes in schizophrenia across
    time paradoxes, patterns, and predictors. In
    Carl Cohen (ED.) SCHIZOPHRENIA INTO LATER LIFE
    Treatment, Research and Policy. APPI Press,
    2003, pp.19-42 ( a review of all ten studies)
  • Harding, C.M. Zubin, J. Strauss, J.S.
    Chronicity in schizophrenia revisited, BRITISH
    JOURNAL OF PSYCHIATRY in Supplement entitled
    Transactional Processes in Onset and Course of
    Schizophrenic Disorders. 1992, 161 (Suppl. 18)
    27-37.

11
More Evidence
  • Davidson, L, Harding, C.M., Spaniol, L. (Eds.).
    Research on Recovery from Severe Mental Illness
    30 years of Accumulating Evidence and Its
    Implications for Practice. (Vol. 1), Center for
    Psychiatric Rehabilitation, Boston University,
    2005 (Vol.2) , 2006
  • Harding, C.M. The interaction of
    biopsychosocial factors , time, and the course of
    schizophrenia Time is the critical co- variate.
    In C.L. Shriqui H.A. Nasrallah (Eds.)
    Contemporary Issues In The Treatment Of
    Schizophrenia. Washington, D.C., APA Press.
    1995, pp. 653-681.

12
More resources -3
  • Harding, C.M. An examination of the complexities
    in the measurement of recovery in severe
    psychiatric disorders. In R.J. Ancill, S.
    Holliday, G.W. MacEwan (Eds.), Schizophrenia
    Exploring The Spectrum Of Psychosis. Chichester,
    J. Wiley Sons, 1994, pp. 153-169.

13
Base Papers for Vermont Study
  • Harding, C.M. Brooks, G.W. Ashikaga, T.
    Strauss, J.S. Breier, A. The Vermont
    longitudinal study of persons with severe mental
    illness I. Methodology, study sample, and
    overall status 32 years later. (lead article)
    AMERICAN JOURNAL OF PSYCHIATRY, 1987, 144(6)
    718-726.
  • Harding, C.M. Brooks, G.W. Ashikaga, T.
    Strauss, J.S. Breier, A. The Vermont
    longitudinal study II. Long-term outcome of
    subjects who retrospectively met DSM-III criteria
    for schizophrenia. (lead article) AMERICAN
    JOURNAL OF PSYCHIATRY, 1987, 144(6) 727-735.

14
Base Papers for the Maine-Vermont Comparison Study
  • DeSisto, M.J. Harding, C.M. McCormick, R.V.
    Ashikaga, T. Gautam, S. The Maine-Vermont three
    decade studies of serious mental illness I.
    Matched comparison of cross-sectional outcome.
    BRITISH JOURNAL OF PSYCHIATRY, 1995, 167,
    331-338.
  • DeSisto, M.J. Harding, C.M. McCormick, R.J.
    Ashikaga, T. Brooks, G.W. The Maine-Vermont
    three decade studies of serious mental illness
    II. Longitudinal course comparisons. BRITISH
    JOURNAL OF PSYCHIATRY, 1995, 167, 338-342.

15
IF RECOVERY AND SIGNIFICANT IMPROVEMENT ARE
POSSIBLE.
  • THEN WHY ARE SO MANY PARTICIPANTS NOT GETTING
    BETTER?
  • SEVERAL MILLION PEOPLE LANGUISHING IN US ALONE

16
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)

17
Please note these questions are not just for
physicians to ask but also for other clinicians,
users, and family members to be curious and to
raise questions
18
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
  • From Dr. Candace Fleming, a Native American
    psychologist

19
Learning to play a detective !
20
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21
Always important to have some fun!
22
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

23
QUESTION 1
  • HAVE OTHER POSSIBLE CAUSES OF SYMPTOMS AND
    BEHAVIORS BEEN ELIMINATED?

24
WHY IS THIS QUESTION IMPORTANT?
  • e.g. Schizophrenia is a diagnosis of exclusion.
    The following differential diagnoses should be
    eliminated BEFORE giving the diagnosis of
    schizophrenia. Not often done. Wrong diagnosis
    wrong treatment

25
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26
DIAGNOSIS OF EXCLUSION(especially schizophrenia)
  • 26 other disorders (medical, neurological, and
    psychiatric) that masquerade with
    schizophrenia-like symptoms !

27
DIAGNOSIS OF EXCLUSION(schizophrenia)
  • Autism (esp. Aspergers Syndrome)
  • Temporal Lobe Epilepsy
  • Tumor
  • Stroke

28
MORE THINGS TO EXCLUDE
  • Brain Trauma
  • Endocrine Metabolic Disorders (e.g. acute
    intermittent porphyria (liver enzyme)
  • Homocystinuria (a disorder of amino acid
    metabolism)

29
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)

30
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

31
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

32
ANOTHER HELPFUL STRATEGY
  • 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)

33
SOURCE FOR BASIS-24
  • Developed by Dr. Susan Eisen
  • www.basissurvey.org/basis24/

34
HOW TO DO BETTER
  • Take the time get triangulated information
  • Get the lab tests done
  • Reassess over time
  • Pay attention to comorbid diagnoses

35
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 only a psychiatric disorder
  • Networks of partnerships treating person in a
    holistic way
  • Partners include hospital, primary care docs,
    mental health and addiction services plus others
    such as OB/GYN, eye specialists, hearing tests,
    dental care, and legal aid.

36
SUGGESTED INSTRUMENTS
  • To clarify a psychiatric diagnosis
  • SCID THE STRUCTURED CLINICAL INTERVIEW FOR
    DSM-IV TR (CLINICAL VERSION)

37
OR IF PSYCHIATRIC DIAGOSIS IS RE-ESTABLISHED
  • All diagnoses are cross-sectional working
    hypotheses
  • Not lifetime labels
  • Not able to predict long-term outcome
  • Must write enough evidence to show evidence of
    the diagnosis into the case record (what is
    present/absent)

38
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

39
Interesting Resources to Check out
  • Harding, C.M. Re-assessing a person with
    schizophrenia and developing a new treatment
    plan. In J.M. Barron (Ed). MAKING DIAGNOSIS
    MEANINGFUL ENHANCING EVALUATION AND TREATMENT
    OF PSYCHOLOGICAL DISORDERS. Washington, D.C. APA
    Press. 1998, pp. 319-338.
  • (source for this training changed many times)

40
More Resources
  • Rosen, A. (2006) The community psychiatrist of
    the future. Current Opinion in Psychiatry.
    Lippincott Williams and Wilkins .
  • Ragins, M. Recovery With Severe Mental Illness
    Changing From A Medical Model to A Psychosocial
    Rehabilitation Model http//www.village-isa.org/Ra
    gin27s20Papers/recov.20with20severe20MI.htm

41
BATHROOM AND MOBILE PHONE BREAK
42
QUESTION 2
  • DOES THIS PERSON WITH A PSYCHIATRIC DISORDER
    HAVE OTHER MEDICAL PROBLEMS ABOUT WHICH TO WORRY?

43
WHY IS THIS QUESTION IMPORTANT?
  • Even though a psychiatric diagnosis may be
    correct, there is a good chance that the person
    may be experiencing a co-morbid condition or two
    or three.
  • If left untreated, he or she may die
    unnecessarily early.

44
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45
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/GYN
    etc
  • Need admission and annual physical by nurse
    practitioner, a health history questionnaire and
    basic lab tests

46
A Resource (Old but Helpful)
  • Hosp Community Psychiatry. 1989
    Dec40(12)1270-6.
  • A medical algorithm for detecting physical
    disease in psychiatric patients.
  • Sox HC Jr, Koran LM, Sox CH, Marton KI, Dugger F,
    Smith T.
  • Source
  • Department of Medicine, Dartmouth-Hitchcock
    Medical Center, Hanover, New Hampshire, USA

47
LABORATORY TESTS TO CONSIDER
  • BIOCHEM
  • TOX SCREEN
  • COMPLETE BLOOD COUNT
  • URINALYSIS
  • THYROID PANEL
  • B-12
  • FOLATE
  • VDRL (for syphilis)
  • HIV
  • _______________
  • CT or
  • MRI (if indicated)

48
Other than the step-down MRI or CT Scans, these
tests cost less than 100 ! Since many people
are entering the system of care through community
mental health and not hospital stays, these tests
might be ordered as part of admission to help
with the differential diagnostic process.
49
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 with user to
    another physician
  • Rescheduling missed appointments
  • Get outside prescriptions into record

50
More Suggested Strategies
  • Offer preventive programs e.g. Weight Watchers,
    Jazzercise, other exercise programs
  • Walking
  • Nutrition, cooking and grocery shopping skills
  • Meditation other relaxation techniques
  • Other Health and Wellness Education Classes on
    blood pressure, weight, and diabetes monitoring.

51
PAYING ATTENTION GETS
  • Finding strengths in self care management
  • Healthier people
  • Reduced mortality rates
  • Avoids confounding diagnosis
  • And contraindicated medications

52
Resource to check out
  • Danson,D.,Jones, R, Macias, C., Barreira,P. J. ,
    Fisher, W.H., Hargreaves, W. A. Harding, C.M.
    Prevalence, severity, and co-occurrence of
    chronic physical health problems of people with
    serious mental illness. PSYCHIATRIC SERVICES,
    2004, 55 1250-1257.

53
QUESTION 3
  • Is there an additional neurological impairment?

54
WHY IS THIS QUESTION IMPORTANT?
  • There are groups of young men who are withdrawn
    and sit quietly and are mostly ignored because
    they cause no trouble.
  • If they qualify for the Deficit Syndrome then
    they might do better if they have a medication
    change, cognitive remediation, and active
    rehabilitation

55
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56
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)

57
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

58
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

59
THE DEFICIT SYNDRÔME - 4
  • Need longitudinal information
  • Use SDS or PDS Criteria
  • Exclude drug effect demoralization
  • Need 2 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

60
THE DEFICIT SYNDRÔME - 5
  • USE SCREENING TOOL THE Neurological Evaluation
    Scale (NES)
  • TRY
  • Atypical Neuroleptics
  • Cognitive Remediation
  • Other Aggressive Rehab

61
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

62
Another Interesting Resource
  • Strauss, J.S. Rakfeldt, J.H. Harding, C.M.
    Lieberman, P. Psychological and social aspects
    of negative symptoms. BRITISH JOURNAL OF
    PSYCHIATRY, 1989, 155 (Suppl. 7) 128-132.

63
QUESTION 4
  • WHO IS THIS PERSON UNDER A COAT OF ILLNESS?

64
WHY IS THIS QUESTION IMPORTANT?
  • Once a person has been labeled, he or she is
    often hidden from view. Finding and working with
    the real person underneath is the key to recovery.

65
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66
ASSESSMENT OF ADULT DEVELOPMENT
  • PSYCHIATRIC PROBLEMS DISRUPT A LIFE
  • NEED TO GRIEVE FOR LOSS OF TIME AND OPPORTUNITIES
  • THE REHABILITATION CRISIS (McCRORY, 1982) which
    describes how clinicians can get in the way of
    recovery process inadvertently
  • ASSESSMENT OF PREMORBID LEVELS OF FUNCTIONING
    (peer relations, school performance and dating
    etc)
  • Use LIFELINE (Harding, 2011)to get to know the
    person and his or her patterns better

67
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

68
What If A Person Has No Goals?L. Davidson P.
Ridgway
  • Is person demoralized and lost hope?
  • Is person socialized into learned helplessness?
  • Has person become risk aversive?
  • Does person have co-occurring depression?
  • Have you earned persons trust?
  • Are there disabling symptoms and environmental
    responses interfering with relationships and
    participation?

69
New Resource Questionnaire to get a handle on
what a person wants and needs to get better
  • REFOCUS- Promoting recovery in community mental
    health services (Rethink recovery series vol. 4)
    Bird, V. et al, Institute of Psychiatry, Kings
    College London
  • Relationships, understanding values and treatment
    preferences, assessing strengths, and supporting
    goal-striving
  • Checklists, worksheets, strengths assessment

70
Some resources to get to know people better
  • www.researchintorecovery.com/refocus and
    rethink.org/refocus
  • Harding, C.M. The Lifeline, 2011
    CourtenayHardingConsulting_at_gmail.com
  • Davidson, L Ridgway, P. What if a person has no
    goals? (dmh.mo.gov/docs/mentalillness/personwithn
    ogoals.pdf)
  • McCrory, D. (1980) The rehabilitation crisis The
    impact of growth. Journal of Applied
    Rehabilitation Counseling, 11(3)136-139.

71
Narrative Therapy
  • Beels, C. Christian (2001) A Different Story
    The Rise of Narrative in Psychotherapy. Phoenix
    Arizona. Zeig, Tucker Theisen, Inc.

72
Question 5
  • WHAT OTHER THINGS HELP OR HINDER PROGRESS?

73
WHY IS THIS QUESTION IMPORTANT?
  • Often a person loses their psychiatric symptoms
    but the clinician does not understand that it
    has happened.
  • This is because the person may continue to get in
    his or her own way because of quirks in their
    personality or despair
  • It is important to separate out the signal from
    the noise.

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75
ASSESSMENT OFCHARACTERLOGICAL 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
    quirk, Axis II, or despair
  • Criteria under reconsideration for DSM 5
  • Look for evidence of problem-solving, a sense of
    humor, a philosophical approach, optimism,
    persistence and strengths in functioning and
    resilience to build upon

76
Consider rewarding positive behaviors and not
focusing on learned poor ones
  • Clinicians seem to pay attention to
    pain-in-the-neck behaviors and miss the
    opportunity to reinforce healthy ones.
  • Praise small congenial behaviors such as saying
    Good morning, or shaking hands, or looking you
    in the eye, or noticing when a hand is needed,
    etc. etc.

77
Assessment of other things that get in the way
of recovery process
  • Need to assess socialization into participant
    (user, consumer) role
  • Medication side effects
  • Not provided with educational or work
    opportunities
  • Lack of other rehabilitation
  • Extreme virulence of illness (only 10)
  • Lack of staff expectations (very important)
  • Loss of hope

78
Resources
  • Benedict Carey Thinking clearly about
    personality disorders, New York Times
    http//www.nytimes.com/2012/11/27/health/clearing-
    the-fog-around-personality-disorders
  • Ted Millon Personality Disorders in Modern Life,
    2nd ed. (2004)
  • www.pearsonassessments.com/mmpi2.aspx

79
QUESTION 6
  • ARE THERE SPECIFIC NEUROCOGNITIVE DEFICITS BEING
    COPED WITH BY THIS PERSON?

80
WHY IS THIS QUESTION IMPORTANT?
  • Since we have been saying that this is a brain
    disease for a couple of decades, wouldnt it be
    appropriate for us to at least take a flash
    neuropsychological picture of how the brain is
    operating and depending on what is found try to
    help reprogram the wiring a little bit?

81
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

82
MUTLIMODAL APPROACH
  • Tests of laterality- prefrontal, frontal,
    parietal, temporal functioning
  • Semantic, episodic working memory
  • Expressive receptive language
  • Constructional skills

83
MATRICS Consensus Neurocognitive Battery (MCCB)
  • An NIMH initiative
  • Used a broad-based interdisciplinary consensus
    process
  • Originally designed for pharmacological research
  • Outcome measure for cognitive remediation
  • Repeated measures of cognitive change
  • )
  • And as a cognitive reference point for
    non-intervention studies
  • Translated into 16 languages to date
  • Very short battery better tolerated
  • Well known neuropsych tests
  • www.matricsinc.org

84
Components of MCCB
  • 10 tests measuring seven cognitive domains
  • 1)Processing Speed
  • 2) Attention/ vigilance
  • 3) Working Memory
  • 4)Verbal Memory
  • 5) Visual Learning
  • 6) Reasoning Problem Solving
  • 7) Social Cognition
  • www.matricsassessment_at_gmail.com

85
Suggested Cognitive Remediation Efforts in
Community Mental Health
  • Once a profile of strengths and problems are
    documented try using cognitive remediation
    computer techniques! (see Alice Medalias work
    at Columbia University and Susan McGurks work
    at Boston University)

86
MUTLIMODAL APPROACH -
  • GOAL IS TO MATCH REHAB TYPE AND INTENSITY TO
    CHANGING NEEDS

87
More Resources
  • Medalia, A. Choi, J.(2009). Cognitive
    Remediation in Schizophrenia. Neuropsychology
    Review, 19353-364.
  • McGurk, S.R. et al. (2007). A Meta-Analysis of
    Cognitive Remediation in Schizophrenia. American
    Journal of Psychiatry, 164 1791-1802.

88
SOME MORE 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 et al, Scz Res., 2004

89
LUNCH BREAKfor one hour
90
QUESTION 7
  • ARE THE MEDICATIONS REALLY WORTH THE TRADE-OFF?

91
WHY IS THIS QUESTION IMPORTANT?
  • For years, the field has accepted the idea that
    the only thing that helps are medications with
    everything as adjunct.
  • Data are showing that patients on meds for a long
    time are dying 25 years earlier than age-related
    cohorts.
  • We need to reconsider more medication
    optimization approaches.

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93
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

94
MORE ON SIDE EFFECTS
  • 20-30 OTHER SIDE EFFECTS e.g. DYSKINESIAS,
    DYSTONIAS, PARKINSONISM
  • EVEN ATYPICALS CAN HAVE SIDE EFFECTS VERY DOSE
    DEPENDENT
  • NEED TO SYSTEMATICALLY CHECK q.6 MOS WITH
    INSTRUMENTS
  • TRAIN PARTICIPANTS TO SELF-MONITOR
  • ATTEND TO SEX DIFFERENCES

95
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

96
DEFINITION OF THE WORD COMPLIANCENot a great
word in this era of shared decision-making!
  • GIVING IN TO A REQUEST, DEMAND, WISH
    ACQUIESENCE A TENDENCY TO GIVE IN TO OTHERS

97
Vs. ADHERENCE(somewhat better)
  • TO STICK FAST
  • TO BECOME ATTACHED
  • TO GIVE ALLEGIANCE TO
  • TO GIVE DEVOTION OR SUPPORT

98
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

99
Discussions of Medications
  • New developments in antipsychotic therapy - an
    interesting discussion report of a group of
    psychopharmacologists J. Clin Psych Nov 2003
  • CATIE STUDY Clinical Antipsychotic Trials of
    Intervention Effectiveness
  • Results underscore need for access to full range
    of medications in www.szdigest.com and also
    NEJM Sept 22, 2005 J. Lieberman et al

100
Meducation
  • Provides understanding of social cultural
    issues involved in medication adherence
  • Can provide a list of critical questions a user,
    consumer, patient should ask his or her physician
    and another one for the pharmacist
  • Offers a tracking chart for client to use

101
Some helpful resources
  • www.mayoclinic.com/health/.../DSECTIONtreatments-
    and-drugs
  • www.nimh.nih.gov/health/...medications/complete-in
    dex.shtml
  • What Your Patients Need to Know About Psychiatric
    Medications by WC Jackson 2007
    www.ncbi.nlm.nih.gov ... v.9(4) 2007
  • Schrank, B.,Sibitz, I. Unger, A. Amering, M.
    How Patients With Schizophrenia Use the Internet
    Qualitative Study. J Med Internet Res. 2010
    Oct-Dec 12(5) 70.

102
Helpful to track down earliest prodromal signs
and symptoms
  • Work on finding usual early warning sign Describe
    mild, moderate, and severe versions
  • Experiment with simple interventions that work
  • Chart the status
  • Make emergency plans
  • (R. Liberman)

103
Morbidity Mortality
104
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

105
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)

106
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

107
MORTALITY- 4
  • Graded relationship between number of
    neuroleptics taken and mortality and dosage
    levels with
  • Fatal arrhythmias
  • Sudden cardiac deaths
  • Venus thrombosis
  • Pulmonary embolism
  • Asthma deaths

108
(even after adjusting for known risk factors of
premature death such as smoking, lack of
exercise, BMI, B/P, serum total and HDL
cholesterol)!
109
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 Tricyclic's)

110
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.
  • Need research to help triage

111
Support for optimization of medications.
  • Literature says that 1st episode participants may
    need little or no medications by adopting wait
    and see
  • 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

112
More Resources
  • Personal Therapy GE Hogarty et al 1997 helps
    adherence
  • W. Fenton Psychiatric Times 2006 Combined
    therapy
  • APA 2004 Practice Guidelines
  • Texas Medication Algorithm No! Was drug company
    sponsored.

113
QUESTION 8
  • WHY IS THIS PERSON TAKING STREET DRUGS IN PLACE
    OF OR IN ADDITION TO PRESCRIPTIONS ?

114
WHY IS THIS QUESTION IMPORTANT?
  • Mental Health and Substance Abuse systems of care
    need to be blended and the work done
    simultaneously in order for anything to work out.
  • Research has shown many different reasons for use
    of substances

115
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116
INFO ON USING STREET DRUGS
  • At least 47 to 75 have co-occurring disorders
  • Most costly to treat
  • Makes initial diagnosis difficult
  • Use of structured interviews helpful (SCID
    subsection clinically useful or ASI the
    Addition Severity Index for research)
  • Info on street drug of choice may be helpful to
    add into diagnostic process

117
Co-Occurring or Dual Dx D/Ocan 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.

118
Some Reasons People Give
  • 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 ? (see work of Prof.
    Mary Ann Test and colleagues)

119
EBP Integrated Dual Disorders Treantment (IDDT)
  • Services provided concurrently
  • Individualized assessment and treatment planning
    in heavy collaboration
  • Use SCID-SA Screener

120
EBP Integrated Dual Disorders Treatment
  • DUAL DISORDERS TREATMENT IMPLEMENTATION RESOURCE
    KIT
  • Information
  • Training Materials
  • Annotated Bibbs
  • Refs
  • http//www.mentalhealthpractices.org

121
EBP Integrated Dual Disorders Treatment
  • Blending
  • Stage-wise Treatment
  • Motivational Interviewing
  • 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

122
Some Lessons Learned
  • Standard confrontational models might not work
    for people with schizophrenia. Other models may
    work better with less stress
  • Blended funding streams and integrated care more
    helpful
  • Gender, age, ethnicity, geographic residence,
    exposure to trauma, make differences

123
The Substance Abuse Mental Health
Administration in U.S. has a wealth of
publications on research and treatment
strategies.www.SAMHSA.GOV
124
QUESTION 9
  • WHAT ARE THE RELEVANT SEX DIFFERENCES?

125
Why is this question important?
  • Not taught very often in med schools yet
  • Females metabolize drugs differently
  • Females often over medicated which cuts their
    Estrogen protection
  • Females often have a later onset which provides a
    stronger platform to return to
  • Males are more vulnerable and who struggle more
    early on but eventually grow stronger in outcome
    and
  • Females may lose their edge at menopause

126
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127
SEX DIFFERENCES ACROSS THE LIFE SPAN
  • NEURAL DEVELOPMENTAL GROWTH
  • BIRTH COMPLICATIONS
  • PEDIATRIC INJURIES
  • PUBERTY AND HORMONES
  • METABOLIC DIFFERENCES
  • MENOPAUSE
  • PRESCRIBING PRACTICES ARE DIFFERENT

128
SOME SEX DIFFERENCES AFECTING ILLNESS EXPRESSION
AND OUTCOME - 1
  • MALES
  • FEMALES
  • Early events may make brain more vulnerable (e.g.
    slight displacement of developing cells by
    Mothers flu, anoxia due to cord around neck,
    less temperature regulation, and more risky
    playground behaviors because of increased
    exploration due to testosterone)
  • Less events

129
SOME SEX DIFFERENCES AFECTING ILLNESS EXPRESSION
AND OUTCOME-2
  • MALES
  • FEMALES
  • Quick metabolism of food and medicine gets into
    blood stream faster
  • May contribute to more side effects
  • Slower metabolism of food and medicine means
    slowly entering blood stream probably less side
    effects
  • Meds cross blood/brain barrier faster drugs
    more efficient

130
Some Sex Differences affecting illness
presentation outcome - 3
  • MALES
  • FMALES
  • Earlier onset often in early to mid teens means
    less education, less job and dating experience
  • Slow progress toward recovery
  • More often later onset with some school
    completed, dating and job experience much
    stronger platform for recovery and initially
    stronger

131
Some Sex Differences Affecting Illness
Presentation and Outcome - 3
  • MALES
  • FEMALES
  • Often symptoms are presented quietly
  • Medications are often less in number and lower
    dosage
  • Course improves more slowly and matches females
    later at trend levels
  • Often symptoms are presented in a boisterous way
  • Medications are often more in number and higher
    in dosage
  • Cuts natural Estrogen protection
  • Otherwise woman have stronger outcomes until
    menopause and loss of Estrogen

132
Resources
  • Chiders, S.E. Harding, C.M. Gender, premorbid
    social functioning, and long-term outcome in
    DSM-III schizophrenia. SCHIZOPHRENIA BULLETIN,
    1990, 16(2) 309-318.
  • Harding, C.M. Hall. G.M. Long-term outcome
    studies of schizophrenia Do females continue to
    display better outcome as expected? International
    Review of Psychiatry, 1997, 9409-418.

133
QUESTION 10
  • WHERE IS THIS PERSON IN THE COURSE OF ILLNESS?

134
WHY IS THIS QUESTION IMPORTANT?
  • Helpful to track episode information to see when
    illness is beginning to lift.

135
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136
COURSE INFORMATION
  • Instead of narrow medical model (acute or
    chronic)
  • Schizophrenia is virulent early and tapers off
    later
  • Similar to other general medical disorders
  • Mother nature is trying to help
  • BURNT OUT vs. The Phoenix

137
MORE ON COURSE
  • Also course of life, itself
  • A lifeline or life history is helpful
  • Mutual participation model
  • Longitudinal patterns and trends
  • Different uses of social relationships
  • Build therapeutic relationships

138
The LIFELINE
  • Quick and easy way to get a life history on one
    line on one piece of paper
  • Builds a therapeutic and appreciative
    relationship
  • Being used by clinicians across the world
  • Covers 12 areas of a life lived
  • Derived from the Life Chart a research
    instrument
  • Takes from 20 to 60 minutes

139
Consider the differential effects of
rehabilitation in interaction with course
  • Propose that possibly .
  • Early rehabilitation interventions from Day 1
    forward may help reduce disability
  • Later rehabilitation interventions may help to
    increase ability

140
Consider getting people back to school or work as
soon as possible.Had calls from MDs, RNs, high
school teachers, college professors and
engineers. Each said, in effect I once had
schizophrenia but I dont tell anyone. Thanks for
talking about recovery.How much do we
underestimate what is possible for people?
141
Some Resources
  • THE LIFELINE v. 2011 by C. M. Harding
    (CourtenayHardingConsulting_at_gmail.com)
  • Strauss JS, Hafez H, Lieberman P, Harding CM. The
    course of psychiatric disorder, III Longitudinal
    principles. Am J Psychiatry. 1985
    Mar142(3)289-96.
  • Harding, C.M. Course types in schizophrenia. An
    analysis of European and American studies.
    SCHIZOPHRENIA BULLETIN. 1988, 14(4)633-643

142
QUESTION 11
  • WHAT MYTHS AND MISINFORMATION ARE STRESSING THE
    PERSON?

143
Why is this question important?
  • Knowledge transfers power from the illness and
    the care system to the person.

144
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145
ASSESSMENT OF UNDERSTANDING THE ILLNESS AND
MEDICATIONS
  • Collaboration and education
  • Helps change the stressful valence can reduce
    relapse rates
  • Teaches how to manage symptoms
  • Never says more than we actually know
  • Promotes competency and empowers
  • Increases self-esteem

146
EBPWELLNESS MANAGEMENT AND RECOVERY PROGRAM-1
  • CLINICIAN BENEFITS
  • A comprehensive step by step approach
  • Ready-to-use materials
  • Skill is using motivational , cognitive
    behavioral and educational strategies
  • ? Satisfaction to see ? outcomes

147
EBP WELLNESS MANAGEMENT AND RECOVERY PROGRAM-2
  • CLINICIANS RECEIVE
  • guide with practical tips
  • handouts, checklists, planning sheets
  • introduction video
  • informational brochures
  • fidelity scale
  • outcome measures

148
EBP WELLNESS MANAGEMENT AND RECOVERY PROGRAM-3
  • Recovery strategies
  • Practical facts about MI
  • Stress-Vulnerability treatment strategies
  • Building social supports
  • reducing
  • relapses
  • using meds
  • effectively
  • coping with
  • stress
  • coping with
  • problems symptoms
  • getting your
  • needs met in the MH system

149
HOPE CAN ARRIVE ONLY WHEN YOU RECOGNIZE THAT
THERE ARE REAL OPTIONS AND THAT YOU HAVE GENUINE
CHOICES. Jerome Groopman, MD (2004)
150
More 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

151
More Resources
  • Liberman RL et al, describing UCLA Models,
    Innovations Research, Vol2(2), 1993
  • P.A. Garrety et al , Schiz Bull, 2000
  • WRAP Plan Mary Ellen Copeland
  • Harding, C.M. Zahniser, J. Empirical correction
    of seven myths about schizophrenia. Acta
    Psychiatrica Scandinavica. 199590 (Suppl.
    384)140-146.

152
BATHROOM AND MOBILE PHONE BREAK
153
QUESTION 12
  • WHO DEPENDS ON THE CLIENT FOR HELP?

154
Why is this question important?
  • Challenges the assumption that all the help is
    being extended to the person with the lived
    experience.
  • Ask and you will find out some surprising
    information!

155
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156
What You Will Find Out
  • Most people with the lived experience have people
    they help with emotional support during a crisis
    or with
  • Concrete help such as the loan of bus money or
    moving furniture or providing companionship

157
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 (M. Hammer,1981)

158
SOCIAL SUPPORTS - 2
  • Social Skills Training (considered a 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.

159
Resources
  • Robert Libermans Social Independent Living
    Skills Modules at UCLA
  • See Innovations Research
  • Vol2 (2) 1993
  • Hardings Star Chart (Social Network) Harding
    Keller, 1998

160
SOCIAL SKILL RESOURCES
  • 1) Penn, D..L., Roberts, D.L., Combs, D., Sterne,
    A. The development of the social cognition and
    interaction training program for schizophrenia
    spectrum disorders. Psychiatric Services, 56
    (4)449-451, 2007.
  • 2) Hogarty GE Personal Therapy for Schizophrenia
    and Related Disorders A Guide to Individualized
    Treatment. New York, Guilford Press, 2002
  • 3) Liberman, R. Liberman, R., DeRisi, W.,
    Mueser, K. Social skills training for
    psychiatric patients. New York Pergamon Press,
    1989.
  • 4) Mueser, K.T. Gingerich, S. The Complete
    Family Guide to Schizophrenia. New York, The
    Guilford Press, 2006.
  • 5) Bellack, A.S., Mueser, K.T., Gingerich,S.,
    Agresta, J. Social Skills Training for
    Schizophrenia A Step by Step Guide (2nd Ed.).
    New York Guilford Press, 2004.
  • 6) Harding, C.M. Curriculum How to Get A Date
    One More Way To Teach Social Skills in PROS. V.
    1, New York, Center for Rehabilitation and
    Recovery, The Coalition of Behavioral Health
    Agencies, 2011

161
Even More Resources
  • Beels, C. C. (1989) The invisible village. New
    Directions for Mental Health Services, 1989
    2740.
  • Strauss, J.S. Harding, C.M. Hafez, H.
    Lieberman, P. The role of the patient in
    recovery from psychosis. In J.S. Strauss, W.
    Böker and H. Brenner (Eds.), Psychosocial
    Management of Schizophrenia. Toronto Hans
    Huber Publisher, 1987, pp. 160-166.
  • Hammer, Muriel ( 1981) Social Supports, Social
    Networks, and Schizophrenia. Schiz Bull.
    7(1)45-57.

162
QUESTION 13
  • WHAT IS THE PERSONS WORLD VIEW?

163
Why is this question important?
  • Working to understand cultural, ethnic,
    religious, and other important factors in the
    persons world is absolutely critical for
    individualized recovery planning.
  • Everyone has a culture (even Northern Europeans
    not just people of color)

164
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165
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?

166
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)

167
CULTURAL SENSITIVITY-2
  • http//www.wiche.edu/archive/mh/culturalCompetence
    Standards
  • SAMHSAs only approved standards for anything
  • Benchmarks
  • Guidelines
  • Outcome Measures
  • Lit Review
  • For everyone for everyone and the major 4
    minority groups

168
More resources of interest
  • Tervalon, M. Murray-Garcia, J. (1998) Cultural
    Humility versus Cultural Competence A Critical
    Distinction in Defining Physician Training
    Outcomes in Multicultural Education. J. of
    HealthCare for the Poor and Underserved., 9(2),
    117- 125.

169
Question 15
  • IS THERE ANY COHESION IN THE SYSTEM OF CARE?

170
Why is this question important?
  • Complex biopsychosocial problems need integrated
    comprehensive systems which collaborate with
    users and carers.
  • It helps people if we have our act together!

171
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172
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

173
LINKAGES - 2
  • Clear and consistent policies from the top down
  • Use community resource checklist (community
    mental health, extension services, consumer
    groups, natural support)
  • Again, the more we have our act together the
    better the participants become

174
Some Resources
  • Principled Leadership. William A. Anthony Kevin
    Ann Huckshorn, Boston University, 2008.
    www.bu.edu/cpr/products/books/titles/leadership.ht
    ml
  • The Comprehensive, Continuous, Integrated System
    of Care (CCISC) process (Minkoff Cline, 2004,
    2005) is a vision-driven system transformation
    process ... www.kenminkoff.com/ccisc.html
  • www.samhsa.gov/co.../topics/healthcare-integration
    /ccisc-model.aspx
  • www.who.int/entity/mediacentre/news/notes/2007/np2
    5/.../index.html

175
Another resource
  •  
  • Harding, C.M. The limited resources debate
    Changing the rules of the game to a win-win
    scenario. AUSTRALASIAN PSYCHIATRY, 1997, 5(6),
    271-273.

176
Training resources
  • Coursey, R. D., Curtis, L., Marsh, D. T.,
    Campbell, J., Harding, C. M., Spaniol, L.,
    Luckstead, A., McKenna, J., Paulson, R.,
    Zahniser, J., Kelley, M., and other members of
    the Adult Panel of the SAMHSA Managed Care
    Initiative
  • Part I. Competencies for the direct service
    staff who work with adults with severe mental
    illnesses in outpatient public mental
    health/managed care systems. AND
  • Part II. Competencies for the direct service
    staff who work with adults with severe mental
    illnesses Specific knowledge, attitudes, skills,
    and bibliography. PSYCHIATRIC REHABILITATION
    JOURNAL. 2000, Spring

177
More resources on training
  • Neligh, G.L. Shore, J. Scully, J. Kort, H.
    Willett, B., Harding, C.M. and Kawamura, G. The
    program for public psychiatry state-university
    collaboration in Colorado. HOSPITAL AND
    COMMUNITY PSYCHIATRY, 1991, 42(1) 44-48.
  •  
  • Zimet, C.N. Harding, C.M. Chapter 19 - The
    Colorado postdoctoral training consortium an
    innovative postdoctoral program in public
    psychology. In Wolford, P., Myers, H.F.,
    Callan, J.E. (Eds.), PUBLIC-ACADEMIC LINKAGES FOR
    IMPROVING PSYCHOLOGICAL SERVICES, RESEARCH, and
    TRAINING. Washington, D.C. APA Press, 1993, pp.
    165-169.

178
14 WHAT TO DO WITH AN OUT OF CONTROL PERSON?
179
Why this is an important question?
  • Psychological strategies can go a long way to
    calm a person without heavy dosing

180
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181
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

182
RISK MANAGEMENT
  • Relapse Prevention Strategies for mental health
    and substance abuse issues
  • 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
    psychological strategies first

183
DIALECTICAL BEHAVIORAL THERAPY
  • For persons diagnosed with Borderline Personality
    Disorder
  • Effective for ..reduces suicidal behaviors,
    psychiatric hospitalization, dropout from
    treatment, substance abuse, anger and
    interpersonal difficulties.
  • Always conducted within a team approach

184
Resources
  • Marsha Linehan et al (2006) Two-year randomized
    controlled trial and follow-up of Dialectical
    Behavioral Therapy vs. Therapy by experts for
    suicidal behaviors and Borderline Personality
    Disorder. Arch Gen Psych, 63(7) 757-766.
  • Linehan, M. Dimeff, L.A. Dialectical Behavior
    Therapy Manual of Treatment Interventions for
    Drug Abusers and Borderline Personality Disorder.
    Seattle, Washington, University of Washington,
    1997.

185
Other Resources
  • The Wellness Recovery Action Plan (WRAP) Mary
    Ellen Copeland, 2011.
  • An Anger Management Training Package for
    Individuals With Disabilities, H. Gulbenkoglu et
    al. London, Kingsley Pubs., 2006.
  • Evidence-Based Practice of Cognitive-Behavioral
    Therapy , Dobson, D Dobson, K New York,
    Guilford Press, 2009.
  • Paul, G. L., Stuve, P., Menditto, A. A. (1997).
    Social-learning program (with token economy) for
    adult psychiatric inpatients. The Clinical
    Psychologist, 50, 14-17.

186
QUESTION 16
  • WHERE DO THE CLINICIAN AND CONSUMER BEGIN TO
    START BUILDING THE RECOVERY PROCESS?

187
Why is this question important?
  • After 150 years of focus on psychopathology,
    deficits, damage and dysfunction, peer advocates
    and rehabilitation research has shown that
    building on strengths helps people reclaim their
    lives.

188
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189
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

190
Some Resources
  • Anthony, W. A. Farkas, M. (2012) The essential
    guide to psychiatric rehabilitation practice.
    Boston MA Boston University.
  • Rapp, C. A. The strengths model Case management
    with people suffering from severe and persistent
    mental illness. New York, NY, US Oxford
    University Press. (1998).

191
More Resources
  • Harding, C.M., Strauss, J.S., Hafez, H.,
    Lieberman, P.L. Work and Mental Illness 1.
    Toward an integration of the rehabilitation
    process. J. Nervous Mental Disease, 1987, 175
    (6) 317-327.

192
Question 17. Has the person ever experienced
trauma in their life?
193
Why is this question important?
  • It is only recently that clinicians have begun to
    acknowledge and understand the role of trauma in
    the impact on psychiatric problems as well as
    challenges for treatment.

194
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195
Traumatic Experiences
  • AT SOME POINT WE NEED TO FIND OUT ABOUT PREVIOUS
    TRAUMATIC EXPERIENCES
  • Effects Avoidance, hypervigilance, emotional
    difficulties, and recall behaviors, anxiety,
    depression, problems sleeping, and sometimes
    hopeless
  • Use SCID-D for assessment

196
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 do not display pathology! (Bonanno
    et al, 2002)

197
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)

198
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

199
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200
Mnemonic for PTSD
  • FEARS
  • Fears
  • Ego construction (numbing withdrawal)
  • Anger
  • Repetition (Flashbacks nightmares)
  • Sleep disturbance
  • Jean Goodwin

201
Mnemonic for COMPLEX PTSD
  • FEARS
  • Fugue Other Dissociative states
  • Ego fragmentation
  • Antisocial Behaviors
  • Re-enactment
  • Suicidality Somatitization
  • Jean Goodwin

202
SOME RESOURCES
  • Journal of Brain Behavioral and Immunity for
    articles on psychoneuroimmunology
  • Trauma-Focused Cognitive Behavioral Therapy -
    NREPP ... www.nrepp.samhsa.gov/viewintervention.as
    px?id135
  • Tips for survivors of a traumatic event.
    www.samhsa.gov/MentalHealth/tips_survivors_managin
    g_your_stress

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18 CAN THIS PERSON READ?
204
Why this question is so important?
  • People coming for services hardly ever get
    assessed for level of literacy and yet we pass
    out materials and prescriptions expecting that
    they can 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

207
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

208
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?
211
Why is this question so important?
  • Belief in something greater than ones self is
    often helpful to survive the challenges of
    psychiatric problems. Sharing information about
    this important area identifies a strength.

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USE OF SPIRITUALITY
  • Research shows that about half of every sample
    relies on some sort of faith (Western or Eastern
    formal religion, informal beliefs , nature, art,
    music etc.) 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?
215
Why is this question important?
  • If you ask you may be surprised!
  • Often it has nothing to do with diagnosis or
    symptoms ..

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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
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