leap.ppt

““I am Not Sick, I am Not Sick, I Don’t Need Help!”I Don’t Need Help!”

LEAP TRAINING LEAP TRAINING

Family Matters ConferenceFamily Matters Conference

NiagaraNiagara Falls, Ontario 2007, Ontario 2007

David Schaich, PsyDDavid Schaich, PsyDClinical DirectorClinical Director

Amador & Associates Amador & Associates 917-923-2653917-923-2653

[email protected]

LEAP™

The Listen-Empathize-Agree-Partner (LEAP) Approach

Psychiatric Community Education Network (PCEN) is a program developed by Bristol-Myers Squibb Company and Otsuka America Pharmaceutical, Inc.The Listen-Empathize-Agree-Partner (LEAP) content is licensed from Dr. Xavier Amador and Vida Press, L.L.C.

This program is dedicated to Jodie S. Lane who knew the value of listening.

© Vida Press, LLC, 2004

D6-H0048AC-4432M/01-04

Introduction

• LEAP involves the use of motivational enhancement techniques to help patients with poor insight accept treatment

• Modeled on evidence-based practices taught to mental healthcare providers, caregivers, and consumers involved in peer support

History of LEAP

• MET: Motivational Enhancement Therapy

• MAIT: Medication Adherence and Insight Therapy

• LEAP: Listen-Empathize-Agree-Partner

LEAP Overview

• Taught to mental healthcare providers, family,and peers

• Turns adversaries into allies

• Reduces tension and conflict

• Increases satisfaction

• Improves participation in treatment

Who Should Learn to LEAP?

• Psychiatrists

• Psychologists

• Social workers

• Psychiatric nurses

• Outpatient front-line mental healthcare providers

• Law-enforcement officers

• Case workers

• Consumer-peer counselors

• Residential counselors

• Family caregivers

Motivational enhancement techniques are equally effective in improving adherence regardless of professional background.

LEAP is particularly relevant for family caregivers because there are more opportunities for interaction than usually afforded healthcare providers.

Overview of the Problem

• Poor adherence

• Complete or partial nonadherence

• Presents obstacles to recovery

• Nonadherence rates in schizophrenia and other serious mental illnesses are 40% to 60%

• Interferes with the “real-world” effectiveness of psychiatric treatment

• Poor insight “anosognosia” is one of the top predictors of poor adherence

Improving Adherence Without Insight into Illness

• Central theme of LEAP: Forget about improving insight and focus on adherence

• Insight into illness is often difficult to change

• Adherence to treatment is easier to change

• Over time, improved adherence can improve insightinto illness

Overview of LEAP

Treatmentteam

Consumerfocus

Common goals

LEAP Workshop Summaries

Workshop I:Research on Poor Insight and Engagementin Treatment

• Research on the clinical significance of insight

• Etiology of poor insight

• Evidence-based practices to help patients with poor insight accept treatment and services

Workshop II:Learning to LEAP

• Communication and interviewing skills to build collaborative relationships

• Listen

• Empathize

• Agree

• Partner

• Treatment agreement

Workshop III: Building the Treatment Triad

Goals

• Break down barriers• Collaboration

• Effective teamwork

• Communication strategies

• Optimize recovery

The Treatment Triad

MentalHealthcare

Provider

Consumer

Family

Workshop IV:Surviving Involuntary Treatment

• How to pursue this treatment option

• Respect and dignity

• Minimize damage to the alliance

• Preserve/strengthen the alliance

Workshop I

Research on Poor Insight and Engagement in Treatment

© Vida Press, LLC, 2004

“I Am Not Sick, I Don’t Need Help!”

• Helping persons with mental illness accept and stay in treatment

565,000

70,000

0

100,000

200,000

300,000

400,000

500,000

600,000

1955 1995

The 1955 census found .5 million in public psychiatric

hospitals

By 1995 only 70,000

Torrey, Out of the Shadows, 1997.

Patients in Public Psychiatric Hospitals 1955 vs. 1995

Where did everyone go?Where did everyone go?

70,000

283,000

0

50,000

100,000

150,000

200,000

250,000

300,000

Hospitals Jails andPrisons

• In 1995, about 70,000 people in public psychiatric hospitals.

• In 1999, about 283,000 people with mental illnesses in our jails and prisons.

(U.S. D.O.J., stats. 1999).

Jails/Prisons are the new “Psychiatric Hospitals.”

Mostly Psychotic DisordersMostly Psychotic Disorders

The Unabomber: Theodore Kaczynski

Poor Insight in the National Headlines

The Long Island Murderer : Colin Ferguson

“So Crazy He Thinks He’s Sane”

The Capital Shooter: Russell Weston

Medication Over Objection

Families Affected by Denial

Of the more than 6 million people with

serious mental illness, about 50%, or

3 million, do not believe they are ill.

“Denial” of Illness

Impairs common-sense judgment and

one’s ability to participate in treatment

But are we dealing with denial?

“Anosognosia”(Ã-nõ’sog-nõ’sê-ã)

Unawareness of Mental Disorder

DSM-IV Field Trial StudyN=221 people with schizophrenia

Aware41%

Unaware33%

ModeratelyUnaware

26%

Amador XF et al. Arch Gen Psychiatry. 1994;51:826-836.

Unawareness of Signsand Symptoms

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20

30

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Amador XF et al. Arch Gen Psychiatry. 1994;51:826-836.

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Other Problems with “Insight”

• Tardive dyskinesia (TD)

• Involuntary movement disorder

• Common side effect with typical psychiatric medications

Rosen AM et al. Am J Psychiatry. 1992;139:372-374;

Caracci G et al. Am J Psychiatry. 1990;147:295-298;

Tremeau et al. Schizophr Res. 1997;24:273;

Arango C et al. Am J Psychiatry. 1999;156:1097-1099.

• In studies, approximately 50% of patients with schizophrenia and TD were unaware of their TD

• Patients’ awareness of schizophrenia varied among those unaware of their TD and vice versa

• Patients were unable to sustain “insight” into having a movement disorder

Clinical Significance of Poor Insight

• Poor insight is associated with

• Nonadherence with treatments and services

• Involuntary commitment

• More complicated course of illness

• Criminalization of mentally ill

Clinical Significance of Poor Insight

• Among the top 2 predictors of medication adherence are• Awareness of being ill

• Relationship in which the patient feels that you

• Respect his/her point of view

• Listen without judging or reality-testing

• Believe he/she should be in treatment

• Improvement in insight is generally not associated with symptom improvement

• Associated features and disorders

• A majority of individuals with schizophrenia have poor insight regarding the fact that they have a psychotic illness. Evidence suggests that poor insight is a manifestation of the illness itself rather that a coping strategy. It may be comparable to the lack of awareness of neurologic deficits seen in stroke, termed anosognosia.

• This symptom predisposes the individual to nonadherence with treatment and has been found to be predictive of higher relapse rates, an increased number of involuntary hospital admissions, poorer psychosocial functioning, and a more complicated course of illness.

DSM-IV-TRTM

Schizophrenia and Other Psychotic Disorders

American Psychiatric Association. DSM-IV-TR. 2000:304.

Causes of Poor Insight

• Psychological defense?

• Cultural differences?

• Neuropsychologic deficits?

Anosognosia for Neurologic DeficitsPresents Similarly to Poor Insight in Schizophrenia

• Severe lack of awareness

• The belief persists despite conflicting evidence

• Confabulation is common (illogical explanations)

• A seemingly unreasonable desire to prove that self-concept is correct (“I am not sick”)

When Dealing With Anosognosia

DO NOT expect

• Gratitude

• Adherence

• Receptiveness

DO expect

• Frustration and anger

• Overt and secretive “nonadherence”

• Suspiciousness

Collaboration is a goal, not a given; consequently, the “doctor knows best” approach does not work.

Anosognosia Language matters

Do Not say:Do Not say:• Refuses to acknowledge• Denies he/she’s ill.• Doesn’t admit.• Won’t admit.

Anosognosia Language matters

Do say:Do say:• Cannot acknowledge• Unaware he/she’s ill.• Unable to admit.

The The personperson vs. the vs. the illnessillness

won’t listen stubborn unappreciative doesn’t care narcissistic arrogant uncooperative

& ungrateful

hallucinations perseverations depressed negative symptoms grandiose delusions hypo-manic ““anosognosia”anosognosia”

Ass_ _ _ _? Illness?Ass_ _ _ _? Illness?

Discussion/Q&A

• Questions…

Workshop II

Learning to LEAP

© Vida Press, LLC, 2004

LLEAP

Listen reflectively to:

• Delusional beliefs.

• Beliefs about not being ill.

• Desire to avoid treatment.

Common ConcernsAbout Reflective Listening With a Delusional Patient

• I will be colluding, or intensifying, the delusion ifI don’t reality-test

• He/She will think I believe them, and that wouldbe dishonest

Experiential Role Play

• Is______going to be interested in talking about his/her delusions?

• How will_______react to my wanting to talk about medication for his/her problem?

• How am I most likely to engage______in some discussion?

Reflective Listening Guidelines

• Set aside the time

• Agree on an agenda

• Don’t react

• Let chaos be

• Echo what you’ve heard

Suggested Questions

1. What are the disadvantages and advantages, if any, to taking medication?

2. Do you believe you have a mental illness?

3. What frustrates you the most?

Suggested Questions (cont.)

4. Is there anything that often frightens you or makes you nervous?

5. What are your plans for the near future?

6. What are the 3 things you want most right now?

Attitudes and Beliefs Checklist(ABC)

• Four general categories of questions to consider and information for which to listen

• Medication

• Mental illness

• Frustrations

• Self-concept and desires

• Pay special attention to attitudes and beliefs that cause interpersonal friction and to those that motivate.

MPATHIZE

• When listening, be sure to express yourempathy for

• Delusional experiences

• Frustration about being portrayed as mentally ill

• Wish to avoid treatment

• Desires and hopes for the future

• Normalize his/her experience whenever possible

Exercise 1:Empathic Statements

• Think of other empathic statements you can use with your client/relative and list them

• Discuss concerns you have about worsening your client’s/relative’s delusions or poor insight

Giving Your Solicited Opinion

• Only give your opinion when it has been asked for

• An opinion that has been asked for carries more weight than an unsolicited opinion

• It is important to avoid or delay giving your opinion

Exercise 2:How can you delay giving your opinion?

• “You don’t argue with me about the CIA conspiracy against me or about whether or notI’m sick! Do you believe me!?”

• “Why are you acting like you believe me? You don’t believe that the CIA is after me. You think I’m crazy, don’t you?!”

Delay Tactics

• “I promise I will answer your question, but if it’s okay with you, I want to wait and listen to you some more first, okay?”

• “I will tell you, but I would rather keep listening to your views on this because I am learning a lot about you I didn’t know. Can I tell you later whatI think?”

• “You know, your opinion is the most important opinion in this room, not mine. So I would like to learn more before I tell you what I think, if that’s alright with you?”

When Sharing Your Views,Use the 3 A’s

Apologize

Acknowledgefallibility

Agree

When you finally give your opinion

Use the Three A’sNever offer a contrary opinion without first completing these three steps. APOLOGIZE “Before I tell you what I think about this, I want to apologize because it might feel hurtful or disappointing.”  ACKNOWLEDGE FALLIBILITY “Also, I could be wrong. I don’t think I am but I might be.

AGREE And, I hope that we can just agree to disagree. I respect your point of view and I will not try and talk you out

of it. I hope you can respect mine.” 

Agree Start with only perceived problems

Immediate needs

To disagree

LListen-isten-EEmpathize-mpathize-AAgree-gree-PPartnerartner(www.IamNotSick.com)(www.IamNotSick.com)

GREE

• Agree on goals you can work on together

• Write them down • Refer to them during future LEAP conversations

• Introduce the topic of medication and use the “medication advantages/disadvantages” form in your booklet or something similar to it • First, ask permission

• Always start with disadvantages

• Common advantages in someone with a serious mental illness and anosognosia:• Social

• Subjectively experienced

• Highlight areas in which the 2 of you agreeFor example: “I agree that…

…avoiding hospitalizations is a top goal.”

…the side effects are a big negative.”

…a job would be great thing for you.”

…it would be nice if people stopped pushing you totake medications.”

• Normalize your patient's experience

GREE

Talking About Medications

• How do you bring up the topic of medicine?

• How could we get _______ to talk about taking psychiatric medications?

• What if your client gets angry and refuses to talk about it?

Exercise 3:Medication Disadvantages and Advantages

Disadvantages

• ________________

• ________________

• ________________

• ________________

• ________________

• ________________

Advantages

• ________________

• ________________

• ________________

• ________________

• ________________

• ________________

ARTNER

• Partner with your patient to help him/her achieve goals• Identify relevant steps

• Agree what each of you will do to reach the desired goal

• If you both agree on reason(s) why your client/ relative would want to be in treatment, create an agreement about what will be tried and forhow long

Guidelines for Creating and Implementing the Partnership

• Write it down together

• Do not inject your own agenda unless invited

• Review the partnership and any progress made by your client/relative every chance you have

• Review how well you are keeping up your end of the partnership

• After each review, ask if the partnership should be modified

• Problem solve around goals not met; create adjunct partnership if needed