Day.Training.Slideshow

11

IMR 2-Day TrainingIMR 2-Day Training

Tim Gearhart MSWTim Gearhart MSW

Dave Thomas, BA, PRSDave Thomas, BA, PRS

ACT Center of IndianaACT Center of Indiana

22

Evidence Based Practice?Evidence Based Practice?

'Evidence-Based Practice (EBP) 'Evidence-Based Practice (EBP) requires that decisions about health requires that decisions about health care are based on the best available, care are based on the best available, current, valid and relevant evidence. current, valid and relevant evidence. These decisions should be made by These decisions should be made by those receiving care, informed by the those receiving care, informed by the tacit and explicit knowledge of those tacit and explicit knowledge of those providing care, within the context of providing care, within the context of available resources.available resources.Martin Dawes, et al (2005)Martin Dawes, et al (2005)

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Illness Management Illness Management ResearchResearch

Reviewed 40 randomized controlled Reviewed 40 randomized controlled studies which included psycho-studies which included psycho-education, medication-focused education, medication-focused programs, relapse prevention, coping programs, relapse prevention, coping skills training, cbt for psychosis. skills training, cbt for psychosis. (Mueser et al)(Mueser et al)

Target population for the lit review Target population for the lit review included: schizophrenia, bipolar included: schizophrenia, bipolar disorder, and general SMIdisorder, and general SMI

Who is your target population?Who is your target population?

44

Outcomes of interestOutcomes of interest

Proximal outcomes: knowledge of MI and Proximal outcomes: knowledge of MI and using medication as prescribedusing medication as prescribed

Distal outcomes: relapses, symptoms, and Distal outcomes: relapses, symptoms, and social functioningsocial functioning

What outcomes are you looking for?What outcomes are you looking for?– Client level? Client level? – CSR related?CSR related?– Fidelity related?Fidelity related?– Clinical competency of staff?Clinical competency of staff?– Agency culture?Agency culture?– Staff burn-out?Staff burn-out?– Appendix 8 + 9Appendix 8 + 9

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Psycho-education Psycho-education findings of 4 large findings of 4 large studiesstudies ¾ showed improved knowledge of ¾ showed improved knowledge of

their mental illness.their mental illness. 1 showed improvement in 1 showed improvement in

medication adherence.medication adherence. DiscussionDiscussion

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Medication Focused Medication Focused ProgramsPrograms

Behavioral TailoringBehavioral Tailoring and simplifying and simplifying medication regimens found increased medication regimens found increased adherence in %100 of the studies adherence in %100 of the studies reviewed. reviewed.

Motivational InterviewingMotivational Interviewing showed showed increased adherence, fewer symptoms increased adherence, fewer symptoms and relapses and improved social and relapses and improved social functioning.functioning.

Medication Psycho-EdMedication Psycho-Ed found minimal found minimal results likely due to memory issues.results likely due to memory issues.

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Relapse Prevention TrainingRelapse Prevention Training

Focus on identifying early warning Focus on identifying early warning signs, triggers, and stress signs, triggers, and stress management skills.management skills.– All programs/studies reviewed All programs/studies reviewed

showed a decrease in relapse or showed a decrease in relapse or hospitalization.hospitalization.

– Significant other involvement shows Significant other involvement shows effectiveness in preventing relapses.effectiveness in preventing relapses.

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Coping Skills TrainingCoping Skills Training

Increases consumer’s ability to Increases consumer’s ability to deal with persistent symptoms deal with persistent symptoms and stressand stress– All program’s/studies reviewed All program’s/studies reviewed

utilized cognitive behavioral utilized cognitive behavioral intervention and produced similar intervention and produced similar outcomes.outcomes.

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Cognitive behavioral TX of Cognitive behavioral TX of psychotic symptomspsychotic symptoms

More effective than standard care More effective than standard care for reducing the severity of for reducing the severity of psychotic symptoms.psychotic symptoms.

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Evidence Base for IMREvidence Base for IMR

PsychoeducationPsychoeducation Behavioral tailoring for medication Behavioral tailoring for medication

adherenceadherence Relapse prevention trainingRelapse prevention training Coping skills trainingCoping skills training

How many programs do you have How many programs do you have that are set up under one of these that are set up under one of these categories?categories?

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Illness Management Illness Management and and

Recovery ProgramRecovery Program IMR is a step-by-step program that IMR is a step-by-step program that

helps consumers set meaningful helps consumers set meaningful goals and learn skills to assist goals and learn skills to assist them in the pursuit of those goals. them in the pursuit of those goals.

Typically lasts 3 to 9 months w/ Typically lasts 3 to 9 months w/ weekly or bi-weekly session.weekly or bi-weekly session.

Group or Individual.Group or Individual. Programmatically flexible.Programmatically flexible.

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Topics of ModulesTopics of Modules Recovery StrategiesRecovery Strategies Practical Facts about Mental IllnessPractical Facts about Mental Illness The Stress-Vulnerability ModelThe Stress-Vulnerability Model Building Social SupportBuilding Social Support Using Medication EffectivelyUsing Medication Effectively Reducing RelapsesReducing Relapses Coping with StressCoping with Stress Coping with Problems and SymptomsCoping with Problems and Symptoms Getting Your Needs Met in the Mental Health SystemGetting Your Needs Met in the Mental Health System Substance AbuseSubstance Abuse

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Program GoalsProgram Goals Inspire hope with positive expectations.Inspire hope with positive expectations. Empower informed decision makers.Empower informed decision makers. Help people set and make progress Help people set and make progress

towards personal recovery goalstowards personal recovery goals Teach people how to use medication Teach people how to use medication

effectivelyeffectively Help people understand and develop Help people understand and develop

relapse prevention plansrelapse prevention plans Teach people strategies for coping with Teach people strategies for coping with

persistent symptoms and other persistent symptoms and other problemsproblems

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Clinical InterventionsClinical Interventions

Handouts are not to stand alone. Handouts are not to stand alone. Clinical techniques are implored Clinical techniques are implored to assist consumers in integrating to assist consumers in integrating skills into daily life.skills into daily life.

MI, CBT, and Edu.MI, CBT, and Edu.

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Motivational Motivational InterventionsInterventions

– Connect info and skills with personal Connect info and skills with personal goalsgoals

– Promote hope and positive Promote hope and positive expectationexpectation

– Explore pros and cons of changeExplore pros and cons of change– Reframe experiences in a positive Reframe experiences in a positive

lightlight

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Cognitive Behavioral InterventionsCognitive Behavioral Interventions

ReinforcementReinforcement Cognitive restructuringCognitive restructuring ShapingShaping Re-framingRe-framing ModelingModeling Role playingRole playing Relaxation trainingRelaxation training

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Educational Educational TechniquesTechniques Interactive teachingInteractive teaching Review homeworkReview homework Check for understandingCheck for understanding Complete worksheetsComplete worksheets Review informationReview information Break down infoBreak down info

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RecoveryRecovery

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Definitions of RecoveryDefinitions of Recovery““Recovery involves the development of new meaning Recovery involves the development of new meaning and purpose in one’s life as one grows beyond the and purpose in one’s life as one grows beyond the catastrophic effects of mental illness.” (Anthony, 1993)catastrophic effects of mental illness.” (Anthony, 1993)

““One of the elements that makes recovery possible is One of the elements that makes recovery possible is the regaining of one’s belief in oneself.” (Chamberlin)the regaining of one’s belief in oneself.” (Chamberlin)

““Recovery is what occurs when a person with a mental Recovery is what occurs when a person with a mental illness discovers (or rediscovers) their strengths and illness discovers (or rediscovers) their strengths and abilities for pursuing personal goals and develops a abilities for pursuing personal goals and develops a sense of identity that allows them to grow beyond sense of identity that allows them to grow beyond their mental illness”their mental illness” (Author Unknown)(Author Unknown)

““Recovery is a process, a way of life, an attitude and a Recovery is a process, a way of life, an attitude and a way of approaching the day’s challenges.” (Deegan)way of approaching the day’s challenges.” (Deegan)

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Recovery is…Recovery is…

An opportunity to grow through ones An opportunity to grow through ones challenges challenges

Becoming a self defined person with a Becoming a self defined person with a self defined purpose self defined purpose

Experiencing authentic happiness, Experiencing authentic happiness, friendships, realization of ones place in friendships, realization of ones place in the world the world

A peace of mind, hope for a future and A peace of mind, hope for a future and joy along the way joy along the way

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Recovery is not…Recovery is not…

A cureA cure Freedom of symptomsFreedom of symptoms An end to stress and/or problemsAn end to stress and/or problems Elimination of relapsesElimination of relapses A life that one originally plannedA life that one originally planned

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Recovery is a Journey Recovery is a Journey of the Heartof the Heart

““It is only with the heart that It is only with the heart that one can see rightly; what is one can see rightly; what is essential is invisible to the essential is invisible to the eye.”eye.”

-Antoine De Saint-Exupery- -Antoine De Saint-Exupery-

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Hope for RecoveryHope for Recovery

Body of research shows a more Body of research shows a more optimistic picture optimistic picture Review of long-term follow up studies Review of long-term follow up studies

of schizophrenia show that between of schizophrenia show that between 42% and 68% of consumers with the 42% and 68% of consumers with the illness experience either full recovery illness experience either full recovery or show substantial improvement in or show substantial improvement in their lives their lives (Hafner et al., 2003)(Hafner et al., 2003)

Growth and enthusiasm for the Growth and enthusiasm for the vision of recovery championed in vision of recovery championed in the consumer movementthe consumer movement

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SAMHSA Consensus on SAMHSA Consensus on

RecoveryRecovery

““Recovery must be the common, Recovery must be the common, recognized outcome of the recognized outcome of the services we support.” services we support.”

Charles Curie; SAMHSA AdministratorCharles Curie; SAMHSA Administrator

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10 Fundamental 10 Fundamental Components of Components of

Recovery:Recovery: Self-DirectionSelf-Direction: the recovery process : the recovery process

must be self-directed and defined his must be self-directed and defined his or her own life goals or her own life goals

Individualized and Person-Individualized and Person-CenteredCentered: There are multiple : There are multiple pathways to recovery based on an pathways to recovery based on an individual’s unique strengths and individual’s unique strengths and resiliencies as well as his or her needs, resiliencies as well as his or her needs, preferences, experiences (including preferences, experiences (including past trauma), and cultural background past trauma), and cultural background in all of its diverse representationsin all of its diverse representations

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Components Components (continued)(continued)

Empowerment: Empowerment: having the authority having the authority to choose from a range of options and to choose from a range of options and to participate in all decisions that will to participate in all decisions that will affect individuals lives, and are affect individuals lives, and are educated and supported in so doing. educated and supported in so doing.

Holistic:Holistic: Recovery encompasses an Recovery encompasses an individual's whole life, including mind, individual's whole life, including mind, body, spirit, and community. body, spirit, and community.

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Components Components (continued)(continued)

Non-LinearNon-Linear: Recovery is not a step-by : Recovery is not a step-by step process but one based on step process but one based on continual growth, occasional setbacks, continual growth, occasional setbacks, and learning from experiencesand learning from experiences

Strengths-Based:Strengths-Based: Recovery focuses Recovery focuses on valuing and building on the multiple on valuing and building on the multiple capacities, resiliencies, talents, coping capacities, resiliencies, talents, coping abilities, and inherent worth of abilities, and inherent worth of individualsindividuals

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Components Components (continued)(continued)

Peer Support:Peer Support: Mutual support Mutual support (including the sharing of experiential (including the sharing of experiential knowledge and skills and social knowledge and skills and social learning) plays an invaluable role in learning) plays an invaluable role in recoveryrecovery

Respect:Respect: Self-acceptance and Self-acceptance and regaining belief in one’s self are regaining belief in one’s self are particularly vital. Respect ensures the particularly vital. Respect ensures the inclusion and full participation of inclusion and full participation of consumers in all aspects of their livesconsumers in all aspects of their lives

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Components Components (continued)(continued)

ResponsibilityResponsibility: Consumers have a : Consumers have a personal responsibility for their own personal responsibility for their own self-care and journeys of recovery. self-care and journeys of recovery. Consumers must strive to understand Consumers must strive to understand and give meaning to their experiences and give meaning to their experiences and identify coping strategies and and identify coping strategies and healing processes to promote their healing processes to promote their own wellness.own wellness.

Hope:Hope: Hope is the catalyst of the Hope is the catalyst of the recovery processrecovery process

Document available at Document available at www.mentalhealth.samhas.govwww.mentalhealth.samhas.gov

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Deegan: ‘Hope, Deegan: ‘Hope, Nurturance, Listening, Nurturance, Listening,

Patience’Patience’

How can mental health How can mental health professionals help professionals help

consumers with their consumers with their recovery?recovery?

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HopeHope...it is not our job to pass judgment on ...it is not our job to pass judgment on

who will and will not recover from who will and will not recover from mental illness and the spirit breaking mental illness and the spirit breaking effects of poverty, stigma, effects of poverty, stigma, dehumanization, degradation and dehumanization, degradation and learned helplessness. Rather, our learned helplessness. Rather, our job is to participate in a conspiracy of job is to participate in a conspiracy of hopehope. It is our job to form a . It is our job to form a community of hopecommunity of hope which which surrounds people with psychiatric surrounds people with psychiatric disabilities.disabilities.

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ListeningListening

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.

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PatiencePatience

……And then finally, it is our job to And then finally, it is our job to wait patientlywait patiently, to sit with, to , to sit with, to watch with wonder, and to watch with wonder, and to witness with reverence the witness with reverence the unfolding of another person’s unfolding of another person’s life.life.

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Relationship of Recovery Relationship of Recovery to Illness Management to Illness Management

Improve ability to manage life one’s illness Improve ability to manage life one’s illness through knowledge, understanding, through knowledge, understanding, acceptance of one’s illnessacceptance of one’s illness

Identifying and achieve ones personal Identifying and achieve ones personal recovery goals through the understanding recovery goals through the understanding and hope of change is possibleand hope of change is possible

Minimizing relapses and re-hospitalizations Minimizing relapses and re-hospitalizations giving people enhanced control in their livesgiving people enhanced control in their lives

Less time spent dealing with mental illness Less time spent dealing with mental illness allowing more time spent on personally allowing more time spent on personally fulfilling and purposeful livesfulfilling and purposeful lives

Less stress due to symptoms and Less stress due to symptoms and impairment leading to a better quality ofimpairment leading to a better quality of life life

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Recovery is Recovery is reaching the reaching the highest level highest level of wellness, of wellness, happiness, happiness, and life and life satisfactionsatisfaction

3636

Regaining MotivationRegaining Motivation

““Motivation - that’s Motivation - that’s thethe

key. If you have a key. If you have a

reason in this world reason in this world for wanting to for wanting to cope, you can do cope, you can do it.”it.”

Peer Specialist, Mt. Carmel Guild Behavioral Healthcare, Program for Assertive Community Treatment

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Regaining Self-EsteemRegaining Self-Esteem

“ “Recovery is about Recovery is about having confidence having confidence and self-esteem. and self-esteem. There are things I’m There are things I’m good at, and I have good at, and I have something positive something positive to offer the world.” to offer the world.”

From EBP Illness Management & From EBP Illness Management & Recovery Implementation Recovery Implementation Resource KitResource Kit

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Regaining MeaningRegaining Meaning

“ “I have to have goals. That’s what gives my I have to have goals. That’s what gives my life meaning. I’m looking to the future.” life meaning. I’m looking to the future.”

From EBP Illness Management & Recovery Implementation Resource KitFrom EBP Illness Management & Recovery Implementation Resource Kit

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IMR Emphasizes Personal IMR Emphasizes Personal Goals as Fundamental Goals as Fundamental

Recovery ToolRecovery Tool For many people, the whole point For many people, the whole point

of recovery is to be able to move of recovery is to be able to move forward in life, and being able to forward in life, and being able to set and pursue personal goalsset and pursue personal goals

Looking into the future-not Looking into the future-not inward-not back to the pastinward-not back to the past

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Setting and Pursuing Setting and Pursuing Personal GoalsPersonal Goals

Being able to set and pursue Being able to set and pursue personal goals is an essential part personal goals is an essential part of recovery and IMR of recovery and IMR

Gives opportunity to explore the Gives opportunity to explore the risk and ambivalence of change risk and ambivalence of change providing the nature and the providing the nature and the motivation for changemotivation for change

Presents opportunities to learn Presents opportunities to learn and applying the information, and applying the information, strategies and skills taught in IMRstrategies and skills taught in IMR

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What might help a What might help a person with their person with their

recovery?recovery?

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Be positive and Be positive and hopefulhopeful

Encourage and Encourage and understand usunderstand us

Be friendly, Be friendly, supportive and supportive and respectfulrespectful

Be firm and Be firm and protective when protective when necessarynecessary

Be available and Be available and have back-up servicehave back-up service

Be up-to-dateBe up-to-date Be willing to admit Be willing to admit

and remedy and remedy mistakesmistakes

Some Ideas from ConsumersSome Ideas from Consumers

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Support from Support from ProfessionalsProfessionals

Close monitoringClose monitoring Emphasize self-Emphasize self-

care and personal care and personal responsibilityresponsibility

Explore and try Explore and try new approachesnew approaches

Use less invasive Use less invasive alternativesalternatives

Use a team Use a team approachapproach

Consider individual Consider individual needs and needs and preferencespreferences

Have good listening Have good listening and communication and communication skillsskills

Care about usCare about us Accept us as we areAccept us as we are

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Introductory video.Introductory video.

4545

Core Values of IMRCore Values of IMR Hope is the key ingredientHope is the key ingredient The person is the expertThe person is the expert Personal choice is a mustPersonal choice is a must Practitioners of IMR are partnersPractitioners of IMR are partners Practitioners demonstrate not Practitioners demonstrate not

dictatedictate Respect is always presentRespect is always present

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Materials for IMRMaterials for IMR

Practitioners Guidelines: Gives ideas for Practitioners Guidelines: Gives ideas for MI, CBT, and Educational Techniques.MI, CBT, and Educational Techniques.

Educational Handouts: Information that Educational Handouts: Information that is actually covered in session.is actually covered in session.

Implementation Tool Kit: Selected Implementation Tool Kit: Selected Articles, Info documents, Implementation Articles, Info documents, Implementation tips, fidelity scales, outcome guides, tips, fidelity scales, outcome guides, intro and demo videosintro and demo videos

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Getting StartedGetting Started

11stst session: Orientation Sheet (Appendix 1) session: Orientation Sheet (Appendix 1) 22ndnd and 3 and 3rdrd session: Knowledge and skills session: Knowledge and skills

inventory (Appendix 2)inventory (Appendix 2) Remaining sessions: Utilize educational Remaining sessions: Utilize educational

handouts. Use progress note (Appendix 3)handouts. Use progress note (Appendix 3)– Continually look for ways Significant Others Continually look for ways Significant Others

might avail themselves to consumer hmwk and might avail themselves to consumer hmwk and goals (Appendix 4)goals (Appendix 4)

Modules build on one another but it isn’t Modules build on one another but it isn’t essential to go through them in order.essential to go through them in order.

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Structure of IMR Structure of IMR SessionsSessions

1. Informal socializing 1. Informal socializing 2. Review previous session2. Review previous session3. Review previous home assignment3. Review previous home assignment4. Follow up on goals (for group, follow up on 4. Follow up on goals (for group, follow up on

goals of 2-3 consumers on rotating basis)goals of 2-3 consumers on rotating basis)5. Set agenda for current session5. Set agenda for current session6. Teach new material from handout6. Teach new material from handout7. Develop a home assignment 7. Develop a home assignment

collaborativelycollaboratively8. Summarize session and progress made8. Summarize session and progress made

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Module 1: Recovery StrategiesModule 1: Recovery Strategiesread the practitioners read the practitioners guidelines.guidelines.

Assist in defining recovery Assist in defining recovery – Life Goals: hopes for overall Life Goals: hopes for overall

improvementsimprovements– Enhancement goals: reflects quality Enhancement goals: reflects quality

of life concernsof life concerns

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Module 1: Recovery StrategiesModule 1: Recovery Strategies

Address ambivalence around Address ambivalence around recovery goals and strategies for recovery goals and strategies for recovery.recovery.– Docere – ExpertDocere – Expert– Ducere – Calling forth that which is Ducere – Calling forth that which is

already there.already there. E.g. Socrates, Photo AlbumE.g. Socrates, Photo Album

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Module 1: Recovery StrategiesModule 1: Recovery StrategiesReal Play (p. 143)Real Play (p. 143)

– ““Why haven’t you achieved this Why haven’t you achieved this goal.”goal.”

– Explain why it is important that they Explain why it is important that they change.change.

– Explain how they should go about Explain how they should go about making that change. making that change.

– ““If you don’t change then…will If you don’t change then…will happen”happen”

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Module 1: Recovery StrategiesModule 1: Recovery Strategies

Favorite Teacher exercise.Favorite Teacher exercise.

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Module 1: Recovery StrategiesModule 1: Recovery StrategiesReal Play Real Play

““If you decided to make this change, If you decided to make this change, how might you go about it?”how might you go about it?”

““Why would you want to go about it Why would you want to go about it that way?”that way?”

““On a scale of 0-10, how important is On a scale of 0-10, how important is this to you? Why not 0?”this to you? Why not 0?”

Provide a summary.Provide a summary. Ask, “So what do you think you’ll do?”Ask, “So what do you think you’ll do?”

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Module 1: Recovery StrategiesModule 1: Recovery Strategies

Module 1 vignette.Module 1 vignette. Vignette (How does Kim utilize Vignette (How does Kim utilize

the curriculum based material?the curriculum based material?

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Recovery GoalsRecovery Goals Individualized?Individualized? Personally meaningful?Personally meaningful? Range from the modest to the Range from the modest to the

ambitious. Don’t Poo Poo!ambitious. Don’t Poo Poo! Exploration of personally Exploration of personally

meaningful goals often needed to meaningful goals often needed to engage consumer engage consumer beforebefore introducing IMR program. Find the introducing IMR program. Find the Hook!Hook!

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Helping clients Set Helping clients Set Recovery GoalsRecovery Goals

Take your timeTake your time Avoid overusing the term “goals”Avoid overusing the term “goals” Don’t impose your own beliefsDon’t impose your own beliefs Explore how person would like life Explore how person would like life

to be differentto be different Don’t discourage ambitious goals, Don’t discourage ambitious goals,

but help people break down to but help people break down to into smaller goals or steps that into smaller goals or steps that are are reasonable & measurablereasonable & measurable . . Program for Success!Program for Success!

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Aim for Well-Defined Goals Aim for Well-Defined Goals that are Measurable and that are Measurable and

AchievableAchievable Help consumers consider goals that Help consumers consider goals that

have to do with improved role have to do with improved role functioning (parenting, working, going functioning (parenting, working, going to classes, homemaking)to classes, homemaking)

Help consumers come up with at least Help consumers come up with at least one goal that could be achieved in the one goal that could be achieved in the next 3 monthsnext 3 months

Be able to answer the question: “How Be able to answer the question: “How will we both know when this goal is will we both know when this goal is achieved?”achieved?”

5858

Examples of Well-Defined Examples of Well-Defined Goals that are Measurable Goals that are Measurable

& Achievable& Achievable Have coffee with my sister once a Have coffee with my sister once a

weekweek Read the headlines every morningRead the headlines every morning Learn two coping skills for distracting Learn two coping skills for distracting

myself from critical voicesmyself from critical voices Identify jobs that are related to my Identify jobs that are related to my

interest in spending time outdoorsinterest in spending time outdoors Take my toddler to the playground Take my toddler to the playground

twice a week twice a week (continued)(continued)

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More examples of goals More examples of goals (cont’d)(cont’d)

Take a 15 minute walk 3 times per weekTake a 15 minute walk 3 times per week Learn to recognize high risk situations for Learn to recognize high risk situations for

drinkingdrinking Identify activities that I could enjoy doing Identify activities that I could enjoy doing

with my familywith my family Take the bus to the peer support centerTake the bus to the peer support center Learn strategies for responding to people Learn strategies for responding to people

who pressure me to give them moneywho pressure me to give them money

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Break Down Goals into Break Down Goals into StepsSteps

Help consumers “program for Help consumers “program for success”success”

Aim for steps that are small and Aim for steps that are small and manageablemanageable

Make steps as specific as possibleMake steps as specific as possible

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Example of Possible First Steps Example of Possible First Steps Towards Goal of Walking 30 Towards Goal of Walking 30 minutes 3 Times per Weekminutes 3 Times per Week

Locate or purchase comfortable Locate or purchase comfortable shoesshoes

Identify a walking route that is Identify a walking route that is safe safe

Start by walking once each week Start by walking once each week for 15 minutesfor 15 minutes

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Follow up on GoalsFollow up on Goals

Check on progress towards goals Check on progress towards goals regularly (weekly or every few regularly (weekly or every few weeks)weeks)

Reinforce steps that were takenReinforce steps that were taken Help person problem-solve Help person problem-solve

obstacles to taking stepsobstacles to taking steps

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Troubleshooting Lack Troubleshooting Lack of Progress Towards of Progress Towards

GoalsGoals To maintain enthusiasm, remind how To maintain enthusiasm, remind how

small goals are related to larger onessmall goals are related to larger ones Evaluate depth of interest in goals Evaluate depth of interest in goals

setset Consider identifying smaller stepsConsider identifying smaller steps Involve significant others moreInvolve significant others more If consumer is lacking hope or self-If consumer is lacking hope or self-

efficacy, building up hope and efficacy, building up hope and confidenceconfidence

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IMR Clinical SkillsIMR Clinical Skills

6565

Module Exposure Module Exposure ExerciseExercise

• What are the goals of the What are the goals of the module?module?

• What stands out to you?What stands out to you?

• How can this module facilitate How can this module facilitate Recovery?Recovery?

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IMR Practitioners Use 3 IMR Practitioners Use 3 Essential Teaching Essential Teaching

StrategiesStrategies

Motivational StrategiesMotivational Strategies

Educational StrategiesEducational Strategies

Cognitive-Behavioral StrategiesCognitive-Behavioral Strategies

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Motivational Motivational StrategiesStrategies

People are motivated to learn things if People are motivated to learn things if they are relevant to personal goals they are relevant to personal goals (Importance)(Importance)

Connect IMR materials to goals Connect IMR materials to goals Explore how illness has interfered with Explore how illness has interfered with

goalsgoals Convey hope and confidence in personConvey hope and confidence in person Help person explore costs and benefits Help person explore costs and benefits

of changeof change (continued)(continued)

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Motivational Strategies Motivational Strategies (cont’d)(cont’d)

Pay-off matrix strategyPay-off matrix strategy Socratic method of asking questions Socratic method of asking questions

rather than giving answersrather than giving answers Explore past successesExplore past successes Reframe past challenges as Reframe past challenges as

evidence of personal strengthsevidence of personal strengths Make the consumer the “expert” Make the consumer the “expert”

and put them in charge of and put them in charge of somethingsomething

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Following up on GoalsFollowing up on Goals

The most powerful motivational The most powerful motivational strategy is helping people progress strategy is helping people progress towards goalstowards goals

Follow up on goals at beginning of Follow up on goals at beginning of each sessioneach session

Help set new goals when others Help set new goals when others achievedachieved

Review progress regularly with Review progress regularly with consumerconsumer

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Home AssignmentsHome Assignments Help consumers transfer information Help consumers transfer information

and skills into their daily livesand skills into their daily lives The “real” therapy is what happens The “real” therapy is what happens

outside of sessionoutside of session Use alternative term if necessary Use alternative term if necessary Always develop home assignments Always develop home assignments

collaboratively at end of each sessioncollaboratively at end of each session Be as specific as possible (when, Be as specific as possible (when,

where, how, etc.) where, how, etc.) (continued)(continued)

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Home Assignments Home Assignments (cont’d)(cont’d)

Always follow up on home assignmentsAlways follow up on home assignments When people don’t do assignments, When people don’t do assignments,

explore obstacles and problem-solveexplore obstacles and problem-solve Assure understanding of the role of Assure understanding of the role of

homeworkhomework Assure assignments are understood & Assure assignments are understood &

feasiblefeasible Shape homework adherence & praise Shape homework adherence & praise

effortsefforts

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Importance & Importance & Confidence RulersConfidence RulersWhere is your client in relation to changing…?Where is your client in relation to changing…?__________________________________________________________________________________________________________________________________________________

Not ReadyNot Ready UnsureUnsureReadyReady

Importance (Why)Importance (Why)

How important is it for you right now to…?How important is it for you right now to…? 0-------------------------------------------100-------------------------------------------10 Why should I change?Why should I change? Why is it important for me to change?Why is it important for me to change? What will I gain or lose?What will I gain or lose? I want to, but……I want to, but……

Confidence (How)Confidence (How)

If you did decide to change, how confident are you that you would succeed?If you did decide to change, how confident are you that you would succeed? 0------------------------------------------100------------------------------------------10 Will I be able to?Will I be able to? What skills do I need?What skills do I need? Will I cope in situations? Will I cope in situations?

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Motivational InterviewingMotivational Interviewing

Stages of ChangeStages of Change What is MIWhat is MI Principles of MI (DEARS)Principles of MI (DEARS) 3 R’s in depth3 R’s in depth Other nifty tools for MIOther nifty tools for MI Monty Roberts - The Horse WhispererMonty Roberts - The Horse Whisperer

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Educational StrategiesEducational Strategies Goal: help consumers learn about Goal: help consumers learn about

their illness & how to manage ittheir illness & how to manage it Use handouts in interactive ways Use handouts in interactive ways

(e.g., take turns reading)(e.g., take turns reading) Ask questions to check on Ask questions to check on

understanding; ask for “own words”understanding; ask for “own words” Use “chunking” to break down Use “chunking” to break down

information into small bites information into small bites (continued)(continued)

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Educational Strategies Educational Strategies (cont’d)(cont’d)

Adopt consumer’s languageAdopt consumer’s language Don’t push consumer to accept Don’t push consumer to accept

diagnosisdiagnosis Review the material, even if Review the material, even if

consumer is knowledgeableconsumer is knowledgeable Encourage consumer to share Encourage consumer to share

material with significant othersmaterial with significant others

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Cognitive Behavioral Cognitive Behavioral StrategiesStrategies

Help consumers practice Help consumers practice strategies and skills in IMR strategies and skills in IMR sessionssessions

Help consumers put skills into Help consumers put skills into action in their everyday livesaction in their everyday lives

7777

Specific CBT Strategies Specific CBT Strategies used in IMRused in IMR

ReinforcementReinforcement ShapingShaping Cognitive restructuringCognitive restructuring ModelingModeling Role playingRole playing ReframingReframing Relaxation TrainingRelaxation Training Systematic desensitization (gradual Systematic desensitization (gradual

exposure to feared but safe situations)exposure to feared but safe situations)

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Social Skills TrainingSocial Skills Training(Building Social Supports)(Building Social Supports)

Review rationale for skillReview rationale for skill Review specific steps of skillReview specific steps of skill Model steps and ask for feedbackModel steps and ask for feedback Engage person in role playEngage person in role play Provide feedback, starting with the Provide feedback, starting with the

positivepositive If indicated, provide a suggestion If indicated, provide a suggestion

for improvement and ask person to for improvement and ask person to do another role play do another role play (continued)(continued)

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Social Skills Training Social Skills Training (cont’d)(cont’d)

Provide additional feedbackProvide additional feedback Develop a home assignment with the Develop a home assignment with the

person to use the skill in the real worldperson to use the skill in the real world Follow up to see how the skill workedFollow up to see how the skill worked

See Bellack, A., Mueser, K., Gingerich, S., & See Bellack, A., Mueser, K., Gingerich, S., & Agresta, J. (2004). Agresta, J. (2004). Social Skills Training For Social Skills Training For Schizophrenia, 2nd EditionSchizophrenia, 2nd Edition. NY: Guilford . NY: Guilford Press.Press.

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Social Skills vignette.Social Skills vignette.

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Closing ThoughtsClosing Thoughts

“ “Having strategies for coping with Having strategies for coping with mental illness is extremely mental illness is extremely important. It’s hard to enjoy your important. It’s hard to enjoy your life if you are constantly sick with life if you are constantly sick with mental illness. . . mental illness. . .

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However, believing in yourself, However, believing in yourself, having hope that things will having hope that things will continue to get better and looking continue to get better and looking forward to your future are also forward to your future are also vital in overcoming mental illness. vital in overcoming mental illness. Our hopes and dreams are not Our hopes and dreams are not delusions. Our hopes and dreams delusions. Our hopes and dreams are what make us human.”are what make us human.”

David Kime, artist, writer, floral designer, David Kime, artist, writer, floral designer, person in recovery from bipolar disorder.person in recovery from bipolar disorder.

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AcknowledgmentsAcknowledgments

Susan Gingerich MSWSusan Gingerich MSW Kim Meuser PhdKim Meuser Phd Jen Fry PhdJen Fry Phd David Penn PhdDavid Penn Phd Ric Krusinsci MSWRic Krusinsci MSW

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[email protected]@iupui.edu

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Tips for IMR Tips for IMR ImplementationImplementation

8686

What is the agency What is the agency goal in relation to IMR?goal in relation to IMR? Improve quality of careImprove quality of care Provision of an EBP Provision of an EBP Funding pressuresFunding pressures Culture changeCulture change Hope instillationHope instillation

8787

Stages of Organizational Stages of Organizational Change Change

((www.ohiosamicc.oe.case.eduwww.ohiosamicc.oe.case.edu)) Pre-contemplation: Unaware or uninterested. Pre-contemplation: Unaware or uninterested.

Focus on risk management.Focus on risk management. Contemplation: Consensus building. Evaluation Contemplation: Consensus building. Evaluation

of readiness, willingness, and ability.of readiness, willingness, and ability. Preparation: Motivating. Identify stakeholders, Preparation: Motivating. Identify stakeholders,

steering committee formation, find champions.steering committee formation, find champions. Action: Implementing. Address barriers. Action: Implementing. Address barriers. Maintenance: Sustaining. Oversight, fidelity, Maintenance: Sustaining. Oversight, fidelity,

outcome monitoring, internal training, milieu.outcome monitoring, internal training, milieu.

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Supervision/Supervision/ConsultationConsultation

Structured group supervision, weekly, not more Structured group supervision, weekly, not more than 6-8 cliniciansthan 6-8 clinicians

Review cases (Assign a case presentation)Review cases (Assign a case presentation) Discuss goals (Agency, Clinician, and Consumer)Discuss goals (Agency, Clinician, and Consumer) Role play challenging situationsRole play challenging situations Selected teaching of core skills, role play, Selected teaching of core skills, role play,

vignettesvignettes Evaluate engagement of consumers, integration Evaluate engagement of consumers, integration

of IMR with team, involvement of significant of IMR with team, involvement of significant othersothers

Discuss current outcomes. Outcomes should Discuss current outcomes. Outcomes should drive practice!drive practice!

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Members of IMR TeamMembers of IMR Team

IMR CliniciansIMR Clinicians

IMR Consumer ProvidersIMR Consumer Providers

IMR Coordinator/Program IMR Coordinator/Program LeaderLeader

Agency DirectorAgency Director

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IMR Clinicians and IMR IMR Clinicians and IMR Consumer ProvidersConsumer Providers

3-8 per treatment team (depending on 3-8 per treatment team (depending on number of consumers served by the number of consumers served by the team)team)

2 days initial training & 1 day follow-up2 days initial training & 1 day follow-up Are expected to work with Are expected to work with at leastat least 3-4 3-4

consumers (or lead 2-3 groups) in the consumers (or lead 2-3 groups) in the first yearfirst year

Have protected time for providing IMRHave protected time for providing IMR

(continued)(continued)

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IMR Clinicians and IMR IMR Clinicians and IMR Consumer Providers Consumer Providers

(cont’d)(cont’d) Receive weekly supervision Receive weekly supervision

focused on IMRfocused on IMR Receive consultation Receive consultation Start working with consumers Start working with consumers

within 4 weeks of 2-day IMR within 4 weeks of 2-day IMR training training

Have accountability for providing Have accountability for providing IMR (e.g., part of job description)IMR (e.g., part of job description)

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IMR Coordinator/Team IMR Coordinator/Team LeaderLeader

Coordinating IMR is in job Coordinating IMR is in job descriptiondescription

Specific proportion of his or her Specific proportion of his or her time is designated and protected time is designated and protected for providing and coordinating IMR for providing and coordinating IMR

Receives IMR training and works Receives IMR training and works with some consumers using IMRwith some consumers using IMR

Provides IMR supervision Provides IMR supervision (continued)(continued)

9393

IMR Coordinator/Team IMR Coordinator/Team Leader Leader (cont’d)(cont’d)

Establishes and monitors IMR Establishes and monitors IMR referral process referral process

Assures that referred consumers Assures that referred consumers receive IMR receive IMR

Monitors the quality and quantity Monitors the quality and quantity of IMR services delivered at the of IMR services delivered at the agencyagency

Reports to the agency director and Reports to the agency director and meets regularly with him or hermeets regularly with him or her

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Agency Director Shows Agency Director Shows Interest and Support by:Interest and Support by:

Attending training & kickoffAttending training & kickoff Attending some supervision Attending some supervision

sessionssessions Meeting regularly with IMR Meeting regularly with IMR

Coordinator/Team LeaderCoordinator/Team Leader Troubleshooting obstacles to IMRTroubleshooting obstacles to IMR

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Common Difficulties Common Difficulties EncounteredEncountered

Lack of protected time for Lack of protected time for practitionerspractitioners

Lack of accountabilityLack of accountability Lack of experience in working with Lack of experience in working with

curriculum-based approachescurriculum-based approaches Challenging for agencies and Challenging for agencies and

practitioners to change the way they practitioners to change the way they practicepractice

Practitioners not receiving supervisionPractitioners not receiving supervision Billing codes (ADL versus CM)Billing codes (ADL versus CM)

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Common Questions Common Questions and Answers about and Answers about

IMRIMR Fitting in structured work into the day-to-day Fitting in structured work into the day-to-day

hustle-bustle of workhustle-bustle of work Balancing between meeting immediate Balancing between meeting immediate

needs and working towards long-term needs and working towards long-term recovery goalsrecovery goals

Changing practice to incorporate IMRChanging practice to incorporate IMR Fitting IMR training on top of everything elseFitting IMR training on top of everything else Supports needed to implement IMRSupports needed to implement IMR The benefits of supervisionThe benefits of supervision Time to prepare for IMRTime to prepare for IMR

9797

How do you do formal structured How do you do formal structured work in the hustle-bustle of clinical work in the hustle-bustle of clinical

work with consumers?work with consumers? Recognize the advantages of teaching Recognize the advantages of teaching

IMR using formal rather than informal IMR using formal rather than informal strategies, including:strategies, including:– More systematic assessment of needs and More systematic assessment of needs and

progress towards meeting themprogress towards meeting them– Opportunities for concerted and more Opportunities for concerted and more

focused teaching of skills in formal workfocused teaching of skills in formal work– Greater assurance that information and skills Greater assurance that information and skills

will be taught by setting aside teaching timewill be taught by setting aside teaching time– Increased confidence that treatment goals Increased confidence that treatment goals

are recovery oriented and based on are recovery oriented and based on collaboration with consumer collaboration with consumer (continued)(continued)

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Formal structure (cont’d)Formal structure (cont’d) Setting aside time for IMR will connote Setting aside time for IMR will connote

to the consumer the importance to the consumer the importance working towards recovery goalsworking towards recovery goals

Time can be set aside each week, in a Time can be set aside each week, in a planned and predictable fashionplanned and predictable fashion

Setting aside time is proactive; doing Setting aside time is proactive; doing it on the fly is more often “reactive”it on the fly is more often “reactive”

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How do you balance between How do you balance between helping consumers meet their day-helping consumers meet their day-

to-day living needs and learning to-day living needs and learning long-term recovery skills?long-term recovery skills?

Appreciate the old saying, “If you feed a man Appreciate the old saying, “If you feed a man a fish, you feed him for a day. If you teach a a fish, you feed him for a day. If you teach a man to fish, you feed him for life.”man to fish, you feed him for life.”

Helping people get their short-term needs Helping people get their short-term needs and their long-term needs is always a and their long-term needs is always a balancing act in the helping professionbalancing act in the helping profession

Don’t neglect the consumer’s most pressing Don’t neglect the consumer’s most pressing needs, but avoid focusing all energy on needs, but avoid focusing all energy on getting all needs metgetting all needs met

Whenever possible, focus IMR teaching on Whenever possible, focus IMR teaching on helping consumers get their practical daily helping consumers get their practical daily needs met in addition to their long-term needs met in addition to their long-term needsneeds

100100

How do you change your How do you change your practice to incorporate practice to incorporate

teaching IMR?teaching IMR? Keep in mind learning IMR is an exciting Keep in mind learning IMR is an exciting

opportunity to learn some new skills (or improve opportunity to learn some new skills (or improve your existing skills) for helping consumers manage your existing skills) for helping consumers manage their mental illness and make progress towards their mental illness and make progress towards personal goalspersonal goals

Recognize that IMR will provide an organized Recognize that IMR will provide an organized forum for discussing the concept of recovery with forum for discussing the concept of recovery with consumers, and understanding what is means to consumers, and understanding what is means to each personeach person

Present IMR to consumers as a new program Present IMR to consumers as a new program aimed at helping them get better control over aimed at helping them get better control over their lives and meet their personal goalstheir lives and meet their personal goals

Show consumers the introductory IMR video and Show consumers the introductory IMR video and explain that IMR works by having regular meetings explain that IMR works by having regular meetings on a scheduled basison a scheduled basis