IMR 2-Day Training Tim Gearhart MSW Dave Thomas, BA, PRS ACT Center of Indiana
Evidence Based Practice? • 'Evidence-Based Practice (EBP) requires that decisions about health care are based on the best available, current, valid and relevant evidence. These decisions should be made by those receiving care, informed by the tacit and explicit knowledge of those providing care, within the context of available resources.Martin Dawes, et al (2005)
Illness Management Research • Reviewed 40 randomized controlled studies which included psycho-education, medication-focused programs, relapse prevention, coping skills training, cbt for psychosis. (Mueser et al) • Target population for the lit review included: schizophrenia, bipolar disorder, and general SMI • Who is your target population?
Outcomes of interest • Proximal outcomes: knowledge of MI and using medication as prescribed • Distal outcomes: relapses, symptoms, and social functioning • What outcomes are you looking for? • Client level? • CSR related? • Fidelity related? • Clinical competency of staff? • Agency culture? • Staff burn-out? • Appendix 8 + 9
Psycho-education findings of 4 large studies • ¾ showed improved knowledge of their mental illness. • 1 showed improvement in medication adherence. • Discussion
Medication Focused Programs • Behavioral Tailoring and simplifying medication regimens found increased adherence in %100 of the studies reviewed. • Motivational Interviewing showed increased adherence, fewer symptoms and relapses and improved social functioning. • Medication Psycho-Ed found minimal results likely due to memory issues.
Relapse Prevention Training • Focus on identifying early warning signs, triggers, and stress management skills. • All programs/studies reviewed showed a decrease in relapse or hospitalization. • Significant other involvement shows effectiveness in preventing relapses.
Coping Skills Training • Increases consumer’s ability to deal with persistent symptoms and stress • All program’s/studies reviewed utilized cognitive behavioral intervention and produced similar outcomes.
Cognitive behavioral TX of psychotic symptoms • More effective than standard care for reducing the severity of psychotic symptoms.
Evidence Base for IMR • Psychoeducation • Behavioral tailoring for medication adherence • Relapse prevention training • Coping skills training • How many programs do you have that are set up under one of these categories?
Illness Management and Recovery Program • IMR is a step-by-step program that helps consumers set meaningful goals and learn skills to assist them in the pursuit of those goals. • Typically lasts 3 to 9 months w/ weekly or bi-weekly session. • Group or Individual. • Programmatically flexible.
Topics of Modules • Recovery Strategies • Practical Facts about Mental Illness • The Stress-Vulnerability Model • Building Social Support • Using Medication Effectively • Reducing Relapses • Coping with Stress • Coping with Problems and Symptoms • Getting Your Needs Met in the Mental Health System • Substance Abuse
Program Goals • Inspire hope with positive expectations. • Empower informed decision makers. • Help people set and make progress towards personal recovery goals • Teach people how to use medication effectively • Help people understand and develop relapse prevention plans • Teach people strategies for coping with persistent symptoms and other problems
Clinical Interventions • Handouts are not to stand alone. Clinical techniques are implored to assist consumers in integrating skills into daily life. • MI, CBT, and Edu.
Motivational Interventions • Connect info and skills with personal goals • Promote hope and positive expectation • Explore pros and cons of change • Reframe experiences in a positive light
Cognitive Behavioral Interventions • Reinforcement • Cognitive restructuring • Shaping • Re-framing • Modeling • Role playing • Relaxation training
Educational Techniques • Interactive teaching • Review homework • Check for understanding • Complete worksheets • Review information • Break down info
Definitions of Recovery “Recovery involves the development of new meaning and purpose in one’s life as one grows beyond the catastrophic effects of mental illness.” (Anthony, 1993) “One of the elements that makes recovery possible is the regaining of one’s belief in oneself.” (Chamberlin) “Recovery is what occurs when a person with a mental illness discovers (or rediscovers) their strengths and abilities for pursuing personal goals and develops a sense of identity that allows them to grow beyond their mental illness” (Author Unknown) “Recovery is a process, a way of life, an attitude and a way of approaching the day’s challenges.” (Deegan)
Recovery is… • An opportunity to grow through ones challenges • Becoming a self defined person with a self defined purpose • Experiencing authentic happiness, friendships, realization of ones place in the world • A peace of mind, hope for a future and joy along the way
Recovery is not… • A cure • Freedom of symptoms • An end to stress and/or problems • Elimination of relapses • A life that one originally planned
Recovery is a Journey of the Heart “It is only with the heart that one can see rightly; what is essential is invisible to the eye.” -Antoine De Saint-Exupery-
Hope for Recovery • Body of research shows a more optimistic picture • Review of long-term follow up studies of schizophrenia show that between 42% and 68% of consumers with the illness experience either full recovery or show substantial improvement in their lives (Hafner et al., 2003) • Growth and enthusiasm for the vision of recovery championed in the consumer movement
SAMHSA Consensus on Recovery “Recovery must be the common, recognized outcome of the services we support.” Charles Curie; SAMHSA Administrator
10 Fundamental Components of Recovery: • Self-Direction: the recovery process must be self-directed and defined his or her own life goals • Individualized and Person-Centered: There are multiple pathways to recovery based on an individual’s unique strengths and resiliencies as well as his or her needs, preferences, experiences (including past trauma), and cultural background in all of its diverse representations
Components (continued) • Empowerment: having the authority to choose from a range of options and to participate in all decisions that will affect individuals lives, and are educated and supported in so doing. • Holistic: Recovery encompasses an individual's whole life, including mind, body, spirit, and community.
Components (continued) • Non-Linear: Recovery is not a step-by step process but one based on continual growth, occasional setbacks, and learning from experiences • Strengths-Based: Recovery focuses on valuing and building on the multiple capacities, resiliencies, talents, coping abilities, and inherent worth of individuals
Components (continued) • Peer Support: Mutual support (including the sharing of experiential knowledge and skills and social learning) plays an invaluable role in recovery • Respect: Self-acceptance and regaining belief in one’s self are particularly vital. Respect ensures the inclusion and full participation of consumers in all aspects of their lives
Components (continued) • Responsibility: Consumers have a personal responsibility for their own self-care and journeys of recovery. Consumers must strive to understand and give meaning to their experiences and identify coping strategies and healing processes to promote their own wellness. • Hope: Hope is the catalyst of the recovery process Document available at www.mentalhealth.samhas.gov
How can mental health professionals help consumers with their recovery? Deegan: ‘Hope, Nurturance, Listening, Patience’
Hope ...it is not our job to pass judgment on who will and will not recover from mental illness and the spirit breaking effects of poverty, stigma, dehumanization, degradation and learned helplessness. Rather, our job is to participate in a conspiracy of hope. It is our job to form a community of hope which surrounds people with psychiatric disabilities.
Listening It is our job to ask people with psychiatric disabilities what it is they want and need in order to grow and then to provide them with good soil in which a new life can secure its roots and grow.
Patience …And then finally, it is our job to wait patiently, to sit with, to watch with wonder, and to witness with reverence the unfolding of another person’s life.
Relationship of Recovery to Illness Management • Improve ability to manage life one’s illness through knowledge, understanding, acceptance of one’s illness • Identifying and achieve ones personal recovery goals through the understanding and hope of change is possible • Minimizing relapses and re-hospitalizations giving people enhanced control in their lives • Less time spent dealing with mental illness allowing more time spent on personally fulfilling and purposeful lives • Less stress due to symptoms and impairment leading to a better quality of life
Recovery is reaching the highest level of wellness, happiness, and life satisfaction
Regaining Motivation “Motivation - that’s the key. If you have a reason in this world for wanting to cope, you can do it.” Peer Specialist, Mt. Carmel Guild Behavioral Healthcare, Program for Assertive Community Treatment
“Recovery is about having confidence and self-esteem. There are things I’m good at, and I have something positive to offer the world.” From EBP Illness Management & Recovery Implementation Resource Kit Regaining Self-Esteem
Regaining Meaning “I have to have goals. That’s what gives my life meaning. I’m looking to the future.” From EBP Illness Management & Recovery Implementation Resource Kit
IMR Emphasizes Personal Goals as Fundamental Recovery Tool • For many people, the whole point of recovery is to be able to move forward in life, and being able to set and pursue personal goals • Looking into the future-not inward-not back to the past
Setting and Pursuing Personal Goals • Being able to set and pursue personal goals is an essential part of recovery and IMR • Gives opportunity to explore the risk and ambivalence of change providing the nature and the motivation for change • Presents opportunities to learn and applying the information, strategies and skills taught in IMR
Be positive and hopeful Encourage and understand us Be friendly, supportive and respectful Be firm and protective when necessary Be available and have back-up service Be up-to-date Be willing to admit and remedy mistakes Some Ideas from Consumers
Close monitoring Emphasize self-care and personal responsibility Explore and try new approaches Use less invasive alternatives Use a team approach Consider individual needs and preferences Have good listening and communication skills Care about us Accept us as we are Support from Professionals
Core Values of IMR • Hope is the key ingredient • The person is the expert • Personal choice is a must • Practitioners of IMR are partners • Practitioners demonstrate not dictate • Respect is always present
Materials for IMR • Practitioners Guidelines: Gives ideas for MI, CBT, and Educational Techniques. • Educational Handouts: Information that is actually covered in session. • Implementation Tool Kit: Selected Articles, Info documents, Implementation tips, fidelity scales, outcome guides, intro and demo videos
Getting Started • 1st session: Orientation Sheet (Appendix 1) • 2nd and 3rd session: Knowledge and skills inventory (Appendix 2) • Remaining sessions: Utilize educational handouts. Use progress note (Appendix 3) • Continually look for ways Significant Others might avail themselves to consumer hmwk and goals (Appendix 4) • Modules build on one another but it isn’t essential to go through them in order.
Structure of IMR Sessions 1. Informal socializing 2. Review previous session 3. Review previous home assignment 4. Follow up on goals (for group, follow up on goals of 2-3 consumers on rotating basis) 5. Set agenda for current session 6. Teach new material from handout 7. Develop a home assignment collaboratively 8. Summarize session and progress made
Module 1: Recovery Strategiesread the practitioners guidelines. • Assist in defining recovery • Life Goals: hopes for overall improvements • Enhancement goals: reflects quality of life concerns
Module 1: Recovery Strategies • Address ambivalence around recovery goals and strategies for recovery. • Docere – Expert • Ducere – Calling forth that which is already there. • E.g. Socrates, Photo Album