20 ways to overcome barriers to recovery (20 th revision) 2012 prof. courtenay m. harding...

20 WAYS TO OVERCOME BARRIERS TO RECOVERY

(20th Revision)2012

Prof. Courtenay M. HardingProf. Courtenay M. Harding

CourtenayHardingConsulting@gmail

Good Morning! OVERALL GENERAL INFORMATION OVERALL GENERAL INFORMATION

FOR TODAYFOR TODAY What’s in the folders?What’s in the folders? How to work with this informationHow to work with this information Breaks for lunch, phone & bathroomBreaks for lunch, phone & bathroom Ask questions as we go alongAsk questions as we go along Evaluations and Certificates at endEvaluations and Certificates at end


THE PRESENTATION PLAN

Review 20 obstacles with Review 20 obstacles with strategies to get some strategies to get some answers or how to better answers or how to better understand the understand the complications. Lots of complications. Lots of resources!resources!


ACKNOWLEDGMENT & APPRECIATION

TO ALL THE CLINICIANS & FAMILIESTO ALL THE CLINICIANS & FAMILIES WHO CAREWHO CARE WHO SPEND TIME PROBLEM WHO SPEND TIME PROBLEM

SOLVINGSOLVING WHO CHALLENGE THE STATUS WHO CHALLENGE THE STATUS

QUOQUO WHO SPEND TIME GOING THE WHO SPEND TIME GOING THE

EXTRA MILEEXTRA MILE


MORE STUDIES USING WIDER DIAGNOSTIC CRITERIA

STUDYSTUDY # # Av. Years Av. Years % % Year & Place of Ss length improvementYear & Place of Ss length improvement _______________________________________or recovery_______________________________________or recovery

HINTERHUBER 157 30 74.8 % HINTERHUBER 157 30 74.8 % 1973 AUSTRIA1973 AUSTRIA KREDITOR 115 20.2 84 % KREDITOR 115 20.2 84 % 1977 LITHUANIA1977 LITHUANIA

MARINOW 280 20 75 % MARINOW 280 20 75 % 1986 BULGARIA1986 BULGARIA

THESE PROJECTS HAVE STUDIED…..

2400 plus people 2400 plus people Across 2-3 decades after first Across 2-3 decades after first

admissionadmission In intact samplesIn intact samples Found surprising confluence of Found surprising confluence of

findingsfindings

FINDINGS

o 46-68 % OF EACH COHORT SIGNIFICANTLY 46-68 % OF EACH COHORT SIGNIFICANTLY IMPROVED AND/OR RECOVEREDIMPROVED AND/OR RECOVERED

o Recovered means: Recovered means:

o No enduring symptoms, No enduring symptoms, o No odd behaviors, No odd behaviors, o No further medication, No further medication, o Living in the community, Living in the community, o Working, and relating well to othersWorking, and relating well to others

Significantly improved –means Significantly improved –means

• Recovered in all areas but oneRecovered in all areas but one– Harding et al, 1987Harding et al, 1987

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.19-42 ( 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): 27-37.


More Evidence Davidson, L, Harding, C.M., & Spaniol, L. (Eds.).

Research on Recovery from Severe Mental Illness: 30 years of Accumulating Evidence and Its Implications for Practice. (Vol. 1), Center for Psychiatric Rehabilitation, Boston University, 2005 & (Vol.2) , 2006

Harding, C.M.: The interaction of biopsychosocial factors , time, and the course of schizophrenia: Time is the critical co- variate. In: C.L. Shriqui & H.A. Nasrallah (Eds.) Contemporary Issues In The Treatment Of Schizophrenia. Washington, D.C., APA Press. 1995, pp. 653-681.


More resources -3

Harding, C.M.: An examination of the complexities in the measurement of recovery in severe psychiatric disorders. In: R.J. Ancill, S. Holliday, & G.W. MacEwan (Eds.), Schizophrenia: Exploring The Spectrum Of Psychosis. Chichester, J. Wiley & Sons, 1994, pp. 153-169.


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): 718-726.

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): 727-735.


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, 331-338.

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, 338-342.


IF RECOVERY AND SIGNIFICANT IMPROVEMENT ARE

POSSIBLE……….

THEN WHY ARE SO MANY THEN WHY ARE SO MANY PARTICIPANTS NOT PARTICIPANTS NOT GETTING BETTER?GETTING BETTER?

SEVERAL MILLION PEOPLE SEVERAL MILLION PEOPLE LANGUISHING IN US ALONELANGUISHING IN US ALONE


HOWEVER………..

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

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…


YOU NEED TO LOOK AT A PERSON TWICE…… once with your heart and then with your head……..

FIRST TO SEE THE SIMILARITIES

AND, ONLY THEN. CAN YOU APPRECIATE THE DIFFERENCES

From Dr. Candace Fleming, a Native American psychologistFrom Dr. Candace Fleming, a Native American psychologist


Learning to play a detective !


Always important to have some fun!


LOOKING FOR THE “PERSON UNDER THE DISORDER”

COMPREHENSIVE RE-EVALUATION COMPREHENSIVE RE-EVALUATION NEEDED NEEDED (based on history, careful (based on history, careful interview, lab findings & physical exam)interview, lab findings & physical exam)

BIO-PSYCHO-SOCIAL-SPIRITUAL BIO-PSYCHO-SOCIAL-SPIRITUAL APPROACHAPPROACH

SYSTEMATIC & MULTIDISCIPLINARYSYSTEMATIC & MULTIDISCIPLINARY


QUESTION #1

HAVE OTHER POSSIBLE HAVE OTHER POSSIBLE CAUSES OF SYMPTOMS CAUSES OF SYMPTOMS AND BEHAVIORS BEEN AND BEHAVIORS BEEN ELIMINATED?ELIMINATED?


WHY IS THIS QUESTION IMPORTANT?

e.g. Schizophrenia is a e.g. Schizophrenia is a diagnosis of exclusion. The diagnosis of exclusion. The following differential diagnoses following differential diagnoses should be eliminated BEFORE should be eliminated BEFORE giving the diagnosis of giving the diagnosis of schizophrenia. Not often done. schizophrenia. Not often done. Wrong diagnosis = wrong Wrong diagnosis = wrong treatmenttreatment


DIAGNOSIS OF EXCLUSION(especially schizophrenia)

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


DIAGNOSIS OF EXCLUSION

(schizophrenia) Autism (esp. Asperger’s Autism (esp. Asperger’s

Syndrome)Syndrome) Temporal Lobe EpilepsyTemporal Lobe Epilepsy TumorTumor StrokeStroke


MORE THINGS TO EXCLUDE

Brain TraumaBrain Trauma Endocrine & Metabolic Disorders Endocrine & Metabolic Disorders

(e.g. acute intermittent porphyria (e.g. acute intermittent porphyria (liver enzyme)(liver enzyme)

Homocystinuria (a disorder of amino Homocystinuria (a disorder of amino acid metabolism)acid metabolism)


MORE THINGS TO EXCLUDE

Vitamin Deficiency (e.g. B 12)Vitamin Deficiency (e.g. B 12) Central Nervous System Infectious Central Nervous System Infectious

Processes (e.g. AIDS, neurosyphilis, Processes (e.g. AIDS, neurosyphilis, or herpes encephalitis)or herpes encephalitis)

Autoimmune Disorders (systemic Autoimmune Disorders (systemic lupus erthymatosa)lupus erthymatosa)

Heavy Metal Toxicity (e.g. Wilson’s Heavy Metal Toxicity (e.g. Wilson’s Disease – too much copper)Disease – too much copper)


EVEN MORE TO EXCLUDE:

Some Drug Induced States (e.g. Some Drug Induced States (e.g. amphetamines, barbiturate withdrawal, amphetamines, barbiturate withdrawal, cocaine, digitalis, disulfram)cocaine, digitalis, disulfram)

Mood disorders, schizoaffective disorder, Mood disorders, schizoaffective disorder, Personality disorders, Personality disorders, Brief Reactive Psychosis, Brief Reactive Psychosis, OCD OCD


Differential Diagnoses for Mood D/O (based on history, careful interview, lab findings

& physical exam)

Multiple SclerosisMultiple Sclerosis StrokeStroke Hyper & Hyper &

HypothyroidismHypothyroidism BereavementBereavement DementiaDementia Cancer (esp. of Cancer (esp. of

Pancreas)Pancreas) Spinal Cord InjurySpinal Cord Injury Peptic UlcerPeptic Ulcer MononucleosisMononucleosis

Huntington’s DiseaseHuntington’s Disease AIDSAIDS End-stage Renal End-stage Renal

DiseaseDisease Head InjuryHead Injury Parkinson’s DiseaseParkinson’s Disease LupusLupus Hyper & Hypo Hyper & Hypo

parathyroidismparathyroidism HepatitisHepatitis


ANOTHER HELPFUL STRATEGY

Basis-24Basis-24 ““a leading behavioral health assessment”a leading behavioral health assessment” ComprehensiveComprehensive Cuts across diagnostic categoriesCuts across diagnostic categories Provides weighted averageProvides weighted average Overall score plus 6 subscalesOverall score plus 6 subscales (sub abuse, symptoms and functioning, (sub abuse, symptoms and functioning,

relationships, self harm, emotional liability, relationships, self harm, emotional liability, psychosis, and depression)psychosis, and depression)


SOURCE FOR BASIS-24

Developed by Dr. Susan EisenDeveloped by Dr. Susan Eisen

www.www.basisbasissurvey.org/survey.org/basis24basis24//


HOW TO DO BETTER………

Take the time get Take the time get triangulated informationtriangulated information

Get the lab tests doneGet the lab tests done Reassess over timeReassess over time Pay attention to comorbid Pay attention to comorbid

diagnosesdiagnoses


Treat or refer other diagnoses

Establish links and a little black book with other medical colleagues across the local community

Work with your colleagues in other fields to understand what happened and how to understand your participant who may still appear to them to have only a psychiatric disorder

Networks of partnerships treating person in a holistic way

Partners include hospital, primary care docs, mental health and addiction services plus others such as OB/GYN, eye specialists, hearing tests, dental care, and legal aid.


SUGGESTED INSTRUMENTS

To clarify a psychiatric To clarify a psychiatric diagnosisdiagnosis

SCID –THE STRUCTURED SCID –THE STRUCTURED CLINICAL INTERVIEW FOR CLINICAL INTERVIEW FOR DSM-IV TR DSM-IV TR (CLINICAL VERSION)(CLINICAL VERSION)


OR IF PSYCHIATRIC DIAGOSIS IS RE-ESTABLISHED

All diagnoses are All diagnoses are cross-sectional cross-sectional working hypothesesworking hypotheses

Not lifetime labelsNot lifetime labels Not able to predict long-term outcomeNot able to predict long-term outcome Must write enough evidence to show Must write enough evidence to show

evidence of the diagnosis into the evidence of the diagnosis into the case record (what is present/absent)case record (what is present/absent)


REMEMBER TO LOOK FOR & RECORD STRENGTHS

Strengths of your participant ( e.g. Strengths of your participant ( e.g. insight? Manage meds? Manage S/S ? insight? Manage meds? Manage S/S ? Uses strategies to recognize oncoming Uses strategies to recognize oncoming prodrprodrôôme? Uses coping to reduce me? Uses coping to reduce anxiety? Computer skills? Has driver’s anxiety? Computer skills? Has driver’s license? Etc………..license? Etc………..

Working with the strengths rather than Working with the strengths rather than deficits, problems and disabilities – that is deficits, problems and disabilities – that is what helps people get betterwhat helps people get better


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. 319-338.

(source for this training changed many times)(source for this training changed many times)


More Resources

Rosen, A. (2006) The community psychiatrist of the future. Current Opinion in Psychiatry. Lippincott Williams and Wilkins .

Ragins, M. Recovery With Severe Mental Illness: Changing From A Medical Model to A Psychosocial Rehabilitation Model http://www.village-isa.org/Ragin%27s%20Papers/recov.%20with%20severe%20MI.htm


BATHROOM AND MOBILE PHONE BREAK


QUESTION # 2

DOES THIS PERSON WITH A PSYCHIATRIC DISORDER

HAVE OTHER MEDICAL PROBLEMS ABOUT WHICH

TO WORRY?



Even though a psychiatric Even though a psychiatric diagnosis may be correct, there diagnosis may be correct, there is a good chance that the person is a good chance that the person may be experiencing a co-may be experiencing a co-morbid condition or two or three.morbid condition or two or three.

If left untreated, he or she may If left untreated, he or she may die unnecessarily early.die unnecessarily early.


OVERVIEW OF SITUATION

40-60 % with medical co-morbidity 40-60 % with medical co-morbidity Not recognized nor treatedNot recognized nor treated Participants get “turfed” back to Participants get “turfed” back to

psychiatry or not referred at allpsychiatry or not referred at all Need primary care, eye & hearing exams, Need primary care, eye & hearing exams,

OB/GYN etcOB/GYN etc Need admission and annual physical by Need admission and annual physical by

nurse practitioner, a health history nurse practitioner, a health history questionnaire and basic lab tests questionnaire and basic lab tests


A Resource (Old but Helpful)

Hosp Community Psychiatry. 1989 Hosp Community Psychiatry. 1989 Dec;40(12):1270-6.Dec;40(12):1270-6.

A medical algorithm for detecting physical A medical algorithm for detecting physical disease in psychiatric patients.disease in psychiatric patients.

Sox HC Jr, Koran LM, Sox CH, Marton KI, Dugger Sox HC Jr, Koran LM, Sox CH, Marton KI, Dugger F, Smith T.F, Smith T.

SourceSource Department of Medicine, Dartmouth-Hitchcock Department of Medicine, Dartmouth-Hitchcock

Medical Center, Hanover, New Hampshire, USAMedical Center, Hanover, New Hampshire, USA


LABORATORY TESTS TO CONSIDER

BIOCHEM BIOCHEM TOX SCREENTOX SCREEN COMPLETE COMPLETE

BLOOD COUNTBLOOD COUNT URINALYSISURINALYSIS THYROID PANELTHYROID PANEL

B-12B-12 FOLATEFOLATE VDRL (for VDRL (for

syphilis)syphilis) HIVHIV

______________________________ CT orCT or MRI (if MRI (if

indicated)indicated)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.


Some Suggested Strategies

Collaboration and linkagesCollaboration and linkages Have a case manager (or other person Have a case manager (or other person

who knows person well) go armed who knows person well) go armed with information and written with information and written questions and take notes with user to questions and take notes with user to another physiciananother physician

Rescheduling missed appointmentsRescheduling missed appointments Get outside prescriptions into recordGet outside prescriptions into record


More Suggested Strategies

Offer preventive Offer preventive programs: e.g. programs: e.g. Weight Watchers, Weight Watchers, Jazzercise, other Jazzercise, other exercise programsexercise programs

WalkingWalking Nutrition, cooking Nutrition, cooking

and grocery and grocery shopping skillsshopping skills

Meditation & other Meditation & other relaxation relaxation techniquestechniques

Other Health and Other Health and Wellness Education Wellness Education Classes on blood Classes on blood pressure, weight, pressure, weight, and diabetes and diabetes monitoring.monitoring.


PAYING ATTENTION GETS ………

Finding strengths in self care Finding strengths in self care managementmanagement

Healthier peopleHealthier people Reduced mortality ratesReduced mortality rates Avoids confounding Avoids confounding

diagnosisdiagnosis And contraindicated And contraindicated

medicationsmedicationsCourtenayHardingConsulting@gmail

Resource to check out

Danson,D.,Jones, R, Macias, C., Barreira,P. J. , Fisher, W.H., Hargreaves, W. A. & Harding, C.M. Prevalence, severity, and co-occurrence of chronic physical health problems of people with serious mental illness. PSYCHIATRIC SERVICES, 2004, 55: 1250-1257.


QUESTION #3

Is there an Is there an additional additional neurological neurological impairment?impairment?



There are groups of young men who There are groups of young men who are withdrawn and sit quietly and are are withdrawn and sit quietly and are mostly ignored because they cause mostly ignored because they cause no trouble.no trouble.

If they qualify for the Deficit If they qualify for the Deficit Syndrome then they might do better Syndrome then they might do better if they have a medication change, if they have a medication change, cognitive remediation, and active cognitive remediation, and active rehabilitationrehabilitation


THE DEFICIT SYNDRÔME

+/- S/S of Schizophrenia Come and Go +/- S/S of Schizophrenia Come and Go (esp. + symptoms)(esp. + symptoms)

Attempts to find primary, enduring stable Attempts to find primary, enduring stable negative symptomsnegative symptoms

Subtype or Additional D/OSubtype or Additional D/O Neurological Impairments ( sensory Neurological Impairments ( sensory

integration, stereognosis, graphesthesia, integration, stereognosis, graphesthesia, right-left confusion, the face-hand test, & right-left confusion, the face-hand test, & audiovisual integration)audiovisual integration)


THE DEFICIT SYNDRÔME - 2

Poor premorbid social functioningPoor premorbid social functioning Reduced glucose uptake in the frontal Reduced glucose uptake in the frontal

cortex, parietal & thalamic areas on PET cortex, parietal & thalamic areas on PET scansscans

Increased anhedonia and fewer psychotic Increased anhedonia and fewer psychotic eventsevents

Earlier onset, seems to be unremitting, Earlier onset, seems to be unremitting, suffer spontaneous movement d/o, severe suffer spontaneous movement d/o, severe cognitive impairmentscognitive impairments



Deficit PARTICIPANTs in comparison to Deficit PARTICIPANTs in comparison to NonDeficit PARTICIPANTs show: NonDeficit PARTICIPANTs show: Equal positive symptoms (hallucinations, Equal positive symptoms (hallucinations,

delusions, and formal thought d/o)delusions, and formal thought d/o) Less severe dysphoric symptoms (e.g. Less severe dysphoric symptoms (e.g.

depressive mood, anxiety, guilt, & hostility)depressive mood, anxiety, guilt, & hostility) Less severity of suspiciousnessLess severity of suspiciousness Similar duration of illnessSimilar duration of illness Brain architecture seems to be more intact in Brain architecture seems to be more intact in

some areassome areas



Need longitudinal informationNeed longitudinal information Use SDS or PDS CriteriaUse SDS or PDS Criteria Exclude: drug effect & demoralizationExclude: drug effect & demoralization Need 2 of the following for more than a Need 2 of the following for more than a

year: year: restricted affect, restricted affect, diminished emotional range, diminished emotional range, poverty of speech,poverty of speech, curbing of interests, curbing of interests, diminished sense of purpose and social drivediminished sense of purpose and social drive



USE SCREENING TOOL: THE USE SCREENING TOOL: THE Neurological Evaluation Scale Neurological Evaluation Scale (NES)(NES)

TRY: TRY: Atypical NeurolepticsAtypical NeurolepticsCognitive RemediationCognitive RemediationOther Aggressive RehabOther Aggressive Rehab


Some Resources:

Brian Kirkpatrick et al, 1989, (SDS -Brian Kirkpatrick et al, 1989, (SDS -The Schedule for the Deficit The Schedule for the Deficit Syndrome), 1993, 2001Syndrome), 1993, 2001

PDS : Proxy for Deficit Syndrome PDS : Proxy for Deficit Syndrome Kirkpatrick 1996 (core deficit + no Kirkpatrick 1996 (core deficit + no dysphoria)dysphoria)

Robert W. Buchanan et al, 1990, Robert W. Buchanan et al, 1990, 1993,1994, 19961993,1994, 1996


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): 128-132.


QUESTION #4

WHO IS THIS WHO IS THIS PERSON PERSON

UNDER A COAT UNDER A COAT OF ILLNESS?OF ILLNESS?



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.


ASSESSMENT OF ADULT DEVELOPMENT

PSYCHIATRIC PROBLEMS DISRUPT A LIFE NEED TO GRIEVE FOR LOSS OF TIME AND

OPPORTUNITIES THE “REHABILITATION CRISIS” (McCRORY,

1982) which describes how clinicians can get in the way of recovery process inadvertently

ASSESSMENT OF PREMORBID LEVELS OF FUNCTIONING (peer relations, school performance and dating etc)

Use LIFELINE (Harding, 2011)to get to know the person and his or her patterns better


What to do when people deny they have an illness?

Can get better without any insight or admission that they have a diagnosis

Usually aware that something is holding them back from getting a life they want

If want to recapture their dreams and accept some kind of help from others or

Focus on what the person thinks is distressing or getting in the way of dream

Listening and engaging– L. Davidson, 2012


What If A Person Has No Goals?L. Davidson & P. Ridgway

Is person demoralized and lost hope?Is person demoralized and lost hope? Is person socialized into learned helplessness?Is person socialized into learned helplessness? Has person become risk aversive?Has person become risk aversive? Does person have co-occurring depression?Does person have co-occurring depression? Have you earned person’s trust?Have you earned person’s trust? Are there disabling symptoms and environmental Are there disabling symptoms and environmental

responses interfering with relationships and responses interfering with relationships and participation?participation?


New Resource Questionnaire to get a handle on what a person wants and needs to get

better

REFOCUS- Promoting recovery in REFOCUS- Promoting recovery in community mental health services community mental health services (Rethink recovery series: vol. 4) Bird, V. et al, (Rethink recovery series: vol. 4) Bird, V. et al, Institute of Psychiatry, Kings College LondonInstitute of Psychiatry, Kings College London

Relationships, understanding values and Relationships, understanding values and treatment preferences, assessing strengths, and treatment preferences, assessing strengths, and supporting goal-strivingsupporting goal-striving

Checklists, worksheets, strengths assessment Checklists, worksheets, strengths assessment


Some resources to get to know people better

www.researchintorecovery.com/refocus and www.researchintorecovery.com/refocus and rethink.org/refocusrethink.org/refocus

Harding, C.M. Harding, C.M. The LifelineThe Lifeline, 2011 , 2011 [email protected]@gmail.com

Davidson, L & Ridgway, P. What if a person has no Davidson, L & Ridgway, P. What if a person has no goals? goals? ((dmh.mo.gov/docs/mentalillness/personwithnogoals.dmh.mo.gov/docs/mentalillness/personwithnogoals.pdfpdf))

McCrory, D. (1980) The rehabilitation crisis: The McCrory, D. (1980) The rehabilitation crisis: The impact of growth. impact of growth. Journal of Applied Rehabilitation Journal of Applied Rehabilitation Counseling,Counseling, 11(3):136-139. 11(3):136-139.


Narrative Therapy

Beels, C. Christian (2001) Beels, C. Christian (2001) A Different Story: The Rise of Narrative in Psychotherapy. Phoenix Arizona. Zeig, Tucker & Theisen, Inc.


Question #5

WHAT OTHER WHAT OTHER THINGS HELP OR THINGS HELP OR HINDER HINDER PROGRESS?PROGRESS?



Often a person loses their psychiatric Often a person loses their psychiatric symptoms but the clinician does not symptoms but the clinician does not understand that it has happened.understand that it has happened.

This is because the person may continue This is because the person may continue to get in his or her own way because of to get in his or her own way because of quirks in their personality or despair quirks in their personality or despair

It is important to separate out the signal It is important to separate out the signal from the noise.from the noise.


ASSESSMENT OFCHARACTERLOGICAL

TRAITS Can get in the way or aid progressCan get in the way or aid progress How did the person respond to crises before How did the person respond to crises before

mental illness?mental illness? Is the schizophrenia gone but not the Is the schizophrenia gone but not the

personality quirk, Axis II, or despairpersonality quirk, Axis II, or despair Criteria under reconsideration for DSM 5Criteria under reconsideration for DSM 5 Look for evidence of problem-solving, a sense Look for evidence of problem-solving, a sense

of humor, a philosophical approach, optimism, of humor, a philosophical approach, optimism, persistence and strengths in functioning and persistence and strengths in functioning and resilience to build uponresilience to build upon


Consider rewarding positive behaviors and not focusing on learned poor ones

Clinicians seem to pay attention to pain-Clinicians seem to pay attention to pain-in-the-neck behaviors and miss the in-the-neck behaviors and miss the opportunity to reinforce healthy ones.opportunity to reinforce healthy ones.

Praise small congenial behaviors such as: Praise small congenial behaviors such as: saying “Good morning”, or shaking saying “Good morning”, or shaking hands, or looking you in the eye, or hands, or looking you in the eye, or noticing when a hand is needed, etc. etc. noticing when a hand is needed, etc. etc.


Assessment of other things that get in the way of recovery process

Need to assess Need to assess socialization into socialization into participant (user, participant (user, consumer) roleconsumer) role

Medication side Medication side effectseffects

Not provided with Not provided with educational or educational or work opportunitieswork opportunities

Lack of other Lack of other rehabilitationrehabilitation

Extreme virulence Extreme virulence of illness (only of illness (only 10%) 10%)

Lack of staff Lack of staff expectations (very expectations (very important)important)

Loss of hopeLoss of hope


Resources

Benedict Carey : Thinking clearly about Benedict Carey : Thinking clearly about personality disorders, New York Times personality disorders, New York Times http://www.nytimes.com/2012/11/27/health/clearing-the-fog-around-personality-disorders

Ted Millon: Ted Millon: Personality Disorders in Modern Life, 2nd ed. (2004), 2nd ed. (2004)

www.pearsonassessments.com/www.pearsonassessments.com/mmpi2.aspxmmpi2.aspx


QUESTION #6

ARE THERE SPECIFIC ARE THERE SPECIFIC NEUROCOGNITIVE NEUROCOGNITIVE DEFICITS BEING COPED DEFICITS BEING COPED WITH BY THIS WITH BY THIS PERSON?PERSON?



Since we have been saying that this Since we have been saying that this is a “brain disease” for a couple of is a “brain disease” for a couple of decades, wouldn’t it be appropriate decades, wouldn’t it be appropriate for us to at least take a flash for us to at least take a flash neuropsychological picture of how neuropsychological picture of how the brain is operating and depending the brain is operating and depending on what is found try to help on what is found try to help reprogram the wiring a little bit?reprogram the wiring a little bit?


SCHIZOPHRENIA & NEUROCOGNITIVE DEFICITS

AttentionAttention VigilanceVigilance Executive functioning (reasoning, Executive functioning (reasoning,

judgment, problem-solving, anticipation, judgment, problem-solving, anticipation, planning, decision-making)planning, decision-making)

LearningLearning MemoryMemory Ability to read affect on facesAbility to read affect on faces Find cognitive strengthsFind cognitive strengths


MUTLIMODAL APPROACH

Tests of laterality- prefrontal, Tests of laterality- prefrontal, frontal, parietal, temporal frontal, parietal, temporal functioningfunctioning

Semantic, episodic & working Semantic, episodic & working memorymemory

Expressive & receptive languageExpressive & receptive language Constructional skillsConstructional skills


MATRICS Consensus Neurocognitive Battery (MCCB)

An NIMH initiativeAn NIMH initiative Used “a broad-based interdisciplinary Used “a broad-based interdisciplinary

consensus process”consensus process” Originally designed for pharmacological Originally designed for pharmacological

researchresearch Outcome measure for cognitive Outcome measure for cognitive

remediationremediation Repeated measures of cognitive change

)

• And as a cognitive reference point for non-intervention studies

• Translated into 16 languages to date

• Very short battery better tolerated

• Well known neuropsych tests

• www.matricsinc.org


Components of MCCB

10 tests measuring 10 tests measuring seven cognitive seven cognitive domainsdomains

1)Processing 1)Processing SpeedSpeed

2) Attention/ 2) Attention/ vigilancevigilance

3) Working 3) Working MemoryMemory

4)Verbal Memory4)Verbal Memory 5) Visual Learning5) Visual Learning 6) Reasoning & 6) Reasoning &

Problem SolvingProblem Solving 7) Social Cognition7) Social Cognition

[email protected]@gmail.comgmail.com


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)


MUTLIMODAL APPROACH -

GOAL IS TO: MATCH GOAL IS TO: MATCH REHAB TYPE AND REHAB TYPE AND INTENSITY TO CHANGING INTENSITY TO CHANGING NEEDSNEEDS


More Resources

Medalia, A. & Choi, J.(2009). Cognitive Medalia, A. & Choi, J.(2009). Cognitive Remediation in Schizophrenia. Remediation in Schizophrenia. Neuropsychology ReviewNeuropsychology Review, 19:353-364., 19:353-364.

McGurk, S.R. et al. (2007). A Meta-Analysis McGurk, S.R. et al. (2007). A Meta-Analysis of Cognitive Remediation in of Cognitive Remediation in Schizophrenia. Schizophrenia. American Journal of American Journal of Psychiatry,Psychiatry, 164: 1791-1802. 164: 1791-1802.


SOME MORE RESOURCES:

G.E. Hogarty - G.E. Hogarty - Cognitive Enhancement Therapy – 2002- – 2002- Guilford PressGuilford Press

G.E. Hogarty & S. Flescher (1999)G.E. Hogarty & S. Flescher (1999) H.D. Brenner et al, Hografe & Huber H.D. Brenner et al, Hografe & Huber

Toronto, 1994Toronto, 1994 W. Spaulding et al W. Spaulding et al BJP,BJP, 1989 1989 Michael F. Green et al, Michael F. Green et al, Scz ResScz Res., 2004., 2004


LUNCH BREAKfor one hour


QUESTION #7

ARE THE ARE THE MEDICATIONS MEDICATIONS REALLY WORTH THE REALLY WORTH THE TRADE-OFF?TRADE-OFF?



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.


ASSESSMENT OF NEED FOR, RESPONSE TO, AND SIDE

EFFECTS FROM MEDICATION

TAKE A THOROUGH HISTORYTAKE A THOROUGH HISTORY GET OLD RECORDSGET OLD RECORDS TALK TO OTHERS WHO KNOW TALK TO OTHERS WHO KNOW

PERSONPERSON COLLABORATE, COLLABORATE, COLLABORATE, COLLABORATE,

COLLABORATE, COLLABORATECOLLABORATE, COLLABORATE


MORE ON SIDE EFFECTS

20-30 OTHER SIDE EFFECTS e.g. 20-30 OTHER SIDE EFFECTS e.g. DYSKINESIAS, DYSTONIAS, DYSKINESIAS, DYSTONIAS, PARKINSONISMPARKINSONISM

EVEN ATYPICALS CAN HAVE SIDE EVEN ATYPICALS CAN HAVE SIDE EFFECTS – VERY DOSE DEPENDENTEFFECTS – VERY DOSE DEPENDENT

NEED TO SYSTEMATICALLY CHECK NEED TO SYSTEMATICALLY CHECK q.6 MOS WITH INSTRUMENTSq.6 MOS WITH INSTRUMENTS

TRAIN PARTICIPANTS TO SELF-TRAIN PARTICIPANTS TO SELF-MONITORMONITOR

ATTEND TO SEX DIFFERENCESATTEND TO SEX DIFFERENCESCourtenayHardingConsulting@gmail

CAUSES OF MISINTERPRETATION

MUST LISTEN TO THE WAY MEDS MAKE MUST LISTEN TO THE WAY MEDS MAKE PEOPLE FEEL FROM THE INSIDE OUTPEOPLE FEEL FROM THE INSIDE OUT

SOMETIMES CLIENTS CAN’T DESCRIBE SOMETIMES CLIENTS CAN’T DESCRIBE SUBTLE FEELINGSSUBTLE FEELINGS

E.g. Side Effect of Akathisia- being compelled E.g. Side Effect of Akathisia- being compelled to be in motion- pacing, rocking, etc thought to to be in motion- pacing, rocking, etc thought to be agitation, elopement, need for seclusion, be agitation, elopement, need for seclusion, acting out, and left untreated.acting out, and left untreated.

USE AIMS + EPS EXAM q.6 MOSUSE AIMS + EPS EXAM q.6 MOS


DEFINITION OF THE WORD “COMPLIANCE”

Not a great word in this era of shared decision-making!

GIVING IN TO A REQUEST, GIVING IN TO A REQUEST, DEMAND, WISH; DEMAND, WISH;

ACQUIESENCE; A ACQUIESENCE; A TENDENCY TO GIVE IN TO TENDENCY TO GIVE IN TO

OTHERSOTHERSCourtenayHardingConsulting@gmail

Vs. “ADHERENCE”(somewhat better)

TO STICK FAST TO STICK FAST TO BECOME ATTACHEDTO BECOME ATTACHED TO GIVE ALLEGIANCE TO TO GIVE ALLEGIANCE TO TO GIVE DEVOTION OR TO GIVE DEVOTION OR

SUPPORTSUPPORT


MEDICATION MANAGEMENT APPROACHES IN PSCYHIATRY

Provides a systematic & Provides a systematic & structured plan for med structured plan for med managementmanagement

Documentation is clearer and Documentation is clearer and more concise more concise

Objective measures of outcomeObjective measures of outcome Shared decision-makingShared decision-making


Discussions of Medications

““New developments in antipsychotic therapy” - New developments in antipsychotic therapy” - an interesting discussion report of a group of an interesting discussion report of a group of psychopharmacologists psychopharmacologists J. Clin PsychJ. Clin Psych Nov 2003 Nov 2003

CATIE STUDY= Clinical Antipsychotic Trials of CATIE STUDY= Clinical Antipsychotic Trials of Intervention EffectivenessIntervention Effectiveness

Results underscore need for access to full range Results underscore need for access to full range of medications” in of medications” in www.szdigest.comwww.szdigest.com and also and also NEJMNEJM Sept 22, 2005 J. Lieberman et al Sept 22, 2005 J. Lieberman et al


“Meducation”

Provides understanding of social & cultural issues involved in medication adherence

Can provide a list of critical questions a user, consumer, patient should ask his or her physician and another one for the pharmacist

Offers a tracking chart for client to use


Some helpful resources

www.mayoclinic.com/health/.../www.mayoclinic.com/health/.../DSECTION=treatments-and-drugsDSECTION=treatments-and-drugs

www.nimh.nih.gov/health/...medications/complete-www.nimh.nih.gov/health/...medications/complete-index.shtmlindex.shtml

What Your What Your PatientsPatients Need to Know About Need to Know About Psychiatric Medications Psychiatric Medications by WC Jackson – 2007 by WC Jackson – 2007 www.ncbi.nlm.nih.gov ›www.ncbi.nlm.nih.gov › ... › v.9(4); 2007 ... › v.9(4); 2007

Schrank, B.,Sibitz, I. Unger, A.& Amering, M.: How Schrank, B.,Sibitz, I. Unger, A.& Amering, M.: How Patients With Schizophrenia Use the Internet: Patients With Schizophrenia Use the Internet: Qualitative Study. Qualitative Study. J Med Internet ResJ Med Internet Res. 2010 Oct-. 2010 Oct-Dec; 12(5): 70.Dec; 12(5): 70.


Helpful to track down earliest prodromal signs and symptoms

Work on finding usual Work on finding usual early warning sign early warning sign Describe mild, Describe mild, moderate, and severe moderate, and severe versionsversions

Experiment with simple Experiment with simple interventions that workinterventions that work

Chart the statusChart the status Make emergency plans Make emergency plans

(R. Liberman)(R. Liberman)


Morbidity & Mortality


MORBIDITY AND MORTALITY

The Metabolic SyndromeThe Metabolic Syndrome Abdominal obesity (excessive fat tissue in and Abdominal obesity (excessive fat tissue in and

around the abdomen) around the abdomen) Atherogenic dyslipidemia (blood fat disorders Atherogenic dyslipidemia (blood fat disorders

— high triglycerides, low HDL cholesterol and — high triglycerides, low HDL cholesterol and high LDL cholesterol — that foster plaque high LDL cholesterol — that foster plaque buildups in artery walls) buildups in artery walls)

Elevated blood pressure Elevated blood pressure


MORBIDITY AND MORTALITY-2

More of More of The Metabolic SyndromeThe Metabolic Syndrome Insulin resistance or glucose intolerance Insulin resistance or glucose intolerance

(the body can’t properly use insulin or (the body can’t properly use insulin or blood sugar) blood sugar)

Prothrombotic state (e.g., high fibrinogen or Prothrombotic state (e.g., high fibrinogen or plasminogen activator inhibitor–1 in the plasminogen activator inhibitor–1 in the blood) blood)

Proinflammatory state (e.g., elevated C-Proinflammatory state (e.g., elevated C-Reactive Protein in the blood) Reactive Protein in the blood)



Increased risks of:Increased risks of: Coronary heart diseaseCoronary heart disease StrokeStroke Peripheral vascular diseasePeripheral vascular disease Type 2 DiabetesType 2 Diabetes Physical inactivityPhysical inactivity Hormonal ImbalanceHormonal Imbalance Expression of familial genetic profileExpression of familial genetic profile


MORTALITY- 4

Graded relationship between number Graded relationship between number of neuroleptics taken and mortality of neuroleptics taken and mortality and dosage levels with…and dosage levels with…

Fatal arrhythmiasFatal arrhythmias Sudden cardiac deathsSudden cardiac deaths Venus thrombosisVenus thrombosis Pulmonary embolismPulmonary embolism Asthma deathsAsthma deaths


(even after adjusting for known risk factors of premature death such as: smoking, lack of exercise, BMI, B/P, serum total and HDL cholesterol)!



On 1On 1stst Generation drugs mortality risk = Generation drugs mortality risk = 2.84 and was just slightly reduced to 2.25 2.84 and was just slightly reduced to 2.25 after adjusting for other factors such as: after adjusting for other factors such as: somatic diseases, BMI, exercise, B/P, BMI, somatic diseases, BMI, exercise, B/P, BMI, alcohol intake and education.alcohol intake and education.

Relative risk for each new drug added 2.50 Relative risk for each new drug added 2.50 additional risk. additional risk.

– Joukamaa et al, 2006Joukamaa et al, 2006 Similar Findings for Atypicals and for Similar Findings for Atypicals and for

Antidepressants (both SSRIs and Tricyclic's)Antidepressants (both SSRIs and Tricyclic's)


New Considerations for optimization of medications Some people seem to need no Some people seem to need no

medications;medications; Some people seem to need Some people seem to need

medications for a short while;medications for a short while; A few people seem to need A few people seem to need

medication for a longer period.medication for a longer period. Need research to help triageNeed research to help triage


Support for optimization of medications………….

Literature says that 1Literature says that 1stst episode episode participants may need little or no participants may need little or no medications by adopting “wait and see”medications by adopting “wait and see”

Nothing in the literature that says Nothing in the literature that says everyone needs meds for a lifetime only everyone needs meds for a lifetime only maybe a small groupmaybe a small group

Taper, taper very very slowly if on for a Taper, taper very very slowly if on for a long timelong time


More Resources:

Personal TherapyPersonal Therapy – GE Hogarty et al – GE Hogarty et al 1997 helps adherence1997 helps adherence

W. Fenton W. Fenton Psychiatric TimesPsychiatric Times 2006 2006 Combined therapyCombined therapy

APA – APA – 2004 Practice Guidelines Texas Medication Algorithm – No! Texas Medication Algorithm – No!

Was drug company sponsored.Was drug company sponsored.


QUESTION # 8WHY IS THIS PERSON WHY IS THIS PERSON

TAKING STREET TAKING STREET DRUGS IN PLACE OF DRUGS IN PLACE OF OR IN ADDITION TO OR IN ADDITION TO PRESCRIPTIONS ?PRESCRIPTIONS ?



Mental Health and Substance Abuse Mental Health and Substance Abuse systems of care need to be blended systems of care need to be blended and the work done simultaneously in and the work done simultaneously in order for anything to work out.order for anything to work out.

Research has shown many different Research has shown many different reasons for use of substances reasons for use of substances


INFO ON USING STREET DRUGS

At least 47% to 75% have co-occurring At least 47% to 75% have co-occurring disordersdisorders

Most costly to treatMost costly to treat Makes initial diagnosis difficultMakes initial diagnosis difficult Use of structured interviews helpful (SCID Use of structured interviews helpful (SCID

subsection clinically useful or ASI – the subsection clinically useful or ASI – the Addition Severity Index for research)Addition Severity Index for research)

Info on street drug of choice may be Info on street drug of choice may be helpful to add into diagnostic processhelpful to add into diagnostic process


Co-Occurring or Dual Dx D/Ocan lead to:

SymptomSymptom RelapsesRelapses hospitalization hospitalization financial and financial and

family problemsfamily problems homelessness homelessness suicidesuicide

Violence, Violence, Sexual and physical Sexual and physical

victimization, victimization, Incarceration, Incarceration, HIV, HIV, Hepatitis B and C Hepatitis B and C and early death.and early death.


Some Reasons People Give

IS PERSON TREATING IS PERSON TREATING DEPRESSIONS OR MEDICATION DEPRESSIONS OR MEDICATION SIDE EFFECTS (e.g. Akinesia) or to SIDE EFFECTS (e.g. Akinesia) or to ameliorate lack of motivation and ameliorate lack of motivation and pleasure or to combat loneliness or pleasure or to combat loneliness or to get a social group ? to get a social group ? (see work of (see work of Prof. Mary Ann Test and colleagues) Prof. Mary Ann Test and colleagues)


EBP: Integrated Dual Disorders Treantment (IDDT)

Services provided Services provided concurrentlyconcurrently

Individualized assessment Individualized assessment and treatment planning in and treatment planning in heavy collaborationheavy collaboration

Use SCID-SA ScreenerUse SCID-SA ScreenerCourtenayHardingConsulting@gmail

EBP: Integrated Dual Disorders Treatment

DUAL DISORDERS TREATMENT DUAL DISORDERS TREATMENT IMPLEMENTATION RESOURCE KITIMPLEMENTATION RESOURCE KIT InformationInformation Training MaterialsTraining Materials Annotated BibbsAnnotated Bibbs RefsRefs http:://http:://

www.mentalhealthpractices.orgwww.mentalhealthpractices.org


EBP: Integrated Dual Disorders Treatment

BlendingBlending Stage-wise TreatmentStage-wise Treatment Motivational InterviewingMotivational Interviewing Substance Abuse CounselingSubstance Abuse Counseling Involving all stakeholdersInvolving all stakeholders 4 basic skills for clinicians4 basic skills for clinicians

Knowledge of substances & how they affect MIKnowledge of substances & how they affect MI Assessment skillsAssessment skills Motivational interviewing skillsMotivational interviewing skills SA Counseling skillsSA Counseling skills


Some Lessons Learned

Standard confrontational models Standard confrontational models might not work for people with might not work for people with schizophrenia. Other models may schizophrenia. Other models may work better with less stresswork better with less stress

Blended funding streams and Blended funding streams and integrated care more helpfulintegrated care more helpful

Gender, age, ethnicity, geographic Gender, age, ethnicity, geographic residence, exposure to trauma, make residence, exposure to trauma, make differencesdifferences


The Substance Abuse & Mental Health

Administration in U.S. has a wealth of publications on research and treatment

strategies.www.SAMHSA.GOV


QUESTION #9

WHAT ARE THE WHAT ARE THE RELEVANT SEX RELEVANT SEX DIFFERENCES?DIFFERENCES?


Why is this question important?

Not taught very often in med schools yetNot taught very often in med schools yet Females metabolize drugs differentlyFemales metabolize drugs differently Females often over medicated which cuts their Females often over medicated which cuts their

Estrogen protectionEstrogen protection Females often have a later onset which provides Females often have a later onset which provides

a stronger platform to return toa stronger platform to return to Males are more vulnerable and who struggle Males are more vulnerable and who struggle

more early on but eventually grow stronger in more early on but eventually grow stronger in outcome andoutcome and

Females may lose their edge at menopauseFemales may lose their edge at menopause


SEX DIFFERENCES ACROSS THE LIFE SPAN

NEURAL DEVELOPMENTAL GROWTHNEURAL DEVELOPMENTAL GROWTH BIRTH COMPLICATIONSBIRTH COMPLICATIONS PEDIATRIC INJURIESPEDIATRIC INJURIES PUBERTY AND HORMONESPUBERTY AND HORMONES METABOLIC DIFFERENCESMETABOLIC DIFFERENCES MENOPAUSEMENOPAUSE PRESCRIBING PRACTICES ARE PRESCRIBING PRACTICES ARE

DIFFERENTDIFFERENT


SOME SEX DIFFERENCES AFECTING ILLNESS EXPRESSION AND OUTCOME - 1

MALESMALES Early events may make brain Early events may make brain

more vulnerable (e.g. slight more vulnerable (e.g. slight displacement of developing displacement of developing cells by Mother’s flu, anoxia cells by Mother’s flu, anoxia due to cord around neck, due to cord around neck, less temperature regulation, less temperature regulation, and more risky playground and more risky playground behaviors because of behaviors because of increased exploration due to increased exploration due to testosterone)testosterone)

FEMALESFEMALES Less eventsLess events


SOME SEX DIFFERENCES AFECTING ILLNESS EXPRESSION AND OUTCOME-2

MALESMALES Quick metabolism of Quick metabolism of

food and medicine gets food and medicine gets into blood stream fasterinto blood stream faster

May contribute to more May contribute to more side effectsside effects

FEMALESFEMALES Slower metabolism of Slower metabolism of

food and medicine food and medicine means slowly entering means slowly entering blood stream = blood stream = probably less side probably less side effectseffects

Meds cross blood/brain Meds cross blood/brain barrier faster = drugs barrier faster = drugs more efficientmore efficient


Some Sex Differences affecting illness presentation & outcome - 3

MALESMALES

Earlier onset often Earlier onset often in early to mid teens in early to mid teens – means less – means less education, less job education, less job and dating and dating experienceexperience

Slow progress Slow progress toward recoverytoward recovery

FMALESFMALES

More often later More often later onset with some onset with some school completed, school completed, dating and job dating and job experience = much experience = much stronger platform stronger platform for recovery and for recovery and initially strongerinitially stronger


Some Sex Differences Affecting Illness Presentation and Outcome - 3

MALES Often symptoms are

presented quietly Medications are often

less in number and lower dosage

Course improves more slowly and matches females later at trend levels

FEMALESFEMALES Often symptoms are

presented in a boisterous way

Medications are often more in number and higher in dosage

Cuts natural Estrogen protection

Otherwise woman have stronger outcomes until menopause and loss of Estrogen

CourtenayHardingConsurlting@gmail

Resources

Chiders, S.E.; Harding, C.M.: Gender, premorbid social functioning, and long-term outcome in DSM-III schizophrenia. SCHIZOPHRENIA BULLETIN, 1990, 16(2): 309-318.

Harding, C.M. & Hall. G.M.: Long-term Harding, C.M. & Hall. G.M.: Long-term outcome studies of schizophrenia: Do outcome studies of schizophrenia: Do females continue to display better outcome females continue to display better outcome as expected? as expected? International Review of International Review of PsychiatryPsychiatry, 1997, 9:409-418, 1997, 9:409-418..


QUESTION # 10

WHERE IS THIS WHERE IS THIS PERSON IN THE PERSON IN THE COURSE OF COURSE OF ILLNESS?ILLNESS?



Helpful to track episode Helpful to track episode information to see information to see when illness is when illness is beginning to lift.beginning to lift.


COURSE INFORMATION

Instead of narrow medical model (acute or chronic)

Schizophrenia is virulent early and tapers off later

Similar to other general medical disorders

Mother nature is trying to help BURNT OUT vs. The Phoenix


MORE ON COURSE Also Also course of lifecourse of life, itself, itself A lifeline or life history is helpfulA lifeline or life history is helpful Mutual participation modelMutual participation model Longitudinal patterns and trendsLongitudinal patterns and trends Different uses of social relationshipsDifferent uses of social relationships Build therapeutic relationshipsBuild therapeutic relationships


“The LIFELINE”

Quick and easy way to get a life history on Quick and easy way to get a life history on one line on one piece of paperone line on one piece of paper

Builds a therapeutic and appreciative Builds a therapeutic and appreciative relationshiprelationship

Being used by clinicians across the worldBeing used by clinicians across the world Covers 12 areas of a life livedCovers 12 areas of a life lived Derived from the Life Chart – a research Derived from the Life Chart – a research

instrumentinstrument Takes from 20 to 60 minutesTakes from 20 to 60 minutes


Consider the differential effects of rehabilitation in interaction with course

Propose that possibly ….Propose that possibly …. Early rehabilitation interventions Early rehabilitation interventions

from Day 1 forward may help from Day 1 forward may help reduce reduce disabilitydisability

Later rehabilitation interventions Later rehabilitation interventions may help to increase may help to increase abilityability


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?


Some Resources

THE LIFELINE – v. 2011 by C. M. Harding THE LIFELINE – v. 2011 by C. M. Harding ([email protected])([email protected])

Strauss JS, Hafez H, Lieberman P, Harding CM. The course of psychiatric disorder, III: Longitudinal principles. Am J Psychiatry. 1985 Mar;142(3):289-96.

Harding, C.M.: Course types in schizophrenia. An analysis of European and American studies. SCHIZOPHRENIA BULLETIN. 1988, 14(4):633-643


QUESTION # 11

WHAT MYTHS AND WHAT MYTHS AND MISINFORMATION MISINFORMATION ARE STRESSING ARE STRESSING THE PERSON?THE PERSON?



Knowledge transfers Knowledge transfers power from the power from the illness and the care illness and the care system to the person.system to the person.


ASSESSMENT OF UNDERSTANDING THE ILLNESS

AND MEDICATIONS

Collaboration and educationCollaboration and education Helps change the stressful valence – can Helps change the stressful valence – can

reduce relapse ratesreduce relapse rates Teaches how to manage symptomsTeaches how to manage symptoms Never says more than we actually knowNever says more than we actually know Promotes competency and empowersPromotes competency and empowers Increases self-esteem Increases self-esteem


EBP:WELLNESS MANAGEMENT AND RECOVERY PROGRAM-1

CLINICIAN BENEFITS:CLINICIAN BENEFITS: A comprehensive step by step A comprehensive step by step

approachapproach Ready-to-use materialsReady-to-use materials Skill is using motivational , Skill is using motivational ,

cognitive behavioral and cognitive behavioral and educational strategieseducational strategies

Satisfaction to see Satisfaction to see outcomes outcomes


EBP: WELLNESS MANAGEMENT AND RECOVERY PROGRAM-2

CLINICIANS RECEIVE: CLINICIANS RECEIVE: guide with practical tipsguide with practical tips handouts, checklists, planning sheetshandouts, checklists, planning sheets introduction videointroduction video informational brochuresinformational brochures fidelity scalefidelity scale outcome measuresoutcome measures


EBP: WELLNESS MANAGEMENT AND RECOVERY PROGRAM-3

• Recovery Recovery strategiesstrategies

• Practical facts Practical facts about MIabout MI

• Stress-Stress-Vulnerability & Vulnerability & treatment treatment strategiesstrategies

• Building social Building social supportssupports

• reducingreducing• relapsesrelapses• using medsusing meds• effectivelyeffectively• coping withcoping with• stressstress• coping withcoping with• problems & symptomsproblems & symptoms• getting yourgetting your• needs met in the MH needs met in the MH

systemsystem


“HOPE CAN ARRIVE ONLY WHEN YOU RECOGNIZE THAT THERE ARE REAL OPTIONS AND THAT YOU HAVE GENUINE CHOICES.” Jerome Groopman, MD (2004)


More Resources Wellness Self-Management & Plus by

Columbia University – Paul Margolies and Tony Salerno

http://www,mentalhealth.samhsa.gov/cmhs/communitysupport/toolkit

http://www.mentalhealthpractices.org/imr_mlpl. html


More Resources

Liberman RL et al, describing UCLA Models, Innovations & Research, Vol2(2), 1993

P.A. Garrety et al , Schiz Bull, 2000 WRAP Plan – Mary Ellen Copeland Harding, C.M.; Zahniser, J.: Empirical

correction of seven myths about schizophrenia. Acta Psychiatrica Scandinavica. 1995:90 (Suppl. 384):140-146.


BATHROOM AND MOBILE PHONE BREAK


QUESTION # 12

WHO DEPENDS ON WHO DEPENDS ON THE CLIENT FOR THE CLIENT FOR HELP?HELP?



Challenges the assumption Challenges the assumption that all the help is being that all the help is being extended to the person with extended to the person with the lived experience.the lived experience.

Ask and you will find out Ask and you will find out some surprising information!some surprising information!


What You Will Find Out…

Most people with the Most people with the lived experience have lived experience have people they help with people they help with emotional support emotional support during a crisis or withduring a crisis or with

Concrete help such as Concrete help such as the loan of bus money the loan of bus money or moving furniture or or moving furniture or providing providing companionshipcompanionship


SOCIAL SUPPORTS

CONNECTION BETWEEN KIND AND CONNECTION BETWEEN KIND AND AMOUNT OF SOCIAL SUPPORTS AMOUNT OF SOCIAL SUPPORTS AND RECOVERY FROM AND AND RECOVERY FROM AND PREVENTION OF ILLNESS OF ALL PREVENTION OF ILLNESS OF ALL KINDSKINDS

NETWORKS = TYPE, AMOUNT, NETWORKS = TYPE, AMOUNT, DENSITY, SIZE, DEGREE OF DENSITY, SIZE, DEGREE OF INTERDEPENDENCE, CLUSTERING, INTERDEPENDENCE, CLUSTERING, DEGREE OF INTIMACY DEGREE OF INTIMACY (M. Hammer,1981)(M. Hammer,1981)


SOCIAL SUPPORTS - 2

Social Skills Training (considered a Promising Social Skills Training (considered a Promising Rehab Practice)Rehab Practice) Reading social cuesReading social cues Acting appropriatelyActing appropriately Practicing acceptable social behaviorsPracticing acceptable social behaviors (e.g. eye contact, small talk etc.)(e.g. eye contact, small talk etc.) Decrease lonelinessDecrease loneliness Increase possibility of finding friends Increase possibility of finding friends

and significant others.and significant others.


Resources…………

Robert Liberman’s Social & Robert Liberman’s Social & Independent Living Skills Independent Living Skills Modules at UCLAModules at UCLA

See See Innovations & ResearchInnovations & Research Vol2 (2) 1993Vol2 (2) 1993 Harding’s Star Chart (Social Harding’s Star Chart (Social

Network) Harding & Keller, Network) Harding & Keller, 19981998


SOCIAL SKILL RESOURCES 1) Penn, D..L., Roberts, D.L., Combs, D., Sterne, A.: The development of the social 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. cognition and interaction training program for schizophrenia spectrum disorders. Psychiatric Services,Psychiatric Services, 56 (4):449-451, 2007. 56 (4):449-451, 2007.

2) Hogarty GE: 2) Hogarty GE: Personal Therapy for Schizophrenia and Related Disorders: A Guide to Personal Therapy for Schizophrenia and Related Disorders: A Guide to Individualized Treatment.Individualized Treatment. New York, Guilford Press, 2002 New York, Guilford Press, 2002

3) Liberman, R. Liberman, R., DeRisi, W., & Mueser, K. : 3) Liberman, R. Liberman, R., DeRisi, W., & Mueser, K. : Social skills training for Social skills training for psychiatric patients.psychiatric patients. New York: Pergamon Press, 1989. New York: Pergamon Press, 1989.

4) Mueser, K.T. & Gingerich, S.: 4) Mueser, K.T. & Gingerich, S.: The Complete Family Guide to Schizophrenia. The Complete Family Guide to Schizophrenia. New New York, The Guilford Press, 2006.York, The Guilford Press, 2006.

5) Bellack, A.S., Mueser, K.T., Gingerich,S., Agresta, J.: 5) Bellack, A.S., Mueser, K.T., Gingerich,S., Agresta, J.: Social Skills Training for Social Skills Training for Schizophrenia: A Step by Step Guide (Schizophrenia: A Step by Step Guide (22ndnd Ed.). New York: Guilford Press, 2004. Ed.). New York: Guilford Press, 2004.

6) Harding, C.M.: Curriculum – 6) Harding, C.M.: Curriculum – How to Get A Date: One More Way To Teach Social How to Get A Date: One More Way To Teach Social Skills in PROS. Skills in PROS. V. 1, New York, Center for Rehabilitation and Recovery, The Coalition V. 1, New York, Center for Rehabilitation and Recovery, The Coalition of Behavioral Health Agencies, 2011of Behavioral Health Agencies, 2011


Even More Resources

Beels, C. C. (1989) The invisible village. New Directions for Mental Health Services, 1989: 27–40.

Strauss, J.S.; Harding, C.M.; Hafez, H.; Lieberman, P.: The role of the patient in recovery from psychosis. In: J.S. Strauss, W. Böker and H. Brenner (Eds.), Psychosocial Management of Schizophrenia. Toronto: Hans Huber Publisher, 1987, pp. 160-166.

Hammer, Muriel ( 1981) Social Supports, Social Networks, and Schizophrenia. Schiz Bull. 7(1):45-57.


QUESTION #13

WHAT IS THE WHAT IS THE PERSON’S PERSON’S WORLD VIEW?WORLD VIEW?



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)


CULTURAL SENSITIVITY

ONLY RECENTLY APPRECIATEDONLY RECENTLY APPRECIATED DIVERSITY IS HALLMARK OF WORLDDIVERSITY IS HALLMARK OF WORLD NEED TO UNDERSTAND AT INTAKE NEED TO UNDERSTAND AT INTAKE

ONWARDONWARD WHAT IS IMPORTANCE OF RELIGIOUS WHAT IS IMPORTANCE OF RELIGIOUS

THINKING versus RELIGIOSITY?THINKING versus RELIGIOSITY? SENSE OF TIME?SENSE OF TIME? DISPLAYED AFFECT?DISPLAYED AFFECT?


CULTURAL SENSITIVITY-2

Disorganized sounding speech - Disorganized sounding speech - a linguistic variation?a linguistic variation?

Importance of family, Importance of family, community and church?community and church?

Is the interpreter asking the Is the interpreter asking the same questions you are? (see same questions you are? (see Utah DMH video)Utah DMH video)


CULTURAL SENSITIVITY-2

http://www.wiche.edu/archive/mh/http://www.wiche.edu/archive/mh/culturalCompetenceStandards culturalCompetenceStandards

SAMHSA’s only approved standards for SAMHSA’s only approved standards for anythinganything

BenchmarksBenchmarks GuidelinesGuidelines Outcome MeasuresOutcome Measures Lit ReviewLit Review For everyone for everyone and the major 4 For everyone for everyone and the major 4

minority groupsminority groups


More resources of interest

Tervalon, M. & Murray-Garcia, J. (1998) Tervalon, M. & Murray-Garcia, J. (1998) Cultural Humility versus Cultural Cultural Humility versus Cultural Competence: A Critical Distinction in Competence: A Critical Distinction in Defining Physician Training Outcomes in Defining Physician Training Outcomes in Multicultural EducationMulticultural Education. J. of HealthCare . J. of HealthCare for the Poor and Underservedfor the Poor and Underserved., 9(2), 117- ., 9(2), 117- 125.125.


Question # 15

IS THERE ANY IS THERE ANY COHESION IN THE COHESION IN THE SYSTEM OF CARE?SYSTEM OF CARE?



Complex biopsychosocial Complex biopsychosocial problems need integrated problems need integrated comprehensive systems which comprehensive systems which collaborate with users and collaborate with users and carers.carers.

It helps people if we have our act It helps people if we have our act together! together!


LINKAGES - 1

Coordination and linkage between all Coordination and linkage between all the players are criticalthe players are critical

Need semi-permeable membranes Need semi-permeable membranes for information sharing, flexibility, for information sharing, flexibility, coordination, continuity and coordination, continuity and integrationintegration

Clear and consistent policies from Clear and consistent policies from the top downthe top down


LINKAGES - 2

Clear and consistent policies from Clear and consistent policies from the top downthe top down

Use community resource checklist Use community resource checklist (community mental health, extension (community mental health, extension services, consumer groups, natural services, consumer groups, natural support)support)

Again, the more we have our act Again, the more we have our act together the better the participants together the better the participants become become


Some Resources Principled Leadership. William A. Anthony & Kevin Ann

Huckshorn, Boston University, 2008. www.bu.edu/cpr/products/books/titles/leadership.html

The Comprehensive, Continuous, Integrated System of Care (CCISC) process (Minkoff & Cline, 2004, 2005) is a vision-driven system “transformation” process ...... www.kenminkoff.com/ccisc.html

www.samhsa.gov/co.../topics/healthcare-integration/ccisc-model.aspx

www.who.int/entity/mediacentre/news/notes/2007/np25/.../index.html


Another resource

Harding, C.M.: The limited resources debate: Changing the rules of the game to a win-win scenario. AUSTRALASIAN PSYCHIATRY, 1997, 5(6), 271-273.


Training resources

Coursey, R. D., Curtis, L., Marsh, D. T., Campbell, J., Harding, C. M., Spaniol, L., Luckstead, A., McKenna, J., Paulson, R., Zahniser, J., Kelley, M., and other members of the Adult Panel of the SAMHSA Managed Care Initiative:

Part I. Competencies for the direct service staff who work with adults with severe mental illnesses in outpatient public mental health/managed care systems. AND

Part II. Competencies for the direct service staff who work with adults with severe mental illnesses: Specific knowledge, attitudes, skills, and bibliography. PSYCHIATRIC REHABILITATION JOURNAL. 2000, Spring


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): 44-48.

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. 165-169.


#14 – WHAT TO DO WITH AN OUT OF CONTROL PERSON?


Why this is an important question?

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


QUESTION # 14 – RISK MANAGEMENT - 2

Research has found the following Research has found the following risk factors for minor and serious risk factors for minor and serious violence:violence:PERSECUTORY IDEATIONPERSECUTORY IDEATIONSUBSTANCE ABUSESUBSTANCE ABUSECHILDHOOD CONDUCT D/OCHILDHOOD CONDUCT D/OVICTIMIZATIONVICTIMIZATION


RISK MANAGEMENT

Relapse Prevention Strategies for mental Relapse Prevention Strategies for mental health and substance abuse issueshealth and substance abuse issues

Try Paul and Lentz Social Learning Try Paul and Lentz Social Learning Environments (behavioral)Environments (behavioral)

Tony Menditto’s program for forensic Tony Menditto’s program for forensic participantsparticipants

Individualized Token Behavioral Individualized Token Behavioral Programs which tend to generalize to Programs which tend to generalize to other environmentsother environments

Reduce Restraint and Seclusion with Reduce Restraint and Seclusion with psychological strategies firstpsychological strategies first


DIALECTICAL BEHAVIORAL THERAPY

For persons diagnosed with Borderline Personality Disorder

Effective for “…..reduces suicidal behaviors, psychiatric hospitalization, dropout from treatment, substance abuse, anger and interpersonal difficulties.”

Always conducted within a team approach


Resources

Marsha Linehan et al (2006) Two-year randomized controlled trial and follow-up of Dialectical Behavioral Therapy vs. Therapy by experts for suicidal behaviors and Borderline Personality Disorder. Arch Gen Psych, 63(7): 757-766.

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.


Other Resources The Wellness Recovery Action Plan (WRAP) The Wellness Recovery Action Plan (WRAP)

Mary Ellen Copeland, 2011.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). Paul, G. L., Stuve, P., & Menditto, A. A. (1997). Social-learning program (with token economy) for Social-learning program (with token economy) for adult psychiatric inpatients. adult psychiatric inpatients. The Clinical The Clinical PsychologistPsychologist,, 50, 14-17. 50, 14-17.


QUESTION #16 WHERE DO THE WHERE DO THE

CLINICIAN AND CLINICIAN AND CONSUMER BEGIN TO CONSUMER BEGIN TO START BUILDING THE START BUILDING THE

RECOVERYRECOVERY PROCESS?PROCESS?



After 150 years of focus on After 150 years of focus on psychopathology, deficits, psychopathology, deficits, damage and dysfunction, peer damage and dysfunction, peer advocates and rehabilitation advocates and rehabilitation research has shown that research has shown that building on strengths helps building on strengths helps people reclaim their livespeople reclaim their lives..


ASSESSMENT OF STRENGTHS

Rehab is built on strengths not problems or Rehab is built on strengths not problems or deficitsdeficits

Strengths of: person, system of care, family, Strengths of: person, system of care, family, case manager, the doc etccase manager, the doc etc

Sense of humor, drivers license, computer Sense of humor, drivers license, computer skills, care of others, watering plants and even skills, care of others, watering plants and even the manipulation of systemsthe manipulation of systems


Some Resources

Anthony, W. A. & Farkas, M. (2012) Anthony, W. A. & Farkas, M. (2012) The The essential guide to psychiatric essential guide to psychiatric rehabilitation practicerehabilitation practice. Boston MA: . Boston MA: Boston Boston UniversityUniversity..

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).


More Resources

Harding, C.M., Strauss, J.S., Hafez, H., Harding, C.M., Strauss, J.S., Hafez, H., Lieberman, P.L.: Work and Mental Illness: Lieberman, P.L.: Work and Mental Illness: 1. Toward an integration of the 1. Toward an integration of the rehabilitation process. rehabilitation process. J. Nervous & Mental J. Nervous & Mental DiseaseDisease, 1987, 175 (6): 317-327., 1987, 175 (6): 317-327.


Question # 17. Has the person ever experienced trauma in their life?



It is only recently that clinicians It is only recently that clinicians have begun to acknowledge and have begun to acknowledge and understand the role of trauma in understand the role of trauma in the impact on psychiatric the impact on psychiatric problems as well as challenges problems as well as challenges for treatment. for treatment.


Traumatic Experiences

AT SOME POINT WE NEED TO FIND AT SOME POINT WE NEED TO FIND OUT ABOUT PREVIOUS OUT ABOUT PREVIOUS TRAUMATIC EXPERIENCESTRAUMATIC EXPERIENCES

Effects: Avoidance, hypervigilance, Effects: Avoidance, hypervigilance, emotional difficulties, and recall emotional difficulties, and recall behaviors, anxiety, depression, problems behaviors, anxiety, depression, problems sleeping, and sometimes hopelesssleeping, and sometimes hopeless

Use SCID-D for assessmentUse SCID-D for assessment


Some Trauma Studies

50-60% of US have a traumatic 50-60% of US have a traumatic experience experience

10% - 17 % Chronic PTSD 10% - 17 % Chronic PTSD (Galea et al, 2002)(Galea et al, 2002)

In community 1 in 10 women/girls and 1 In community 1 in 10 women/girls and 1 in 20 men/boys have PTSD in 20 men/boys have PTSD (Kessler et al, 1995)(Kessler et al, 1995)

Most do not & do not display pathology! Most do not & do not display pathology! (Bonanno et al, 2002)(Bonanno et al, 2002)


Predictors of the Emergence of PTSD LACK OF SOCIAL SUPPORTLACK OF SOCIAL SUPPORT LACK OF EDUCATIONLACK OF EDUCATION TOUGH FAMILY BACKGROUNDTOUGH FAMILY BACKGROUND PRIOR PSYCHIATRIC HISTORYPRIOR PSYCHIATRIC HISTORY DISSOCIATIVE REACTIONDISSOCIATIVE REACTION

• (Berwin et al 2000, Ozer et al, 2003)(Berwin et al 2000, Ozer et al, 2003)


Psychophysiological Sequelae of Stress and Trauma Psychogenic Stress of all kinds can be Psychogenic Stress of all kinds can be

Genotoxic in Cellular Structures Genotoxic in Cellular Structures Changes in both internal and external Changes in both internal and external

environments can lead to environments can lead to ± ± changes in changes in gene structuresgene structures

The Brain is a Plastic Organ as wellThe Brain is a Plastic Organ as well Healing is possibleHealing is possible


Mnemonic for PTSD

FEARSFEARS

FearsFears Ego construction (numbing & withdrawal)Ego construction (numbing & withdrawal) AngerAnger Repetition (Flashbacks & nightmares)Repetition (Flashbacks & nightmares) Sleep disturbanceSleep disturbance

• Jean GoodwinJean Goodwin


Mnemonic for COMPLEX PTSD

FEARSFEARSFugue & Other Dissociative statesFugue & Other Dissociative states

Ego fragmentationEgo fragmentation

Antisocial BehaviorsAntisocial Behaviors

Re-enactmentRe-enactment

Suicidality & SomatitizationSuicidality & Somatitization

• Jean GoodwinJean GoodwinCourtenayHardingConsulting@gmail

SOME RESOURCES

Journal of Brain Behavioral and Immunity Journal of Brain Behavioral and Immunity for for articles on psychoneuroimmunologyarticles on psychoneuroimmunology

Trauma-Focused Cognitive Behavioral Therapy - NREPP ... www.nrepp.samhsa.gov/viewintervention.aspx?id=135

Tips for survivors of a traumatic event. Tips for survivors of a traumatic event. www.samhsa.gov/MentalHealth/tips_survivors_mwww.samhsa.gov/MentalHealth/tips_survivors_managing_your_stressanaging_your_stress


# 18 – CAN THIS PERSON READ?


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.


Realizing that admitting you can’t read is Realizing that admitting you can’t read is more embarrassing to a person than more embarrassing to a person than talking about symptoms!talking about symptoms!

Receiving information in the way a person Receiving information in the way a person can understandcan understand

Learning to read might improve self-Learning to read might improve self-esteem and reduce symptomsesteem and reduce symptoms

Helps close the gap in healthcare Helps close the gap in healthcare disparitiesdisparities

Assessment of the level of functional literacy


REALM-R Rapid Estimate of Adult Literacy

in Medicine, Revised

(a 5 minute 11 word list for English (a 5 minute 11 word list for English speakers which provides a quick speakers which provides a quick

measure of literacy)measure of literacy)Bass et al 2003 Bass et al 2003


Ways to enhance understanding in persons with low level literacy-1

Slow down speech fluencySlow down speech fluency Use “living room” language Use “living room” language

instead of medical terminologyinstead of medical terminology Show or draw pictures to Show or draw pictures to

enhance understanding and enhance understanding and subsequent recallsubsequent recall


Ways to enhance understanding in persons with low level literacy-2

Limit amount of information given at each interaction and repeat instructions

Use a “teach back” or “show me” approach to confirm understanding

Be respectful, caring, and sensitive thereby empowering people to participate in their own health care.

– Williams, Davis, Parker & Weiss. Fam Med. 2002, 34:387)


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


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.


USE OF SPIRITUALITY

Research shows that about half of every Research shows that about half of every sample relies on some sort of faith sample relies on some sort of faith (Western or Eastern formal religion, (Western or Eastern formal religion, informal beliefs , nature, art, music etc.) informal beliefs , nature, art, music etc.) to provide help and supportsto provide help and supports

Need to ask and talk about it if person is Need to ask and talk about it if person is interestedinterested


AND 20) “WHAT DOES THE PERSON THINK HE OR SHE IS RECOVERING FROM?”



If you ask you may be surprised!

Often it has nothing to do with diagnosis or symptoms …………..


CHERYL GAGNE’S LIST from peers:

Loss of self, connection, & hopeLoss of roles and opportunitiesdevaluing and disempowering

programs, practices, and environments

Prejudice and discrimination in society

Internalized oppression and shame

!!


WHAT MADE THE DIFFERENCE ACCORDING TO THOSE INTERVIEWED FROM VERMONT STUDY?

Decent food, Decent food, clothing and clothing and housinghousing

People with whom People with whom to beto be

A way to be A way to be productiveproductive

A way to manage A way to manage s/s and medss/s and meds

Individualized Individualized rx rx

Case Case managementmanagement

Psycho-Psycho-educationeducation

Integration Integration back into the back into the communitycommunity


WHAT DID THE VERMONTERS ALSO SAY MADE THE DIFFERENCE?

Hope!Hope! ““Someone believed in me”Someone believed in me” ““Someone told me that I had a Someone told me that I had a

chance to get better”chance to get better” ““My own persistence”My own persistence” Hope connects with natural self-Hope connects with natural self-

healing capacitieshealing capacities


“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)


Another Resource

Strauss, J.S.; Harding, C.M.: Relationships between adult development and the course of mental disorder. In: J. Rolf, A. Master, D. Cicchetti, K. Nuechterlein, and S. Weintraub (Eds.), RISK AND PROTECTIVE FACTORS IN THE DEVELOPMENT OF PSYCHOPATHY. New York, Cambridge University, 1990.


AS A CLINICIAN BEING SYSTEMATIC CREATIVE, & STRUCTURED IN YOUR APPROACH YOURSELF AND YOUR YOURSELF AND YOUR

RELATIONSHIP ARE THE BEST RELATIONSHIP ARE THE BEST TOOLS IN YOUR KIT BAGTOOLS IN YOUR KIT BAG


MANY THANKS FOR PARTICIPATING. HOPE SOME OF THIS

INFORMATION WILL BE HELPFUL.


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.


20 ways to overcome barriers to recovery (20 th revision) 2012 prof. courtenay m. harding...

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