Implementing Recovery-Oriented Practices

1. Implementing Recovery-Oriented Practices Step 3 in the Recovery-Oriented Care Continuum: Promoting Recovery Through Psychological and Social Means July 28, 2011 David Kingdon, M.D. Professor of Mental Health Care Delivery University of Southampton United Kingdom Honorary Consultant Adult Psychiatrist Southern Health NHS Foundation Trust Larry Davidson, Ph.D. Project Director, Recovery to Practice (RTP) Development Services Group (DSG), Inc. Jayme Lynch, CPS Director Peer Support and Wellness Center Georgia Mental Health Consumer Network Image: RTP Logo Image: SAMHSA Logo

2. Step 3 in the Recovery-Oriented Care Continuum If You’re Not Hearing Any Audio… • To access the audio for this Webinar, please dial the conference service directly and enter the participant access code: • Audio Conferencing (Toll-Free):1.800.857.5137 • Participant Access Code:3001132 Image: Phone

3. Step 3 in the Recovery-Oriented Care Continuum Webinar Agenda • 2:00–2:05 p.m. • 2:05–2:10 p.m. • 2:10–2:25 p.m. • 2:25–2:40 p.m. • 2:40–2:55 p.m. • 2:55–3:30 p.m. Welcome Introductions and Overview of Today’s Workshop Cognitive-Behavioral Psychotherapeutic Approaches to SMIs Community-Based Supports Consumer-Run Programs Discussion Wilma Townsend SAMHSA/CMHS Larry Davidson DSG, Inc. David Kingdon University of Southampton United Kingdom Larry Davidson DSG, Inc. Jayme Lynch Peer Support and Wellness Center Georgia Mental Health Consumer Network

4. Step 3 in the Recovery-Oriented Care Continuum Process for Questions, Answers, and Downloading Slides • Our speakers will present their slides, which will be followed by moderated questions and answers. We invite you to ask questions or make comments! To ask a question, click on the Q/A tab and type your question in the window that opens, OR press *1 for the operator, who will take your question in the order in which it is received. • This Webinar will be recorded and archived for future use. Please visit http://www.dsgonline.com/rtp/resources.html for more information.

5. Cognitive-Behavioral Psychotherapeutic Approaches to Serious Mental Illnesses (SMIs) Step 3 in the Recovery-Oriented Care Continuum Presented by David Kingdon, M.D. Professor of Mental Health Care Delivery University of Southampton, UK Honorary Consultant Adult Psychiatrist for the Southern Health NHS Foundation Trust Image: David Kingdon, M.D.

6. CBT for Severe Mental Illness: A Brief History of Development Step 3 in the Recovery-Oriented Care Continuum Techniques are based on the general principles of CBTthat were initially developed for the treatment of depression. Developed against a backdrop of intense skepticism because of past failures of other individual psychotherapies CBT added to antipsychotic medication is now a first-linetreatment for schizophrenia. CBT: cognitive behavioral therapy

7. CBT for Severe Mental Illness: Key Elements That Contrast With Other Approaches Step 3 in the Recovery-Oriented Care Continuum Psychosis and bipolar disorder are on a continuum between normal and ill, rather than all or nothing. Does not require acceptance of diagnosis or biologic model of illness causation Interest in personal understanding of symptoms

8. Therapeutic Process of CBT Step 3 in the Recovery-Oriented Care Continuum • There is a strong focus on individualized engagement of the patient, building on good psychiatric practice. • Agendas are less explicit, feelings are elicited with great care, and homework is used sparingly. • Assessment is based on clinical practice. • Emphasis is placed on understanding the first episode in detail, which may hold the key to current beliefs. • Information on current beliefs and how they were reached is assembled into a formulation. ENGAGEMENT ASSESSMENT FORMULATION

9. A Formulation for Making Sense of Patients’ Beliefs and Experiences Step 3 in the Recovery-Oriented Care Continuum Predisposing factors Precipitatingfactors Perpetuating factors Protective factors Current problems Thoughts Social Physical Feelings Behavior Underlying concerns(schemas)

10. Overall Aim of CBT for Psychosis Step 3 in the Recovery-Oriented Care Continuum Work with hallucinations (persistent/ abusive) Work with delusions (systematized and high conviction) AIM Toreducedistressand disability Work with negative symptoms

11. Psychosocial Management in Bipolar Disorder Step 3 in the Recovery-Oriented Care Continuum Focus on medication Social rhythm management Early intervention Interpersonal work • The psychosocial therapies all seem to include three to four core elements: • Psychoeducation and adjustment • Social rhythm regulation and managing substance use • Attitudes toward medication and enhancing adherence • Relapse prevention—learning about warning signs and symptoms Scott et al., 2006

12. Step 3 in the Recovery-Oriented Care Continuum Meta-Analysis of Randomized Controlled Trials (RCTs)for Psychosis (Wykes et al., 2007) • Average effect size for target symptom (33 studies*) = .40 (95% CIs: .25 – .55) • Average effect size for “rigorous” RCTs (12 studies) = .22 (95% CIs: .02 – .43) • Significant effects (ranging from .35 –.44) for • Positive symptoms (32 studies) • Negative symptoms (23 studies) • Functioning (15 studies) • Mood (13 studies) • Social anxiety (2 studies) *20 from UK; 5 from US; 2 from Germany, Australia, Netherlands; 1 from Canada, Italy, Israel; 27 individual CBTp; 7 group CBTp

13. Current Evidence Supporting the Efficacy of CBT in Psychosis Step 3 in the Recovery-Oriented Care Continuum None Casestudies 1-2 randomized controlled trials Meta-analyses/randomized controlled trials Under 18 18-65 Over65 Caucasian Non-Caucasian Prodromal Early Persistent Acute wards Forensic Community

14. Step 3 in the Recovery-Oriented Care Continuum Image: Clinical guidelines for schizophrenia

15. Step 3 in the Recovery-Oriented Care Continuum Image: Criteria for CBT therapy Revised (2009): 16 sessions are now recommended www.nice.org.uk/nicemedia/live/11786/43610/43610.pdf

16. Step 3 in the Recovery-Oriented Care Continuum Image: Comparison of guidelines Gaebel et al., 2005 Image: Comparison of key recommendations between guidelines

17. Current Studies (Psychosis) Step 3 in the Recovery-Oriented Care Continuum General US LA Veteran’s Administration RCT – recruiting Beijing RCT – good early results Early intervention Medical Research Council (MRC) EDIE – awaiting results US NIMH RAISE – early intervention “package” includes some CBT Specific targets MRC COMMAND – command hallucinations: completed recruitment Texas – CBT and cognitive remediation: recruiting DIALOG+ – service user feedback shaping CBT response MRC WIT – worry intervention for paranoia UK NHS-funded – mindfulness groups for voices

18. Clinical Limitations of the CBT Approach Step 3 in the Recovery-Oriented Care Continuum Availability is still a key limitation: In 2005, 49 percent (69 of 142) of patients with schizophrenia were referred in West Southampton (similar levels in UK, 2009). Kingdon & Kirschen, 2006 Image: Graph

19. Training Step 3 in the Recovery-Oriented Care Continuum Ongoing Supervision “Expert” Diploma (1 year of teaching)/M.Sc. (1 year of research) CBT for severe mental illness (1 to 2 days per week) Clinical psychologists “Therapist” Diploma in Psychosocial Interventions Includes CBT and family work (1 year, 1 to 2 days per week) “Insight” Training: 5 to 10 days CBT for psychosis “Practitioner” Day workshops, lectures General mental health training

20. Step 3 in the Recovery-Oriented Care Continuum Image: Book covers

21. Step 3 in the Recovery-Oriented Care Continuum http://theinsightpartnership.co.uk/ Image: Screen shot of Insight CBT Partnership

22. Overview Step 3 in the Recovery-Oriented Care Continuum CBT techniques Continue to evolve in the treatment of psychosis Are being reconsidered in bipolar disorder Aims of CBT Reduce the distress and disability caused by persistent symptoms Improve treatment collaboration Empower and enhance recovery Further dissemination requires increased Availability and take-up of training Use of evidence-based care pathways www.emotionalwellbeing.nhs.uk (live from early September)

23. Community-Based Supports Step 3 in the Recovery-Oriented Care Continuum Presented by Larry Davidson, Ph.D. Project Director, Recovery to Practice, DSG, Inc. Image: Larry Davidson, Ph.D.

24. Step 3 in the Recovery-Oriented Care Continuum Providing Community-Based Supports • Purpose/function of psychological and social interventions • Treatment • Rehabilitation • Skill Development • Tools and Environmental Accommodations Image: Clock Image: Person in wheelchair at sink Image: Woman walking dog Image: Pencil on paper

25. Step 3 in the Recovery-Oriented Care Continuum Brief History and Introduction • Vocational Rehabilitation began during and after World War II. • Fountain House also started in New York in the 1940s. • Group homes and residential alternatives arose after the 1954 de-institutionalization initiative. • By the 1970s, de-institutionalization was being considered a “failed policy” for two main reasons: • Funding was never provided to create the community-based supports people needed to live meaningful lives in the community. • The interventions that had been developed were not effective in affording people lives beyond the mental health system. • (One study suggested that it took an average of 43 years to get a job.)

26. Step 3 in the Recovery-Oriented Care Continuum The Move to Community-Based Work Assertive community treatment developed in the 1960s-1970s. • Based on several lessons • Many people still needed support. • Skills did not generalize from a hospital or classroom. • Learning requires modeling. • With modeling and support, people could live full lives in the community. Image: Bicycle Image: Person lifting car on mechanical jack

27. Step 3 in the Recovery-Oriented Care Continuum In Vivo Support targets Vygotsky’s “Zone of Proximal Development” “… the distance between the actual developmental level as determined by independent problem solving and the level of potential development as determined through problem solving under adult guidance or in collaboration with more capable peers …”

28. Step 3 in the Recovery-Oriented Care Continuum Zone of Proximal Development(and the Art of Care/Recovery Planning) The Possible Image: Silhouette of person thinking The Not Yet Possible Image: Smart Car Image: Businesswoman and businessman Image: House Image: Newlyweds

29. Step 3 in the Recovery-Oriented Care Continuum Role of Activity Analysis Steps involved in performing new behavior Participation in meaningful activity (not one that only leads to desired outcome further down the road!) What I need to do for a specific activity Image: Silhouette of person thinking What I can do now with support (“scaffolding”)

30. Step 3 in the Recovery-Oriented Care Continuum Scaffolding … is the process by which one person supports another person to acquire new behaviors, skills, and habits through use of the zone of proximal development. The person who facilitates the new learning may be a teacher, mentor, coach, rehab practitioner, or simply a “more capable peer” (from Vygotsky’s original definition)—basically anyone who has already learned the particular action to be modeled for the other person. Scaffolding involves: • non-intrusive instruction and demonstration of tasks within the person’s capacity, and • carrying out the remaining parts of the task him or herself. Image: Scaffolding of building at sunset

31. Step 3 in the Recovery-Oriented Care Continuum Essential Components of Supported Activities • Enhancing or creating access to opportunities for people to participate in the naturally occurring and personallymeaningful activities of their choice. • Provision of in vivo supports (e.g., personal instruction, scaffolding, emotional support) and environmental accommodations needed for a person to be successful. This combination has shown promise, as well as results, in improving employment (supported employment), housing (supported housing), education (supported education), and socialization (supported socialization) outcomes, as well as improvements in other important life domains (e.g., supported parenting, supported spirituality).

32. Step 3 in the Recovery-Oriented Care Continuum Lessons Learned Thus Far • With opportunities and supports, people can live, work, play, learn, and love in naturally occurring community settings. • Most often, the most important support that can be provided to people with serious mental illnesses is another (trusted) person who can “show them the ropes.” • Provision of community supports can offer a central role for peer providers who are trained in their provision. • To be afforded meaningful lives in the community, people must be in the community in order to learn how best to live in it (“integration” is harder than “inclusion”).

33. Step 3 in the Recovery-Oriented Care Continuum Community Integration Recovery Citizenship Community Life Love, Work, and Play inpt W A L L O F E X C L U S I O N tx Housing, Faith, and Belonging rehab Image: Silhouette of person thinking

34. Step 3 in the Recovery-Oriented Care Continuum Community Inclusion Citizenship Recovery Community Life Love, Work, and Play Self-Care and Social Support Housing, Faith, and Belonging Image: Silhouette of person thinking

35. Consumer-Run Programs and Businesses Step 3 in the Recovery-Oriented Care Continuum Presented by Jayme Lynch, CPS Director Peer Support and Wellness Center Georgia Mental Health Consumer Network Image: Jayme Lynch, CPS

36. Step 3 in the Recovery-Oriented Care Continuum Georgia Mental Health Consumer Network Peer Support and Wellness Center Image: Photo of Peer Support and Wellness Center A peer-operated alternative to traditional mental health services

37. Trauma-Informed Environment We recognize that trauma often appears in the experiences of our peers. Step 3 in the Recovery-Oriented Care Continuum Image: Two masks of faces • We maintain an atmosphere of respect and dignity. Image: Flowers and text “Respect” Image (text): “Dignity plus respect equals inclusion”

38. Wellness Activities Step 3 in the Recovery-Oriented Care Continuum Image (text): “Whole health now” Image: Calligraphy pen Image (text): “Wellness, Recovery, Action, Planning” • Daily activities address whole health, wellness, and havinga life in the community. Image (text): “Smart shopper” Image (logo): DTR Image: Man bowling Image: Cycle of “career planning”

39. Respite Step 3 in the Recovery-Oriented Care Continuum Three Respite beds A proactive interview informs the relationship. An alternative to psychiatric hospitalization Often the best opportunities for growth arise during crisis situations and their outcomes. The focus is on learning and growing together.

40. Step 3 in the Recovery-Oriented Care Continuum • Eighty-six percent of Respite guests report that accessing a Respite bed had or may have kept them out of the hospital. Image: Pie chart

41. 24/7 Warm Line Peers throughout the State of Georgia utilize our Warm Line 24 hours a day. Partnership with Georgia Crisis and Access Line Step 3 in the Recovery-Oriented Care Continuum Peer support over the phone Image: Man on telephone Image (logo): Georgia Crisis & Access Line

42. Staff Training Step 3 in the Recovery-Oriented Care Continuum All staff are Certified Peer Specialists Trained in Warm Line Protocol CPR, First Aid GMHCN Policies and Procedures Peer Support Whole Health, and Wellness, Recovery, Action, and Planning (WRAP) Trauma-Informed Peer Support created by Beth Filson Intentional Peer Support (IPS) created by Shery Mead

43. Co-Supervision Step 3 in the Recovery-Oriented Care Continuum • Staff members meet with other staff once a month. • Co-supervision helps to maintain a friendly work environment. Image: Two women having coffee

44. Four Tasks of Intentional Peer Support (IPS) Connection Worldview Mutuality Moving Toward Step 3 in the Recovery-Oriented Care Continuum Image: Eye reflecting picture of globe and text: “What is your worldview?” Image: Many hands coming together Image (text): “Connection” Image: Figures following forward direction of arrows

45. IPS Focuses onLearning vs. Helping Step 3 in the Recovery-Oriented Care Continuum “Help” has a potential of fostering dependency. Learning emphasizes mutuality in emotionally distressing situations that would otherwise be stopped or interrupted.

46. Resources http://www.gmhcn.org/ http://www.gacps.org/ (CPS) http://mentalhealthpeers.com/ (IPS) Step 3 in the Recovery-Oriented Care Continuum Image: World Wide Web

47. Step 3 in the Recovery-Oriented Care Continuum Q&A, Discussion, and Summary • To ask a question, click on the Q/A Tab and type your question in the window that opens, OR press *1 for the operator, who will take your question in the order in which it is received. Larry Davidson, Ph.D. Project Director, Recovery to Practice DSG, Inc. ldavidson@dsgonline.com Thanks for joining our Webinar today! Image: Larry Davidson, Ph.D.

48. Step 3 in the Recovery-Oriented Care Continuum For More Information… • For a copy of today’s presentation http://www.dsgonline.com/rtp/resources.html • Recovery to Practice Resource CenterRecoverytoPractice@dsgonline.com