Transcript Illness Management and Recovery (IMR)

Illness Management and
Recovery (IMR)
Presented by NH-BBH
June 14, 2007
Harry Cunningham
[email protected]
The Day the Voices Stopped
• “I have a vision that goes like this: In this
new century, mentally ill people will have
the science…, and the means to leave our
ghettos of isolation behind us.”
– Ken Steele
What’s the Big Deal?
“A wide variety of effective, communitybased services, carefully refined through
years of research, exist for even the most
severe mental illness yet are not being
translated into community settings.”
A Report of the Surgeon General on Mental Health,
1999
The five current Evidence Based
Practices (EBPs)
• Assertive Community Treatment (ACT)
• Integrated Dual Disorders Treatment
(IDDT)
• Family Psychoeducation (FPE)
• Supported Employment (SE)
• Illness Management and Recovery
(IMR)
Potential future EBPs
• Peer support programming
• Treatment for people with borderline
personality disorders (DBT?)
• Trauma services
• Supported housing
• ?
Overview of Training
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What is Illness Management and Recovery?
The importance of recovery
Core values in IMR
8 key strategies to doing IMR
Research behind the practice
Engagement and orientation of clients
On-the-job-training of some of the 10 topic areas
Doing IMR in a group
Where do you go from here?
What Is Illness Management and
Recovery?
• Illness Management and Recovery is a
program that helps people set meaningful
goals for themselves, acquire information
and skills to develop more mastery over
their psychiatric illness, and make progress
towards their own personal recovery.
Core Ingredients of the Illness
Management and Recovery Program:
• 6 to 12 months of weekly sessions conducted
by trained practitioners
• 10 educational handouts that contain practical
information and strategies
• A practitioners’ guide with tips for teaching
people about mental illness and helping them
implement strategies
Focus of Services to SMI
Consumers in Recent Decades
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1960s- Get clients out of the Hospital
1970s- Keep clients out of the Hospital
1980s- Rehabilitate clients (Do to them)
1990s&2000s- Help clients toward
Recovery (Do with them)
EBPs are a Movement in Mental
Health
• Increase access for consumers to recoverybased services that have demonstrated
effectiveness
• Help administrators and providers of mental
health services to set up and maintain
services that have demonstrated
effectiveness
The Importance of Recovery
“Recovery involves the development of new
meaning and purpose in one’s life as one
grows beyond the catastrophic effects of
mental illness.”
(Anthony, 1993).
Characteristics of Recovery
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Is defined and accomplished by the person
Can be viewed as a process or outcome
Distinguished from rehabilitation
Involves personal and social success in areas
the consumer defines as important to them
• Is a universal human experience
• Includes the themes of hope, self-confidence,
expectations, well-being, & optimism
• “A life worth living” (Patricia Deegan video)
How I am Seen By Others And Understand Myself
Before Being Diagnosed with Mental Illness
Patricia
Recovery Is Related to
Motivation
• Motivation: “an inner urge that prompts a person
to action.”
• Illness management and recovery can best happen
when a consumer is motivated to act.
• Motivation sources:
* Hold the hope for someone.
* Peer support.
* Relationship to professional.
* Inner urge.
* Mystery???
What Might Motivate Consumers
to Practice IMR?
What Would Motivate You to
Practice IMR?
Core Values In IMR
 Hope is the Key Ingredient
The long term course of MI cannot be predicted
Being able to influence one’s own destiny is the basis for future
hope and optimism
Having other people believe in us is empowering; we sometimes have
to “hold” hope for others
 Consumers don’t fail the practice, the practice fails
them
Consumers should be given unconditional support for their participation
Programs should work under easy re-entry and “fail-safe” principles
 The person is the expert in his or her own experience
of mental illness
On what strategies have worked for them
On what has been helpful and what has not
CORE VALUES IN IMR
(Continued)
• Personal Choice is Paramount
The ability and right of people to make their own decisions, including when those
decisions differ from recommendations made by their treatment providers
The task then becomes to work with them to evaluate the consequences of decisions in
terms of their hopes and dreams. Acceptance is also paramount.
• Practitioners are Collaborators
Practitioner as consultant in a non-hierarchal relationship
• Practitioners demonstrate Respect for people who
experience psychiatric symptoms
As capable decision-makers and active participants in their own treatment
Respect for differing values and opinions
To seek common ground when there is a difference in point of view
How Is IMR Different From the
Ways I Am Already Working
With Consumers?
8 Key Strategies to Doing
IMR
Key 1. Client Centered goal
setting toward recovery
• Focus on client’s context of life rather than
just on their symptoms
• Strengths vs. Problems
• Mutual responsibility in planning and
pursuing goals rather than “following”
treatment
• Constant reassessment and adjustment of
plan
Moving From a Disease Model of
Mental Illness
• Examples of disease goals
*Take medications
* Reduce voices
* Stop reacting to delusions
* Maintain housing
* Manage finances
Examples of Goals That Go
Beyond a Focus on Symptoms
• To get closer to 2 current friends who I value.
• To improve the appearance of my apartment so I
can have friends over.
• To play a larger role in the operations of my
church.
• To own my own car so I can hike in the
mountains.
• To go to the movies once a month.
Key 2: Good Basic Knowledge
About Mental Health:
– Origin and course of MI
– Symptoms and diagnosis
– Medications
– Recovery
– Community resources
Key 3: A Monitor~Response to
Identified Symptoms and
Unhealthy Behavior
• Increased awareness of “I can effect it”
• Choices of things that make it better and make it
worse
• Relapse prevention plan
• Wellness plan
• Even though I may not have caused it, I can have
the most effect on it
• Acceptance of mutual responsibility: Shared
Decision Making
Key 4: A Strength-Based
Approach
• People with severe and persistent mental illness
can learn, grow and change.
• The focus of the helping process is upon the
consumer’s strengths, interests and abilities, not
upon their deficits or pathology.
People who are successful in
living have goals and dreams.
They use their strengths to
attain their aspirations.
Key 5: Educational Teaching
Strategies
Interactive teaching, not lecturing
• Asking “open-ended” questions to review
information and check comprehension
• Using a variety of methods to present the handout
material:
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summarizing the key points,
giving examples
taking turns reading aloud
asking people to read on their own
• Adopting participants’ language to facilitate
comprehension of material
Key 6: Motivational Teaching
Strategies
• Help person see how learning information and
skills is related to achieving personal goals
• Convey hope, belief, and confidence that
person can make desired changes and
accomplish goals
• Help person explore costs and benefits of
maintaining the status quo vs. costs and
benefits of change
Key 7: Cognitive-Behavioral
Teaching Strategies
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Reinforcement
Shaping
Modeling
Role playing
Cognitive
restructuring
Key 8: Emphasis on Stages of
Change in Ongoing Assessment
• Pre-Engagement
Task: Outreach, raise awareness, increase hope
• Contemplation
Task: Weigh pros and cons, help imagine a better life
• Preparation
Task: Collect information about alternative actions.
• Action
Task: Modify lifestyle, staff as consultant(not expert)
• Maintenance
Task: Maintain new balance, monitor against old habits
IMR Intro Video
IMR Materials (Cont.)
IMR Workbook
The basics of Illness Management and Recovery
• Educational Handouts with ample worksheets
and checklists are provided to participants
• Practitioners’ Guide provides guidelines for each
topic in the educational handouts
IMR Materials (Cont.)
IMR Videos
• Short video introduces the program to
participants
• Practice demonstration video illustrates the
teaching strategies for practitioners
Evidenced-Based Components of
Illness Management
• Education about mental illness and its
treatment
• Relapse prevention training
• Behavioral tailoring for medication
• Coping skills training
• Social skills training
• Dual Disorder strategies
10 Topic Areas
1. Recovery Strategies
2. Practical Facts about Mental Illness
(schizophrenia, bipolar disorder, major
depression)
3. The Stress-Vulnerability Model and
Treatment Strategies
4. Building Social Support
5. Using Medication Effectively
10 Topic Areas
(cont.)
6. Alcohol and Drug Use
7. Reducing relapses
8. Coping with stress
9. Coping with problems and symptoms
10. Getting your needs met in the mental
health system
Learning IMR On-The-Job
• Start with 2-3 clients ASAP
• Keep 1-2 sessions ahead of client
• The curriculum and teaching strategies can
be learned as you go
• Biweekly training/supervision allows
practitioners to gain the knowledge
IMR is Structured yet Flexible
Not intended to be presented as a “cookie
cutter” practice!
The ideal is to integrate:
– best available research
– your individual clinical expertise
– with consumer’s preferences
Seeing and Doing IMR
Who is IMR Designed For?
• Almost anyone with a severe mental illness
• Research and educational materials cover 4 areas
of symptoms: schizophrenia, schizoaffective
disorder, bipolar disorder, major depression
• You often can’t predict who will benefit and who
won’t
• Customize to the unique needs of the consumer
Examples of consumers who may
benefit from IMR
• People with distressing persistent symptoms
• People who experience frequent
hospitalizations
• People who have frequent crises
• People wanting to live more independently
• People wanting to improve employment
skills
• People wanting to increase friendships
Engagement Barriers: Staff
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She’s too high/low functioning
He doesn’t show up for anything
She’s got too many crises going on
He never sticks around for more than 3 months
She needs maintenance, not recovery
I already do this with clients
I don’t have time for extra work
Engagement Barriers: Client
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Nothing really helps, why try IMR
It’s too risky to risk
It’s too much commitment
It sounds too much like school
I’m not mentally ill, or schizophrenic, or…
I know all of that stuff already
Approaches to Engage Clients
How would you like to learn more about:
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recovery, future possibilities for you
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medications, support from medical staff
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mental illness, diagnosis
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reducing relapses
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coping with stress
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support from family and other people
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reduce/manage symptoms
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leaving the hospital
Approaches to Clients (cont.)
How would you like to be more involved:
• Play more of a role in the treatment team
• Set goals that reflect personal and social success
that are important to you
Can you use your relationship with client?
• Find ways to help staff work more with you
• Have staff better understand you
• Trust me!
Trial Offer
• Come this week and decide if you want to
continue
Orientation for Clients
(Page 39)
• Usually lasts one meeting
• Expectations made clear
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Attendance
Roles of consumer and practitioner
Homework
Mutual responsibility
Sets positive expectations of change
• Reduces treatment drop-out rate!
Homework
• Collaboratively agreed upon by the
practitioner and the person at the end of each
session
• Related to the person’s goal and/or the
curriculum topic
• Individually tailored to the person
Homework (continued)
• Behaviorally specific
• May involve significant others or treatment
team members
• Followed up at the next session
• Analyze and problem-solve any difficulties in
doing assignments.
Examples of Homework
• Reviewing a handout, checklist, or plan with
significant other
• Practicing a skill (e.g., striking up a conversation)
• Getting more information about achieving a goal
(e.g., checking out costs of local health clubs)
• Taking a step towards a personal goal
• Practicing a coping strategy at home (e.g.,
relaxation exercises)
Knowledge and Skills Inventory
• Strengths Assessment
Or
• Knowledge and Skills Inventory (Page 41)
Your choice!
Involvement of Family & Other
Supportive People
• Encourage family members and other supportive
people to participate
• With the participant’s permission
• Supportive people can help in a variety of ways:
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Assisting with homework
Reading handouts
Role in relapse prevention plan
Achieving specific goals
Attending some sessions
Structure of Sessions
• Informal socializing and identification of any
major problems (1-3 minutes)
• Review previous sessions (1-3 minutes)
• Review homework (3-5 minutes)
• Follow-up on goals (1-3 minutes)
• Set agenda for current session (1-2 minutes)
Structure of Sessions (continued)
• Teach new material or review previously
taught material (20-30 minutes)
• Agree on new homework assignment (3-5
minutes)
• Summarize progress made in current
session (3-5 minutes)
Topic Area 1: Recovery
Strategies
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Introduces the concept of “recovery”
Encourages people to develop own definition
Tone of hope and optimism to move forward
Helps consumers establish personally
meaningful goals
• Identifies and puts into practice strategies
toward personal recovery goals
(Kim and Francis)
Topic 3: Stress-Vulnerability
Model
• Discussion of the origin and course of MI
• How to then prevent a worsening course
• What important ideas for consumers are
contained in this Model?
Topic 4: Building Social Support
• Understand the importance of social support
in one’s own life to one’s recovery
• Skills to meet new people
• Skills to get closer to people you already
know
(Video, Susan and Mark)
Building Social Support Exercise:
Starting a casual conversation
• Explain and identify “icebreakers”
• You model using an icebreaker to start a
conversation
• Role-play the consumer doing the same
• Give positive feedback.
• Make 1 corrective suggestion
• Same role-play using the corrective action
Topic 5: Using Medication
Effectively
• Consumers are encouraged to make their own
choices about medication taking
– Explore role of medication in managing symptoms
– Benefits of my medication/Side effects my medication
– Informed decision making about medications
• Strategies for getting the most out of medication
are described
– Medication regimen matches life demands
– Building routine into medication taking, Simplify!
– Keep the benefits in mind
Topic 6: Drug and Alcohol Use
Part I: Psycho-education about D&A use.
*Commonly used substances and their effects
*Why do people use drugs and alcohol?
*Unique relationship between D&A and MI.
*Problems related to D&A use.
Part II: Making a decision about D&A
use.
*Weighing the pros and cons of using/sobriety
*Deciding to cut down or stop using
Drug and Alcohol Use
Part III: Actions to cut down or stop
using
*Dealing with high risk situations.
*Finding new ways of getting needs met.
*Making a personal sobriety plan.
Topic 7: Reducing Relapses:
Four areas of focus
• Identify early warning signs of relapse
• Identify precipitants (triggers) to relapse
• Plan ways to respond to first signs of
relapse
• Involve others to support efforts to monitor
and respond to signs of relapse so they don’t
become full-blown relapse
(Video: Susan and Tracy)
Doing IMR in a Group
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6-10 consumers
2 Co-leaders
Meet weekly or 2x a week
40-50 sessions
Use IMR Educational Handouts
Use “Group Guidelines”
Advantages to Doing IMR in a
Group Format
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Some agencies have strong group tradition
Easier to stay focused on the skills
Peer helping peer
Role playing is more effective
(generalizing)
• Problem-solving is richer
• Can be more cost effective
IMR Group Supervision
Purpose:
*Support and affirmation for practitioners to do their job
*Generate fresh ideas
*Learn, learn, learn
Focus:
*Clients only! (Present 1-3 client situations per supervision)
Tools:
*Strength assessment, client’s IMR goals,
*Problem solving model
Outcomes:
*A plan: 1-3 ideas to try with helping the client
*Fist steps to carrying out those ideas
*Recognition of success and achievements
Ongoing Supervision/Training
(Outline of a sample session done every 1-2 weeks)
•Go-round of Current Problems/Issues doing IMR
(15 minutes)
•Review last meeting’s practice assignment (5 minutes)
•Introduce a Skill (10 minutes)
•Model Skill (5 minutes)
•Role-Play Skill (10 minutes)
•Develop Practice Assignment (5 minutes)
5 Step Problem Solving Method
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1. Define: What is the Problem?
2. Brainstorm Possible Solutions
3. List Pluses and Minuses of Solutions
4. Choose the best Solution or combination
of Solutions
• 5. Plan the steps to carry out the Best
Solution: Action Plan
Monitoring the Practice
• Internal monitoring
*Referrals
*Follow-up to referrals
*Faithfulness to the model (Fidelity Scales)
*Consumer outcomes
What Factors Helped?
• A strong program leader
• Senior Administrative
support
• Regular supervision and
training
• Practitioners given credit
for time spent
• Toolkits
• Consultation and Training
• Compensation for lost
productivity
What Factors Hurt?
• Administrative
indifference
• Staff turnover
• No hospital integration
• Program leader apathy
• “We already do this”
• No rewards
• Lack of monitoring
Closing Thoughts
“Having strategies for coping with mental illness is
extremely important. It is hard to enjoy your life if
you are constantly sick with mental illness. . . .
However, believing in yourself, having hope that
things will continue to get better and looking forward
to your future are also vital in overcoming mental
illness. Our hopes and dreams are not delusions.
Our hopes and dreams are what makes us human.”
David Kime, artist, writer, floral designer, person in
recovery from bipolar disorder
THAT”S ALL FOLKS!
What Questions Do You
Have?
[email protected]