sixteen critical questions
TRANSCRIPT
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
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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!
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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
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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
FINDINGSo 46-68 % OF EACH COHORT SIGNIFICANTLY 46-68 % OF EACH COHORT SIGNIFICANTLY
IMPROVED AND/OR RECOVEREDIMPROVED AND/OR RECOVEREDo 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.
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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.
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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.
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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.
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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.
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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
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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…
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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
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Learning to play a detective !
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Always important to have some fun!
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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
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QUESTION #1
HAVE OTHER POSSIBLE HAVE OTHER POSSIBLE CAUSES OF SYMPTOMS CAUSES OF SYMPTOMS AND BEHAVIORS BEEN AND BEHAVIORS BEEN ELIMINATED?ELIMINATED?
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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
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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 !
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DIAGNOSIS OF EXCLUSION
(schizophrenia) Autism (esp. Asperger’s Autism (esp. Asperger’s
Syndrome)Syndrome) Temporal Lobe EpilepsyTemporal Lobe Epilepsy TumorTumor StrokeStroke
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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)
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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)
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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
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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
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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)
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SOURCE FOR BASIS-24 Developed by Dr. Susan EisenDeveloped by Dr. Susan Eisen
www.www.basisbasissurvey.org/survey.org/basis24basis24//
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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
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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.
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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)
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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)
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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
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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)
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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
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BATHROOM AND MOBILE PHONE BREAK
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QUESTION # 2DOES THIS PERSON WITH
A PSYCHIATRIC DISORDER HAVE OTHER MEDICAL
PROBLEMS ABOUT WHICH TO WORRY?
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WHY IS THIS QUESTION IMPORTANT?
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.
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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
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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
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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 indicated)MRI (if indicated)
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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.
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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 with who knows person well) go armed with information and written questions and information and written questions and take notes with user to another take notes with user to another physicianphysician
Rescheduling missed appointmentsRescheduling missed appointments Get outside prescriptions into recordGet outside prescriptions into record
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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.
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PAYING ATTENTION GETS ………
Finding strengths in self care Finding strengths in self care managementmanagement
Healthier peopleHealthier people Reduced mortality ratesReduced mortality rates Avoids confounding diagnosisAvoids confounding diagnosis And contraindicated And contraindicated
medicationsmedications
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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.
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QUESTION #3
Is there an Is there an additional additional neurological neurological impairment?impairment?
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WHY IS THIS QUESTION IMPORTANT?
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 if Syndrome then they might do better if they have a medication change, they have a medication change, cognitive remediation, and active cognitive remediation, and active rehabilitationrehabilitation
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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)
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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
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THE DEFICIT SYNDRÔME - 3 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
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THE DEFICIT SYNDRÔME - 4
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 year: Need 2 of the following for more than a 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
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THE DEFICIT SYNDRÔME - 5
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
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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
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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.
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QUESTION #4
WHO IS THIS WHO IS THIS PERSON PERSON
UNDER A COAT UNDER A COAT OF ILLNESS?OF ILLNESS?
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WHY IS THIS QUESTION IMPORTANT?
Once a person has been labeled, he or she is often hidden from view. Finding and working with the real person underneath is the key to recovery.
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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
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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
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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?
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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
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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.pdmh.mo.gov/docs/mentalillness/personwithnogoals.pdfdf))
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.
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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.
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Question #5
WHAT OTHER WHAT OTHER THINGS HELP OR THINGS HELP OR HINDER HINDER PROGRESS?PROGRESS?
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WHY IS THIS QUESTION IMPORTANT?
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.
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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 personality Is the schizophrenia gone but not the personality
quirk, Axis II, or despairquirk, Axis II, or despair Criteria under reconsideration for DSM 5Criteria under reconsideration for DSM 5 Look for evidence of problem-solving, a sense of Look for evidence of problem-solving, a sense of
humor, a philosophical approach, optimism, humor, a philosophical approach, optimism, persistence and strengths in functioning and persistence and strengths in functioning and resilience to build uponresilience to build upon
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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.
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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 hopeCourtenayHardingConsulting@gmail
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
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QUESTION #6
ARE THERE SPECIFIC ARE THERE SPECIFIC NEUROCOGNITIVE NEUROCOGNITIVE DEFICITS BEING COPED DEFICITS BEING COPED WITH BY THIS WITH BY THIS PERSON?PERSON?
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WHY IS THIS QUESTION IMPORTANT?
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?
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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
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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
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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
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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 Memory3) Working Memory
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
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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)
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MUTLIMODAL APPROACH -
GOAL IS TO: MATCH GOAL IS TO: MATCH REHAB TYPE AND REHAB TYPE AND INTENSITY TO CHANGING INTENSITY TO CHANGING NEEDSNEEDS
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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.
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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
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LUNCH BREAKfor one hour
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QUESTION #7
ARE THE ARE THE MEDICATIONS MEDICATIONS REALLY WORTH THE REALLY WORTH THE TRADE-OFF?TRADE-OFF?
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WHY IS THIS QUESTION IMPORTANT?
For years, the field has accepted the idea that the only thing that helps are medications with everything as adjunct.
Data are showing that patients on meds for a long time are dying 25 years earlier than age-related cohorts.
We need to reconsider more “medication optimization” approaches.
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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
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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 q.6 NEED TO SYSTEMATICALLY CHECK q.6 MOS WITH INSTRUMENTSMOS WITH INSTRUMENTS
TRAIN PARTICIPANTS TO SELF-MONITORTRAIN PARTICIPANTS TO SELF-MONITOR ATTEND TO SEX DIFFERENCESATTEND TO SEX DIFFERENCES
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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
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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 OTHERSOTHERS
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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
SUPPORTSUPPORTCourtenayHardingConsulting@gmail
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
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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
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“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 useCourtenayHardingConsulting@gmail
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 Psychiatric
Medications 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-Dec; . 2010 Oct-Dec; 12(5): 70.12(5): 70.
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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)
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Morbidity & Mortality
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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
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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)
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MORBIDITY AND MORTALITY-3
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
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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
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(even after adjusting for known risk factors of premature death such as: smoking, lack of exercise, BMI, B/P, serum total and HDL cholesterol)!
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MORBIDITY AND MORTALITY-6
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)
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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
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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
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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.
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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 ?
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WHY IS THIS QUESTION IMPORTANT?
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
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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
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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.
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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)
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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.orgCourtenayHardingConsulting@gmail
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
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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
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The Substance Abuse & Mental Health
Administration in U.S. has a wealth of publications on research and treatment
strategies.www.SAMHSA.GOV
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QUESTION #9
WHAT ARE THE WHAT ARE THE RELEVANT SEX RELEVANT SEX DIFFERENCES?DIFFERENCES?
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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 a Females often have a later onset which provides a
stronger platform to return tostronger platform to return to Males are more vulnerable and who struggle more Males are more vulnerable and who struggle more
early on but eventually grow stronger in outcome early on but eventually grow stronger in outcome andand
Females may lose their edge at menopauseFemales may lose their edge at menopause
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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
DIFFERENTDIFFERENTCourtenayHardingConsulting@gmail
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
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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
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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
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Some Sex Differences Affecting Illness Presentation and Outcome - 3MALES 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
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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 outcome Harding, C.M. & Hall. G.M.: Long-term outcome studies of schizophrenia: Do females continue studies of schizophrenia: Do females continue to display better outcome as expected? to display better outcome as expected? International Review of PsychiatryInternational Review of Psychiatry, 1997, 9:409-, 1997, 9:409-418418..
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QUESTION # 10WHERE IS THIS WHERE IS THIS PERSON IN THE PERSON IN THE COURSE OF COURSE OF ILLNESS?ILLNESS?
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WHY IS THIS QUESTION IMPORTANT?
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.
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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
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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
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“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
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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
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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?
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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
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QUESTION # 11
WHAT MYTHS AND WHAT MYTHS AND MISINFORMATION MISINFORMATION ARE STRESSING ARE STRESSING THE PERSON?THE PERSON?
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Why is this question important?
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.
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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
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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
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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
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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
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“HOPE CAN ARRIVE ONLY WHEN YOU RECOGNIZE THAT THERE ARE REAL OPTIONS AND THAT YOU HAVE GENUINE CHOICES.” Jerome Groopman, MD (2004)
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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
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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.
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BATHROOM AND MOBILE PHONE BREAK
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QUESTION # 12
WHO DEPENDS ON WHO DEPENDS ON THE CLIENT FOR THE CLIENT FOR HELP?HELP?
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Why is this question important?
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!
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CourtenayHardingConsulting@gmail
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
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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)
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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.
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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, 1998Network) Harding & Keller, 1998
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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
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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.
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QUESTION #13
WHAT IS THE WHAT IS THE PERSON’S PERSON’S WORLD VIEW?WORLD VIEW?
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Why is this question important?
Working to understand cultural, ethnic, religious, and other important factors in the person’s world is absolutely critical for individualized recovery planning.
Everyone has a culture (even Northern Europeans not just people of color)
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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?
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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)
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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
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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.
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Question # 15
IS THERE ANY IS THERE ANY COHESION IN THE COHESION IN THE SYSTEM OF CARE?SYSTEM OF CARE?
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Why is this question important?
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!
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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
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LINKAGES - 2 Clear and consistent policies from the Clear and consistent policies from the
top downtop 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
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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
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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.
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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
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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.
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#14 – WHAT TO DO WITH AN OUT OF CONTROL PERSON?
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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
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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
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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 Programs Individualized Token Behavioral Programs
which tend to generalize to other which tend to generalize to other environmentsenvironments
Reduce Restraint and Seclusion with Reduce Restraint and Seclusion with psychological strategies firstpsychological strategies first
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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
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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.
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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.
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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?
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Why is this question important?
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..
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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
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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).
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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.
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Question # 17. Has the person ever experienced trauma in their life?
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Why is this question important?
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.
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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
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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)
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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)
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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
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CourtenayHardingConsulting@gmail
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
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Mnemonic for COMPLEX PTSD
FEARSFEARSFugue & Other Dissociative statesFugue & Other Dissociative statesEgo fragmentationEgo fragmentationAntisocial BehaviorsAntisocial BehaviorsRe-enactmentRe-enactmentSuicidality & 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
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# 18 – CAN THIS PERSON READ?
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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.
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Realizing that admitting you can’t read is Realizing that admitting you can’t read is more embarrassing to a person than talking more embarrassing to a person than talking about symptoms!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-esteem Learning to read might improve self-esteem and reduce symptomsand reduce symptoms
Helps close the gap in healthcare Helps close the gap in healthcare disparitiesdisparities
Assessment of the level of functional literacy
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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
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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
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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)
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# 19 Does this person believe in something bigger than self?
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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.
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CourtenayHardingConsulting@gmail
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
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AND 20) “WHAT DOES THE PERSON THINK HE OR SHE IS RECOVERING FROM?”
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Why is this question important?
If you ask you may be surprised!
Often it has nothing to do with diagnosis or symptoms …………..
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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
!!
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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
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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 capacitiesCourtenayHardingConsulting@gmail
“To hope under the most extreme circumstances is an act of defiance that….permits a person to live his [her] life on his [her] own terms. It is the part of the human spirit to endure and give a miracle a chance to happen.” Jerome Groopman, MD (2004)
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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.
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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
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MANY THANKS FOR PARTICIPATING. HOPE SOME OF THIS
INFORMATION WILL BE HELPFUL.
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Presenter Information Courtenay M. Harding, Ph.D., recently retired as a professor in the department of psychiatry at
the College of Physicians and Surgeons of Columbia University. She was trained at the University of Vermont and Yale. She also just retired as the director of the Center for Rehabilitation and Recovery at the Coalition of Behavioral Health Agencies in NYC. Dr. Harding moved to New York from Boston where she was the Senior Director of Boston University’s well-known Center for Psychiatric Rehabilitation under William Anthony. Among her research endeavors, Dr. Harding participated in two three-decade NIMH studies of schizophrenia and other serious illnesses and found that many once profoundly disabled persons could and did significantly improve and/ or even fully recover. These findings, similar to nine other long-term studies from across the world, helped to create the Institute for the Study of Human Resilience in order to investigate ways in which people reclaimed their lives including getting back to work. To date, she has received 52 federal, state, and foundation grants and contracts for schizophrenia research and studies of mental health services. She has been the recipient of over 46 awards and honors including the Alexander Gralnick Research Investigator Award from the American Psychological Association’s foundation for “exceptional contributions to the study of schizophrenia and other serious mental illness and for mentoring a new generation of researchers” Dr. Harding has published extensively about schizophrenia, rehabilitation, and recovery and has presented findings from her studies and clinical work in over 500 state, national, and international meetings. She has worked with 30 states, Australia, New Zealand, 11 European, and 9 Asian countries including China to redesign their systems of care.
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