IMR 2-Day Training: IMR 2-Day Training Tim Gearhart MSW Dave Thomas, BA, PRS ACT Center of Indiana


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


Illness Management Research: Illness Management Research Reviewed 40 randomized controlled studies which included psycho-education, medication-focused programs, relapse prevention, coping skills training, cbt for psychosis. (Mueser et al) Target population for the lit review included: schizophrenia, bipolar disorder, and general SMI Who is your target population?


Outcomes of interest: Outcomes of interest Proximal outcomes: knowledge of MI and using medication as prescribed Distal outcomes: relapses, symptoms, and social functioning What outcomes are you looking for? Client level? CSR related? Fidelity related? Clinical competency of staff? Agency culture? Staff burn-out? Appendix 8 + 9


Psycho-education findings of 4 large studies: Psycho-education findings of 4 large studies ¾ showed improved knowledge of their mental illness. 1 showed improvement in medication adherence. Discussion


Medication Focused Programs: Medication Focused Programs Behavioral Tailoring and simplifying medication regimens found increased adherence in %100 of the studies reviewed. Motivational Interviewing showed increased adherence, fewer symptoms and relapses and improved social functioning. Medication Psycho-Ed found minimal results likely due to memory issues.


Relapse Prevention Training: Relapse Prevention Training Focus on identifying early warning signs, triggers, and stress management skills. All programs/studies reviewed showed a decrease in relapse or hospitalization. Significant other involvement shows effectiveness in preventing relapses.


Coping Skills Training: Coping Skills Training Increases consumer’s ability to deal with persistent symptoms and stress All program’s/studies reviewed utilized cognitive behavioral intervention and produced similar outcomes.


Cognitive behavioral TX of psychotic symptoms: Cognitive behavioral TX of psychotic symptoms More effective than standard care for reducing the severity of psychotic symptoms.


Evidence Base for IMR: Evidence Base for IMR Psychoeducation Behavioral tailoring for medication adherence Relapse prevention training Coping skills training How many programs do you have that are set up under one of these categories?


Illness Management and Recovery Program: Illness Management and Recovery Program IMR is a step-by-step program that helps consumers set meaningful goals and learn skills to assist them in the pursuit of those goals. Typically lasts 3 to 9 months w/ weekly or bi-weekly session. Group or Individual. Programmatically flexible.


Topics of Modules: Topics of Modules Recovery Strategies Practical Facts about Mental Illness The Stress-Vulnerability Model Building Social Support Using Medication Effectively Reducing Relapses Coping with Stress Coping with Problems and Symptoms Getting Your Needs Met in the Mental Health System Substance Abuse


Program Goals: Program Goals Inspire hope with positive expectations. Empower informed decision makers. Help people set and make progress towards personal recovery goals Teach people how to use medication effectively Help people understand and develop relapse prevention plans Teach people strategies for coping with persistent symptoms and other problems


Clinical Interventions: Clinical Interventions Handouts are not to stand alone. Clinical techniques are implored to assist consumers in integrating skills into daily life. MI, CBT, and Edu.


Motivational Interventions: Motivational Interventions Connect info and skills with personal goals Promote hope and positive expectation Explore pros and cons of change Reframe experiences in a positive light


Cognitive Behavioral Interventions: Cognitive Behavioral Interventions Reinforcement Cognitive restructuring Shaping Re-framing Modeling Role playing Relaxation training


Educational Techniques: Educational Techniques Interactive teaching Review homework Check for understanding Complete worksheets Review information Break down info


Recovery: Recovery


Definitions of Recovery: Definitions of Recovery 'Recovery involves the development of new meaning and purpose in one’s life as one grows beyond the catastrophic effects of mental illness.' (Anthony, 1993) 'One of the elements that makes recovery possible is the regaining of one’s belief in oneself.' (Chamberlin) 'Recovery is what occurs when a person with a mental illness discovers (or rediscovers) their strengths and abilities for pursuing personal goals and develops a sense of identity that allows them to grow beyond their mental illness' (Author Unknown) 'Recovery is a process, a way of life, an attitude and a way of approaching the day’s challenges.' (Deegan)


Recovery is…: Recovery is… An opportunity to grow through ones challenges Becoming a self defined person with a self defined purpose Experiencing authentic happiness, friendships, realization of ones place in the world A peace of mind, hope for a future and joy along the way


Recovery is not…: Recovery is not… A cure Freedom of symptoms An end to stress and/or problems Elimination of relapses A life that one originally planned


Recovery is a Journey of the Heart: Recovery is a Journey of the Heart 'It is only with the heart that one can see rightly; what is essential is invisible to the eye.' -Antoine De Saint-Exupery-


Hope for Recovery: Hope for Recovery Body of research shows a more optimistic picture Review of long-term follow up studies of schizophrenia show that between 42% and 68% of consumers with the illness experience either full recovery or show substantial improvement in their lives (Hafner et al., 2003) Growth and enthusiasm for the vision of recovery championed in the consumer movement


SAMHSA Consensus on Recovery: SAMHSA Consensus on Recovery 'Recovery must be the common, recognized outcome of the services we support.' Charles Curie; SAMHSA Administrator


10 Fundamental Components of Recovery:: 10 Fundamental Components of Recovery: Self-Direction: the recovery process must be self-directed and defined his or her own life goals Individualized and Person-Centered: There are multiple pathways to recovery based on an individual’s unique strengths and resiliencies as well as his or her needs, preferences, experiences (including past trauma), and cultural background in all of its diverse representations


Components (continued): Components (continued) Empowerment: having the authority to choose from a range of options and to participate in all decisions that will affect individuals lives, and are educated and supported in so doing. Holistic: Recovery encompasses an individual's whole life, including mind, body, spirit, and community.


Components (continued): Components (continued) Non-Linear: Recovery is not a step-by step process but one based on continual growth, occasional setbacks, and learning from experiences Strengths-Based: Recovery focuses on valuing and building on the multiple capacities, resiliencies, talents, coping abilities, and inherent worth of individuals


Components (continued): Components (continued) Peer Support: Mutual support (including the sharing of experiential knowledge and skills and social learning) plays an invaluable role in recovery Respect: Self-acceptance and regaining belief in one’s self are particularly vital. Respect ensures the inclusion and full participation of consumers in all aspects of their lives


Components (continued): Components (continued) Responsibility: Consumers have a personal responsibility for their own self-care and journeys of recovery. Consumers must strive to understand and give meaning to their experiences and identify coping strategies and healing processes to promote their own wellness. Hope: Hope is the catalyst of the recovery process Document available at www.mentalhealth.samhas.gov


Deegan: ‘Hope, Nurturance, Listening, Patience’: Deegan: ‘Hope, Nurturance, Listening, Patience’ How can mental health professionals help consumers with their recovery?


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


Listening: Listening It is our job to ask people with psychiatric disabilities what it is they want and need in order to grow and then to provide them with good soil in which a new life can secure its roots and grow.


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


Relationship of Recovery to Illness Management : Relationship of Recovery to Illness Management Improve ability to manage life one’s illness through knowledge, understanding, acceptance of one’s illness Identifying and achieve ones personal recovery goals through the understanding and hope of change is possible Minimizing relapses and re-hospitalizations giving people enhanced control in their lives Less time spent dealing with mental illness allowing more time spent on personally fulfilling and purposeful lives Less stress due to symptoms and impairment leading to a better quality of life


Slide35: Recovery is reaching the highest level of wellness, happiness, and life satisfaction


Regaining Motivation: Regaining Motivation 'Motivation - that’s the key. If you have a reason in this world for wanting to cope, you can do it.' Peer Specialist, Mt. Carmel Guild Behavioral Healthcare, Program for Assertive Community Treatment


Regaining Self-Esteem: Regaining Self-Esteem 'Recovery is about having confidence and self-esteem. There are things I’m good at, and I have something positive to offer the world.' From EBP Illness Management andamp; Recovery Implementation Resource Kit


Regaining Meaning: Regaining Meaning 'I have to have goals. That’s what gives my life meaning. I’m looking to the future.' From EBP Illness Management andamp; Recovery Implementation Resource Kit


IMR Emphasizes Personal Goals as Fundamental Recovery Tool: IMR Emphasizes Personal Goals as Fundamental Recovery Tool For many people, the whole point of recovery is to be able to move forward in life, and being able to set and pursue personal goals Looking into the future-not inward-not back to the past


Setting and Pursuing Personal Goals: Setting and Pursuing Personal Goals Being able to set and pursue personal goals is an essential part of recovery and IMR Gives opportunity to explore the risk and ambivalence of change providing the nature and the motivation for change Presents opportunities to learn and applying the information, strategies and skills taught in IMR


What might help a person with their recovery?: What might help a person with their recovery?


Slide42: Be positive and hopeful Encourage and understand us Be friendly, supportive and respectful Be firm and protective when necessary Be available and have back-up service Be up-to-date Be willing to admit and remedy mistakes Some Ideas from Consumers


Support from Professionals: Support from Professionals Close monitoring Emphasize self-care and personal responsibility Explore and try new approaches Use less invasive alternatives Use a team approach Consider individual needs and preferences Have good listening and communication skills Care about us Accept us as we are


Slide44: Introductory video.


Core Values of IMR: Core Values of IMR Hope is the key ingredient The person is the expert Personal choice is a must Practitioners of IMR are partners Practitioners demonstrate not dictate Respect is always present


Materials for IMR: Materials for IMR Practitioners Guidelines: Gives ideas for MI, CBT, and Educational Techniques. Educational Handouts: Information that is actually covered in session. Implementation Tool Kit: Selected Articles, Info documents, Implementation tips, fidelity scales, outcome guides, intro and demo videos


Getting Started: Getting Started 1st session: Orientation Sheet (Appendix 1) 2nd and 3rd session: Knowledge and skills inventory (Appendix 2) Remaining sessions: Utilize educational handouts. Use progress note (Appendix 3) Continually look for ways Significant Others might avail themselves to consumer hmwk and goals (Appendix 4) Modules build on one another but it isn’t essential to go through them in order.


Structure of IMR Sessions: Structure of IMR Sessions 1. Informal socializing 2. Review previous session 3. Review previous home assignment 4. Follow up on goals (for group, follow up on goals of 2-3 consumers on rotating basis) 5. Set agenda for current session 6. Teach new material from handout 7. Develop a home assignment collaboratively 8. Summarize session and progress made


Module 1: Recovery Strategiesread the practitioners guidelines.: Module 1: Recovery Strategies read the practitioners guidelines. Assist in defining recovery Life Goals: hopes for overall improvements Enhancement goals: reflects quality of life concerns


Module 1: Recovery Strategies: Module 1: Recovery Strategies Address ambivalence around recovery goals and strategies for recovery. Docere – Expert Ducere – Calling forth that which is already there. E.g. Socrates, Photo Album


Module 1: Recovery StrategiesReal Play (p. 143): Module 1: Recovery Strategies Real Play (p. 143) 'Why haven’t you achieved this goal.' Explain why it is important that they change. Explain how they should go about making that change. 'If you don’t change then…will happen'


Module 1: Recovery Strategies: Module 1: Recovery Strategies Favorite Teacher exercise.


Module 1: Recovery StrategiesReal Play : Module 1: Recovery Strategies Real Play 'If you decided to make this change, how might you go about it?' 'Why would you want to go about it that way?' 'On a scale of 0-10, how important is this to you? Why not 0?' Provide a summary. Ask, 'So what do you think you’ll do?'


Module 1: Recovery Strategies : Module 1: Recovery Strategies Module 1 vignette. Vignette (How does Kim utilize the curriculum based material?


Recovery Goals : Recovery Goals Individualized? Personally meaningful? Range from the modest to the ambitious. Don’t Poo Poo! Exploration of personally meaningful goals often needed to engage consumer before introducing IMR program. Find the Hook!


Helping clients Set Recovery Goals: Helping clients Set Recovery Goals Take your time Avoid overusing the term 'goals' Don’t impose your own beliefs Explore how person would like life to be different Don’t discourage ambitious goals, but help people break down to into smaller goals or steps that are reasonable andamp; measurable . Program for Success!


Aim for Well-Defined Goals that are Measurable and Achievable: Aim for Well-Defined Goals that are Measurable and Achievable Help consumers consider goals that have to do with improved role functioning (parenting, working, going to classes, homemaking) Help consumers come up with at least one goal that could be achieved in the next 3 months Be able to answer the question: 'How will we both know when this goal is achieved?'


Examples of Well-Defined Goals that are Measurable & Achievable: Examples of Well-Defined Goals that are Measurable andamp; Achievable Have coffee with my sister once a week Read the headlines every morning Learn two coping skills for distracting myself from critical voices Identify jobs that are related to my interest in spending time outdoors Take my toddler to the playground twice a week (continued)


More examples of goals (cont’d): More examples of goals (cont’d) Take a 15 minute walk 3 times per week Learn to recognize high risk situations for drinking Identify activities that I could enjoy doing with my family Take the bus to the peer support center Learn strategies for responding to people who pressure me to give them money


Break Down Goals into Steps: Break Down Goals into Steps Help consumers 'program for success' Aim for steps that are small and manageable Make steps as specific as possible


Example of Possible First Steps Towards Goal of Walking 30 minutes 3 Times per Week: Example of Possible First Steps Towards Goal of Walking 30 minutes 3 Times per Week Locate or purchase comfortable shoes Identify a walking route that is safe Start by walking once each week for 15 minutes


Follow up on Goals: Follow up on Goals Check on progress towards goals regularly (weekly or every few weeks) Reinforce steps that were taken Help person problem-solve obstacles to taking steps


Troubleshooting Lack of Progress Towards Goals: Troubleshooting Lack of Progress Towards Goals To maintain enthusiasm, remind how small goals are related to larger ones Evaluate depth of interest in goals set Consider identifying smaller steps Involve significant others more If consumer is lacking hope or self-efficacy, building up hope and confidence


IMR Clinical Skills: IMR Clinical Skills


Module Exposure Exercise: Module Exposure Exercise What are the goals of the module? What stands out to you? How can this module facilitate Recovery?


IMR Practitioners Use 3 Essential Teaching Strategies : IMR Practitioners Use 3 Essential Teaching Strategies Motivational Strategies Educational Strategies Cognitive-Behavioral Strategies


Motivational Strategies: Motivational Strategies People are motivated to learn things if they are relevant to personal goals (Importance) Connect IMR materials to goals Explore how illness has interfered with goals Convey hope and confidence in person Help person explore costs and benefits of change (continued)


Motivational Strategies (cont’d) : Motivational Strategies (cont’d) Pay-off matrix strategy Socratic method of asking questions rather than giving answers Explore past successes Reframe past challenges as evidence of personal strengths Make the consumer the 'expert' and put them in charge of something


Following up on Goals: Following up on Goals The most powerful motivational strategy is helping people progress towards goals Follow up on goals at beginning of each session Help set new goals when others achieved Review progress regularly with consumer


Home Assignments: Home Assignments Help consumers transfer information and skills into their daily lives The 'real' therapy is what happens outside of session Use alternative term if necessary Always develop home assignments collaboratively at end of each session Be as specific as possible (when, where, how, etc.) (continued)


Home Assignments (cont’d): Home Assignments (cont’d) Always follow up on home assignments When people don’t do assignments, explore obstacles and problem-solve Assure understanding of the role of homework Assure assignments are understood andamp; feasible Shape homework adherence andamp; praise efforts


Importance & Confidence Rulers: Importance andamp; Confidence Rulers Where is your client in relation to changing…? _________________________________________________________________________ Not Ready Unsure Ready Importance (Why) How important is it for you right now to…? 0-------------------------------------------10 Why should I change? Why is it important for me to change? What will I gain or lose? I want to, but…… Confidence (How) If you did decide to change, how confident are you that you would succeed? 0------------------------------------------10 Will I be able to? What skills do I need? Will I cope in situations?­­­­­­­­­­­­­­


Motivational Interviewing: Motivational Interviewing Stages of Change What is MI Principles of MI (DEARS) 3 R’s in depth Other nifty tools for MI Monty Roberts - The Horse Whisperer


Educational Strategies: Educational Strategies Goal: help consumers learn about their illness andamp; how to manage it Use handouts in interactive ways (e.g., take turns reading) Ask questions to check on understanding; ask for 'own words' Use 'chunking' to break down information into small bites (continued)


Educational Strategies (cont’d): Educational Strategies (cont’d) Adopt consumer’s language Don’t push consumer to accept diagnosis Review the material, even if consumer is knowledgeable Encourage consumer to share material with significant others


Cognitive Behavioral Strategies: Cognitive Behavioral Strategies Help consumers practice strategies and skills in IMR sessions Help consumers put skills into action in their everyday lives


Specific CBT Strategies used in IMR: Specific CBT Strategies used in IMR Reinforcement Shaping Cognitive restructuring Modeling Role playing Reframing Relaxation Training Systematic desensitization (gradual exposure to feared but safe situations)


Social Skills Training(Building Social Supports): Social Skills Training (Building Social Supports) Review rationale for skill Review specific steps of skill Model steps and ask for feedback Engage person in role play Provide feedback, starting with the positive If indicated, provide a suggestion for improvement and ask person to do another role play (continued)


Social Skills Training (cont’d): Social Skills Training (cont’d) Provide additional feedback Develop a home assignment with the person to use the skill in the real world Follow up to see how the skill worked See Bellack, A., Mueser, K., Gingerich, S., andamp; Agresta, J. (2004). Social Skills Training For Schizophrenia, 2nd Edition. NY: Guilford Press.


Slide80: Social Skills vignette.


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


Slide82: However, believing in yourself, having hope that things will continue to get better and looking forward to your future are also vital in overcoming mental illness. Our hopes and dreams are not delusions. Our hopes and dreams are what make us human.' David Kime, artist, writer, floral designer, person in recovery from bipolar disorder.


Acknowledgments: Acknowledgments Susan Gingerich MSW Kim Meuser Phd Jen Fry Phd David Penn Phd Ric Krusinsci MSW


Slide84: tgearhar@iupui.edu


Tips for IMR Implementation: Tips for IMR Implementation


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


Stages of Organizational Change : Stages of Organizational Change (www.ohiosamicc.oe.case.edu) Pre-contemplation: Unaware or uninterested. Focus on risk management. Contemplation: Consensus building. Evaluation of readiness, willingness, and ability. Preparation: Motivating. Identify stakeholders, steering committee formation, find champions. Action: Implementing. Address barriers. Maintenance: Sustaining. Oversight, fidelity, outcome monitoring, internal training, milieu.


Supervision/Consultation: Supervision/Consultation Structured group supervision, weekly, not more than 6-8 clinicians Review cases (Assign a case presentation) Discuss goals (Agency, Clinician, and Consumer) Role play challenging situations Selected teaching of core skills, role play, vignettes Evaluate engagement of consumers, integration of IMR with team, involvement of significant others Discuss current outcomes. Outcomes should drive practice!


Members of IMR Team: Members of IMR Team IMR Clinicians IMR Consumer Providers IMR Coordinator/Program Leader Agency Director


IMR Clinicians and IMR Consumer Providers: IMR Clinicians and IMR Consumer Providers 3-8 per treatment team (depending on number of consumers served by the team) 2 days initial training andamp; 1 day follow-up Are expected to work with at least 3-4 consumers (or lead 2-3 groups) in the first year Have protected time for providing IMR (continued)


IMR Clinicians and IMR Consumer Providers (cont’d): IMR Clinicians and IMR Consumer Providers (cont’d) Receive weekly supervision focused on IMR Receive consultation Start working with consumers within 4 weeks of 2-day IMR training Have accountability for providing IMR (e.g., part of job description)


IMR Coordinator/Team Leader: IMR Coordinator/Team Leader Coordinating IMR is in job description Specific proportion of his or her time is designated and protected for providing and coordinating IMR Receives IMR training and works with some consumers using IMR Provides IMR supervision (continued)


IMR Coordinator/Team Leader (cont’d): IMR Coordinator/Team Leader (cont’d) Establishes and monitors IMR referral process Assures that referred consumers receive IMR Monitors the quality and quantity of IMR services delivered at the agency Reports to the agency director and meets regularly with him or her


Agency Director Shows Interest and Support by:: Agency Director Shows Interest and Support by: Attending training andamp; kickoff Attending some supervision sessions Meeting regularly with IMR Coordinator/Team Leader Troubleshooting obstacles to IMR


Common Difficulties Encountered: Common Difficulties Encountered Lack of protected time for practitioners Lack of accountability Lack of experience in working with curriculum-based approaches Challenging for agencies and practitioners to change the way they practice Practitioners not receiving supervision Billing codes (ADL versus CM)


Common Questions and Answers about IMR: Common Questions and Answers about IMR Fitting in structured work into the day-to-day hustle-bustle of work Balancing between meeting immediate needs and working towards long-term recovery goals Changing practice to incorporate IMR Fitting IMR training on top of everything else Supports needed to implement IMR The benefits of supervision Time to prepare for IMR


How do you do formal structured work in the hustle-bustle of clinical work with consumers?: How do you do formal structured work in the hustle-bustle of clinical work with consumers? Recognize the advantages of teaching IMR using formal rather than informal strategies, including: More systematic assessment of needs and progress towards meeting them Opportunities for concerted and more focused teaching of skills in formal work Greater assurance that information and skills will be taught by setting aside teaching time Increased confidence that treatment goals are recovery oriented and based on collaboration with consumer (continued)


Formal structure (cont’d): Formal structure (cont’d) Setting aside time for IMR will connote to the consumer the importance working towards recovery goals Time can be set aside each week, in a planned and predictable fashion Setting aside time is proactive; doing it on the fly is more often 'reactive'


How do you balance between helping consumers meet their day-to-day living needs and learning long-term recovery skills?: How do you balance between helping consumers meet their day-to-day living needs and learning long-term recovery skills? Appreciate the old saying, 'If you feed a man a fish, you feed him for a day. If you teach a man to fish, you feed him for life.' Helping people get their short-term needs and their long-term needs is always a balancing act in the helping profession Don’t neglect the consumer’s most pressing needs, but avoid focusing all energy on getting all needs met Whenever possible, focus IMR teaching on helping consumers get their practical daily needs met in addition to their long-term needs


How do you change your practice to incorporate teaching IMR?: How do you change your practice to incorporate teaching IMR? Keep in mind learning IMR is an exciting opportunity to learn some new skills (or improve your existing skills) for helping consumers manage their mental illness and make progress towards personal goals Recognize that IMR will provide an organized forum for discussing the concept of recovery with consumers, and understanding what is means to each person Present IMR to consumers as a new program aimed at helping them get better control over their lives and meet their personal goals Show consumers the introductory IMR video and explain that IMR works by having regular meetings on a scheduled basis