20 WAYS TO OVERCOME BARRIERS TO RECOVERY

1
20 WAYS TO OVERCOME BARRIERS TO RECOVERY

• Prof. Courtenay M. Harding
• Professor of Psychiatry and Director,
• Center for Rehabilitation and Recovery
• The Coalition of Behavioral Health Agencies - NYC

2
(No Transcript)
3
Good Morning!

• OVERALL GENERAL INFORMATION FOR TODAY
• Whats in the folders?
• How to work with this information
• Take a break for phone bathroom
• Ask questions as we go along
• Evaluations and Certificates at end

4
THE PRESENTATION PLAN

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

5
(No Transcript)
6
IF RECOVERY AND SIGNIFICANT IMPROVEMENT ARE
POSSIBLE.

• THEN WHY ARE SO MANY PARTICIPANTS NOT GETTING
  BETTER?
• 2.5 5 MILLION PEOPLE LANGUISHING IN US ALONE

7
ACKNOWLEDGMENT APPRECIATION

• TO ALL THE CLINICIANS FAMILIES
• WHO CARE
• WHO SPEND TIME PROBLEM SOLVING
• WHO CHALLENGE THE STATUS QUO
• WHO SPEND TIME GOING THE EXTRA MILE

8
HOWEVER..

• If your participant seems to be stuck on the
  path to recovery lets look at some possible
  reasons and ways to change the Individual
  Recovery Plan (IRP)

9
Learning to play a detective !
10
(No Transcript)
11
LOOKING FOR THE PERSON UNDER THE DISORDER

• COMPREHENSIVE RE-EVALUATION NEEDED (based on
  history, careful interview, lab findings
  physical exam)
• BIO-PSYCHO-SOCIAL-SPIRITUAL APPROACH
• SYSTEMATIC MULTIDISCIPLINARY

12
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

13
QUESTION 1

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

14
(No Transcript)
15
DIAGNOSIS OF EXCLUSION(especially schizophrenia)

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

16
DIAGNOSIS OF EXCLUSION(schizophrenia)

• Autism (esp. Aspergers Syndrome)
• Temporal Lobe Epilepsy
• Tumor
• Stroke

17
MORE THINGS TO EXCLUDE

• Brain Trauma
• Endocrine Metabolic Disorders (e.g. acute
  intermittent porphyria (liver enzyme)
• Homocystinuria (a disorder of amino acid
  metabolism)

18
MORE THINGS TO EXCLUDE

• Vitamin Deficiency (e.g. B 12)
• Central Nervous System Infectious Processes (e.g.
  AIDS, neurosyphilis, or herpes encephalitis)
• Autoimmune Disorders (systemic lupus erthymatosa)
• Heavy Metal Toxicity (e.g. Wilsons Disease too
  much copper)

19
EVEN MORE TO EXCLUDE

• Some Drug Induced States (e.g. amphetamines,
  barbiturate withdrawal, cocaine, digitalis,
  disulfram)
• Mood disorders, schizoaffective disorder,
• Personality disorders,
• Brief Reactive Psychosis,
• OCD

20
Differential Diagnoses for Mood D/O (based on
history, careful interview, lab findings
physical exam)

• Multiple Sclerosis
• Stroke
• Hyper Hypothyroidism
• Bereavement
• Dementia
• Cancer (esp. of Pancreas)
• Spinal Cord Injury
• Peptic Ulcer
• Mononucleosis

• Huntingtons Disease
• AIDS
• End-stage Renal Disease
• Head Injury
• Parkinsons Disease
• Lupus
• Hyper Hypo parathyroidism
• Hepatitis

21
SUGGESTED INSTRUMENT

• Basis-24
• a leading behavioral health assessment
• Comprehensive
• Cuts across diagnostic categories
• Provides weighted average
• Overall score plus 6 subscales
• (sub abuse, symptoms and functioning,
  relationships, self harm, emotional liability,
  psychosis, and depression)

22
SUGGESTED INSTRUMENT

• SCID THE STRUCTURED CLINICAL INTERVIEW FOR
  DSM-IV TR
• CLINICAL VERSION

23
HOW TO DO BETTER

• Take the time get triangulated information
• Get the lab tests done
• Reassess over time
• Pay attention to comorbid d/o

24
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 a psychiatric disorder
• Health Homes are coming as networks of
  partnerships treating person in a holistic way
• Partners include hospital, primary care docs,
  mental health and addiction services

25
OR IF PSYCHIATRIC DIAGOSIS IS RE-ESTABLISHED

• All diagnosis are cross-sectional working
  hypotheses
• Not lifetime labels
• Not able to predict long-term outcome
• Write enough evidence to convict person of the
  diagnosis into the case record

26
REMEMBER TO LOOK FOR RECORD STRENGTHS

• Strengths of your participant ( e.g. insight?
  Manage meds? Manage S/S ? Uses strategies to
  recognize oncoming prodrôme? Uses coping to
  reduce anxiety? Computer skills? Has drivers
  license? ETC
• Working with the strengths rather than deficits,
  problems and disabilities that is what helps
  people get better

27
EBPWELLNESS MANAGEMENT AND RECOVERY PROGRAM-1

• CLINICIAN BENEFITS
• A comprehensive step by step approach
• Ready-to-use materials
• Skills is using motivational , cognitive
  behavioral and educational strategies
• ? Satisfaction to see ? outcomes

28
EBP WELLNESS MANAGEMENT AND RECOVERY PROGRAM-2

• CLINICIANS RECEIVE
• guide with practical tips
• handouts, checklists, planning sheets
• intro video
• info brochures
• fidelity scale
• outcome measures

29
EBP WELLNESS MANAGEMENT AND RECOVERY PROGRAM-3

• reducing
• relapses
• using meds
• effectively
• coping with
• stress
• coping with
• problems symptoms
• getting your
• needs met in the mh system

• Recovery strategies
• Practical facts about mi
• Stress-Vulnerability treatment strategies
• Building social supports

30
EBP ILLNESS (WELLNESS) MANAGEMENT AND RECOVERY
PROGRAM-4

• RESOURCES
• Wellness Self-Management Plus by Columbia
  University Paul Margolies and Tony Salerno
• http//www,mentalhealth.samhsa.gov/cmhs/communitys
  upport/toolkit
• http//www.mentalhealthpractices.org/imr_mlpl.
• html
• Liberman RL et al, describing UCLA Models,
  Innovations Research, Vol2(2), 1993
• P.A. Garrety et al , Schiz Bull, 2000

31
QUESTION 2

• Is there an additional neurological impairment?

32
(No Transcript)
33
THE DEFICIT SYNDRÔME

• /- S/S of Schizophrenia Come and Go (esp.
  symptoms)
• Attempts to find primary, enduring stable
  negative symptoms
• Subtype or Additional D/O
• Neurological Impairments ( sensory integration,
  stereognosis, graphesthesia, right-left
  confusion, the face-hand test, audiovisual
  integration)

34
THE DEFICIT SYNDRÔME - 2

• Poor premorbid social functioning
• Reduced glucose uptake in the frontal cortex,
  parietal thalamic areas on PET scans
• Increased anhedonia and fewer psychotic events
• Earlier onset, seems to be unremitting, suffer
  spontaneous movement d/o, severe cognitive
  impairments

35
THE DEFICIT SYNDRÔME - 3

• Deficit PARTICIPANTs in comparison to NonDeficit
• PARTICIPANTs show
• Equal positive symptoms (hallucinations,
  delusions, and formal thought d/o)
• Less severe dysphoric symptoms (e.g. depressive
  mood, anxiety, guilt, hostility)
• Less severity of suspiciousness
• Similar duration of illness
• Brain architecture seems to be more intact in
  some areas

36
THE DEFICIT SYNDRÔME - 4

• Need longitudinal information
• Use SDS or PDS Criteria
• Exclude drug effect demoralization
• Need 2 of of the following for more than a year
• restricted affect,
• diminished emotional range,
• poverty of speech,
• curbing of interests,
• diminished sense of purpose and social drive

37
THE DEFICIT SYNDRÔME - 5

• USE SCREENING TOOL THE Neurological Evaluation
  Scale (NES)
• TRY
• Atypical Neuroleptics
• Cognitive Remediation
• Other Aggressive Rehab

38
Some Resources

• Brian Kirkpatrick et al, 1989, (SDS -The Schedule
  for the Deficit Syndrome), 1993, 2001
• PDS Proxy for Deficit Syndrome Kirkpatrick 1996
  (core deficit no dysphoria)
• Robert W. Buchanan et al, 1990, 1993,1994, 1996

39
QUESTION 3

• DOES THIS PERSON HAVE OTHER MEDICAL PROBLEMS
  ABOUT WHICH TO WORRY?

40
(No Transcript)
41
OVERVIEW OF SITUATION

• 40-60 with medical co-morbidity
• Not recognized nor treated
• Participants get turfed back to psychiatry or
  not referred at all
• Need primary care, eye hearing exams, OB etc
• Need physical by nurse practitioner, a health
  history questionnaire and basic lab tests

42
LABORATORY TESTS TO ORDER

• BIOCHEM 23
• TOX SCREEN
• COMPLETE BLOOD COUNT
• URINALYSIS
• THYROID FUNCTION TESTS (T4 TSH)

• B-12
• FOLATE
• VDRL (for syphilis)
• HIV
• _______________
• CT or
• MRI (if indicated)

43
Some Suggested Strategies

• Collaboration and linkages
• Have a case manager or other person who knows
  person well go armed with information and written
  questions and take notes
• Rescheduling missed appt.s
• Get outside prescriptions into record

44
Medical Algorithm for Detecting Physical Disease
in Psychiatric Patients

• Harold C. Sox, Jr. et al Hospital and Community
  Psychiatry, vol.40 (12) 1270-1276

45
Some Suggested Strategies

• Offer preventive programs e.g. Weight Watchers,
  Jazzercise, other exercise programs, nutrition,
  cooking and grocery shopping skills, meditation,
  other relaxation techniques, walking, blood
  pressure and diabetes monitoring.
• Health and Wellness Education Classes

46
PAYING ATTENTION GETS

• Finding strengths in self care management
• Healthier people
• Reduced mortality rates
• Avoids confounding diagnosis
• And contraindicated medications

47
QUESTION 4

• WHO IS THIS PERSON UNDER A COAT OF ILLNESS?

48
(No Transcript)
49
ASSESSMENT OF ADULT DEVELOPMENT

• PSYCHIATRIC PROBLEMS DISRUPT A LIFE
• NEED TO GRIEVE FOR LOSS OF TIME AND OPPORTUNITIES
• THE REHABILITATION CRISIS (McCRORY, 1982)
• ASSESSMENT OF PREMORBID LEVELS OF FUNCTIONING
  (PEER RELATIONS, SCHOOL PERFORMANCE AND DATING
  etc)

50
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

51
Question 5

• WHAT OTHER THINGS HELP OR HINDER PROGRESS?

52
(No Transcript)
53
Assessment of THINGS THAT GET IN THE WAY OF
RECOVERY PROCESS

• NEED TO ASSESS SOCIALIZATION INTO PARTICIPANT
  ROLE
• LIMITED ECONOMIC OPPORTUNITIES
• MEDICATION SIDE EFFECTS, LACK OF REHABILITATION,
  EXTREME VIRULENCE OF ILLNESS, LACK OF STAFF
  EXPECTATIONS, LOSS OF HOPE

54
ASSESSMENT OFCHARACTERLOGICAL TRAITS

• Can get in the way or aid progress
• How did the person respond to crises before
  mental illness?
• Is the schizophrenia gone but not the personality
  ?
• Look for problem-solving, a sense of humor, a
  philosophical approach, optimism, persistence and
  strengths in functioning

55
QUESTION 6

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

56
SCHIZOPHRENIA NEUROCOGNITIVE DEFICITS

• Attention
• Vigilance
• Executive functioning (reasoning, judgment,
  problem-solving, anticipation, planning,
  decision-making)
• Learning
• Memory
• Ability to read affect on faces
• Find cognitive strengths

57
MUTLIMODAL APPROACH

• Tests of laterality- prefrontal, frontal,
  parietal, temporal functioning
• Semantic, episodic working memory
• Expressive receptive language
• Constructional skills

58
MUTLIMODAL APPROACH -2

• NEW COGNITIVE RETRAINING EFFORTS
• VIDEO CUE TRAINING
• GOAL IS TO MATCH REHAB TYPE AND INTENSITY TO
  NEEDS

59
SOME RESOURCES

• G.E. Hogarty - Cognitive Enhancement Therapy
  2002- Guilford Press
• G.E. Hogarty S. Flescher (1999)
• H.D. Brenner et al Hografe Huber Toronto, 1994
• W. Spaulding et al BJP, 1989
• Michael F. Green AJP, 1996
• MATRICS new 60 minute battery
• Harding - A Classical but short battery

60
QUESTION 7

• ARE THE MEDICATIONS REALLY WORTH THE TRADE-OFF?

61
(No Transcript)
62
ASSESSMENT OF NEED FOR, RESPONSE TO, AND SIDE
EFFECTS FROM MEDICATION

• TAKE A THOROUGH HISTORY
• GET OLD RECORDS
• TALK TO OTHERS WHO KNOW PERSON
• COLLABORATE, COLLABORATE, COLLABORATE, COLLABORATE

63
CAUSES OF MISINTERPRETATION

• MUST LISTEN TO THE WAY MEDS MAKE PEOPLE FEEL FROM
  THE INSIDE OUT
• SOMETIMES CLIENTS CANT DESCRIBE SUBTLE FEELINGS
• E.g. Side Effect of Akathisia- being compelled to
  be in motion- pacing, rocking, etc thought to be
  agitation, elopement, need for seclusion, acting
  out, and left untreated.
• USE AIMS EPS EXAM q.6 MOS

64
MORE ON SIDE EFFECTS

• 20-30 OTHER SIDE EFFECTS e.g. DYSKINESIAS,
  DYSTONIAS, PARKINSONISM
• EVEN NEW ATYPICALS CAN HAVE SIDE EFFECTS DOSE
  DEPENDENT
• NEED TO SYSTEMATICALLY CHECKED q.6 MOS WITH
  INSTRUMENTS
• TRAIN PARTICIPANTS TO SELF-MONITOR
• ATTEND TO SEX DIFFERENCES

65
DEFINITION OF THE WORD COMPLIANCE

• GIVING IN TO A REQUEST, DEMAND, WISH
  ACQUIESENCE A TENDENCY TO GIVE IN TO OTHERS

66
vs ADHERENCE

• TO STICK FAST
• TO BECOME ATTACHED
• TO GIVE ALLEGIANCE TO
• TO GIVE DEVOTION OR SUPPORT

67
MORE ADVICE

• nothing in the literature that says everyone
  needs meds for a lifetime only maybe a small
  group
• taper, taper very very slowly if on for a long
  time

68
EBP- MedMAP MEDICATION MANAGEMENT APPROACHES IN
PSCYHIATRY

• Provides a systematic structured plan for med
  management
• Documentation is clearer and more concise
• Objective measures of outcome
• Shared decision-making

69
EBP- MedMAP MEDICATION MANAGEMENT APPROACHES IN
PSCYHIATRY - 2

• New developments in antipsychotic therapy - an
  interesting discussion report of a group of
  psychopharmacologists J. Clin Psych Nov 2003
• CATIE Clinical Antipsychotic Trials of
  Intervention Effectiveness
• CATIE Results underscore need for access to
  full range of medications in www.szdigest.com
  and also NEJM Sept 22, 2005 J. Lieberman et al

70
Morbidity Mortality
71
MORBIDITY AND MORTALITY

• The Metabolic Syndrome
• Abdominal obesity (excessive fat tissue in and
  around the abdomen)
• Atherogenic dyslipidemia (blood fat disorders
   high triglycerides, low HDL cholesterol and
  high LDL cholesterol that foster plaque
  buildups in artery walls)
• Elevated blood pressure

72
MORBIDITY AND MORTALITY-2

• More of The Metabolic Syndrome
• Insulin resistance or glucose intolerance (the
  body cant properly use insulin or blood sugar)
• Prothrombotic state (e.g., high fibrinogen or
  plasminogen activator inhibitor1 in the blood)
• Proinflammatory state (e.g., elevated C-Reactive
  Protein in the blood)

73
MORBIDITY AND MORTALITY-3

• Increased risks of
• Coronary heart disease
• Stroke
• Peripheral vascular disease
• Type 2 Diabetes
• Physical inactivity
• Hormonal Imbalance
• Expression of familial genetic profile

74
MORBIDITY AND MORTALITY-4

• Graded relationship between number of
  neuroleptics taken and mortality
• (even after adjusting for known risk factors of
  premature death such as smoking, lack of
  exercise, BMI, B/P, serum total and HDL
  cholesterol).

75
MORTALITY-5

• Graded relationship between number of
  neuroleptics taken and mortality and dosage
  levels with
• Fatal arrhythmias
• Sudden cardiac deaths
• Venus thrombosis
• Pulmonary embolism
• Asthma deaths

76
MORBIDITY AND MORTALITY-6

• On 1st Generation drugs mortality risk 2.84 and
  was just slightly reduced to 2.25 after adjusting
  for other factors such as somatic diseases, BMI,
  exercise, B/P, BMI, alcohol intake and education.
• Relative risk for each new drug added 2.50
  additional risk.
• Joukamaa et al, 2006
• Similar Findings for Atypicals and for
  Antidepressants (both SSRIs and Tricyclics)

77
(No Transcript)
78
New Considerations for optimization of medications

• Some people seem to need no medications
• Some people seem to need medications for a short
  while
• A few people seem to need medication for a longer
  period.

79
Support for optimization of medications.

• Literature says that 1st episode participants may
  need little or no medications
• Nothing in the literature that says everyone
  needs meds for a lifetime only maybe a small
  group
• Taper, taper very very slowly if on for a long
  time

80
More Resources

• Personal Therapy GE Hogarty et al 1997 helps
  adherence
• W. Fenton Psych Times 2006 Combined therapy
• MedMAP http//www.mentalhealth.SAMHSA.org
• APA 2004 Practice Guidelines
• Texas Medication Algorithm No!

81
QUESTION 8

• WHY IS THIS PERSON TAKING STREET DRUGS IN PLACE
  OF OR IN ADDITION TO PRESCRIPTIONS ?

82
(No Transcript)
83
INFO ON USING STREET DRUGS

• At least 47 co-occurring disorders
• Most costly to treat
• IS PERSON TREATING DEPRESSIONS OR MEDICATION SIDE
  EFFECTS (e.g. Akinesia) or to ameliorate lack of
  motivation and pleasure or to combat loneliness
  or to get a social group ?

84
INFO ON USING STREET DRUGS -2

• MAKES INITIAL DIAGNOSIS DIFFICULT
• USE OF STRUCTURED INTERVIEWS HELPFUL (SCID OR
  ASI)
• INFO ON STREET DRUG OF CHOICE MAY BE HELPFUL TO
  ADD INTO DIAGNOSTIC PROCESS
• STANDARD CONFRONTATIONAL MODELS MIGHT NOT WORK
  FOR PEOPLE WITH SCHIZOPHRENIA
• BLENDED FUNDING STREAMS AND INTEGRATED CARE MORE
  HELPFUL

85
Co-Occurring or Dual Dx D/Ocan lead to

• Symptom
• Relapses
• hospitalization
• financial and family problems
• homelessness
• suicide

• Violence,
• Sexual and physical victimization,
• Incarceration,
• HIV,
• Hepatitis B and C
• and early death.

86
EBP Integrated Dual Disorders Treantment (IDDT)

• Services provided concurrently
• Individualized assessment and treatment planning
  in heavy collaboration
• Use SCID-SA Screener

87
EBP Integrated Dual Disorders Treatment

• DUAL DISORDERS TREATMENT IMPLEMENTATION RESOURCE
  KIT
• Information
• Training Materials
• Annotated Bibbs
• Refs
• http//www.mentalhealthpractices.org

88
EBP Integrated Dual Disorders Treatment

• Blending
• Stage-wise Treatment
• Motivational Treatment
• Substance Abuse Counseling
• Involving all stakeholders
• 4 basic skills for clinicians
• Knowledge of substances how they affect MI
• Assessment skills
• Motivational interviewing skills
• SA Counseling skills

89
QUESTION 9

• WHAT ARE THE RELEVANT SEX DIFFERENCES?

90
(No Transcript)
91
SEX DIFFERENCES ACROSS THE LIFE SPAN

• NEURAL DEVELOPMENTAL GROWTH
• BIRTH COMPLICATIONS
• PEDIATRIC INJURIES
• PUBERTY AND HORMONES
• METABOLIC DIFFERENCES
• MENOPAUSE
• PRESCRIBING PRACTICES ARE DIFFERENT

92
QUESTION 10

• WHERE IS THIS PERSON IN THE COURSE OF ILLNESS?

93
(No Transcript)
94
COURSE INFORMATION

• Schizophrenia is virulent early and tapers off
  later
• Like other general medical disorders
• Mother nature is trying to help
• BURNT OUT vs. The phoenix

95
MORE ON COURSE

• ALSO COURSE OF LIFE, ITSELF
• USE A LIFELINE OR LIFE HISTORY
• MUTUAL PARTICIPATION MODEL
• LONGITUDINAL PATTERNS AND TRENDS
• DIFFERENT USES OF SOCIAL RELATIONSHIPS
• BUILD THERAPEUTIC RELATIONSHIPS

96
QUESTION 11

• WHAT MYTHS AND MISINFORMATION ARE STRESSING THE
  PERSON?

97
(No Transcript)
98
ASSESSMENT OF UNDERSTANDING THE ILLNESS AND
MEDICATIONS

• Knowledge is power
• Collaboration and education
• Helps change the stressful valence can reduce
  relapse rates
• Teaches how to manage symptoms
• Promotes competency and empowers
• Increases self-esteem

99
QUESTION 12

• WHO DEPENDS ON THE CLIENT FOR HELP?

100
(No Transcript)
101
SOCIAL SUPPORTS

• CONNECTION BETWEEN KIND AND AMOUNT OF SOCIAL
  SUPPORTS AND RECOVERY FROM AND PREVENTION OF
  ILLNESS OF ALL KINDS
• NETWORKS TYPE, AMOUNT, DENSITY, SIZE, DEGREE
  OF INTERDEPENDENCE, CLUSTERING, DEGREE OF INTIMACY

102
SOCIAL SUPPORTS - 2

• Social Skills Training (Promising Rehab Practice)
• Reading social cues
• Acting appropriately
• Practicing acceptable social behaviors
• (e.g. eye contact, small talk etc)
• Decrease loneliness
• Increase possibility of finding friends and
  significant others.

103
More resources

• Robert Libermans Social Independent Living
  Skills Modules at UCLA
• See Innovations Research
• Vol2 (2) 1993
• Hardings Star Chart (Social Network) Harding
  Keller, 1998

104
QUESTION 13

• WHAT IS THE PERSONS WORLD VIEW?

105
(No Transcript)
106
CULTURAL SENSITIVITY

• ONLY RECENTLY APPRECIATED
• DIVERSITY IS HALLMARK OF WORLD
• NEED TO UNDERSTAND AT INTAKE ONWARD
• WHAT IS IMPORTANCE OF RELIGIOUS THINKING versus
  RELIGIOSITY?
• SENSE OF TIME?
• DISPLAYED AFFECT?

107
CULTURAL SENSITIVITY-2

• Disorganized sounding speech - a linguistic
  variation?
• Importance of family, community and church?
• Is the interpreter asking the same questions you
  are? (see Utah DMH video)

108
CULTURAL SENSITIVITY-2

• WWW.WICHE.EDU/MENTALHEALTH
• SAMHSAs only approved standards for anything
• Benchmarks
• Guidelines
• Outcome Measures
• Lit Review
• For everyone and for the core 4 minority groups

109
Question 15

• IS THERE ANY COHESION IN THE SYSTEM OF CARE?

110
(No Transcript)
111
LINKAGES - 1

• Coordination and linkage between all the players
  are critical
• Need semi-permeable membranes for information
  sharing, flexibility, coordination, continuity
  and integration
• Clear and consistent policies from the top down
• The more we have our act together the better the
  participants become

112
LINKAGES - 2

• Clear and consistent policies from the top down
• Use community resource checklist (cmhcs,
  extension serv, consumer groups, nat support)
• The more we have our act together the better the
  participants become

113
QUESTION 14 RISK MANAGEMENT - 2

• Research has found the following risk factors for
  minor and serious violence
• PERSECUTORY IDEATION
• SUBSTANCE ABUSE
• CHILDHOOD CONDUCT D/O
• VICTIMIZATION

114
14 WHAT TO DO WITH AN OUT OF CONTROL PERSON?
115
(No Transcript)
116
RISK MANAGEMENT

• Relapse Prevention Strategies
• Try Paul and Lentz Social Learning Environments
  (behavioral)
• Tony Mendittos program for forensic participants
• Individualized Token Behavioral Programs which
  tend to generalize to other environments
• Reduce Restraint and Seclusion with other
  psychological strategies first

117
QUESTION 16

• WHERE DO THE CLINICIAN AND CONSUMER BEGIN TO
  START BUILDING THE RECOVERY PROCESS?

118
(No Transcript)
119
ASSESSMENT OF STRENGTHS

• REHAB IS BUILT ON STRENGTHS NOT PROBLEMS OR
  DEFICITS
• STRENGTHS OF PERSON, SYSTEM OF CARE, FAMILY,
  CASE MANAGER, THE DOC ETC
• SENSE OF HUMOR, DRIVERS LICENSE, COMPUTER SKILLS,
  CARE OF OTHERS, WATERING PLANTS AND EVEN THE
  MANIPULATION OF SYSTEMS

120
New questions

• 17) AT SOME POINT WE NEED TO FIND OUT ABOUT
  PREVIOUS TRAUMATIC EXPERIENCES
• Avoidance, hypervigilance, emotional
  difficulties, and recall behaviors, anxiety,
  depression, probs sleeping, and sometimes
  hopeless
• Use SCID-D for assessment

121
17 WHAT ABOUT TRAUMA?
122
(No Transcript)
123
Predictors of the Emergence of PTSD

• LACK OF SOCIAL SUPPORT
• LACK OF EDUCATION
• TOUGH FAMILY BACKGROUND
• PRIOR PSYCHIATRIC HISTORY
• DISSOCIATIVE REACTION
• (Berwin et al 2000, Ozer et al, 2003)

124
Some Trauma Studies

• 50-60 of US have a traumatic experience
• 10 - 17 Chronic PTSD (Galea et al, 2002)
• In community 1 in 10 women/girls and 1 in 20
  men/boys have PTSD (Kessler et al, 1995)
• Most do not. Not pathological! (Bonanno et al,
  2002)

125
Psychophysiological Sequelae of Stress and Trauma

• Psychogenic Stress of all kinds can be Genotoxic
  in Cellular Structures
• Changes in both internal and external
  environments can lead to changes in gene
  structures
• The Brain is a Plastic Organ as well
• Healing is possible

126
(No Transcript)
127
Mnemonic for PTSD

• FEARS
• Fears
• Ego construction (numbing withdrawal)
• Anger
• Repetition (Flashbacks nightmares)
• Sleep disturbance
• Jean Goodwin

128
Mnemonic for COMPLEX PTSD

• FEARS
• Fugue Other Dissociative states
• Ego fragmentation
• Antisocial Behaviors
• Re-enactment
• Suicidality Somatitization
• Jean Goodwin

129
18 CAN THIS PERSON READ?
130
(No Transcript)
131
Assessment of the level of functional literacy

• Realizing that admitting you cant read is more
  embarrassing to a person than talking about
  symptoms!
• Receiving information in the way a person can
  understand
• Learning to read might improve self-esteem and
  reduce symptoms
• Helps close the gap in healthcare disparities

132
REALM-R Rapid Estimate of Adult Literacy in
Medicine, Revised

• (a 5 minute 11 word list for English speakers
  which provides a quick measure of
  literacy) Bass et al 2003

133
Ways to enhance understanding in persons with low
level literacy-1

• Slow down speech fluency
• Use living room language instead of medical
  terminology
• Show or draw pictures to enhance understanding
  and subsequent recall

134
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,
  34387)

135
19 Does this person believe in something
bigger than self?
136
(No Transcript)
137
USE OF SPIRITUALITY

• Research shows that about half of every sample
  relies on some sort of faith (Western formal,
  informal, nature, Eastern, personal) to provide
  help and supports
• Need to ask and talk about it if person is
  interested

138
AND 20) WHAT DOES THE PERSON THINK HE OR SHE IS
RECOVERING FROM?
139
(No Transcript)
140
CHERYL GAGNES LIST from peers Loss of self,
connection, hope Loss of roles and
opportunities devaluing and disempowering
programs, practices, and environments Prejudice
and discrimination in society Internalized
oppression and shame

• !

141
WHAT MADE THE DIFFERENCE ACCORDING TO THOSE
INTERVIEWED?

• Decent food, clothing and housing
• People with whom to be
• A way to be productive
• A way to manage s/s and meds

• Individualized rx
• Case management
• Psycho-education
• Integrated back into the community

142
WHAT DID THE VERMONTERS SAY MADE THE DIFFERENCE?

• Hope!
• Someone believed in me
• Someone told me i had a chance to get better
• My own persistence
• Hope connects with natural self-healing capacities

143
HOPE CAN ARRIVE ONLY WHEN YOU RECOGNIZE THAT
THERE ARE REAL OPTIONS AND THAT YOU HAVE GENUINE
CHOICES. Jerome Groopman, MD (2004)
144
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)
145
BEING SYSTEMATIC CREATIVE, STRUCTURED IN YOUR
APPROACH

• YOURSELF AND YOUR RELATIONSHIP ARE THE BEST TOOLS
  IN YOUR KIT BAG

146
(No Transcript)
147
SHOW ME THE EVIDENCE AND MANY THANKS FOR COMING!