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

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Presentation on theme: "20 WAYS TO OVERCOME BARRIERS TO RECOVERY (20 th Revision) 2012 Prof. Courtenay M. Harding"— Presentation transcript:

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

2 Good Morning! OVERALL GENERAL INFORMATION FOR TODAY OVERALL GENERAL INFORMATION FOR TODAY  What’s 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

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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! 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 CARE WHO SPEND TIME PROBLEM SOLVING WHO SPEND TIME PROBLEM SOLVING WHO CHALLENGE THE STATUS QUO WHO CHALLENGE THE STATUS QUO WHO SPEND TIME GOING THE EXTRA MILE WHO SPEND TIME GOING THE EXTRA MILE

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7 MORE STUDIES USING WIDER DIAGNOSTIC CRITERIA STUDY # Av. Years % STUDY # Av. Years % Year & Place of Ss length improvement Year & Place of Ss length improvement _______________________________________or recovery _______________________________________or recovery HINTERHUBER % HINTERHUBER % 1973 AUSTRIA 1973 AUSTRIA KREDITOR % KREDITOR % 1977 LITHUANIA 1977 LITHUANIA MARINOW % MARINOW % 1986 BULGARIA 1986 BULGARIA

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

9 FINDINGS o % OF EACH COHORT SIGNIFICANTLY IMPROVED AND/OR RECOVERED o Recovered means: o No enduring symptoms, o No odd behaviors, o No further medication, o Living in the community, o Working, and relating well to others Significantly improved –means Significantly improved –means Recovered in all areas but one 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 ( 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):

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

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

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): 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):

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, 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,

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

16 HOWEVER……….. If your participant seems to be “stuck” on the path to recovery let’s look at some possible reasons and ways to change the Individual Recovery Plan (IRP)…… If your participant seems to be “stuck” on the path to recovery let’s 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 !

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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) COMPREHENSIVE RE-EVALUATION NEEDED (based on history, careful interview, lab findings & physical exam) BIO-PSYCHO-SOCIAL-SPIRITUAL APPROACH BIO-PSYCHO-SOCIAL-SPIRITUAL APPROACH SYSTEMATIC & MULTIDISCIPLINARY SYSTEMATIC & MULTIDISCIPLINARY

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

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

27 DIAGNOSIS OF EXCLUSION (schizophrenia) Autism (esp. Asperger’s Syndrome) Autism (esp. Asperger’s Syndrome) Temporal Lobe Epilepsy Temporal Lobe Epilepsy Tumor Tumor Stroke Stroke

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

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

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

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

32 ANOTHER HELPFUL STRATEGY Basis-24 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 Developed by Dr. Susan Eisen

34 HOW TO DO BETTER……… Take the time get triangulated information Take the time get triangulated information Get the lab tests done Get the lab tests done Reassess over time Reassess over time Pay attention to comorbid diagnoses 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 To clarify a psychiatric diagnosis SCID –THE STRUCTURED CLINICAL INTERVIEW FOR DSM-IV TR (CLINICAL VERSION) 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 All diagnoses are cross-sectional working hypotheses Not lifetime labels Not lifetime labels Not able to predict long-term outcome 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) 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 driver’s license? Etc……….. 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 driver’s license? Etc……….. Working with the strengths rather than deficits, problems and disabilities – that is what helps people get better 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 (source for this training changed many times) (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 isa.org/Ragin%27s%20Papers/recov.%20with%20 severe%20MI.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. 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. If left untreated, he or she may die unnecessarily early.

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45 OVERVIEW OF SITUATION % with medical co-morbidity % with medical co-morbidity Not recognized nor treated Not recognized nor treated Participants get “turfed” back to psychiatry or not referred at all Participants get “turfed” back to psychiatry or not referred at all Need primary care, eye & hearing exams, OB/GYN etc 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 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 Dec;40(12): Hosp Community Psychiatry Dec;40(12): Hosp Community Psychiatry. Hosp Community Psychiatry. A medical algorithm for detecting physical disease in psychiatric patients. A medical algorithm for detecting physical disease in psychiatric patients. Sox HC Jr, Koran LM, Sox CH, Marton KI, Dugger F, Smith T. Sox HC Jr, Koran LM, Sox CH, Marton KI, Dugger F, Smith T. Sox HC JrKoran LMSox CHMarton KIDugger FSmith T Sox HC JrKoran LMSox CHMarton KIDugger FSmith T Source Source Department of Medicine, Dartmouth-Hitchcock Medical Center, Hanover, New Hampshire, USA Department of Medicine, Dartmouth-Hitchcock Medical Center, Hanover, New Hampshire, USA

47 LABORATORY TESTS TO CONSIDER BIOCHEM BIOCHEM TOX SCREEN TOX SCREEN COMPLETE BLOOD COUNT COMPLETE BLOOD COUNT URINALYSIS URINALYSIS THYROID PANEL 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 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 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 Rescheduling missed appointments Get outside prescriptions into record Get outside prescriptions into record

50 More Suggested Strategies Offer preventive programs: e.g. Weight Watchers, Jazzercise, other exercise programs Offer preventive programs: e.g. Weight Watchers, Jazzercise, other exercise programs Walking Walking Nutrition, cooking and grocery shopping skills 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 Finding strengths in self care management Healthier people Healthier people Reduced mortality rates Reduced mortality rates Avoids confounding diagnosis Avoids confounding diagnosis And contraindicated medications 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:

53 QUESTION #3 Is there an additional neurological impairment? 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. 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 If they qualify for the Deficit Syndrome then they might do better if they have a medication change, cognitive remediation, and active rehabilitation

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

57 THE DEFICIT SYNDRÔME - 2 Poor premorbid social functioning Poor premorbid social functioning Reduced glucose uptake in the frontal cortex, parietal & thalamic areas on PET scans Reduced glucose uptake in the frontal cortex, parietal & thalamic areas on PET scans Increased anhedonia and fewer psychotic events Increased anhedonia and fewer psychotic events Earlier onset, seems to be unremitting, suffer spontaneous movement d/o, severe cognitive impairments 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: 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 Need longitudinal information Use SDS or PDS Criteria Use SDS or PDS Criteria Exclude: drug effect & demoralization Exclude: drug effect & demoralization Need 2 of the following for more than a year: 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) USE SCREENING TOOL: THE Neurological Evaluation Scale (NES) TRY: 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 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) PDS : Proxy for Deficit Syndrome Kirkpatrick 1996 (core deficit + no dysphoria) Robert W. Buchanan et al, 1990, 1993,1994, 1996 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):

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

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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 demoralized and lost hope? Is person socialized into learned helplessness? Is person socialized into learned helplessness? Has person become risk aversive? Has person become risk aversive? Does person have co-occurring depression? Does person have co-occurring depression? Have you earned person’s trust? Have you earned person’s trust? Are there disabling symptoms and environmental responses interfering with relationships and participation? 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 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 Relationships, understanding values and treatment preferences, assessing strengths, and supporting goal-striving Checklists, worksheets, strengths assessment Checklists, worksheets, strengths assessment

70 Some resources to get to know people better and rethink.org/refocus and rethink.org/refocus Harding, C.M. The Lifeline, 2011 Harding, C.M. The Lifeline, Davidson, L & Ridgway, P. What if a person has no goals? (dmh.mo.gov/docs/mentalillness/personwithnogo als.pdf) Davidson, L & Ridgway, P. What if a person has no goals? (dmh.mo.gov/docs/mentalillness/personwithnogo als.pdf) McCrory, D. (1980) The rehabilitation crisis: The impact of growth. Journal of Applied Rehabilitation Counseling, 11(3): McCrory, D. (1980) The rehabilitation crisis: The impact of growth. Journal of Applied Rehabilitation Counseling, 11(3):

71 Narrative Therapy Beels, C. Christian (2001) 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? 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. 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 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. It is important to separate out the signal from the noise.

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75 ASSESSMENT OF CHARACTERLOGICAL TRAITS Can get in the way or aid progress Can get in the way or aid progress How did the person respond to crises before mental illness? How did the person respond to crises before mental illness? Is the schizophrenia gone but not the personality quirk, Axis II, or despair Is the schizophrenia gone but not the personality quirk, Axis II, or despair Criteria under reconsideration for DSM 5 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 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. 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. 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 Need to assess socialization into participant (user, consumer) role Medication side effects Medication side effects Not provided with educational or work opportunities 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 Benedict Carey : Thinking clearly about personality disorders, New York Times clearing-the-fog-around-personality- disorders clearing-the-fog-around-personality- disorders Ted Millon:, 2nd ed. (2004) Ted Millon: Personality Disorders in Modern Life, 2nd ed. (2004) px px

79 QUESTION #6 ARE THERE SPECIFIC NEUROCOGNITIVE DEFICITS BEING COPED WITH BY THIS PERSON? 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, wouldn’t 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? Since we have been saying that this is a “brain disease” for a couple of decades, wouldn’t 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 Attention Vigilance Vigilance Executive functioning (reasoning, judgment, problem-solving, anticipation, planning, decision-making) Executive functioning (reasoning, judgment, problem-solving, anticipation, planning, decision-making) Learning Learning Memory Memory Ability to read affect on faces Ability to read affect on faces Find cognitive strengths Find cognitive strengths

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

83 MATRICS Consensus Neurocognitive Battery (MCCB) An NIMH initiative An NIMH initiative Used “a broad-based interdisciplinary consensus process” Used “a broad-based interdisciplinary consensus process” Originally designed for pharmacological research Originally designed for pharmacological research Outcome measure for cognitive remediation 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

84 Components of MCCB 10 tests measuring seven cognitive domains 10 tests measuring seven cognitive domains 1)Processing Speed 1)Processing Speed 2) Attention/ vigilance 2) Attention/ vigilance 3) Working Memory 3) Working Memory 4)Verbal Memory 5) Visual Learning 6) Reasoning & Problem Solving 7) Social Cognition 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 Medalia’s work at Columbia University and Susan McGurk’s work at Boston University)

86 MUTLIMODAL APPROACH - GOAL IS TO: MATCH REHAB TYPE AND INTENSITY TO CHANGING NEEDS 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, 19: Medalia, A. & Choi, J.(2009). Cognitive Remediation in Schizophrenia. Neuropsychology Review, 19: McGurk, S.R. et al. (2007). A Meta-Analysis of Cognitive Remediation in Schizophrenia. American Journal of Psychiatry, 164: McGurk, S.R. et al. (2007). A Meta-Analysis of Cognitive Remediation in Schizophrenia. American Journal of Psychiatry, 164:

88 SOME MORE RESOURCES: G.E. Hogarty - – Guilford Press G.E. Hogarty - Cognitive Enhancement Therapy – Guilford Press G.E. Hogarty & S. Flescher (1999) G.E. Hogarty & S. Flescher (1999) H.D. Brenner et al, Hografe & Huber Toronto, 1994 H.D. Brenner et al, Hografe & Huber Toronto, 1994 W. Spaulding et al BJP, 1989 W. Spaulding et al BJP, 1989 Michael F. Green et al, Scz Res., 2004 Michael F. Green et al, Scz Res., 2004

89 LUNCH BREAK for one hour

90 QUESTION #7 ARE THE MEDICATIONS REALLY WORTH THE TRADE-OFF? 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 TAKE A THOROUGH HISTORY GET OLD RECORDS GET OLD RECORDS TALK TO OTHERS WHO KNOW PERSON TALK TO OTHERS WHO KNOW PERSON COLLABORATE, COLLABORATE, COLLABORATE, COLLABORATE COLLABORATE, COLLABORATE, COLLABORATE, COLLABORATE

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

95 CAUSES OF MISINTERPRETATION MUST LISTEN TO THE WAY MEDS MAKE PEOPLE FEEL FROM THE INSIDE OUT MUST LISTEN TO THE WAY MEDS MAKE PEOPLE FEEL FROM THE INSIDE OUT SOMETIMES CLIENTS CAN’T DESCRIBE SUBTLE FEELINGS SOMETIMES CLIENTS CAN’T 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. 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 USE AIMS + EPS EXAM q.6 MOS

96 DEFINITION OF THE WORD “COMPLIANCE” Not 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 STICK FAST TO BECOME ATTACHED TO BECOME ATTACHED TO GIVE ALLEGIANCE TO TO GIVE ALLEGIANCE TO TO GIVE DEVOTION OR SUPPORT TO GIVE DEVOTION OR SUPPORT

98 MEDICATION MANAGEMENT APPROACHES IN PSCYHIATRY Provides a systematic & structured plan for med management Provides a systematic & structured plan for med management Documentation is clearer and more concise Documentation is clearer and more concise Objective measures of outcome Objective measures of outcome Shared decision-making 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 “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 CATIE STUDY= Clinical Antipsychotic Trials of Intervention Effectiveness Results underscore need for access to full range of medications” in and also NEJM Sept 22, 2005 J. Lieberman et al Results underscore need for access to full range of medications” in and also NEJM Sept 22, 2005 J. Lieberman et alwww.szdigest.com

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 ents-and-drugs ents-and-drugs ents-and-drugs ents-and-drugs -index.shtml -index.shtml -index.shtml -index.shtml What Your Patients Need to Know About Psychiatric Medications by WC Jackson – ›... › v.9(4); 2007 What Your Patients Need to Know About Psychiatric Medications by WC Jackson – ›... › v.9(4); 2007 What Your Patients Need to Know About Psychiatric Medicationsv.9(4); 2007 What Your Patients Need to Know About Psychiatric Medicationsv.9(4); 2007 Schrank, B.,Sibitz, I. Unger, A.& Amering, M.: How Patients With Schizophrenia Use the Internet: Qualitative Study. J Med Internet Res Oct-Dec; 12(5): 70. Schrank, B.,Sibitz, I. Unger, A.& Amering, M.: How Patients With Schizophrenia Use the Internet: Qualitative Study. J Med Internet Res Oct-Dec; 12(5): 70. SchrankSibitz UngerAmering SchrankSibitz UngerAmering

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 The Metabolic Syndrome Abdominal obesity (excessive fat tissue in and around the abdomen) 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) Atherogenic dyslipidemia (blood fat disorders — high triglycerides, low HDL cholesterol and high LDL cholesterol — that foster plaque buildups in artery walls) Elevated blood pressure Elevated blood pressure

105 MORBIDITY AND MORTALITY-2 More of The Metabolic Syndrome More of The Metabolic Syndrome Insulin resistance or glucose intolerance (the body can’t properly use insulin or blood sugar) Insulin resistance or glucose intolerance (the body can’t properly use insulin or blood sugar) Prothrombotic state (e.g., high fibrinogen or plasminogen activator inhibitor–1 in the blood) Prothrombotic state (e.g., high fibrinogen or plasminogen activator inhibitor–1 in the blood) Proinflammatory state (e.g., elevated C- Reactive Protein in the blood) Proinflammatory state (e.g., elevated C- Reactive Protein in the blood)

106 MORBIDITY AND MORTALITY-3 Increased risks of: 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 1 st 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 no medications; Some people seem to need medications for a short while; Some people seem to need medications for a short while; A few people seem to need medication for a longer period. A few people seem to need medication for a longer period. Need research to help triage Need research to help triage

111 Support for optimization of medications…………. Literature says that 1 st episode participants may need little or no medications by adopting “wait and see” Literature says that 1 st 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 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 Taper, taper very very slowly if on for a long time

112 More Resources: Personal Therapy – GE Hogarty et al 1997 helps adherence Personal Therapy – GE Hogarty et al 1997 helps adherence W. Fenton Psychiatric Times 2006 Combined therapy W. Fenton Psychiatric Times 2006 Combined therapy APA – APA – 2004 Practice Guidelines Texas Medication Algorithm – No! Was drug company sponsored. 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 ? 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. 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 Research has shown many different reasons for use of substances

115

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

117 Co-Occurring or Dual Dx D/O can lead to: Symptom Symptom Relapses Relapses hospitalization hospitalization financial and family problems financial and family problems homelessness homelessness suicide 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) 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 Services provided concurrently Individualized assessment and treatment planning in heavy collaboration Individualized assessment and treatment planning in heavy collaboration Use SCID-SA Screener Use SCID-SA Screener

120 EBP: Integrated Dual Disorders Treatment DUAL DISORDERS TREATMENT IMPLEMENTATION RESOURCE KIT DUAL DISORDERS TREATMENT IMPLEMENTATION RESOURCE KIT  Information  Training Materials  Annotated Bibbs  Refs  org

121 EBP: Integrated Dual Disorders Treatment Blending Blending Stage-wise Treatment Stage-wise Treatment Motivational Interviewing Motivational Interviewing Substance Abuse Counseling Substance Abuse Counseling Involving all stakeholders Involving all stakeholders 4 basic skills for clinicians 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 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 Blended funding streams and integrated care more helpful Gender, age, ethnicity, geographic residence, exposure to trauma, make differences 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.

124 QUESTION #9 WHAT ARE THE RELEVANT SEX DIFFERENCES? WHAT ARE THE RELEVANT SEX DIFFERENCES?

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

126

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

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

129 SOME SEX DIFFERENCES AFECTING ILLNESS EXPRESSION AND OUTCOME-2 MALES Quick metabolism of food and medicine gets into blood stream faster May contribute to more side effects FEMALES 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 Earlier onset often in early to mid teens – means less education, less job and dating experience Slow progress toward recovery FMALES 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 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 FEMALES 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 l

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): 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, 9: 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, 9:

133 QUESTION # 10 WHERE IS THIS PERSON IN THE COURSE OF ILLNESS? 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. Helpful to track episode information to see when illness is beginning to lift.

135

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

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

139 Consider the differential effects of rehabilitation in interaction with course Propose that possibly …. Propose that possibly …. Early rehabilitation interventions from Day 1 forward may help reduce disability Early rehabilitation interventions from Day 1 forward may help reduce disability Later rehabilitation interventions may help to increase ability 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 don’t tell anyone. Thanks for talking about recovery.” How much do we underestimate what is possible for people?

141 Some Resources THE LIFELINE – v by C. M. Harding THE LIFELINE – v by C. M. Harding Strauss JS, Hafez H, Lieberman P, Harding CM. The course of psychiatric disorder, III: Longitudinal principles. Am J Psychiatry Mar;142(3): The course of psychiatric disorder, III: Longitudinal principles. Harding, C.M.: Course types in schizophrenia. An analysis of European and American studies. SCHIZOPHRENIA BULLETIN. 1988, 14(4):

142 QUESTION # 11 WHAT MYTHS AND MISINFORMATION ARE STRESSING THE PERSON? 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. Knowledge transfers power from the illness and the care system to the person.

144

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

146 EBP:WELLNESS MANAGEMENT AND RECOVERY PROGRAM-1 CLINICIAN BENEFITS: 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: 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 Recovery strategies Practical facts about MI Practical facts about MI Stress- Vulnerability & treatment strategies Stress- Vulnerability & treatment strategies Building social supports 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 Wellness Self-Management & Plus by Columbia University – Paul Margolies and Tony Salerno   mmunitysupport/toolkit mmunitysupport/toolkit   html 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. 1995:90 (Suppl. 384):

152 BATHROOM AND MOBILE PHONE BREAK

153 QUESTION # 12 WHO DEPENDS ON THE CLIENT FOR HELP? 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. 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! Ask and you will find out some surprising information!

155

156 What You Will Find Out… Most people with the lived experience have people they help with emotional support during a crisis or with 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 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 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) 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) 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 Liberman’s Social & Independent Living Skills Modules at UCLA Robert Liberman’s Social & Independent Living Skills Modules at UCLA See Innovations & Research See Innovations & Research Vol2 (2) 1993 Vol2 (2) 1993 Harding’s Star Chart (Social Network) Harding & Keller, 1998 Harding’s 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): , ) 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): , ) Hogarty GE: Personal Therapy for Schizophrenia and Related Disorders: A Guide to Individualized Treatment. New York, Guilford Press, ) Hogarty GE: Personal Therapy for Schizophrenia and Related Disorders: A Guide to Individualized Treatment. New York, Guilford Press, ) Liberman, R. Liberman, R., DeRisi, W., & Mueser, K. : Social skills training for psychiatric patients. New York: Pergamon Press, ) Liberman, R. Liberman, R., DeRisi, W., & Mueser, K. : Social skills training for psychiatric patients. New York: Pergamon Press, ) Mueser, K.T. & Gingerich, S.: The Complete Family Guide to Schizophrenia. New York, The Guilford Press, ) Mueser, K.T. & Gingerich, S.: The Complete Family Guide to Schizophrenia. New York, The Guilford Press, ) Bellack, A.S., Mueser, K.T., Gingerich,S., Agresta, J.: Social Skills Training for Schizophrenia: A Step by Step Guide (2 nd Ed.). New York: Guilford Press, ) Bellack, A.S., Mueser, K.T., Gingerich,S., Agresta, J.: Social Skills Training for Schizophrenia: A Step by Step Guide (2 nd Ed.). New York: Guilford Press, ) 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, ) 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: 27– 40. 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 Hammer, Muriel ( 1981) Social Supports, Social Networks, and Schizophrenia. Schiz Bull. 7(1):

162 QUESTION #13 WHAT IS THE PERSON’S WORLD VIEW? WHAT IS THE PERSON’S WORLD VIEW?

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

164

165 CULTURAL SENSITIVITY ONLY RECENTLY APPRECIATED ONLY RECENTLY APPRECIATED DIVERSITY IS HALLMARK OF WORLD DIVERSITY IS HALLMARK OF WORLD NEED TO UNDERSTAND AT INTAKE ONWARD NEED TO UNDERSTAND AT INTAKE ONWARD WHAT IS IMPORTANCE OF RELIGIOUS THINKING versus RELIGIOSITY? WHAT IS IMPORTANCE OF RELIGIOUS THINKING versus RELIGIOSITY? SENSE OF TIME? SENSE OF TIME? DISPLAYED AFFECT? DISPLAYED AFFECT?

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

167 CULTURAL SENSITIVITY-2 CompetenceStandards CompetenceStandards CompetenceStandards CompetenceStandards SAMHSA’s only approved standards for anything SAMHSA’s only approved standards for anything Benchmarks Benchmarks Guidelines Guidelines Outcome Measures Outcome Measures Lit Review Lit Review For everyone for everyone and the major 4 minority groups 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), 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),

169 Question # 15 IS THERE ANY COHESION IN THE SYSTEM OF CARE? 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. Complex biopsychosocial problems need integrated comprehensive systems which collaborate with users and carers. It helps people if we have our act together! It helps people if we have our act together!

171

172 LINKAGES - 1 Coordination and linkage between all the players are critical Coordination and linkage between all the players are critical Need semi-permeable membranes for information sharing, flexibility, coordination, continuity and integration Need semi-permeable membranes for information sharing, flexibility, coordination, continuity and integration Clear and consistent policies from the top down Clear and consistent policies from the top down

173 LINKAGES - 2 Clear and consistent policies from the top down Clear and consistent policies from the top down Use community resource checklist (community mental health, extension services, consumer groups, natural support) 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 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, The Comprehensive, Continuous, Integrated System of Care (CCISC) process (Minkoff & Cline, 2004, 2005) is a vision-driven system “transformation” process model.aspx model.aspx dex.html dex.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),

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): 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

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 Psychological strategies can go a long way to calm a person without heavy dosing

180

181 QUESTION # 14 – RISK MANAGEMENT - 2 Research has found the following risk factors for minor and serious violence: 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 Relapse Prevention Strategies for mental health and substance abuse issues Try Paul and Lentz Social Learning Environments (behavioral) Try Paul and Lentz Social Learning Environments (behavioral) Tony Menditto’s program for forensic participants Tony Menditto’s program for forensic participants Individualized Token Behavioral Programs which tend to generalize to other environments Individualized Token Behavioral Programs which tend to generalize to other environments Reduce Restraint and Seclusion with psychological strategies first 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): Linehan, M. & Dimeff, L.A. Dialectical Behavior Therapy Manual of Treatment Interventions for Drug Abusers and Borderline Personality Disorder. Seattle, Washington, University of Washington,

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

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

189 ASSESSMENT OF STRENGTHS Rehab is built on strengths not problems or deficits Rehab is built on strengths not problems or deficits Strengths of: person, system of care, family, case manager, the doc etc 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 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. 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): 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):

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. 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

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

196 Some Trauma Studies 50-60% of US have a traumatic experience 50-60% of US have a traumatic experience 10% - 17 % Chronic PTSD (Galea et al, 2002) 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) 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) Most do not & do not display pathology! (Bonanno et al, 2002)

197 Predictors of the Emergence of PTSD LACK OF SOCIAL SUPPORT LACK OF SOCIAL SUPPORT LACK OF EDUCATION LACK OF EDUCATION TOUGH FAMILY BACKGROUND TOUGH FAMILY BACKGROUND PRIOR PSYCHIATRIC HISTORY PRIOR PSYCHIATRIC HISTORY DISSOCIATIVE REACTION DISSOCIATIVE REACTION (Berwin et al 2000, Ozer et al, 2003) (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 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 Changes in both internal and external environments can lead to ± changes in gene structures The Brain is a Plastic Organ as well The Brain is a Plastic Organ as well Healing is possible Healing is possible

199

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

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

202 SOME RESOURCES Journal of Brain Behavioral and Immunity for articles on psychoneuroimmunology Journal of Brain Behavioral and Immunity for articles on psychoneuroimmunology Trauma-Focused Cognitive Behavioral Therapy - NREPP... =135 Trauma-Focused Cognitive Behavioral Therapy - NREPP... Tips for survivors of a traumatic event. anaging_your_stress Tips for survivors of a traumatic event. anaging_your_stress

203 # 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.

205

206 Realizing that admitting you can’t read is more embarrassing to a person than talking about symptoms! Realizing that admitting you can’t read is more embarrassing to a person than talking about symptoms! Receiving information in the way a person can understand Receiving information in the way a person can understand Learning to read might improve self- esteem and reduce symptoms Learning to read might improve self- esteem and reduce symptoms Helps close the gap in healthcare disparities Helps close the gap in healthcare disparities Assessment of the level of functional literacy

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 Slow down speech fluency Use “living room” language instead of medical terminology Use “living room” language instead of medical terminology Show or draw pictures to enhance understanding and subsequent recall Show or draw pictures to enhance understanding and subsequent recall

209 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, 34:387)

210 # 19 Does this person believe in something bigger than self?

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

212

213 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 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 Need to ask and talk about it if person is interested

214 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 …………..

216

217 CHERYL GAGNE’S 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 !

218 WHAT MADE THE DIFFERENCE ACCORDING TO THOSE INTERVIEWED FROM VERMONT STUDY?  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  Integration back into the community

219 WHAT DID THE VERMONTERS ALSO SAY MADE THE DIFFERENCE? Hope! “Someone believed in me” “Someone believed in me” “Someone told me that I had a chance to get better” “Someone told me that I had a chance to get better” “My own persistence” “My own persistence” Hope connects with natural self- healing capacities Hope connects with natural self- healing capacities

220 “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)

221 Another Resource Strauss, J.S.; Harding, C.M.: Relationships between adult development and the course of mental disorder. In: J. Rolf, A. Master, D. Cicchetti, K. Nuechterlein, and S. Weintraub (Eds.), RISK AND PROTECTIVE FACTORS IN THE DEVELOPMENT OF PSYCHOPATHY. New York, Cambridge University,

222 AS A CLINICIAN BEING SYSTEMATIC CREATIVE, & STRUCTURED IN YOUR APPROACH YOURSELF AND YOUR RELATIONSHIP ARE THE BEST TOOLS IN YOUR KIT BAG

223 MANY THANKS FOR PARTICIPATING. HOPE SOME OF THIS INFORMATION WILL BE HELPFUL.

224 Presenter Information Courtenay M. Harding, Ph.D., recently retired as a professor in the department of psychiatry at the College of Physicians and Surgeons of Columbia University. She was trained at the University of Vermont and Yale. She also just retired as the director of the Center for Rehabilitation and Recovery at the Coalition of Behavioral Health Agencies in NYC. Dr. Harding moved to New York from Boston where she was the Senior Director of Boston University’s well-known Center for Psychiatric Rehabilitation under William Anthony. Among her research endeavors, Dr. Harding participated in two three-decade NIMH studies of schizophrenia and other serious illnesses and found that many once profoundly disabled persons could and did significantly improve and/ or even fully recover. These findings, similar to nine other long-term studies from across the world, helped to create the Institute for the Study of Human Resilience in order to investigate ways in which people reclaimed their lives including getting back to work. To date, she has received 52 federal, state, and foundation grants and contracts for schizophrenia research and studies of mental health services. She has been the recipient of over 46 awards and honors including the Alexander Gralnick Research Investigator Award from the American Psychological Association’s foundation for “exceptional contributions to the study of schizophrenia and other serious mental illness and for mentoring a new generation of researchers” Dr. Harding has published extensively about schizophrenia, rehabilitation, and recovery and has presented findings from her studies and clinical work in over 500 state, national, and international meetings. She has worked with 30 states, Australia, New Zealand, 11 European, and 9 Asian countries including China to redesign their systems of care.


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