1a. introduction to cep workbook 2013 read only

8/13/2019 1a. Introduction to CEP Workbook 2013 READ ONLY

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This workshop has been organized by the Mental Health Education and ResourceCentre (MHERC). The content of the workshop presented in this handbook is drawnfrom the my teaching delivered through the National Addiction Centre (Aotearoa NewZealand), especially PSMX 404 Coexisting Disorders Assessment, from Te Ariari OTe Oranga and from my own workshops done both independently and with thesupport of Matua Raki. It remains my intellectual property, but can be used for not-for-profit teaching purposes if appropriately credited.

The essence of Te Ariari o te Oranga involves the application of the values ofperson-focused care, wellbeing orientated treatment and integrated care in ameaningful way, bringing them to life within the relationship between the client andthe clinician.

The material presented in this workshop is drawn from Te Ariari o te Oranga (Todd2010), though is updated here in several areas. Copyright is asserted by Fraser Todd

over the content. It may be freely used with permission.

The name Te Ariari o te Oranga means the dynamics of well-being. The name wascoined by that staff ad students of Te Ngaru Learning Systems, was given to a seriesof bicultural training events on co-exiting and mental health and substance useproblems (CEP) over the past decade, and given to the document Te Ariari o teOranga: The Assessment and Management of Co-existing Mental Health andSubstance Use Problems (Todd 2010) by Paraire Huata. As a term, it captures thepractice and teaching of CEP in New Zealand where bicultural approaches arehonoured.

Fraser Todd


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Welcome to this WorkshopThis introductory workshop provides an overview of coexisting mental health and substance useproblems (CEP). The main focus is on the philosophy of the CEP model currently being promotednationally by Matua Raki, the National Addiction Treatment Workforce Development Programme,with the support of the other Workforce Development programmes.

The essence of this approach involves the application of the values of person-focused care, wellbeingorientated treatment and integrated care in a meaningful way, bringing them to life within therelationship between the client and the clinician. This will be the main focus of the introductoryworkshop.

Agenda Day 1

Sessions 1 & 2: Introduction & Overview of CEP

Lunch

Session 3: The Aetiological Formulation

Session 4: Continuation of previous sessions, coverage of outstanding issues and wrap-up


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These will be the subjects of the more advanced workshops later in the year.

Thinking About CEP

With increasing knowledge and detail, clinicians often find it complicated dealing with theMH and AOD problems and have no cognitive room to deal with further issues. Theyexperience cognitive overload. In other words, the number of things they must think aboutand manage is too great for their brains to handle.

When faced with large amounts of complicated information, clinicians will often forget to dothings they know well to do, and focus on the details they are most familiar with.

Similarly mental health care becomes more detailed, dividing up into detailed areas ofspecific focus such as anxiety disorders, eating disorder, alcohol and drug problems and soon.

The key to managing complicated problems is to connect the details, to integrate them into a

whole. Complex things are multi-dimensional but manageable.

While expert practitioners do know more detail, the key difference between them and novicepractitioners is the connections they make between their pieces of knowledge. Theyintegrate information by making connections and using frameworks.

Similarly, learning about CEP is about using frameworks to integrate knowledge and skills

There are a range of frameworks and structures that can organise CEP knowledge and turnif from complicated to complex. The key ones are those that provide the big picture andmake up the spirit of Te Ariari

The Spirit of Te Ariari

Person-focused careo Especially personal values, strengths and vision of well-being.

Wellbeing orientated careo Using quality of life as the most important outcome and focusing equally on

enhancing positive attributes and removing barriers to well-being Integrated care

o Driving care from the needs of the person and fitting the system round these ratherthan vice versa

Walking the talko

While we know the above, we are seldom able to put it into practice for a number ofreasons. Walking the talk involves using specific techniques to incorporate theminto our clinical work.

Exercise 1: Personal and Professional Values

Complete the Values Paper Card Sort Questionnaire (below)

In Pairs or threes, share your three most important values


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One person leads a discussion with the other around one of their top threevalues:

1. What is about this value that is important to you?

2. To what extent do you feel you are or are not able to live up to this value?

3. Are there ways you would like to be living up to this value more than youare at the moment?

4. How do you express these values in your work?

5. Are there ways you would like to express this value more in your work?

Personal Values Card Questionnaire (Adapted from Bill Millers Personal Values Card Sort)

Instructions:1. Consider each of the values in the list and place a tick in the appropriate box to

indicate whether that value is not important, important or very important to you.2. Aim to have no more than 10- 15 ticks in the very important box 3. Look over the values you have rated very important and rate from 1 -5 or so the most

important to you, in order of importance

Value Description NotImportant

Important VeryImportant

Top 5Rating

Acceptance To be accepted as I am

Accuracy To be accurate in myopinions and beliefs

Achievement To have importantaccomplishments

Adventure To have new and excitingexperiences

Attractiveness To be physically

attractiveAuthority To be in charge of and

responsible for othersAutonomy To be self-determined

and independentBeauty To appreciate beauty

around meCaring To take care of others

Challenge To take on difficultchallenges

Change To have a life full ofchallenge and variety

Comfort To have a pleasant andcomfortable life


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Commitment To make enduring andmeaningful commitments

Compassion To feel and act onconcern for others

Contribution TO make a lastingcontribution in the world

Cooperation To work collaborativelywith others

Courtesy To be considerate andpolite

Creativity To have new and originalideas

Dependability To be reliable andtrustworthy

Duty To carry out my duty andobligations

Ecology To live in harmony withthe environment

Excitement To have a life full of thrillsand stimulation

Faithfulness To be loyal and true inrelationships

Fame To be known andrecognized

Family To have a happy, lovingfamily

Fitness To be physically fit andstrong

Flexibility To adjust to newcircumstances easily

Forgiveness To be forgiving of others

Friendship To have close, supportivefriends

Fun To play and have fun

Generosity To give what I have toothers

Genuineness To act in a manner that istrue to who I am

God's will To seek and obey the willof God

Growth To keep changing andgrowing

Health To be physically well andhealthy

Helpfulness To be helpful to others

Honesty To be honest and truthful

Hope To maintain a positiveand optimistic outlook

Humility To be modest andunassuming

Humour To see the humourousside of myself & the world

Independence To be free fromdependence on others

Industry To work hard and well at


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my life tasksInner Peace To experience personal

peaceIntimacy To share my innermost

experiences with othersJustice To promote fair and equal

treatment for allKnowledge To learn and contribute

valuable knowledgeLeisure To take time to relax and

enjoyLoved To be loved by those

close to meLoving To give love to others

Mastery To be competent in myeveryday activities

Mindfulness To live conscious &mindful of the presentmoment

Moderation To avoid excesses andfind a middle ground

Monogamy To have one close, lovingrelationship

Non-conformity To question & challengeauthority and norms

Nurturance To take care of andnurture others

Openness To be open to newexperiences, ideas &opinions

Order To have a life that is wellordered and organisedPassion To have deep feelings

about ideas/activities/people

Pleasure To feel good

Popularity To be well liked by manypeople

Power To have control overothers

Purpose To have meaning anddirection in my life

Rationality To be guided by reasonand logic

Responsibility To make and carry outresponsible decisions

Risk To take risks andchances

Romance To have intense, excitinglove in my life

Safety To be safe and secure

Self-acceptance To accept myself as I am

Self-control To be disciplined in myown actions

Self-esteem To feel good about


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myselfSelf-knowledge To have a deep and

honest understanding ofmyself

Service To be of service to others

Sexuality To have and active andgratifying sex life

Simplicity To live life simply, withminimal needs

Solitude To have time spacewhere I can be apart fromothers

Spirituality To grow and maturespiritually

Stability To have a life that staysfairly consistent

Tolerance To accept and respectthose who differ from me

Tradition To follow respectedpatterns of the past

Virtue To live a morally pureand excellent life

Wealth To have plenty of money

World Peace To work to promotepeace in the world

Choose one of the top 5 most important values.

Discuss

What is it about this value that is important to you?

In what ways are you living up to this value in your life?

In what ways are you not living up to this value as you would like to?


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How might you live up to this value more?

Part A: An Overview of CEP

This section provides an overview of CEP in New Zealand and a summary of the necessarybackground knowledge base on CEP. Further information is available in Te Ariari O Te Oranga.

CEP in New Zealand There has been an interest in CEP in New Zealand since the early 1990s. Double Trouble groupswere the initial response in many places. These involved the establishment of group treatments forpeople with both substance use and mental health problems alongside standard substance use grouptreatments, mainly within Alcohol and Drug services. Early Psychosis teams were also pioneers byincluding CEP approaches, especially for young people with psychosis who were using cannabis.

The Assessment and Management of People with Co-existing Substance Use and Mental HealthDisorders (Todd, Robertson, Sellman 1998) were a set of guidelines with clinical applications toscenarios based on the models used internationally at the time. This was the basis of widespreadtraining over the next decade had a little impact on clinical practice but which failed to generate

significant change.

Barriers to improving CEP practice included:o The failure of Mental Health systems to support clinical training despite systems issues

being highlighted from the outset o DHBs seeing CEP as an add -on to their current services requiring extra resources rather

than core business o Negative attitudes and suspicion between AOD and Mental Health services o A view that substance use was not the business of Mental Health Services and vice versa;

that MH services treated, for example, depression or psychosis and not substance useproblems.

As a consequence, most clinical training during the mid-2000s focused on attitude change, especiallytowards a more person-centred approach in which clinicians were seen as working with people ratherthan disorders. Relationship building and collaboration between MH and AOD services was also afocus.


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From around 2007, new efforts were made to enhance the CEP capability of services andpractitioners. A closer relationship between the service interests of the Ministry of Health and clinicalpractice led to the release in 2010 of Te Ariari O Te Oranga (a clinical framework) and IntegratedSolutions (guidance for mangers and services), which are companions to each other.

Subsequently there have been a number of significant developments:o Establishment of a Ministry of Health Advisory Group led by the Director of Mental Healthto monitor and promote enhanced CEP capability in the DHBs

o CEP incorporated into all relevant MOH strategic plans and documentso CEP prioritized by the workforce development programmes, led by Matua Rakio The development of a number of resources to support practitioners and services enhancing

their CEP capabilityo Training provided to a number of DHBs o The development of local and national CEP practitioner networks.

Enhancing CEP Capability Enhancing CEP capability involves change on systems, services and practitioner levels.Tools are available to help services assess their current CEP capability. CEP capability is bestconceptualized on a continuum as MH or AOD only (the service does not detect the presence of theother), a range of CEP Capabilities (detect through routine screening, detect and assess,detect/assess/plan management) and CEP Enhanced (are able to detect, assess, and treat mostrelevant cases of CEP within the one service).

Most services do not need to be CEP enhanced. The best approach is for a service to identify its levelof CEP capability, determine what level of capability it would like to have and plan to developtowards this.

The Canterbury District Health Board has an implementation group to oversees developments onsystem, service and clinical levels. The capability enhancement approach is shown in the diagrambelow. There are three approaches, each covering similar material but adapted to the specific needs atthe time:1. Generic training for as many staff as possible across services2. Work with specific services to help plan and implement capability enhancement3. Learning around specific clinical situations through CADS liaison roles within mental healthteams.


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Background Information: The Nature, Extent andImpact of CEP

Definitions

Coexisting substance use and mental health problems (CEP) are known by many different names;Double Trouble, Dual Diagnosis, Mental Illness with Chemical Abuse (MICA), Co -occurringDisorders, or Co-existing Problems. They all mean much the same thing. Co-existing has been theterm used in New Zealand for the last decade and problems was chosen to move away from the focuson disorders while still being acceptable to MH services.

The usual definition is the co-occurrence of mental health and substance use problems in the sameperson at the same time.

Research definitions often report lifetime rates of CEP; the person has MH and AOD problems atsome point in their life, not necessarily at the same time. Current CEP in research usually means thatthe problems were present during the last month.

The Nature of CEPCEP is not a single thing. Rather, there are as many different subtypes as there are combinations ofdrugs and mental health problems.

Problems related to CEP range from the simple and straightforward to the multi-dimensional andcomplicated.

The more complicated cases of CEP are among the most difficult to treat and expose the weaknessesin the health system.


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As such, there are general or generic things that need to occur for all people with CEP, as well asspecific things for each combination of MH and AOD problems.

In almost all cases, when a MH problem is complicated by AOD problems, engagement, treatmentoutcome, suicide rates and psychosocial functioning are much worse.

The Impact of CEP

The presence of CEP is associated with a range of poorer outcomes including: Poorer compliance with treatment and medication More relapses More readmissions Poorer outcomes Treatment resistance Increased rates of suicide and violence Higher rates of unemployment

EpidemiologyCEP is common.In general terms, the rate of AOD problems in people with specific mental health disorders rangesfrom 25-30% for most anxiety disorders and major depression, to 50% of those with bipolar disorderand schizophrenia. Rates in those with antisocial personality disorder are up to 80%.In those in treatment for AOD problems, rates of comorbid MH disorders appear to be very high. ANew Zealand study of two community AOD services showed that 70% had an axis I non-AODDSMIV diagnosis in Mood and anxiety disorders were the most common.

Of note just under a third had a current diagnosis of PTSD, and 10% had a current diagnosis ofbipolar disorder, with less than half of them being in current mental health treatment.

Also of note are the very low rates of psychosis in those with AOD problems, and even lower rates ofschizophrenia. This is very important given the past emphasis in CEP on chronic psychotic disorders they are very uncommon.

A Brief History of CEP

CEP is an artifact of the way health problems are diagnosed and health systems structured. Itemerged as an issue in the 1980s due to a number of developments in treatment, not least the move ofclients from hospital to the community. Increased access to alcohol and drugs undoubtedly played apart, as did the advent of DSMIII and its insistence that if criteria for more than one diagnosis wasmet, all diagnoses should be made.

Large population studies such as the ECA and NCS studies also raised awareness of CEP and

community mental health clinicians began reporting on the high prevalence CEP and the pooroutcomes it was associated with.

Most of the treatment models used today were developed during the early 1990s, most prominentlythose by Osher and Koefed, Drake, Carey and Mueser. At the heart of these models were theprinciples of comprehensiveness and integration.

During the 2000s, the need for widespread screening leading where appropriate to assessment waspromoted and several treatment guidelines were published including TIP42 and the UK DualDiagnosis Toolkit. These guidelines summarise the major standard approaches to CEP that hadbeen developed over the past decade and are considered best practice.

Aetiology (Causes) Traditional ViewsThe causes of CEP have traditionally been described as:1. Substance use causes mental health problems2. Mental heath problems cause substance use problems


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3. Common underlying factors cause both substance use and mental health problems which arethemselves not necessarily causally related.

Of note common factor models seldom specify what the common factors actually are.

Aetiology (Causes) Common/Trans-diagnostic FactorsIn fact, in most cases, all the above models are usually involved in either causing or maintainingproblems.

For some combinations, the substance use may cause the mental health problems e.g. Alcohol anddepression, stimulants and psychosis.

For other combinations, the mental health problems appear to be the main driver for the developmentof substance use problems, especially in the case of bipolar disorder, PTSD and social phobia.

Common factors often underpin CEP. Factors which underpin and lead to the development andmaintenance of several disorders are also called Trans-diagnostic factors.

Different factors may be important in individuals and it is essential to identify if this occurs, given

that many of the factors are treatable and that other problems are unlikely to resolve until theythemselves are treated effectively.

Common Trans-diagnostic factors include: Shared genes Attention control Impulsivity Negative urgency Negative emotionality Cog/Attention bias Emotion regulation Rumination Perfectionism Coping (approach/avoid) Sleep Social context

Limitations of Current Approaches

The best practice guidelines such as TIP 42 have a number of limitations.

First, the gold standard integrated dual diagnosis team approach of Drake and colleagues, as well asinterventions such as motivation interviewing are very hard to put into practice in clinical settingswith fidelity. Pejorative attitudes between MH and AOD clinicians remain significant barriers toimplementation.

After the release of TIP42, a number of systematic reviews have indicated that the best practiceapproaches are not effective in changing both MH and AOD problems, and that while theseapproaches have been shown to improve psychosocial functioning, they do not appear to changesymptoms. The strongest evidence is for group approaches, long-term residential treatments andcontingency management.

While there is some improvement in functioning with the standard CEP approaches, engagementremains highly problematic.Only 30-50% of people with severe CEP engage in treatment.

The standard treatments are built around the paradigms for treating chronic illnesses such asschizophrenia, which is uncommon. They may not be applicable to other types of CEP.

Most of the strategies for treating CEP involve change at the level of the service and system, such asbringing together AOD and MH treatments. At the clinical level there remains a lack of guidance forhow to implement these change. Finally, integration is a key principle, but invariable deals with the


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integration of AOD and MH treatments. For most people with CEP, there is a lot more to integratethan just the AOD and MH problems.

Part B: Te Ariari and the 7 Key Principles

This section looks at the spirit of Te Ariari in more depth and provides an overview of the Te Ariariframework. Two of the 7 Key Principles will be focused on in more depth, as they are integral to theSpirit of Te Ariari

The Spirit of Te Ariari

As mentioned, the Spirit of Te Ariari is a philosophical context for care based on four values:1. Person-focused care2. Wellbeing orientated care3. Integrated care4. Walking the talk; or expressing these values in our clinical practice.

Person-focused Care

Exercise 2: Person-focused Care

In small groups:

1. Appoint one of your group to note the discussion and give feedback

2. Discuss what the concept of person-focused care means?

3. What strategies do or can you use in your work to make it person -focused

List some of the strategies that you could bring into your practice


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There is good evidence that a person-focused approach increases engagement, motivation, treatmentcompliance and service satisfaction.

There is a lot written about person-focused or person-centred care. While we are usually able todescribe it, we frequently fail to put it into practice with the people we work with. Reasons for thisinclude cognitive overload, lack of time and therefore a focus on the detail of our work, a lack ofsimple techniques to implement it and a lack of value placed on by the systems we work in.

For person-focused care to be integral to our practice, we need to include it as a central part of ouroverall framework of care something we consciously think about as a key driver of what we do. Wealso need specific strategies to implement it.

Some strategies include: Referring to the person as a person, preferably by their name rather than their role in our

system (patient/client/consumer) Taking time to get to know the person, especially:

o Personal valueso Strengths (especially character strengths)o Their vision of what wellbeing is for them

Empowering the person within the therapeutic relationship

Several specific techniques and tools are very useful1. WHOQOL-100 and WHOQOL-Bref

Using quality of life as the key outcome measure, using it at baseline and then at crucialpoints during follow- up gives a measure of a persons o verall quality of life, this, after all isthe key thing they and we are seeking. The WHOQOL is a widely used and validatedinstrument developed by the World Health Organization.

The full 100-quesiton version is a very good instrument. However, the Bref is a brieferinstrument of 24 questions and seems preferable in clinical practice.

2. Personal Values Card Sort/Paper QuestionnaireThis is the first exercise you did. The Values Card Sort was developed by Bill Miller ofMotivational Interviewing fame. It is a very nice exercise to do, but requires that you have aset of Values Cards on you and it takes 20-30 minutes. I have developed the paperquestionnaire based on the Values Cards; it takes less time and can be given as homework

tasks, thus being more practical in a busy outpatient setting and it works very well.However, if you have time, I think the Values Card Sort itself is preferable.


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3. Character Strengths measuresCharacter strengths are very useful things to be aware of. Helping a person identify theircharacter strengths (they are not always what people initially think they are), and thenputting one or two of the key ones into practice in a new way, each day, for one week hasbeen shown to enhance subjective well-being for at least the next six months.

There are a number of ways of identifying a persons core character strengths. The simplestis to ask them which, from a list (see appendix), are their top strengths. A more effective wayis to use a rating scale or test such as the VIA -signature strengths test accessed free at thewww.authentichappiness.com website. A person needs to register and log on, and take thetest online. It takes 20-30 minutes.

A paper-based version is in development brief version is in development locally and we willlet you know when it is available.

4. Best Possible Selves ExerciseThis is a positive psychology intervention that aims to improve a persons optimism andhope. Undertaking this exercise has been shown to lead to measurable increases subjectivewell-being sustained for at least six months.

It is also a very useful way to help a person identify their hopes and aspirations for theirlives; i.e. what well-being means to them.

Exercise 3: Best Possible Selves

Think about your best possible self at some point in the future say,in 5 years time.

Imagine yourself after everything has gone as well as it possibly could.You have worked hard and succeeded at accomplishing all of your lifegoals.

Think of this as the realization of your own best potential. You arerealistically identifying the best possible way that things might turnout in your life.

Take a few moments to write down what this life would be like.


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Well-being Orientated Care

Well-being

orientated care relates closely to the second key principle of Te Ariari, Recovery and Well-being.

The second value and one that provides the key overarching framework by which to organise care isthat of well-being orientated care.

This framework is as follows:

People desire a state of flourishing; a high degree of wellbeing.


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They experience distress when they are languishing i.e there is a significant gap between theirdesired state of wellbeing and their actual state of wellbeing.

They try many strategies to improve their wellbeing before they seek help from us specialist services.

The traditional role of health services plays a small part in their movement towards increasedwellbeing

This framework is obvious; we know it well when it is stated. However, we often fail to put it in topractice in our work.

The importance of it is that it reminds use that there is more to wellbeing than simply treatingdisease or disorder, and more to it than maintaining the health gains made when we are able to treatthose disorders.

There are active things that can be done to enhance well-being beyond minimizing the barriers.

Of note: People who have had complete recovery from major depression have a significantly lower

degree of well-being compared to people who have never had major depression. Quality of life can be improved with no improvement in symptoms of disorder Effective positive interventions have an effect size for improving depression around the same

as CBT for depression. In particular, forgiveness exercises have a much higher effect size.Positive interventions and CBT are not mutually exclusive.

We are well placed to help people take positive steps toward enhanced wellbeing, and even ifwe choose not to we should see our role as a part of the bigger picture

Therefore, key steps to a well-being orientated approach include:1. Identifying the persons vision of well-being2. Enhancing functioning in positive domains3. Improving functioning in deficit domains4. Incorporating positive interventions into treatment planning.

Therefore, specific evidence-based strategies and techniques to enhance well-being include:1. Values card sort2. Character Strengths (VIA-signature strengths above)3. Gratitude interventions4. Cultivate optimism (best possible selves)5. Avoid over-thinking or rumination (mindfulness) and social comparison6. Nurture social relationships7. Develop strategies for coping; find meaning, social supports8. Practice acts of kindness to self (loving kindness medication) and others9. Learn to forgive10. Increase flow activities


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Exercise 4: RACHEL Values Best Possible Selves

Take a few minutes to quietly read through the scenario of Rachel(below).

As you read, imagine what Rachels top three values would be andwhat she would describe as her Best Possible Self in 5 years time.

Write them down.

Case Scenario Rachel

Rachel is a 30-year-old European mother of a 5 year-old daughterwho was referred to your service via the local Emergency Departmentafter having taken an overdose of 15 Paracetamol tablets the previousnight. Rachel stated that the overdose had been an impulsive actionafter drinking a bottle of wine and having an argument with herpartner about finances. She stated that she was not trying to killherself or that she was at risk of future overdose as she was veryembarrassed at the outcome. She is reluctant to attend theappointment with your service, but does so under pressure from herpartner who threatens to leave her unless she does something abouther drinking and her moodiness.

History of Presenting Problems Rachel describes depressed mood meeting criteria for moderate MajorDepressive Episode since her late teens.

Her mood is worse for a few weeks, once every three months onaverage. At these times she finds life a struggle and has thoughts thatshe would be better off dead but has never actually developed theintent to kill herself.


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She experienced a sexual assault (rape) at a party while severelyintoxicated at the age of 18 years. Since then she has experienced

frequent intrusive memories and ruminations related to the rape whichhas impacted on her intimate relationships, and experiences hyper-arousal much of the time though it is worse when socializing in largergroups. She denies any other significant mental health problems.

Alcohol and Drug History Rachel did not drink regularly or to intoxication until after the sexualassault at age18 years. She started drinking to intoxication most

weekend nights when socialising, and by the age of 20 years wasdrinking half to three quarters of a bottle of wine most evenings aswell. Her alcohol use decreased when, at age 22 years she entered arelationship with the father of her daughter, and over the next fewyears she would only drink occasionally. Her partner left her when shebecame pregnant and decided to keep the child.She stopped drinking when she became pregnant at aged 25 years anddid not consume alcohol again until her daughter was a year old and

she entered a new relationship with her current partner who alsodrinks heavily.

She has used cannabis on a daily basis since her mid teens andexperiences craving, irritability and significant generalized anxietywhen she goes without it for more than a few days, but find it helpsher mood.

She currently smokes 50gms of tobacco a week and would like to stop,as it is very expensive.

Other Relevant HistoryYoungest of three siblings with an older sister and the eldest abrother.Her father died in a motor vehicle accident when Rachel was 22 yearsold.

Father alcohol dependence.Paternal Grandfather alcohol dependence


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Brother convictions for assault, cannabis possession, heavy cannabisuser

Mother social phobia, less problematic the last few years

Personal History:She attended six different primary schools due to her fathers frequentchange in employment.

At primary school she struggled academically with mathematics andreading but was otherwise intelligent. She often got into trouble for

disobedience and being easily distracted. She was noted to have ashort temper and be intolerant of discipline, talking back to teachers.

She was sexually abused on one occasion at the age of 5 by a friend ofher fathers.

She was frequently truant from secondary school and noted to beirritable and argumentative when she did attend. Upon leaving school

she worked in a range of waitressing, bar and sales jobs untilbecoming pregnant. Over the past two years she has taken severaltertiary papers in social work and hopes to get a job in the future incommunity support.

Her current relationship tends to involve frequent arguments thoughnot violence. She has one or two friends whom she has know for tenyears.

Rachels Three Main Values:

1. 2. 3.

Rachels Best Possible Self:


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.

. .

Integrated CareDelivering person-focused wellbeing-oriented integrated care must start with the needs of theclient and their family, identify detailed issues within that context, organise services flexibly tosupport these needs and design systems that support services to do this.Systems integration = brings systems closer together

Treatmentintegration =combinestreatments underone service

Integrated care =brings all

treatments togetherbehind the need ofthe person

Integrated carecomes from:

Understanding a persons vision of well -being

Starting with the needs of the person Considering both pathways to wellbeing and barriers to well-being (deficits) Aetiological formulation from multi-dimensional/comprehensive assessment Effective collaboration (within and outside multidisciplinary team) Systems orgnised to support integrated care.

Much of what we do as clinicians and practitioners involves integration.

There are a number of key points in the clinical process, which we can leverage to enhanceintegration

The tools and strategies we use clinically include:1. Taking a wellbeing perspective


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2. Screening and assessment processes that integrate a range of sources of information andinformation across multiple domains3. Specific processes and structures within the assessment to integrate issues such as MH and AODproblems timelines, ecograms4. The process of forming an opinion and a multi-dimensional formulation5. Combining of perspectives within the multi-disciplinary team

6. Collaboration with others outside the MDT

Exercise 5: Self-directed Learning TimelinesIn the days after completing this workshop, take a few moments tothink about this exercise.

Timelines are very useful tools for identifying the relationship betweenvarious events, disorders and patterns of substance use over time.

The following is a timeline for the scenario of Rachel (above)


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Walking the Talk As mentioned, there are numerous barriers stopping us putting these values and principles intopractice. It is therefore important to have clear, simple and quick strategies we can use in our practiceto help us apply them.

Below is a table summarising the important values and principles we have mentioned and some usefulsome techniques and strategies for putting them in to practice.

Person-centred Values Personal Values Questionnaire

Strengths VIA signature strengths

Wellbeing Vision of well-being WHOQOL

Best Possible Selves

Integrated Care Well-being perspective,timelines, Formulation,Collaboration

Culture

Engagement

Motivation Implementation intention,self-efficacy, autonomy, MI

Assessment Screening, Brief,Comprehensive

WHO-assistComp Asst + Formulation

Management Brief FRAMES

Comprehensive 404 Template

The Te Ariari Framework The 7 Key Principles Te Ariari is organized around 7 key principles:1. Cultural considerations2. Wellbeing


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3. Engagement4. Motivation5. Assessment6. Management7. Integrated Care

These principles were chosen because they seem to be the ones that require enhancing in the contextof our current approaches to treatment. It is likely that in a few years, different principles will needstressing.

These principles are applied in each of five phases of treatment.

1. Pre-treatment2. Early treatment3. Middle treatment4. Late treatment5. Autonomous independence

Thus the Te Ariari framework can be expressed as a matrix with related goals at each phase oftreatment

Within this framework each phase of treatment can be associate with key goals and specific strategies.These will be discussed in detail in the advanced workshops later this year.

For further information, see Te Ariari o te Oranga.


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The 7 Key Principles are discussed in more depth in Te Ariari o te Oranga, will be the focus ofspecific advanced workshops, and will be outlined in the Self-directed Learning Module Part B whichshould be available by late April 2013 from FrasersCEPblog.

Below are brief comments on each.

Principle 1: Cultural Considerations

Cultural issues are essential to consider in terms of their relevance to values and engagementespecially. There is a need for others to step forward and take a lead in developing this area. To allowspace for this, cultural issues will not be discussed in this workshop. Further reading is available inTe Ariari o te Oranga.

Some questions to ponder:

1. What is the second largest ethnic subgroup in New Zealand?

2. What percentage of people in Christchurch identify as Pakeha?

3. What is the second largest ethnic subgroup in Christchurch

4. Do you have a mihi?

Principle 2: Recovery and Well-being Wellbeing has been discussed above.


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Recovery expresses central values and processes from a consumer perspective.

Essential in this is that consumers should determine their goals, who they work with and whattreatments they wish to have.

Each person s pathway to recovery is unique and self-determined.

Key aspects of recovery include developing of a sense of identity that is not tied to the patient role,allows the consumer to develop a sense of meaning as a valuable member of society, and encouragesthem to take responsibility for managing their lives.

It is useful to think of being a consumer as being a member of a minority, colonized culture. Valuesthat we apply to tangata whaiora and mana whenua could equally be applied to consumers. Theseinclude the principles of:

Partnership Participation Protection (of resources and taonga)

Principle 3: Engagement The model described in Te Ariari o te Oranga has been updated. The current model will be availablein the SDL Part B (available late April on frasersCEPblog.com)

The diagram below mentions key engagement strategies which are described in Te Ariari o teOranga.

Principle 4: Motivation

The model of motivation in Te Ariari has been updated and will be available in SDL Part B.

The current model is outlined in the diagram below uses the stages of change model, collapsed intothree main stages and highlights the important transition points between contemplation andpreparation, and preparation and action, in which people often get stuck. Techniques to help


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transition from deliberation (pre-contemplation and contemplation) to action include increasing goalcommitment, using implementation intentions and dealing with procrastination.

Principle 5: Assessment Current model focuses more explicitly on a stepped care approach.

The screening tools recommended (WHO Assist for AOD and MINI-screen for MH problems) areincluded in the support material.

Principle 6: Management See Te Ariari. The advanced workshops on management will include information on managing

withdrawal and on incorporating motivational and wellbeing approaches into a standard outpatientfollow-up appointment, among other things.

Principle 7: Integrated Care Discussed above


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APPENDICES AND RESOURCES

Included1. Personal Values Card Questionnaire2. Character Strengths Questionnaire (72)3. Personal Activity Fit Diagnostic4. Some Positive Interventions

Personal Values Card Questionnaire (Adapted from Bill Millers Personal Values Card Sort)


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Instructions:1. Consider each of the values in the list and place a tick in the appropriate box to

indicate whether that value is not important, important or very important to you.2. Aim to have no more than 10-1 5 ticks in the very important box 3. Look over the values you have rated very important and rate from 1 -5 or so the most

important to you, in order of importance

Value Description NotImportant

Important VeryImportant

Top 5Rating

Acceptance To be accepted as I am

Accuracy To be accurate in myopinions and beliefs

Achievement To have importantaccomplishments

Adventure To have new and excitingexperiences

Attractiveness To be physicallyattractive

Authority To be in charge of andresponsible for others

Autonomy To be self-determinedand independent

Beauty To appreciate beautyaround me

Caring To take care of others

Challenge To take on difficultchallenges

Change To have a life full ofchallenge and varietyComfort To have a pleasant and

comfortable lifeCommitment To make enduring and

meaningful commitmentsCompassion To feel and act on

concern for othersContribution TO make a lasting

contribution in the worldCooperation To work collaboratively

with othersCourtesy To be considerate and

politeCreativity To have new and original

ideasDependability To be reliable and

trustworthyDuty To carry out my duty and

obligationsEcology To live in harmony with

the environmentExcitement To have a life full of thrills

and stimulationFaithfulness To be loyal and true in

relationshipsFame To be known and

recognized


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Family To have a happy, lovingfamily

Fitness To be physically fit andstrong

Flexibility To adjust to newcircumstances easily

Forgiveness To be forgiving of others

Friendship To have close, supportivefriends

Fun To play and have fun

Generosity To give what I have toothers

Genuineness To act in a manner that istrue to who I am

God's will To seek and obey the willof God

Growth To keep changing andgrowing

Health To be physically well andhealthy

Helpfulness To be helpful to others

Honesty To be honest and truthful

Hope To maintain a positiveand optimistic outlook

Humility To be modest andunassuming

Humour To see the humorous

side of myself & the worldIndependence To be free fromdependence on others

Industry To work hard and well atmy life tasks

Inner Peace To experience personalpeace

Intimacy To share my innermostexperiences with others

Justice To promote fair and equaltreatment for all

Knowledge To learn and contributevaluable knowledge

Leisure To take time to relax andenjoy

Loved To be loved by thoseclose to me

Loving To give love to others

Mastery To be competent in myeveryday activities

Mindfulness To live conscious &mindful of the presentmoment

Moderation To avoid excesses andfind a middle ground

Monogamy To have one close, lovingrelationship


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Non-conformity To question & challengeauthority and norms

Nurturance To take care of andnurture others

Openness To be open to newexperiences, ideas &

opinionsOrder To have a life that is well

ordered and organisedPassion To have deep feelings

about ideas/activities/people

Pleasure To feel good

Popularity To be well liked by manypeople

Power To have control overothers

Purpose To have meaning anddirection in my life

Rationality To be guided by reasonand logic

Responsibility To make and carry outresponsible decisions

Risk To take risks andchances

Romance To have intense, excitinglove in my life

Safety To be safe and secure

Self-acceptance To accept myself as I am

Self-control To be disciplined in myown actions

Self-esteem To feel good aboutmyself

Self-knowledge To have a deep andhonest understanding ofmyself

Service To be of service to others

Sexuality To have and active andgratifying sex life

Simplicity To live life simply, with

minimal needsSolitude To have time space

where I can be apart fromothers

Spirituality To grow and maturespiritually

Stability To have a life that staysfairly consistent

Tolerance To accept and respectthose who differ from me

Tradition To follow respectedpatterns of the past

Virtue To live a morally pureand excellent life


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Character Strengths Questionnaire (72)*

(This questionnaire has been developed and made available by Alison Ogier-Price)

Read each statement below and circle the number to the right that corresponds most with howwell you believe the statement applies to you right now (go with your immediate instinct) fromvery much unlike me to very much like me (Try not to use 3: neither like nor unlike morethan necessary).

This statement is... Verymuchunlike

me

Unlikeme

Neitherlike norunlike

me

Like me Verymuchlikeme

1. It is important that I live in a world of beauty 1 2 3 4 5

2. Pain and disappointment seldom get the better of me 1 2 3 4 5

3. I work at my best when I am in a group 1 2 3 4 5

4. I like to think of new ways to do things 1 2 3 4 55. I am curious about the world 1 2 3 4 5

6. I believe that everyone should have a say 1 2 3 4 5

7. I always let bygones be bygones 1 2 3 4 5

8. I often stop and count my blessings 1 2 3 4 5

9. I always look on the bright side 1 2 3 4 5

10. I often say funny things that make people laugh 1 2 3 4 5

11.I keep my promises 1 2 3 4 5

12. When the topic calls for it, I can be a highly rationalthinker

1 2 3 4

13. I am as excited about the good fortune of others as I amabout my own

1 2 3 4 5

14. I can always get people to do things together even if theyhave their differences

1 2 3 4 5

15. I go out of my way to visit museums and othereducational sites

1 2 3 4 5

16. I easily accept love from others 1 2 3 4 5

17. I prefer to let other people talk about themselves 1 2 3 4 5

18. Others often come to me for advice 1 2 3 4 5

19. I make good choices in friendships and relationships 1 2 3 4 5

20. I do not give up 1 2 3 4 5

21. I exercise on a regular basis 1 2 3 4 5

22. I am very good at sensing what other people are feeling 1 2 3 4 5

23. I have a calling in life 1 1 2 3 4

24. I throw myself into everything in life 1 2 3 4 5

25. I have created something of beauty recently 1 2 3 4 5

26. I have taken frequent stands in the face of strong 1 2 3 4 5


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opposition27. I gladly sacrifice my self-interest for the benefit of groups

I am in1 2 3 4 5

28. People consider me to be imaginative 1 2 3 4 5

29. I dont get bored 1 2 3 4 5

30. I treat all people equally regardless of who they might be 1 2 3 4 5

31. I dont try to get event or take revenge 1 2 3 4 5

32. I have been richly blessed in my life 1 2 3 4 5

33. I am a goal-orientated person 1 2 3 4 5

34. It try to have fun in all kinds of situations 1 2 3 4 5

35. Others trust me to keep their secrets 1 2 3 4 5

36. I dont make snap judgments 1 2 3 4 5

37. I am never too busy to help a friend 1 2 3 4 5

38. I am good at planning group activities 1 2 3 4 5

39. I am thrilled when I learn something new 1 2 3 4 5

40 There are people in my life who care as much about myown feelings and well-being as they do about their own

1 2 3 4 5

41. I dont often talk about my accomplishments 1 2 3 4 5

42. My friends value my objectivity 1 2 3 4 5

43. I think through the consequences before I act 1 2 3 4 5

44. I finish what I start 1 2 3 4 5

45. I control my emotions 1 2 3 4 5

46. No matter what the social situation, I am able to fit in 1 2 3 4 5

47. My life has a strong purpose 1 2 3 4 5

48. I look forward to each new day 1 2 3 4 5

49. I experience deep emotions when I see beautiful things 1 2 3 4 5

50. I must stand up for what I believe, even if negative resultshappen

1 2 3 4 5

51. It is important to me to respect decisions made by mygroup

1 2 3 4 5

52. Being able to come up with new and different ideas is oneof my strong points

1 2 3 4 5

53. I am always busy with something interesting 1 2 3 4 5

54. If I do not like someone, it is still easy for me to treat theperson fairly

1 2 3 4 5

55. I try to respond with understanding when someone treatsme badly

1 2 3 4 5

56. When I look at my life, I find many things to be gratefulfor

1 2 3 4 5

57. Despite challenge, I always remain hopeful about thefuture

1 2 3 4 5

58. I try to add some humour to whatever I do 1 2 3 4 5

59. I am true to my own values 1 2 3 4 5


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60. Thinking things through is part of who I am 1 2 3 4 5

61. I voluntarily help others I see in need 1 2 3 4 5

62. In a group, I try to make sure everyone feels included 1 2 3 4 5

63. I always go out of my way to attend educational events 1 2 3 4 5

64. I always feel the presence of love in my life 1 2 3 4 5

65. I do not act as if I am a special or important person 1 2 3 4 5

66. I am always able to look at things and see the big picture 1 2 3 4 5

67. I avoid activities that are physically dangerous 1 2 3 4 5

68. I dont get sidetracked when I work 1 2 3 4 5

69. I can always say enough is enough 1 2 3 4 5

70. I always listen to people talk about their problems 1 2 3 4 5

71. I am a spiritual person 1 2 3 4 5

72. I have lots of energy 1 2 3 4 5


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Character Strengths Questionnaire (72) ScoringUsing the numbers that you circled on this questionnaire enter each number next to the correspondingquestion number below, 1 through 72, down each of the 3 columns.Then add together the 3 numbers on each line and enter the total for that strength.

Statements Total Strength

1 ________ 25 ________ 49 ________ ________ Appreciation of Beauty

2 ________ 26 _______ 50 ________ ________ Bravery

3 ________ 27 ________ 51 ________ ________ Citizenship/Teamwork

4 ________ 28 ________ 52 ________ _________ Creativity

5 ________ 29 ________ 53 ________ ________ Curiosity

6 ________ 30 ________ 54 ________ ________ Fairness

7 ________ 31 ________ 55 ________ ________ Forgiveness/Mercy

8 ________ 32 ________ 56 ________ ________ Gratitude

9 ________ 33 ________ 57 ________ ________ Hope

10 ________ 34 ________ 58 ________ ________ Humour/Playfulness

11 ________ 35 ________ 59 ________ ________ Integrity/Honest/Authenticity

12 ________ 36 ________ 60 ________ ________ Judgment/Critical Thinking

13 ________ 37 ________ 61 ________ ________ Kindness

14 ________ 38 ________ 62 ________ ________ Leadership

15 ________ 39 ________ 63 ________ ________ Love of Learning

16 ________ 40 ________ 64 ________ ________ Love/Intimacy

17 ________ 41 ________ 65 ________ ________ Modest/Humility

18 ________ 42 ________ 66 ________ ________ Perspective

19 ________ 43 ________ 67 ________ ________ Prudence/Caution

20 ________ 44 ________ 68 ________ ________ Perseverance/Industry

21 ________ 45 ________ 69 ________ ________ Self-control/Self-regulation

22 ________ 46 ________ 70 ________ ________ Social Intelligence

23 ________ 47 ________ 71 ________ ________ Spirituality

24 ________ 48 ________ 72 ________ ________ Zest/Enthusiasm


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Top Character Strengths

On your scoring sheet (previous page) are listed 24 strengths from Appreciation of Beauty toZest.

1. Look at that total score next to each of these strengths. Circle the highest number, and allof those with that number. Then circle the next highest number until you have selected 5or 6 strengths.

2. Write these top 5 or 6 highest scoring strengths in the table below, in no particularorder:

Top Character Strengths Questions Total1 2 3 4 5 6

1.

2. 3. 4. 5. 6. 7. 8.

3. Some of the top scoring strengths you know you have but you find them exhausting oryou dont get enjoyment from them. Cross these off the list.

4. For each strength remaining in the table above, think about the 6 statements below andmake a mark or tick in the Questions boxes alongside the strength if the experiencedescribed applies to you when you engage that strength1) A feeling of excitement, joy, zest and enthusiasm while using it (particularly at first)2) Invigorating rather than exhausting while using it3) Intrinsically motivated to use the strength4) A feeling of inevitability in using the strength (try and stop me)5) Continuous learning of new ways to use the strength or a sense of yearning to find

new ways6) The pursuit of personal projects (activities, hobbies) that revolve around it

5. Add the total number of marks for each strength and enter into the Total column.

6. Write the three highest scoring strengths in the table below. If there are more than 3,pick the 3 you like the most.

Signature Strengths 1.2.3.


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Person Activity Fit Diagnostic

(Sonja Lyubomirsky, adapted from Ken Sheldon)

Instructions: Consider each of the following 12 happiness activit ies. Reflect on what i twould be l ike to do i t every week for an extended period of t ime.

Then rate each activity by writ ing the appropriate number (1 to 7) in the blank spacenext to the terms NATURAL, ENJOY, VALUE, GUILTY, and SITUATION.

People do things or many different reasons. Rate why you might keep doing thisactivity in terms of the following reasons. Use this scale:

1 2 3 4 5 6 7

not at all somewhat very much

NATURAL: Ill keep doing this activity because it will feel natural to me and Illbe able to st ick with i t .

ENJOY: Ill keep doing this activity because I will enjoy doing it; I ll f ind it to b einteresting and challenging.

VALUE: Ill keep doing this activity because I will value and identify with doing it; Ill do i tfreely even when its not enjoyable.

GUILTY: Ill keep doing this activity because I would feel ashamed, guilty, oranxious if I didnt do it; Ill force myself.

SITUATION: Ill keep doing this activity because somebody else will want me to orbecause my situation will force me to.

1. Expressing gratitude: Counting your blessings for what you have (either to a close oneor privately, through contemplation or a journal) or conveying your grati tude andappreciation to one of more individuals whom youve never properly thanked.

___ NATURAL ___ ENJOY ___ VALUE ___ GUILTY ___ SITUATION

2. Cultivating optimism: Keeping a journal in which you imagine and write about the bestpossible future for yourself or practicing to look at the bright side of every situation.


3. Avoiding over thinking and social comparison: Using strategies (such as distraction) to cutdown on how often you dwell on your problems and compare yourself with others.


4. Practicing random acts of kindness: Doing good things for others, whether fr iends orstrangers, either directly or anonymously, either spontaneously or planned.



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5. Nurturing relationships: Picking a relationship in need of strengthening, and investingti me an d energy in healing, cultivating, affirming, and enjoying it.


6. Developing strategies for coping: Practicing ways to endure or surmount a recent stress,hardship, or trauma.


7. Learning to forgive: Keeping a journal or writ ing a letter in which you work on lett inggo of anger and r esentment toward one or more individuals who have hurt orwronged you.


8. Doing more activities that truly engage you: Increasing the number of experiences athome and work in which you lose yourself , which re challenging and absorbing (i .e. ,f low experiences).


9. Savoring lifes joys: Paying close attention, taking delight, and replaying lifesmomentary pleasures and wonders, through thinking, writ ing, drawing, or sharingwith one another.


10. Committing to your goals: Picking one, two, or three significant goals that aremeaningful to you and devoting t ime and effort to pursuing them.


11. Practicing religion and spirituality: Becoming more involved in your church, temple, ormosque or reading and pondering spir i tually themed books.


12. Taking care of your body: Engaging in physical activity, meditating, and smiling and laughing.



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How to calculate your fit score and determine your self of best fitting activities:

Step 1: For each of the 12 activit ies:subtract the average of the GUILTY and SITUATION rating from the average of theNATURAL, ENJOY and VALUE ratings.

In other words, for each of the 12 activit ies:

FIT SCORE = (NATURAL + ENJOY + VALUE)/3 (GUILTY + SITUATION)/2

Step 2: Write down the four activities with the highest

FIT SCORES:1) __________________________2) __________________________3) __________________________4) __________________________

Your name: __________________

The date: ____________________


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Exercise: Open Mindset

People tend to have either a fixed mindset or an open (growth) mindset.

A fixed mindset is an attitude where you believe you, your abilities & circumstances cannot change.

A growth mindset is an attitude where you believe that you can change.

A growth mindset is associated with significantly higher levels of motivation, goal achievement andresilience in the face of failure.

Developing a growth mindset in others:

Explain the nature of brain plasticity and growth with acquiring a skill, even in adults. The brain islike a muscle, it develops when used and needs to be exercised

Praise effort not ability

Do not compare a person to others; rather compare their current performance with their past

performances

Exercise: Positive Communication There are four main ways of responding to good news in a relationship:

1. Passive Constructive (PC)

2. Passive Destructive (PD)

3. Active Destructive (AD)

4. Active Constructive (AC)

Passive responding is responding to the other person in a limp, unenthusiastic way.Active responding is responding to the other person in an energetic and enthusiastic way.

Destructive responding is responding in a negative manner, be it passive (turning the conversationback to yourself and your issues) or active (commenting on the negative aspects of the good news.

Constructive responding is responding that is encouraging and supportive in nature, be it passive(unenthusiastic e.g.

thats nice

then not following up on the conversation) or active (stronglyenthusiastic support).

Our ability to respond with enthusiasm to good news is far more important than how we respond tobad news.

Active Constructive responding is associated with greater functioning in relationshipsExercise: Pleasure and Savoring

Savoring is the process of mindfully engaging in thoughts or activities that encourage positive eventsto lead to positive feelings.

Reminisce about the past

Savor the present moment

Anticipate the future

Exercise: Three Good Things

Each night before you go to bed:


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1. Think about anything good that happened to you today. It need not be anything big or important.

2. Write down these three positive things.

3. Reflect on why each good thing happened. Determining the

why

of the event is the most

important thing. Decide on reasons that make sense to you.

Exercise: Flow Activities

Seligman considers flow activities to be one of the most important pathways to well-being. Flow is aparticular way of engaging with the world.

A flow activity has the following characteristics:1. It is an activity that involves a degree of challenge, but a challenge that is achievable2. The activity has clear goals and feedback on performance is available3. You feel completely absorbed in the activity, such that your sense of the passing of time isdiminished4. You feel at one with what you are doing, rather than maintaining a perspective of external

observer.5. The activity is intrinsically rewarding in its own right.

Flow activities include things like playing a game of squash, a day at work when you are busy,absorbed in your task and the day goes by very quickly, playing a musical instrument, gardening,creative activities.

Activities are typically high in challenge and high in skill requirements.

Which particular activity leads to flow for a person differs.

Exercise: Loving Kindness Meditation (LKM) and Compassion

LKM is a meditation or mindfulness technique in which the person focuses on and contemplates withcompassion another person in a non-judgmental way and from a perspective of reverence for all livingthings. To be practiced effectively it requires mindfulness skills.

Reflecting on others with compassion is a similar process but does not necessarily requiremindfulness skills. Rather, it is simply a matter of thinking about another person, especially someonewho has hurt or wronged you, and having compassion for the pain they experience that leads him orher to behave that way.

Forgiveness (Enright)

Forgiveness is a difficult thing to achieve and often requires a course of treatment. However, it is oneof the more potent positive interventions, especially for those who have suffered traumaticexperiences in the past.

Of note, the key to forgiveness is to free yourself from the pain of the past trauma, rather than toabsolve the person you are trying to forgive from responsibility.

Enright has identified four phases to forgiveness and describes strategies to help people learn toforgive

Enright, R.D. The Forgiving Life. American Psychological Association Washington D.C. 2012.

Phase 1 Uncovering Anger

Phase 2 Deciding to Forgive


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Phase 3 Working on Forgiveness

Phase 4 Discovery and Release (from the emotional prison)

Exercise: Self-compassion

Self-compassion is similar to LKM (above) with the focus on yourself. Contemplating yourself andyour perceived failings, and looking at these with forgiveness and compassion.

Exercise: Mindfulness

Mindfulness is a meditative technique that is used to focus the persons attention on the sensations ofthe present moment.

It has a wide range of applications, including helping with specific problems such as rumination, poorattention control and impulsivity.

It is also an important way of enhancing your sense of personal well-being.

It is strongly recommended that practitioners learn mindfulness techniques and learn how to teach itto tangata whaiora

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