Presentation on theme: "20 WAYS TO OVERCOME BARRIERS TO RECOVERY (20th Revision) 2012"— Presentation transcript:
1 20 WAYS TO OVERCOME BARRIERS TO RECOVERY (20th Revision) 2012 Prof. Courtenay M. Harding
2 CourtenayHardingConsulting@gmail Good Morning!OVERALL GENERAL INFORMATION FOR TODAYWhat’s in the folders?How to work with this informationBreaks for lunch, phone & bathroomAsk questions as we go alongEvaluations and Certificates at end
7 MORE STUDIES USING WIDER DIAGNOSTIC CRITERIA STUDY # Av. Years %Year & Place of Ss length improvement_______________________________________or recoveryHINTERHUBER %1973 AUSTRIAKREDITOR %1977 LITHUANIAMARINOW %1986 BULGARIA
8 THESE PROJECTS HAVE STUDIED….. 2400 plus peopleAcross 2-3 decades after first admissionIn intact samplesFound surprising confluence of findings
9 FINDINGS No enduring symptoms, No odd behaviors, 46-68 % OF EACH COHORT SIGNIFICANTLY IMPROVED AND/OR RECOVEREDRecovered means:No enduring symptoms,No odd behaviors,No further medication,Living in the community,Working, and relating well to othersSignificantly improved –meansRecovered in all areas but oneHarding 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 CourtenayHardingConsulting@gmail More EvidenceDavidson, 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) , 2006Harding, 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 CourtenayHardingConsulting@gmail More resources -3Harding, 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?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)……
17 CourtenayHardingConsulting@gmail 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 From Dr. Candace Fleming, a Native American psychologist YOU NEED TO LOOK AT A PERSON TWICE…… once with your heart and then with your head……..FIRST TO SEE THE SIMILARITIESAND, ONLY THEN. CAN YOU APPRECIATE THE DIFFERENCESFrom Dr. Candace Fleming, a Native American psychologist
22 LOOKING FOR THE “PERSON UNDER THE DISORDER” COMPREHENSIVE RE-EVALUATION NEEDED (based on history, careful interview, lab findings & physical exam)BIO-PSYCHO-SOCIAL-SPIRITUAL APPROACHSYSTEMATIC & MULTIDISCIPLINARY
23 CourtenayHardingConsulting@gmail QUESTION #1HAVE 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
28 CourtenayHardingConsulting@gmail MORE THINGS TO EXCLUDEBrain TraumaEndocrine & Metabolic Disorders (e.g. acute intermittent porphyria (liver enzyme)Homocystinuria (a disorder of amino acid metabolism)
29 CourtenayHardingConsulting@gmail MORE THINGS TO EXCLUDEVitamin Deficiency (e.g. B 12)Central Nervous System Infectious Processes (e.g. AIDS, neurosyphilis, or herpes encephalitis)Autoimmune Disorders (systemic lupus erthymatosa)Heavy Metal Toxicity (e.g. Wilson’s Disease – too much copper)
30 CourtenayHardingConsulting@gmail EVEN MORE TO EXCLUDE:Some Drug Induced States (e.g. amphetamines, barbiturate withdrawal, cocaine, digitalis, disulfram)Mood disorders, schizoaffective disorder,Personality disorders,Brief Reactive Psychosis,OCD
32 ANOTHER HELPFUL STRATEGY Basis-24“a leading behavioral health assessment”ComprehensiveCuts across diagnostic categoriesProvides weighted averageOverall score plus 6 subscales(sub abuse, symptoms and functioning, relationships, self harm, emotional liability, psychosis, and depression)
33 CourtenayHardingConsulting@gmail SOURCE FOR BASIS-24Developed by Dr. Susan Eisen
34 CourtenayHardingConsulting@gmail HOW TO DO BETTER………Take the time get triangulated informationGet the lab tests doneReassess over timePay attention to comorbid diagnoses
35 Treat or refer other diagnoses Establish links and a little black book with other medical colleagues across the local communityWork 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 disorderNetworks of partnerships treating person in a holistic wayPartners 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 diagnosisSCID –THE STRUCTURED CLINICAL INTERVIEW FOR DSM-IV TR (CLINICAL VERSION)
37 OR IF PSYCHIATRIC DIAGOSIS IS RE-ESTABLISHED All diagnoses are cross-sectional working hypothesesNot lifetime labelsNot able to predict long-term outcomeMust 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………..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)
40 CourtenayHardingConsulting@gmail More ResourcesRosen, 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
42 CourtenayHardingConsulting@gmail QUESTION # 2DOES THIS PERSON WITH A PSYCHIATRIC DISORDER HAVE OTHER MEDICAL PROBLEMS ABOUT WHICH TO WORRY?
43 WHY IS THIS QUESTION IMPORTANT? Even though a psychiatric diagnosis may be correct, there is a good chance that the person may be experiencing a co-morbid condition or two or three.If left untreated, he or she may die unnecessarily early.
45 CourtenayHardingConsulting@gmail OVERVIEW OF SITUATION40-60 % with medical co-morbidityNot recognized nor treatedParticipants get “turfed” back to psychiatry or not referred at allNeed primary care, eye & hearing exams, OB/GYN etcNeed 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):A medical algorithm for detecting physical disease in psychiatric patients.Sox HC Jr, Koran LM, Sox CH, Marton KI, Dugger F, Smith T.SourceDepartment of Medicine, Dartmouth-Hitchcock Medical Center, Hanover, New Hampshire, USA
48 CourtenayHardingConsulting@gmail 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 linkagesHave a case manager (or other person who knows person well) go armed with information and written questions and take notes with user to another physicianRescheduling missed appointmentsGet outside prescriptions into record
50 More Suggested Strategies Offer preventive programs: e.g. Weight Watchers, Jazzercise, other exercise programsWalkingNutrition, cooking and grocery shopping skillsMeditation & other relaxation techniquesOther Health and Wellness Education Classes on blood pressure, weight, and diabetes monitoring.
51 PAYING ATTENTION GETS ……… Finding strengths in self care managementHealthier peopleReduced mortality ratesAvoids confounding diagnosisAnd contraindicated medications
52 CourtenayHardingConsulting@gmail Resource to check outDanson,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 CourtenayHardingConsulting@gmail QUESTION #3Is there an additional neurological impairment?
54 WHY IS THIS QUESTION IMPORTANT? There are groups of young men who are withdrawn and sit quietly and are mostly ignored because they cause no trouble.If they qualify for the Deficit Syndrome then they might do better if they have a medication change, cognitive remediation, and active rehabilitation
56 CourtenayHardingConsulting@gmail THE DEFICIT SYNDRÔME+/- S/S of Schizophrenia Come and Go (esp. + symptoms)Attempts to find primary, enduring stable negative symptomsSubtype or Additional D/ONeurological Impairments ( sensory integration, stereognosis, graphesthesia, right-left confusion, the face-hand test, & audiovisual integration)
57 CourtenayHardingConsulting@gmail THE DEFICIT SYNDRÔME - 2Poor premorbid social functioningReduced glucose uptake in the frontal cortex, parietal & thalamic areas on PET scansIncreased anhedonia and fewer psychotic eventsEarlier onset, seems to be unremitting, suffer spontaneous movement d/o, severe cognitive impairments
58 CourtenayHardingConsulting@gmail THE DEFICIT SYNDRÔME - 3Deficit 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 suspiciousnessSimilar duration of illnessBrain architecture seems to be more intact in some areas
59 CourtenayHardingConsulting@gmail THE DEFICIT SYNDRÔME - 4Need longitudinal informationUse SDS or PDS CriteriaExclude: drug effect & demoralizationNeed 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 CourtenayHardingConsulting@gmail THE DEFICIT SYNDRÔME - 5USE SCREENING TOOL: THE Neurological Evaluation Scale (NES)TRY:Atypical NeurolepticsCognitive RemediationOther Aggressive Rehab
61 CourtenayHardingConsulting@gmail Some Resources:Brian Kirkpatrick et al, 1989, (SDS -The Schedule for the Deficit Syndrome), 1993, 2001PDS : Proxy for Deficit Syndrome Kirkpatrick 1996 (core deficit + no dysphoria)Robert W. Buchanan et al, 1990, 1993,1994, 1996
62 Another Interesting Resource Strauss, J.S.; Rakfeldt, J.H.; Harding, C.M.; Lieberman, P.: Psychological and social aspects of negative symptoms. BRITISH JOURNAL OF PSYCHIATRY, 1989, 155 (Suppl. 7):
63 WHO IS THIS PERSON UNDER A COAT OF ILLNESS? QUESTION #4WHO 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.
66 ASSESSMENT OF ADULT DEVELOPMENT PSYCHIATRIC PROBLEMS DISRUPT A LIFENEED TO GRIEVE FOR LOSS OF TIME AND OPPORTUNITIESTHE “REHABILITATION CRISIS” (McCRORY, 1982) which describes how clinicians can get in the way of recovery process inadvertentlyASSESSMENT 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 diagnosisUsually aware that something is holding them back from getting a life they wantIf want to recapture their dreams and accept some kind of help from others orFocus on what the person thinks is distressing or getting in the way of dreamListening and engagingL. Davidson, 2012
68 What If A Person Has No Goals? L. Davidson & P. Ridgway Is person demoralized and lost hope?Is person socialized into learned helplessness?Has person become risk aversive?Does person have co-occurring depression?Have you earned person’s trust?Are there disabling symptoms and environmental responses interfering with relationships and participation?
69 CourtenayHardingConsulting@gmail New Resource Questionnaire to get a handle on what a person wants and needs to get betterREFOCUS- Promoting recovery in community mental health services (Rethink recovery series: vol. 4) Bird, V. et al, Institute of Psychiatry, Kings College LondonRelationships, understanding values and treatment preferences, assessing strengths, and supporting goal-strivingChecklists, worksheets, strengths assessment
70 Some resources to get to know people better and rethink.org/refocusHarding, C.M. The Lifeline, 2011Davidson, L & Ridgway, P. What if a person has no goals? (dmh.mo.gov/docs/mentalillness/personwithnogoals.pdf)McCrory, D. (1980) The rehabilitation crisis: The impact of growth. Journal of Applied Rehabilitation Counseling, 11(3):
71 CourtenayHardingConsulting@gmail Narrative TherapyBeels, C. Christian (2001) A Different Story: The Rise of Narrative in Psychotherapy. Phoenix Arizona. Zeig, Tucker & Theisen, Inc.
72 CourtenayHardingConsulting@gmail Question #5WHAT OTHER THINGS HELP OR HINDER PROGRESS?
73 WHY IS THIS QUESTION IMPORTANT? Often a person loses their psychiatric symptoms but the clinician does not understand that it has happened.This is because the person may continue to get in his or her own way because of quirks in their personality or despairIt is important to separate out the signal from the noise.
75 ASSESSMENT OF CHARACTERLOGICAL TRAITS Can get in the way or aid progressHow did the person respond to crises before mental illness?Is the schizophrenia gone but not the personality quirk, Axis II, or despairCriteria under reconsideration for DSM 5Look for evidence of problem-solving, a sense of humor, a philosophical approach, optimism, persistence and strengths in functioning and resilience to build upon
76 CourtenayHardingConsulting@gmail Consider rewarding positive behaviors and not focusing on learned poor onesClinicians seem to pay attention to pain-in-the-neck behaviors and miss the opportunity to reinforce healthy ones.Praise small congenial behaviors such as: saying “Good morning”, or shaking hands, or looking you in the eye, or noticing when a hand is needed, etc. etc.
77 Assessment of other things that get in the way of recovery process Need to assess socialization into participant (user, consumer) roleMedication side effectsNot provided with educational or work opportunitiesLack of other rehabilitationExtreme virulence of illness (only 10%)Lack of staff expectations (very important)Loss of hope
78 CourtenayHardingConsulting@gmail ResourcesBenedict Carey : Thinking clearly about personality disorders, New York TimesTed Millon: Personality Disorders in Modern Life, 2nd ed. (2004)
79 CourtenayHardingConsulting@gmail QUESTION #6ARE 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?
81 SCHIZOPHRENIA & NEUROCOGNITIVE DEFICITS AttentionVigilanceExecutive functioning (reasoning, judgment, problem-solving, anticipation, planning, decision-making)LearningMemoryAbility to read affect on facesFind cognitive strengths
82 CourtenayHardingConsulting@gmail MUTLIMODAL APPROACHTests of laterality- prefrontal, frontal, parietal, temporal functioningSemantic, episodic & working memoryExpressive & receptive languageConstructional skills
83 MATRICS Consensus Neurocognitive Battery (MCCB) An NIMH initiativeUsed “a broad-based interdisciplinary consensus process”Originally designed for pharmacological researchOutcome measure for cognitive remediationRepeated measures of cognitive change)And as a cognitive reference point for non-intervention studiesTranslated into 16 languages to dateVery short battery better toleratedWell known neuropsych tests
84 CourtenayHardingConsulting@gmail Components of MCCB10 tests measuring seven cognitive domains1)Processing Speed2) Attention/ vigilance3) Working Memory4)Verbal Memory5) Visual Learning6) Reasoning & Problem Solving7) Social Cognition
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 CourtenayHardingConsulting@gmail MUTLIMODAL APPROACH -GOAL IS TO: MATCH REHAB TYPE AND INTENSITY TO CHANGING NEEDS
87 CourtenayHardingConsulting@gmail More ResourcesMedalia, 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:
88 CourtenayHardingConsulting@gmail SOME MORE RESOURCES:G.E. Hogarty - Cognitive Enhancement Therapy – Guilford PressG.E. Hogarty & S. Flescher (1999)H.D. Brenner et al, Hografe & Huber Toronto, 1994W. Spaulding et al BJP, 1989Michael F. Green et al, Scz Res., 2004
90 CourtenayHardingConsulting@gmail QUESTION #7ARE 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.
93 ASSESSMENT OF NEED FOR, RESPONSE TO, AND SIDE EFFECTS FROM MEDICATION TAKE A THOROUGH HISTORYGET OLD RECORDSTALK TO OTHERS WHO KNOW PERSONCOLLABORATE, COLLABORATE, COLLABORATE, COLLABORATE
94 CourtenayHardingConsulting@gmail MORE ON SIDE EFFECTS20-30 OTHER SIDE EFFECTS e.g. DYSKINESIAS, DYSTONIAS, PARKINSONISMEVEN ATYPICALS CAN HAVE SIDE EFFECTS – VERY DOSE DEPENDENTNEED TO SYSTEMATICALLY CHECK q.6 MOS WITH INSTRUMENTSTRAIN PARTICIPANTS TO SELF-MONITORATTEND TO SEX DIFFERENCES
95 CAUSES OF MISINTERPRETATION MUST LISTEN TO THE WAY MEDS MAKE PEOPLE FEEL FROM THE INSIDE OUTSOMETIMES CLIENTS CAN’T DESCRIBE SUBTLE FEELINGSE.g. Side Effect of Akathisia- being compelled to be in motion- pacing, rocking, etc thought to be agitation, elopement, need for seclusion, acting out, and left untreated.USE AIMS + EPS EXAM q.6 MOS
96 CourtenayHardingConsulting@gmail 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 FASTTO BECOME ATTACHEDTO GIVE ALLEGIANCE TOTO GIVE DEVOTION OR SUPPORT
98 MEDICATION MANAGEMENT APPROACHES IN PSCYHIATRY Provides a systematic & structured plan for med managementDocumentation is clearer and more conciseObjective measures of outcomeShared decision-making
99 Discussions of Medications “New developments in antipsychotic therapy” - an interesting discussion report of a group of psychopharmacologists J. Clin Psych Nov 2003CATIE STUDY= Clinical Antipsychotic Trials of Intervention EffectivenessResults underscore need for access to full range of medications” in and also NEJM Sept 22, 2005 J. Lieberman et al
100 CourtenayHardingConsulting@gmail “Meducation”Provides understanding of social & cultural issues involved in medication adherenceCan provide a list of critical questions a user, consumer, patient should ask his or her physician and another one for the pharmacistOffers a tracking chart for client to use
101 Some helpful resources What Your Patients Need to Know About Psychiatric Medications by WC Jackson – › ... › v.9(4); 2007Schrank, 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.
102 Helpful to track down earliest prodromal signs and symptoms Work on finding usual early warning sign Describe mild, moderate, and severe versionsExperiment with simple interventions that workChart the statusMake emergency plans(R. Liberman)
104 MORBIDITY AND MORTALITY The Metabolic SyndromeAbdominal obesity (excessive fat tissue in and around the abdomen)Atherogenic dyslipidemia (blood fat disorders — high triglycerides, low HDL cholesterol and high LDL cholesterol — that foster plaque buildups in artery walls)Elevated blood pressure
105 MORBIDITY AND MORTALITY-2 More of The Metabolic SyndromeInsulin 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)Proinflammatory state (e.g., elevated C-Reactive Protein in the blood)
106 MORBIDITY AND MORTALITY-3 Increased risks of:Coronary heart diseaseStrokePeripheral vascular diseaseType 2 DiabetesPhysical inactivityHormonal ImbalanceExpression of familial genetic profile
107 CourtenayHardingConsulting@gmail MORTALITY- 4Graded relationship between number of neuroleptics taken and mortality and dosage levels with…Fatal arrhythmiasSudden cardiac deathsVenus thrombosisPulmonary embolismAsthma deaths
108 CourtenayHardingConsulting@gmail (even after adjusting for known risk factors of premature death such as: smoking, lack of exercise, BMI, B/P, serum total and HDL cholesterol)!
109 MORBIDITY AND MORTALITY-6 On 1st Generation drugs mortality risk = 2.84 and was just slightly reduced to 2.25 after adjusting for other factors such as: somatic diseases, BMI, exercise, B/P, BMI, alcohol intake and education.Relative risk for each new drug added 2.50 additional risk.Joukamaa et al, 2006Similar Findings for Atypicals and for Antidepressants (both SSRIs and Tricyclic's)
110 New Considerations for optimization of medications Some people seem to need no medications;Some people seem to need medications for a short while;A few people seem to need medication for a longer period.Need research to help triage
111 Support for optimization of medications…………. Literature says that 1st episode participants may need little or no medications by adopting “wait and see”Nothing in the literature that says everyone needs meds for a lifetime only maybe a small groupTaper, taper very very slowly if on for a long time
112 CourtenayHardingConsulting@gmail More Resources:Personal Therapy – GE Hogarty et al 1997 helps adherenceW. Fenton Psychiatric Times Combined therapyAPA – 2004 Practice GuidelinesTexas Medication Algorithm – No! Was drug company sponsored.
113 CourtenayHardingConsulting@gmail QUESTION # 8WHY IS THIS PERSON TAKING STREET DRUGS IN PLACE OF OR IN ADDITION TO PRESCRIPTIONS ?
114 WHY IS THIS QUESTION IMPORTANT? Mental Health and Substance Abuse systems of care need to be blended and the work done simultaneously in order for anything to work out.Research has shown many different reasons for use of substances
116 INFO ON USING STREET DRUGS At least 47% to 75% have co-occurring disordersMost costly to treatMakes initial diagnosis difficultUse of structured interviews helpful (SCID subsection clinically useful or ASI – the Addition Severity Index for research)Info on street drug of choice may be helpful to add into diagnostic process
117 Co-Occurring or Dual Dx D/O can lead to: SymptomRelapseshospitalizationfinancial and family problemshomelessnesssuicideViolence,Sexual and physical victimization,Incarceration,HIV,Hepatitis B and Cand early death.
118 Some Reasons People Give IS PERSON TREATING DEPRESSIONS OR MEDICATION SIDE EFFECTS (e.g. Akinesia) or to ameliorate lack of motivation and pleasure or to combat loneliness or to get a social group ? (see work of Prof. Mary Ann Test and colleagues)
119 EBP: Integrated Dual Disorders Treantment (IDDT) Services provided concurrentlyIndividualized assessment and treatment planning in heavy collaborationUse SCID-SA Screener
121 EBP: Integrated Dual Disorders Treatment BlendingStage-wise TreatmentMotivational InterviewingSubstance Abuse CounselingInvolving all stakeholders4 basic skills for cliniciansKnowledge of substances & how they affect MIAssessment skillsMotivational interviewing skillsSA Counseling skills
122 CourtenayHardingConsulting@gmail Some Lessons LearnedStandard confrontational models might not work for people with schizophrenia. Other models may work better with less stressBlended funding streams and integrated care more helpfulGender, age, ethnicity, geographic residence, exposure to trauma, make differences
123 CourtenayHardingConsulting@gmail The Substance Abuse & Mental Health Administration in U.S. has a wealth of publications on research and treatment strategies.
124 CourtenayHardingConsulting@gmail QUESTION #9WHAT ARE THE RELEVANT SEX DIFFERENCES?
125 Why is this question important? Not taught very often in med schools yetFemales metabolize drugs differentlyFemales often over medicated which cuts their Estrogen protectionFemales often have a later onset which provides a stronger platform to return toMales are more vulnerable and who struggle more early on but eventually grow stronger in outcome andFemales may lose their edge at menopause
127 SEX DIFFERENCES ACROSS THE LIFE SPAN NEURAL DEVELOPMENTAL GROWTHBIRTH COMPLICATIONSPEDIATRIC INJURIESPUBERTY AND HORMONESMETABOLIC DIFFERENCESMENOPAUSEPRESCRIBING PRACTICES ARE DIFFERENT
128 SOME SEX DIFFERENCES AFECTING ILLNESS EXPRESSION AND OUTCOME - 1 MALESFEMALESEarly 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)Less events
129 SOME SEX DIFFERENCES AFECTING ILLNESS EXPRESSION AND OUTCOME-2 MALESFEMALESQuick metabolism of food and medicine gets into blood stream fasterMay contribute to more side effectsSlower metabolism of food and medicine means slowly entering blood stream = probably less side effectsMeds cross blood/brain barrier faster = drugs more efficient
130 Some Sex Differences affecting illness presentation & outcome - 3 MALESFMALESEarlier onset often in early to mid teens – means less education, less job and dating experienceSlow progress toward recoveryMore 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 MALESFEMALESOften symptoms are presented quietlyMedications are often less in number and lower dosageCourse improves more slowly and matches females later at trend levelsOften symptoms are presented in a boisterous wayMedications are often more in number and higher in dosageCuts natural Estrogen protectionOtherwise woman have stronger outcomes until menopause and loss of Estrogen
132 CourtenayHardingConsulting@gmail ResourcesChiders, 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:
133 CourtenayHardingConsulting@gmail QUESTION # 10WHERE 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.
136 CourtenayHardingConsulting@gmail COURSE INFORMATIONInstead of narrow medical model (acute or chronic)Schizophrenia is virulent early and tapers off laterSimilar to other general medical disordersMother nature is trying to helpBURNT OUT vs. The Phoenix
137 CourtenayHardingConsulting@gmail MORE ON COURSEAlso course of life, itselfA lifeline or life history is helpfulMutual participation modelLongitudinal patterns and trendsDifferent uses of social relationshipsBuild therapeutic relationships
138 CourtenayHardingConsulting@gmail “The LIFELINE”Quick and easy way to get a life history on one line on one piece of paperBuilds a therapeutic and appreciative relationshipBeing used by clinicians across the worldCovers 12 areas of a life livedDerived from the Life Chart – a research instrumentTakes from 20 to 60 minutes
139 CourtenayHardingConsulting@gmail Consider the differential effects of rehabilitation in interaction with coursePropose that possibly ….Early rehabilitation interventions from Day 1 forward may help reduce disabilityLater rehabilitation interventions may help to increase ability
140 CourtenayHardingConsulting@gmail 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 CourtenayHardingConsulting@gmail Some ResourcesTHE LIFELINE – v by C. M. HardingStrauss JS, Hafez H, Lieberman P, Harding CM. The course of psychiatric disorder, III: Longitudinal principles. Am J Psychiatry Mar;142(3):Harding, C.M.: Course types in schizophrenia. An analysis of European and American studies. SCHIZOPHRENIA BULLETIN , 14(4):
142 CourtenayHardingConsulting@gmail QUESTION # 11WHAT 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.
145 ASSESSMENT OF UNDERSTANDING THE ILLNESS AND MEDICATIONS Collaboration and educationHelps change the stressful valence – can reduce relapse ratesTeaches how to manage symptomsNever says more than we actually knowPromotes competency and empowersIncreases self-esteem
146 EBP:WELLNESS MANAGEMENT AND RECOVERY PROGRAM-1 CLINICIAN BENEFITS:A comprehensive step by step approachReady-to-use materialsSkill is using motivational , cognitive behavioral and educational strategies Satisfaction to see outcomes
147 EBP: WELLNESS MANAGEMENT AND RECOVERY PROGRAM-2 CLINICIANS RECEIVE:guide with practical tipshandouts, checklists, planning sheetsintroduction videoinformational brochuresfidelity scaleoutcome measures
148 EBP: WELLNESS MANAGEMENT AND RECOVERY PROGRAM-3 Recovery strategiesPractical facts about MIStress-Vulnerability & treatment strategiesBuilding social supportsreducingrelapsesusing medseffectivelycoping withstressproblems & symptomsgetting yourneeds met in the MH system
149 CourtenayHardingConsulting@gmail “HOPE CAN ARRIVE ONLY WHEN YOU RECOGNIZE THAT THERE ARE REAL OPTIONS AND THAT YOU HAVE GENUINE CHOICES.” Jerome Groopman, MD (2004)
150 CourtenayHardingConsulting@gmail More ResourcesWellness Self-Management & Plus by Columbia University – Paul Margolies and Tony Salernohtml
151 CourtenayHardingConsulting@gmail More ResourcesLiberman RL et al, describing UCLA Models, Innovations & Research, Vol2(2), 1993P.A. Garrety et al , Schiz Bull, 2000WRAP Plan – Mary Ellen CopelandHarding, C.M.; Zahniser, J.: Empirical correction of seven myths about schizophrenia. Acta Psychiatrica Scandinavica :90 (Suppl. 384):
156 CourtenayHardingConsulting@gmail What You Will Find Out…Most people with the lived experience have people they help with emotional support during a crisis or withConcrete help such as the loan of bus money or moving furniture or providing companionship
157 CourtenayHardingConsulting@gmail SOCIAL SUPPORTSCONNECTION BETWEEN KIND AND AMOUNT OF SOCIAL SUPPORTS AND RECOVERY FROM AND PREVENTION OF ILLNESS OF ALL KINDSNETWORKS = TYPE, AMOUNT, DENSITY, SIZE, DEGREE OF INTERDEPENDENCE, CLUSTERING, DEGREE OF INTIMACY (M. Hammer,1981)
158 CourtenayHardingConsulting@gmail SOCIAL SUPPORTS - 2Social Skills Training (considered a Promising Rehab Practice)Reading social cuesActing appropriatelyPracticing acceptable social behaviors(e.g. eye contact, small talk etc.)Decrease lonelinessIncrease possibility of finding friends and significant others.
159 CourtenayHardingConsulting@gmail Resources…………Robert Liberman’s Social & Independent Living Skills Modules at UCLASee Innovations & ResearchVol2 (2) 1993Harding’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): , 2007.2) Hogarty GE: Personal Therapy for Schizophrenia and Related Disorders: A Guide to Individualized Treatment. New York, Guilford Press, 20023) Liberman, R. Liberman, R., DeRisi, W., & Mueser, K. : Social skills training for psychiatric patients. New York: Pergamon Press, 1989.4) Mueser, K.T. & Gingerich, S.: The Complete Family Guide to Schizophrenia. New York, The Guilford Press, 2006.5) Bellack, A.S., Mueser, K.T., Gingerich,S., Agresta, J.: Social Skills Training for Schizophrenia: A Step by Step Guide (2nd Ed.). New York: Guilford Press, 2004.6) Harding, C.M.: Curriculum – How to Get A Date: One More Way To Teach Social Skills in PROS. V. 1, New York, Center for Rehabilitation and Recovery, The Coalition of Behavioral Health Agencies, 2011
161 CourtenayHardingConsulting@gmail Even More ResourcesBeels, 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, ppHammer, Muriel ( 1981) Social Supports, Social Networks, and Schizophrenia. Schiz Bull. 7(1):45-57.
162 CourtenayHardingConsulting@gmail QUESTION #13WHAT 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)
165 CourtenayHardingConsulting@gmail CULTURAL SENSITIVITYONLY RECENTLY APPRECIATEDDIVERSITY IS HALLMARK OF WORLDNEED TO UNDERSTAND AT INTAKE ONWARDWHAT IS IMPORTANCE OF RELIGIOUS THINKING versus RELIGIOSITY?SENSE OF TIME?DISPLAYED AFFECT?
166 CULTURAL SENSITIVITY-2 Disorganized sounding speech - a linguistic variation?Importance of family, community and church?Is the interpreter asking the same questions you are? (see Utah DMH video)
167 CULTURAL SENSITIVITY-2 SAMHSA’s only approved standards for anythingBenchmarksGuidelinesOutcome MeasuresLit ReviewFor 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),
169 CourtenayHardingConsulting@gmail Question # 15IS THERE ANY COHESION IN THE SYSTEM OF CARE?
170 Why is this question important? Complex biopsychosocial problems need integrated comprehensive systems which collaborate with users and carers.It helps people if we have our act together!
172 CourtenayHardingConsulting@gmail LINKAGES - 1Coordination and linkage between all the players are criticalNeed semi-permeable membranes for information sharing, flexibility, coordination, continuity and integrationClear and consistent policies from the top down
173 CourtenayHardingConsulting@gmail LINKAGES - 2Clear and consistent policies from the top downUse community resource checklist (community mental health, extension services, consumer groups, natural support)Again, the more we have our act together the better the participants become
174 CourtenayHardingConsulting@gmail Some ResourcesPrincipled 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 ...
175 CourtenayHardingConsulting@gmail Another resourceHarding, C.M.: The limited resources debate: Changing the rules of the game to a win-win scenario. AUSTRALASIAN PSYCHIATRY, 1997, 5(6),
176 CourtenayHardingConsulting@gmail Training resourcesCoursey, 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. ANDPart 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
181 QUESTION # 14 – RISK MANAGEMENT - 2 Research has found the following risk factors for minor and serious violence:PERSECUTORY IDEATIONSUBSTANCE ABUSECHILDHOOD CONDUCT D/OVICTIMIZATION
182 CourtenayHardingConsulting@gmail RISK MANAGEMENTRelapse Prevention Strategies for mental health and substance abuse issuesTry Paul and Lentz Social Learning Environments (behavioral)Tony Menditto’s program for forensic participantsIndividualized Token Behavioral Programs which tend to generalize to other environmentsReduce Restraint and Seclusion with psychological strategies first
183 DIALECTICAL BEHAVIORAL THERAPY For persons diagnosed with Borderline Personality DisorderEffective for “…..reduces suicidal behaviors, psychiatric hospitalization, dropout from treatment, substance abuse, anger and interpersonal difficulties.”Always conducted within a team approach
184 CourtenayHardingConsulting@gmail ResourcesMarsha 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, 1997.
185 CourtenayHardingConsulting@gmail Other ResourcesThe Wellness Recovery Action Plan (WRAP) Mary Ellen Copeland, 2011.An Anger Management Training Package for Individuals With Disabilities, H. Gulbenkoglu et al. London, Kingsley Pubs., 2006.Evidence-Based Practice of Cognitive-Behavioral Therapy , Dobson, D & Dobson, K New York, Guilford Press, 2009.Paul, G. L., Stuve, P., & Menditto, A. A. (1997). Social-learning program (with token economy) for adult psychiatric inpatients. The Clinical Psychologist, 50,
186 CourtenayHardingConsulting@gmail QUESTION #16WHERE 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.
189 ASSESSMENT OF STRENGTHS Rehab is built on strengths not problems or deficitsStrengths of: person, system of care, family, case manager, the doc etcSense of humor, drivers license, computer skills, care of others, watering plants and even the manipulation of systems
190 CourtenayHardingConsulting@gmail Some ResourcesAnthony, 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 CourtenayHardingConsulting@gmail More ResourcesHarding, 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.
195 Traumatic Experiences AT SOME POINT WE NEED TO FIND OUT ABOUT PREVIOUS TRAUMATIC EXPERIENCESEffects: Avoidance, hypervigilance, emotional difficulties, and recall behaviors, anxiety, depression, problems sleeping, and sometimes hopelessUse SCID-D for assessment
196 CourtenayHardingConsulting@gmail Some Trauma Studies50-60% of US have a traumatic experience10% - 17 % Chronic PTSD (Galea et al, 2002)In community 1 in 10 women/girls and 1 in 20 men/boys have PTSD (Kessler et al, 1995)Most do not & do not display pathology! (Bonanno et al, 2002)
197 Predictors of the Emergence of PTSD LACK OF SOCIAL SUPPORTLACK OF EDUCATIONTOUGH FAMILY BACKGROUNDPRIOR PSYCHIATRIC HISTORYDISSOCIATIVE REACTION(Berwin et al 2000, Ozer et al, 2003)
198 Psychophysiological Sequelae of Stress and Trauma Psychogenic Stress of all kinds can be Genotoxic in Cellular StructuresChanges in both internal and external environments can lead to ± changes in gene structuresThe Brain is a Plastic Organ as wellHealing is possible
200 CourtenayHardingConsulting@gmail Mnemonic for PTSDFEARSFearsEgo construction (numbing & withdrawal)AngerRepetition (Flashbacks & nightmares)Sleep disturbanceJean Goodwin
201 Mnemonic for COMPLEX PTSD FEARSFugue & Other Dissociative statesEgo fragmentationAntisocial BehaviorsRe-enactmentSuicidality & SomatitizationJean Goodwin
202 CourtenayHardingConsulting@gmail SOME RESOURCESJournal of Brain Behavioral and Immunity for articles on psychoneuroimmunologyTrauma-Focused Cognitive Behavioral Therapy - NREPP ...Tips for survivors of a traumatic event.
203 CourtenayHardingConsulting@gmail # 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.
206 Assessment of the level of functional literacy 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 understandLearning to read might improve self-esteem and reduce symptomsHelps close the gap in healthcare disparities
207 REALM-R Rapid Estimate of Adult Literacy in Medicine, Revised (a 5 minute 11 word list for English speakers which provides a quick measure of literacy) Bass et al 2003
208 Ways to enhance understanding in persons with low level literacy-1 Slow down speech fluencyUse “living room” language instead of medical terminologyShow 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 instructionsUse a “teach back” or “show me” approach to confirm understandingBe 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.
213 CourtenayHardingConsulting@gmail USE OF SPIRITUALITYResearch 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 supportsNeed 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 …………..
217 CourtenayHardingConsulting@gmail 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 CourtenayHardingConsulting@gmail WHAT MADE THE DIFFERENCE ACCORDING TO THOSE INTERVIEWED FROM VERMONT STUDY?Decent food, clothing and housingPeople with whom to beA way to be productiveA way to manage s/s and medsIndividualized rxCase managementPsycho-educationIntegration back into the community
219 WHAT DID THE VERMONTERS ALSO SAY MADE THE DIFFERENCE? Hope!“Someone believed in me”“Someone told me that I had a chance to get better”“My own persistence”Hope connects with natural self-healing capacities
220 CourtenayHardingConsulting@gmail “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 CourtenayHardingConsulting@gmail Another ResourceStrauss, 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, 1990.
222 YOURSELF AND YOUR RELATIONSHIP ARE THE BEST TOOLS IN YOUR KIT BAG AS A CLINICIAN BEING SYSTEMATIC CREATIVE, & STRUCTURED IN YOUR APPROACHYOURSELF AND YOUR RELATIONSHIP ARE THE BEST TOOLS IN YOUR KIT BAG
223 CourtenayHardingConsulting@gmail 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.