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Intro to IMR handout 9.08

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					Illness Management and
        Recovery:
          An Introduction

         Jody Meek, M.D.
   Office of Mental Health, Region VII
 Psychiatrist, Director of Clinical Services
Summary of Illness Management
       and Recovery

IMR is a program that helps people set
meaningful goals for themselves, acquire
information and skills to develop more
sense of mastery over their psychiatric
illness, and make progress towards their
own personal recovery.
    Illness Management Research*
• Reviewed 40 randomized controlled studies of
  illness management programs

• Identified five effective components of
  successful programs

• *See: Mueser, K.T. et al. (2002). Illness management and recovery for
  severe mental illness: A review of the research, Psychiatric Services, 53,
  1272-1284.
  Effective Components of Illness
      Management Programs
• Psychoeducation
• Behavioral tailoring for medication
  adherence
• Relapse prevention training
• Coping skills training
• Social skills training
       Psychoeducation
• Improves clients’ knowledge
  about mental illness and its
  treatment
• Equips them with information
  about their treatment
 Behavioral Tailoring for
      Medication

Improves clients taking
medication as prescribed
Relapse Prevention Training


• Reduces relapses

• Reduces re-hospitalizations
   Coping Skills Training
• Reduces severity of persistent
  symptoms

• Reduces distress experienced from
  persistent symptoms
       Social Skills Training

• Improves social functioning including
  quality and # of relationships

• Improves skills that are related to
  achieving recovery goals
    One Definition of Recovery:
• “Recovery is a process, a way of life,
  an attitude, and a way of
  approaching the day’s challenges. It
  is not a perfectly linear process. At
  times our course is erratic and we
  falter, slide back, regroup, and start
  again…
• …The need is to reestablish a new
  and valued sense of integrity and
  purpose within and beyond the limits
  of the disability; the inspiration is to
  live, work, and love in a community
  in which one makes a significant
  contribution.” Patricia Deegan, 1988
     Essential Themes of Recovery
•   Hope
•   Expectations
•   Respect
•   Optimism
•   Well-being
•   Confidence
•   Empowerment
•   Meaningful roles
 How does Illness Management relate
             to Recovery?
• Improved ability to manage one’s illness is a common
  recovery goal
• Avoiding relapses and hospitalizations gives people
  greater control over their lives
• Less time dealing with mental illness allows more
  time for pursuing personal goals
• Less distress from symptoms, leads to better quality
  of life
               Recovery Goals
• Individualized

• Personally meaningful

• Range from the modest to ambitious

• Exploration for personally meaningful goals often
  needed to engage client before introducing IMR
  program
        Core Ingredients of Illness
        Management and Recovery
• 5 to 10 months of weekly or twice weekly sessions
• 9 educational handouts (+ one optional)
• Practitioners use motivational, educational, and
  cognitive behavioral techniques
• Clients set and pursue personal recovery goals
• Clients practice skills in IMR sessions
• Home assignments are developed together
• Significant others may be involved
        IMR Resource Materials
• Educational handout for client for each
  module
• Practitioners’ guidelines for clinician for each
  module
• Group leader’s session-by-session guide for
  each module
• Introductory videotape (15 min)
• Practice demonstration videotape (3 hrs)
        1. Recovery Strategies

• Build hope for reaching goals

• Help identify recovery goals

• Help develop plans to achieve goals
        2. Practical Facts about
              Mental Illness
• Provide optimism about the future
• Help identify symptoms
• Reduce blame and stigma regarding mental
  illness
• Teaching modules covering Major Depression,
  Bipolar Disorder and Schizophrenia
   3. Stress-Vulnerability Model
• Role of stress and biological vulnerability
  in causing symptoms and impairments
• Convey optimism that treatment and
  coping strategies work
• Provide information about treatment
  options
     4. Building Social Support

• Benefits of social support

• Meeting new people

• Getting closer to people you already
  know
  5. Using Medication Effectively
• Accurate information about medications
• Weighing pros and cons of taking
  medications
• Developing a partnership with medical
  staff
• Developing strategies for taking meds
        6. Reducing Relapses


• Identifying triggers of past relapses
• Recognizing early warning signs
• What helps when a relapse is starting to
  happen?
• Developing a relapse prevention plan
        7. Coping with Stress

• Identifying stressors and strategies for
  preventing stress
• Identifying and practicing strategies for
  coping with stress that can’t be avoided
• Encouraging involvement of significant
  others
     8. Coping with Problems and
         Persistent Symptoms

• Using a step-by-step method for solving
  problems and achieving goals
• Identifying problem areas, especially
  persistent symptoms
• Selecting & practicing strategies for
  coping with problems and persistent
  symptoms
   9. Getting Your Needs Met in the
        Mental Health System

• Identifying current services received and
  those that person would like to pursue

• Develop and practicing skills for
  advocating for oneself in the system
    Drug and Alcohol (Optional)
• Effects of substance abuse on biological
  vulnerability
• Helping consumer weigh the pros and
  cons of using drugs and alcohol
• If consumer wants to change his or her
  use, helping to develop an action plan
     Structure of IMR Sessions
1. Informal socializing
2. Review previous session
3. Review home assignments
4. Follow up on goals (for group, follow up
   on goals of 2-3 clients on rotating basis)
5. Set agenda for current session
  Structure for IMR Sessions, cont’d

6. Teach new material from handout
   (usually a few pages); use educational,
   motivational, CBT and social skills
   training strategies as needed
7. Develop a home assignment in
   collaboration with client(s)
8. Summarize session and progress made
   IMR practitioners Use 3 different
         Teaching Strategies

• Motivational Strategies

• Educational Strategies

• Cognitive-Behavioral Strategies
        Motivational Strategies
• People are motivated to learn things if they
  are relevant to personal goals
• Connect IMR materials to goals
• Explore how illness has interfered with goals
• Convey hope and confidence in the person
• Help the person explore the costs and benefits
  of change
        Educational Strategies
• Goal: help clients learn more about their
  illness & how to manage it
• Use handouts in interactive ways (e.g., take
  turns reading)
• Ask questions to check on understanding; ask
  for “own words”
• Break down information into small bites
• Adopt consumer’s language
• Don’t push consumer to accept diagnosis
  Cognitive-Behavioral Strategies
• Shaping task focused behavior, homework
  completion
• Modeling, role playing, positive feedback
• Behavioral tailoring
• Relapse prevention training
• Relaxation training
• Coping skills enhancement
           Home Assignments
• Help consumers transfer information and skills
  into their daily lives
• The “real” therapy is what happens outside of
  the session
• Use alternative term if necessary
• Always develop home assignments
  collaboratively at end of each session
• Be as specific as possible (when, where, how,
  etc)
      Involving Significant Others
• Support progress towards recovery goals & help
  practice skills learned in IMR
• Significant others are defined by the client
• Explore who the consumer spends time with
• Approach significant others with “good news”
• Send handouts & conduct follow-up phone calls
• Aim for monthly contact with significant others
• If needed, professionals can be significant others
            Tracking Progress
• Use goal tracking sheet to monitor progress
• Follow up on goals every session (individual)
  or every 2-3 sessions (group)
• Break down goals into smaller steps if lack of
  progress, or modify
• Bring goal tracking sheets to supervision
       Measuring Outcomes using the
                IMR Scales
•   15 item questionnaire covering IMR domains
•   Behaviorally anchored
•   User-friendly language
•   Clinician version and consumer version
•   Completed at baseline and every 3 months
•   Use to evaluate the success of IMR
•   Can be integrated into treatment planning for IMR
              Supervision
• Weekly group supervision, not more than 6-8
  clinicians
• Review cases
• Discuss goals, share treatment formulations,
  troubleshoot problems
• Role play challenging situations
• Selected teaching of core skills
   Members of IMR Team
• IMR Clinicians (5-8)
• ? IMR Consumer Providers
• IMR Coordinator/Program Leader
• Agency Director
         IMR Clinicians
• Have protected time to provide IMR,
  prepare for sessions, attend supervision
• Receive weekly group supervision on IMR
• Have accountability for providing IMR
• Become IMR experts and educate others
  in agency about IMR and recovery
   IMR Coordinator/Team Leader
• Coordinating IMR is part of job
• Specific proportion of time designated and
  protected for supervising and coordinating
  IMR
• Receives IMR training and works with some
  consumers using IMR
• Provides weekly IMR supervision
 IMR Coordinator/Team Leader (cont)

• Established and monitors IMR referral
  process
• Assures that referred clients receive IMR
• Monitors the quality and quantity of IMR
  services delivered at the agency
• Reports to the agency director and meets
  regularly with him/her.
  Agency Director Shows Interest
         and Support by:
• Attending training
• Attending some supervision sessions
• Meeting regularly with IMR
  Coordinator/Team Leader
• Troubleshooting obstacles to IMR
           Toolkit Components
• Manual
• Information brochures for different
  stakeholders (client, family, clinician, etc)
• Introductory video
• Training video
• Fidelity scales
• Outcome measure
             IMR Toolkit
• Can be downloaded at:


http://mentalhealth.samhsa.gov/
cmhs/CommunitySupport/toolkits/
 illness/
     OMH Region VII Experience
• Began IMR implementation plan in Winter ‘04-
  ’05 at Shreveport Mental Health Center in
  adult treatment services
• Trained a “core group of clinicians” (3) on IMR
• This core group were responsible to train 2-3
  additional clinicians whom they supervised
• It was required that all adult clinicians would
  participate in IMR and this expectation was
  added to their PPR
         Region VII Experience
• Most clinicians utilized IMR in a Group format
• Developed an efficient IMR Group Progress
  note
• Director of Clinical Services served as IMR
  supervisor and performed Fidelity scales
• IMR gradually expanded to rural clinics in the
  region
            Region VII Benefits
• The clinics that have the highest fidelity to the
  IMR program, have more success in guiding
  clients down their road to recovery
  – More success in referrals to lower levels of care
• Clinicians like having standardized tools to
  utilize to benefit their clients
  – Don’t have to develop their own tools
  – Other clinicians can cover their Groups seamlessly
    Region VII: Lessons Learned
• Would benefit from a designated IMR
  Coordinator with significant proportion of
  time devoted to promote IMR
• Improvement in recruiting clients into IMR
  programs
• More emphasis on “graduating” from an IMR
  program
• Improved supervision for IMR clinicians

				
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