Psychiatric Rehabilitation Assessment Template by slp21736


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Psychiatric Rehabilitation
    Training Institute
    Illness Management
        and Recovery
         Gary Bond
        October 2002
     Learning Objectives
 Explain   illness management and
 Identify key concepts
 Illustrate with concrete examples
 Summarize the research
 Outline some nuts and bolts
      Exercise for Practitioners
          During Training
 Think about some    consumer you are
 currently working with who has one or
 more of the following issues:
  –Feels hopeless
  –Has symptoms that are bothering
  –Is not taking medications as
  –Is at risk for relapse
      What is Illness
     Management and
     Recovery (IMR)?
    Where did it come from?
How does it compare to consumer-
 developed approaches, such as
 Wellness Recovery Action Plan?
  Definition of Illness Management
        (Mueser et al., 2002)
Broad set of strategies to help consumers:
  –Collaborate with professionals to
   manage mental illness
  –Reduce effects of illness
  –Reduce susceptibility to relapses
  –Cope with symptoms
  –Discover (or rediscover) strengths
            Roots of
Illness Management and Recovery
 Consumerism/self-help   in health
  care field
 Mental health consumer movement
 Literature on psychotherapy
   Influence of Consumerism in
     Health Care Field on IMR

              have all the answers
 Doctors don’t
 Norman Cousins – Laugh therapy
 Maxwell Moltz – Psychocybernetics
Some Common Attitudes Among
 Patients with Medical Problems
 “Just   give me a pill, doctor.”

 “Idon’t need treatment, I feel fine”
 (e.g., someone with high blood
   In chronic illnesses (diabetes,
arthritis, obesity, cardiac disorders,
            stroke, cancer):
 Patients who take an active role in
–Understanding their illness
–Making informed treatment choices
–Being persistent in self-care
       Have better outcomes
         (Wennberg, Dartmouth)
         Implications of
       Health Care Findings
 Patients should be educated
  regarding treatment choices,
  warning signs, lifestyle changes, etc.
 Practitioners should be trained in
  methods to ensure patient
  participation in treatment choices
  Influence of Mental Health
 Consumer Movement on IMR
 Recovery   stories (first person
 Spread of self-help organizations
 Manuals and workbooks originating
  in consumer/self-help movement
 These approaches sometimes called
  “illness self-management”
     Definition of Recovery

 “Recovery  involves the
 development of new meaning and
 purpose in one’s life as one grows
 beyond the catastrophic effects of
 mental illness” (Anthony, 1993).
  Characteristics of Recovery
 Unique to each person
 Defined and accomplished by
 Both process and outcome
 Personal and social success
 Universal human experience
 Themes of hope, self-confidence,
  enjoyment, well-being, and
         Relationship of
Illness Management to Recovery
 Regain mastery over one’s life
 Move from hierarchical to
  collaborative relationships with
  treatment providers
 Learn how to direct one’s treatment
 Spend less time on illness –
  More time pursing personal goals
         Examples of
  Illness Self-Management
 Wellness  Recovery Action Plan
  (WRAP) (Copeland)
 Recovery Workbook (Spaniol)
 Mental Health through Will-
  Training (Low)
 GROW manual

 Integrated package of
 Simple and clear
 Provides instructions for
  planning your life
Components of WRAP
 Wellness   toolbox
 Daily maintenance plan
 Triggers
 Early warning signs
 Crisis plan
 Post crisis plan
 Wellness Toolbox:
Things you do to feel better

    Talking to a friend
    Journaling
    Relaxation
    Diet
    Exercise
Daily Maintenance Plan
  Dailyroutines that
  contribute to well-being

  Forme:
   – A cup of coffee and
    newspaper in the morning
   –Go jogging at 11 pm
External events that may
     lead to relapse
    Family friction
    Work stress
    Anniversaries
    Financial problems
Early Warning Signs:
Internal events signaling
  possible deterioration
  Sleeping too much
  Sleeping too little
  Change in eating pattern
  Growing a beard
  Nonstop talking
   Herz and Melville (1985):
   Warning Signs of Relapse
Tens e and nervous         80%
Eating les s               72%
Trouble c oncentrating     70%
Trouble s leeping          67%
Enjoy things les s         65%
Res tless nes s            63%
Can't remember things      63%
          Crisis Plan
 Template for indicating what to do
    when consumer is in crisis
 Written when   consumer is thinking
 Identifies 5 support people
 Gives specific instructions
 Indicates which treatments consumer
  wants and doesn’t want
 Identifies people consumer wants and
  doesn’t want to help and how
 Post Crisis Plan
 Returning after a
  hospitalization can be
 Have a plan to help during
  that transition
  Influence of Psychotherapy
            on IMR
 Techniques borrowed   and adapted
 from related fields:
  –Skills training
  –Cognitive-behavioral therapy
  –Stress management
            Skills Training
 These social learning   principles used
 to teach skills:

    Role   playing
    Positive and     corrective feedback

    Generalizing skills
  Important Step Often Omitted:
Generalizing Skills to “Real World”
    Teach skills   at the point they are
    Teach skills in settings where
     skills are used
    Build in reminders
    Build in rewards
    Get family and friends to support
Who Benefits from Skills Training?
 Individuals   with cognitive
  impairment learn skills more slowly
 Most   research limited to
      Some Principles of
 Cognitive-Behavioral Therapy
 Form   collaborative partnership with
 Give rationale for treatment
 Suggest alternative interpretations
  for irrational thoughts
 Remain non-confrontational
 Suggest behavioral tests: Try this
  out, see if your theory is correct
Similarities Between IMR and
  Illness Self-Management
   Same  goals
   Similar rationale
   Overlap in methods and
   Borrow from much of
    the same literature
            Some Goals of IMR
 Instill
 Develop treatment team collaboration
 Help people establish personally
  meaningful goals
 Give information about mental illness
 Develop skills for reducing relapses
 Provide information about resources
 Help enhance support system
    Differences Between IMR and
      Illness Self-Management
                              Illness Self-
          IMR                 Management
 Based  on quantitative    Based  on personal
  studies                   success stories, no
  Evidence-based             rigorous studies
 Stresses collaboration    Stresses self-help
  with professionals         and peer support
 Includes strong
  emphasis on using
One Further Difference Between
  IMR and Some Illness Self-
   Management Approaches
 Illnessself-management often
  limited to educational programs
 IMR emphasizes cognitive-
  behavioral techniques
Illness Management and
   Research Evidence
            Facets of
Illness Management and Recovery
     Psychoeducation
     Strategiesto facilitate taking
      medication as prescribed
     Relapse prevention
     Teaching strategies for coping
      with symptoms
   What is it?
 Is it effective?
   What Is Psychoeducation?

 Term used  in many ways
 Definition used here:
  –Providing consumers with practical
   information on their illness and
  Psychoeducation: Format
 Typicallygiven in groups
 Can be provided individually
     Strategies to Maximize
 Provide to consumers who ask for it
 Give explanations that consumers
 Use interactive teaching
 Don’t overload with too much
  information in a single session
 Show personal relevance to each
  consumer’s goals
Types of Psychoeducation
 General psychoeducation
 Medication education
 Other  specialty groups
 (e.g., substance abuse)
     Comprehensive Curriculum
Recovery strategies    Using medication
Mental health facts    Alcohol and drugs
Stress-vulnerability   Preventing relapse
 model                 Stress management
Social support         Coping with
Treatment choices       symptoms
                       Mental health system
Resources for Psychoeducation
 Many  different workbooks and
  handouts available
 Liberman medication and symptom
  management videotapes
 Thresholds videotapes
Research on Psychoeducation

4  studies of psychoeducation
  on illness management
 8 studies specifically on
  medication education
        Research Findings
 Clearly  better than discussion group
 Increases knowledge
 Little or no impact on behavior:
   –No effects on taking medication
    as prescribed
   –No effects on symptoms, social
    functioning, or rehospitalization
 Psychoeducation: Bottom Line
 Psychoeducation is    necessary but
  not sufficient for illness
 Giving people information is not
  enough to change behavior
Strategies to Increases
Taking Medications as
     What are they?
Are compatible with IMR?
   Are they effective?
    Rationale for Including
 Medication Use as Part of IMR
 Medications:   Sensitive topic with
  some consumers
 Forced taking of meds:
  Antithetical to consumer choice
  and to recovery
 Not taking meds: For many
  consumers, incompatible with
 Effectiveness of Antipsychotics

 Reduce relapse rates compared to no
  medications (Shown in 200+ studies)
 Reduce positive symptoms
 About 70% of individuals with
  schizophrenia have improved
  symptom control on antipsychotics,
  compared to controls receiving
    Medications and Recovery

 Medications are   clearly a mixed
   –critical to find best meds and best
 Without meds, the research
  evidence clearly shows illness
  management is often more difficult
Taking Medications as Prescribed:
      Behavioral tailoring
      Simplifyingregimen
      Motivational interviewing/ CBT
       Behavioral Tailoring

 Developing  strategies for
  incorporating medication into daily
 Example: Place meds next to
  toothbrush as reminder
        Simplifying Regimen
 Definition:  Reducing number and
  frequency of medications
 Rationale: It is easier to get into a
  routine that is simple than one that is
 May be especially important if
  consumer has cognitive impairments
                What is
       Motivational Interviewing?
   is a set of strategies:
 It
  –Supportive, not argumentative
  –Timing plays a crucial role
  –Emphasis is on the reasons to
   change, rather than on how to
      Principles of
Motivational Interviewing
  Express empathy
  Develop  discrepancy
  Avoid argumentation
  Roll with resistance
  Support self-efficacy
         Research on
Taking Medications as Prescribed
                Controlled Studies
 Behavioral
  Tailoring     4/4 effective
 Simplifying
  Regimen       1/1 effective
 Motivational
  Interviewing/ 2/2 effective
Taking Medications as Prescribed

 Evidence:   Strong for behavioral
  tailoring, weak for other areas
 Motivational interviewing used for
  consumers not fully accepting:
            Meds  Recovery
Relapse Prevention

    What is it?
  Is it effective?
  Relapse Prevention: Components
 Psychoeducation
 Identify environmental triggers
 Identify warning signs
 Develop coping strategies
 Continuously monitor for warning signs
 Rapid intervention when indicated
 Stress management training
 Involve relatives in program
     Relapse Prevention:
     Research Evidence
 5/5 controlled  studies showed
  decreases in relapses and
 3 of studies also found
  improvements in social
  functioning and other outcomes
Teaching Strategies for
Coping with Symptoms
       What is it?
     Is it effective?
        Rationale for
    Teaching Coping Skills

 Persistent psychoticsymptoms
  present in 25-40% of persons with
 Psychotic symptoms predict
  relapses and rehospitalizations
 Consumers distressed by persistent
  psychotic symptoms
    Coping Strategies: Used
Intuitively by Many Consumers

     strategy often idiosyncratic
 Best
 Whatever works for you
       (Breier & Strauss)
               Coping Model
          (Adapted from Lazarus)

Appraisal of     Symptoms      Perceived
symptom                         Efficacy


        Teaching Coping Skills
 Use  of cognitive-behavioral
 Assessment of coping
 In-session and out-of-session
 Target positive, negative, and
  affective symptoms and other
  sources of stress
  Teaching Coping Skills:
   Typical Components
 Psychoeducation
 Personalizing to   individual
 Brainstorming
 Systematic   selection of coping
 Behavioral rehearsal
          Research on
     Teaching Coping Skills

4  controlled studies
 All studies show decreases in
  symptom severity
 Some studies also indicate less
  distress and lower rates of
     IMR Research: Summary
 Psychoeducation improves
  knowledge, but not other outcomes
 Behavioral tailoring increases taking
  medication as prescribed
 Relapse prevention training reduces
  relapses and rehospitalizations
 Teaching coping reduces symptoms
  and distress
     Nuts and Bolts:
What Does IMR Look Like?

        From IMR
Implementation Resource Kit
   (Mueser & Gingerich)
Selection of Participants for IMR
 Can  be offered to anyone who
  experiences psychiatric symptoms
 Educational handouts available for
  schizophrenia, bipolar disorder,
  and major depression
 May be preferable to wait if
  someone is currently under
  extreme stress
   Is Illness Management for
 Does   participation in illness
  management assume that consumer
  is already highly motivated?
 IMR research: Studies may be
  selecting a special subgroup
 Dropout rates: 22% – 55% in
  psychoeducation studies
        Session Format
 Can  be individual or group
 Structured, predictable
  sessions are recommended
 Typically 45 -60 minutes (but
  shorter if appropriate)
 Take breaks if necessary
       Typical Session Format
                               # Mi nutes
Informal socializing              3
Review previous session           3
Review homew ork                  5
Follow -up on goals               3
Set current s ess ion agenda      2
Teach new material                30
Agree on new homew ork            5
Summarize progres s               3
   Location of IMR Training
 Sessions can  be held anywhere
  – home or public setting (coffee
  shop) may be OK
 Ample lighting, comfortable
  seating, some privacy
 Quiet, free of distractions
Educational Handouts
   Simple language
   Summary boxes
   Probe questions
   Checklists
   Planning sheets
   Success stories
         Summary Box:
     Strategies for Recovery
 self-help          making   time for
  programs            recreation
 staying active     expressing
 developing a        creativity
  support system     seeking out
 maintaining         spirituality
  physical health    following
 being aware of      through with
  the environment     treatment choices
            Sample Checklist
 Area of my          Not       Moderately    Very
     life          Satisfied    Satisfied   Satisfied
Living situation
Belonging to a
        Probe Questions
 (Identifying what you would
  like to improve in your life
    will help you set goals):
 What two    areas of your life are you
  not satisfied with and would like to
 What goals would you like to set
  for yourself in these areas?
   Example from Handout:
    Choosing Treatments
“I have chosen treatment that
includes a self-help group, a part-
time job, and taking medication. I
like to be pro-active. Following
through with those things makes
me feel strong, like I can handle
my daily challenges.”
Use of Educational Handouts
 Review  the contents
 Help consumer personalize content
 Assign homework assignments
  based on handouts
 Ask consumer to share handouts
  with family members
Involvement of Significant Others
  Keep  them informed
  Practice skills with them
  In some instances, involve them in
   training sessions (especially in
   developing relapse prevention
    Practitioner Qualifications

 Warm,   kind, empathic
 Teaching skills
 Ability to take “shaping” approach
  to knowledge: Give feedback for
  small successes
     Core Values of IMR

 Hope  is the key ingredient
 Person is expert on own experience
  of mental illness
 Personal choice is paramount
 Practitioners are collaborators
 Practitioners must demonstrate

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