Illness Management and Recovery (IMR)

1. Illness Management and Recovery (IMR) Presented by NH-BBH June 14, 2007 Harry Cunningham cunningh@mhcgm.org

2. The Day the Voices Stopped • “I have a vision that goes like this: In this new century, mentally ill people will have the science…, and the means to leave our ghettos of isolation behind us.” • Ken Steele

3. What’s the Big Deal? “A wide variety of effective, community-based services, carefully refined through years of research, exist for even the most severe mental illness yet are not being translated into community settings.” A Report of the Surgeon General on Mental Health, 1999

4. The five current Evidence Based Practices(EBPs) • Assertive Community Treatment (ACT) • Integrated Dual Disorders Treatment (IDDT) • Family Psychoeducation (FPE) • Supported Employment (SE) • Illness Management and Recovery (IMR)

5. Potential future EBPs • Peer support programming • Treatment for people with borderline personality disorders (DBT?) • Trauma services • Supported housing • ?

6. Overview of Training • What is Illness Management and Recovery? • The importance of recovery • Core values in IMR • 8 key strategies to doing IMR • Research behind the practice • Engagement and orientation of clients • On-the-job-training of some of the 10 topic areas • Doing IMR in a group • Where do you go from here?

7. What Is Illness Management and Recovery? • Illness Management and Recovery is a program that helps people set meaningful goals for themselves, acquire information and skills to develop more mastery over their psychiatric illness, and make progress towards their own personal recovery.

8. Core Ingredients of the Illness Management and Recovery Program: • 6 to 12 months of weekly sessions conducted by trained practitioners • 10 educational handouts that contain practical information and strategies • A practitioners’ guide with tips for teaching people about mental illness and helping them implement strategies

9. Focus of Services to SMI Consumers in Recent Decades • 1960s- Get clients out of the Hospital • 1970s- Keep clients out of the Hospital • 1980s- Rehabilitate clients (Do to them) • 1990s&2000s- Help clients toward Recovery (Do with them)

10. EBPs are a Movement in Mental Health • Increase access for consumers to recovery-based services that have demonstrated effectiveness • Help administrators and providers of mental health services to set up and maintain services that have demonstrated effectiveness

11. The Importance of Recovery “Recovery involves the development of newmeaning and purpose in one’s life as one grows beyond the catastrophic effects of mental illness.” (Anthony, 1993).

12. Characteristics of Recovery • Is defined and accomplished by the person • Can be viewed as a process or outcome • Distinguished from rehabilitation • Involves personal and social success in areas the consumer defines as important to them • Is a universal human experience • Includes the themes of hope, self-confidence, expectations, well-being, & optimism • “A life worth living” (Patricia Deegan video)

13. How I am Seen By Others And Understand Myself Before Being Diagnosed with Mental Illness Values & Beliefs Culture Hopes & Dreams Family Patricia Spirituality Friends Class Sexuality Politics Work

14. Recovery Is Related to Motivation • Motivation: “an inner urge that prompts a person to action.” • Illness management and recovery can best happen when a consumer is motivated to act. • Motivation sources: * Hold the hope for someone. * Peer support. * Relationship to professional. * Inner urge. * Mystery???

15. What Might Motivate Consumers to Practice IMR?

16. What Would Motivate You to Practice IMR?

17. Core Values In IMR • Hope is the Key Ingredient The long term course of MI cannot be predicted Being able to influence one’s own destiny is the basis for future hope and optimism Having other people believe in us is empowering; we sometimes have to “hold” hope for others • Consumers don’t fail the practice, the practice fails them Consumers should be given unconditional support for their participation Programs should work under easy re-entry and “fail-safe” principles • The person is the expert in his or her own experience of mental illness On what strategies have worked for them On what has been helpful and what has not

18. CORE VALUES IN IMR (Continued) • Personal Choice is Paramount The ability and right of people to make their own decisions, including when those decisions differ from recommendations made by their treatment providers The task then becomes to work with them to evaluate the consequences of decisions in terms of their hopes and dreams. Acceptance is also paramount. • Practitioners are Collaborators Practitioner as consultant in a non-hierarchal relationship • Practitioners demonstrate Respect for people who experience psychiatric symptoms As capable decision-makers and active participants in their own treatment Respect for differing values and opinions To seek common ground when there is a difference in point of view

19. How Is IMR Different From the Ways I Am Already Working With Consumers?

20. 8 Key Strategies to Doing IMR

21. Key 1. Client Centered goal setting toward recovery • Focus on client’s context of life rather than just on their symptoms • Strengthsvs. Problems • Mutual responsibility in planning and pursuing goals rather than “following” treatment • Constant reassessment and adjustment of plan

22. Moving From a Disease Model of Mental Illness • Examples of disease goals *Take medications * Reduce voices * Stop reacting to delusions * Maintain housing * Manage finances

23. Examples of Goals That Go Beyond a Focus on Symptoms • To get closer to 2 current friends who I value. • To improve the appearance of my apartment so I can have friends over. • To play a larger role in the operations of my church. • To own my own car so I can hike in the mountains. • To go to the movies once a month.

24. Key 2: Good Basic Knowledge About Mental Health: • Origin and course of MI • Symptoms and diagnosis • Medications • Recovery • Community resources

25. Key 3: A Monitor~Response to Identified Symptoms and Unhealthy Behavior • Increased awareness of “I can effect it” • Choices of things that make it better and make it worse • Relapse prevention plan • Wellness plan • Even though I may not have caused it, I can have the most effect on it • Acceptance of mutual responsibility: Shared Decision Making

26. Key 4: A Strength-Based Approach • People with severe and persistent mental illness can learn, grow and change. • The focus of the helping process is upon the consumer’s strengths, interests and abilities, not upon their deficits or pathology. People who are successful in living have goals and dreams. They use their strengths to attain their aspirations.

27. Key 5: Educational Teaching Strategies Interactive teaching, not lecturing • Asking “open-ended” questions to review information and check comprehension • Using a variety of methods to present the handout material: • summarizing the key points, • giving examples • taking turns reading aloud • asking people to read on their own • Adopting participants’ language to facilitate comprehension of material

28. Key 6: Motivational Teaching Strategies • Help person see how learning information and skills is related to achieving personal goals • Convey hope, belief, and confidence that person can make desired changes and accomplish goals • Help person explore costs and benefits of maintaining the status quo vs. costs and benefits of change

29. Key 7: Cognitive-Behavioral Teaching Strategies • Reinforcement • Shaping • Modeling • Role playing • Cognitive restructuring

30. Key 8: Emphasis on Stages of Change in Ongoing Assessment • Pre-Engagement Task: Outreach, raise awareness, increase hope • Contemplation Task: Weigh pros and cons, help imagine a better life • Preparation Task:Collect information about alternative actions. • Action Task: Modify lifestyle, staff as consultant(not expert) • Maintenance Task: Maintain new balance, monitor against old habits

31. IMR Intro Video

32. IMR Materials (Cont.) IMR Workbook The basics of Illness Management and Recovery • Educational Handouts with ample worksheets and checklists are provided to participants • Practitioners’ Guide provides guidelines for each topic in the educational handouts

33. IMR Materials (Cont.) IMR Videos • Short video introduces the program to participants • Practice demonstration video illustrates the teaching strategies for practitioners

34. Evidenced-Based Components of Illness Management • Education about mental illness and its treatment • Relapse prevention training • Behavioral tailoring for medication • Coping skills training • Social skills training • Dual Disorder strategies

35. 10 Topic Areas 1. Recovery Strategies 2. Practical Facts about Mental Illness (schizophrenia, bipolar disorder, major depression) 3. The Stress-Vulnerability Model and Treatment Strategies 4. Building Social Support 5. Using Medication Effectively

36. 10 Topic Areas (cont.) • Alcohol and Drug Use • Reducing relapses 8. Coping with stress 9. Coping with problems and symptoms 10. Getting your needs met in the mental health system

37. Learning IMR On-The-Job • Start with 2-3 clients ASAP • Keep 1-2 sessions ahead of client • The curriculum and teaching strategies can be learned as you go • Biweekly training/supervision allows practitioners to gain the knowledge

38. IMR is Structured yet Flexible Not intended to be presented as a “cookie cutter” practice! The ideal is to integrate: • best available research • your individual clinical expertise • with consumer’s preferences

39. Seeing and Doing IMR

40. Who is IMR Designed For? • Almost anyone with a severe mental illness • Research and educational materials cover 4 areas of symptoms: schizophrenia, schizoaffective disorder, bipolar disorder, major depression • You often can’t predict who will benefit and who won’t • Customize to the unique needs of the consumer

41. Examples of consumers who may benefit from IMR • People with distressing persistent symptoms • People who experience frequent hospitalizations • People who have frequent crises • People wanting to live more independently • People wanting to improve employment skills • People wanting to increase friendships

42. Engagement Barriers: Staff • She’s too high/low functioning • He doesn’t show up for anything • She’s got too many crises going on • He never sticks around for more than 3 months • She needs maintenance, not recovery • I already do this with clients • I don’t have time for extra work

43. Engagement Barriers: Client • Nothing really helps, why try IMR • It’s too risky to risk • It’s too much commitment • It sounds too much like school • I’m not mentally ill, or schizophrenic, or… • I know all of that stuff already

44. Approaches to Engage Clients How would you like to learnmore about: • recovery, future possibilities for you • medications, support from medical staff • mental illness, diagnosis • reducing relapses • coping with stress • support from family and other people • reduce/manage symptoms • leaving the hospital

45. Approaches to Clients (cont.) How would you like to be more involved: • Play more of a role in the treatment team • Set goals that reflect personal and social success that are important to you Can you use your relationship with client? • Find ways to help staff work more with you • Have staff better understand you • Trust me! Trial Offer • Come this week and decide if you want to continue

46. Orientation for Clients(Page 39) • Usually lasts one meeting • Expectations made clear • Attendance • Roles of consumer and practitioner • Homework • Mutual responsibility • Sets positive expectations of change • Reduces treatment drop-out rate!

47. Homework • Collaboratively agreed upon by the practitioner and the person at the end of each session • Related to the person’s goal and/or the curriculum topic • Individually tailored to the person

48. Homework (continued) • Behaviorally specific • May involve significant others or treatment team members • Followed up at the next session • Analyze and problem-solve any difficulties in doing assignments.

49. Examples of Homework • Reviewing a handout, checklist, or plan with significant other • Practicing a skill (e.g., striking up a conversation) • Getting more information about achieving a goal (e.g., checking out costs of local health clubs) • Taking a step towards a personal goal • Practicing a coping strategy at home (e.g., relaxation exercises)

50. Knowledge and Skills Inventory • Strengths Assessment Or • Knowledge and Skills Inventory (Page 41) Your choice!