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ICMS Training
Session 6
Rutgers, The State University of New Jersey
Overview:
• Illness Management and Recovery (IMR).
• Intervention strategies for individuals with the co-occurring
disorders of substance use and mental illness
– Motivational Interviewing (OARS)
• Intervention strategies for special populations
– Older adults, persons with justice involvement
• Team building strategies
Department of Psychiatric Rehabilitation & Counseling Professions
What are Evidence-Based Practices?
• Integrated Treatment for Co-Occurring Disorders
• Assertive Community Treatment (ACT)
• Pharmacologic Treatment
• Psycho-Education for Families
• Supported Employment
• Illness Management and Recovery (IMR)
Department of Psychiatric Rehabilitation & Counseling Professions
What is RECOVERY?
Department of Psychiatric Rehabilitation & Counseling Professions
One definition of Recovery
• Recovery is a process, a way of life, an attitude, and a
way of approaching the day’s challenges. It is not a
perfectly linear process. At times our course is erratic
and we falter, slide back, regroup, and start again. . .
Department of Psychiatric Rehabilitation & Counseling Professions
• …The need is to reestablish a new and
valued sense of integrity and purpose within
and beyond the limits of the disability; the
inspiration is to live, work, and love in a
community in which one makes a significant
contribution.”
Patricia Deegan, 1988
http://www.recoverystories.info/pat-deegan-film-clips/
Department of Psychiatric Rehabilitation & Counseling Professions
ILLNESS MANAGEMENT AND
RECOVERY (IMR)
GINGERICH & MUESER, 2005
Department of Psychiatric Rehabilitation & Counseling Professions
Illness Management and Recovery(IMR)
• IMR is an evidence-based practice that helps people with mental
illness:
– Set meaningful personal goals
– Acquire skills necessary to cope with and manage their illness
– Make progress toward their recovery
Department of Psychiatric Rehabilitation & Counseling Professions
Overarching Goals of IMR
• Inspire people to become hopeful about their recovery
• Prepare people to be informed decision-makers about
their own treatment
• Help people gain more sense of control over their mental
illness
• Free people up to spend less time dealing with their
illness and more time enjoying life
Department of Psychiatric Rehabilitation & Counseling Professions
Core Values of IMR
Hope is the key
ingredient
Practitioners of IMR
are partners
The person is the
expert
Practitioners
demonstrate, not
dictate
Personal choice
is a must
Respect is
always present
Department of Psychiatric Rehabilitation & Counseling Professions
IMR Modules
• Recovery Strategies
• Practical Facts about Mental Illness
• The Stress-Vulnerability Model
•
•
•
•
Building Social Support
Using Medication Effectively
Drug and Alcohol Use
Reducing Relapses
•
•
•
•
Coping with Stress and Common Problems
Coping with Symptoms
Getting your Needs Met in the Mental Health System
Healthy Lifestyles
Department of Psychiatric Rehabilitation & Counseling Professions
Overview of Modules
Module
Topics
1
Recovery
Strategies
1.
2.
3.
4.
5.
Defining Recovery
Exploring Areas of Life You Would Like to Improve
Identifying A Personal Recovery Goal
Breaking Down Your Goal
Following Up on Your Goal and Solving Problems
2
Practical
Facts About
Mental
Illnesses
1.
2.
Understanding the Disorder and its Diagnosis
Learning What Happens after People Develop
Symptoms
Taking Positive Steps to Manage the Disorder
Dealing with Negative Attitudes and Beliefs about
Mental Illness (Stigma)
3.
4.
Department of Psychiatric Rehabilitation & Counseling Professions
Overview of Modules
Module
3
4
Topics
The Stress- 1.
Vulnerability 2.
Model
Building
Social
Support
Department of
3.
4.
Understanding the Causes of Mental Illnesses
Learning What Improves Symptoms and Reduces
Relapses
Understanding Treatment Options
Reducing Relapses
1.
2.
3.
4.
5.
6.
Recognizing the Importance of Social Support
Connecting with People
Having Enjoyable Conversations
Sharing Personal Information
Understanding Other People
Developing Closer Relationships
Department of Psychiatric Rehabilitation & Counseling Professions
Overview of Modules
Module
5
6
Topics
Using
Medications
Effectively
1.
Drug and
Alcohol Use
1.
2.
3.
4.
2.
3.
4.
5.
6.
Department of
Learning about the Role of Medication in Managing
Symptoms
Identifying and Dealing with Side Effects
Making an Informed Decision about Medication
Getting the Best Results from Medication
Identifying Common Reasons People Use Drugs and
Alcohol
Recognizing Problems that Alcohol and Drugs Can
Cause
Weighing Pros and Cons of Sobriety
Identifying Personal Reasons for Sobriety
Finding New Ways of Getting your Needs Met
Making a Personal Sobriety Plan
Department of Psychiatric Rehabilitation & Counseling Professions
Overview of Modules
Module
Topics
7
Reducing
Relapses
1.
2.
3.
4.
Identifying Triggers of Relapse
Recognizing Early Warning Signs of Relapse
Developing a Relapse Prevention Plan
Putting your Relapse Prevention Plan into Practice
8
Coping with
Stress
1.
2.
3.
4.
5.
Learning What Causes Stress
Identifying the Signs of Stress
Preventing and Coping with Stress
Using Relaxation Techniques
Making a Plan for Preventing and Coping with Stress
Department of
Department of Psychiatric Rehabilitation & Counseling Professions
Overview of Modules
Module
Topics
9
Coping with
Persistent
Symptoms
10
Getting your
1.
Needs Met in
2.
the Mental
3.
Health System
Department of
1.
2.
3.
4.
5.
6.
7.
Identifying Persistent Symptoms
Coping with Depression
Coping with Anxiety
Coping with Hallucinations and Delusions
Coping with Sleep Problems and Low Energy
Coping with Anger Problems and Concentration
Making a Plan for Continuing to Use Coping
Strategies
Overview of Community Mental Health Services
Financial and Health Insurance Benefits
Advocating for Yourself in the Mental Health System
Department of Psychiatric Rehabilitation & Counseling Professions
Overview of Modules
Module
11
Healthy
Lifestyles
Department of
Topics
1.
2.
3.
4.
5.
Diet, Part I
Diet, Part II
Exercise
Personal Hygiene
Sleep
Department of Psychiatric Rehabilitation & Counseling Professions
IMR: Group Discussion
• How does illness management relate to
recovery?
• Think of services contained in ICMS…
– How do these services relate to IMR?
– What are the expected outcomes?
Department of Psychiatric Rehabilitation & Counseling Professions
INTEGRATED TREATMENT
FOR CO-OCCURRING
DISORDERS
Department of Psychiatric Rehabilitation & Counseling Professions
Stats from SAMHSA
• Annual total estimated societal cost of substance abuse in the
United States is $510.8 billion.
• By 2020, behavioral health disorders will surpass all physical
diseases as a major cause of disability worldwide.
• Half of all lifetime cases of mental and substance use
disorders begin by age 14 and three-fourths by age 24.
SAMHSA, 2011: http://store.samhsa.gov/shin/content//SMA11-4629/01FullDocument.pdf
Department of Psychiatric Rehabilitation & Counseling Professions
20
Stats from SAMHSA
• In 2008, an estimated 9.8 million adults aged 18+ in the US
had a serious mental illness. Two million youth aged 12 to 17
had a major depressive episode during the past year.
• In 2009, an estimated 23.5 million Americans aged 12+
needed treatment for substance use.
SAMHSA, 2011: http://store.samhsa.gov/shin/content//SMA11-4629/01FullDocument.pdf
Department of Psychiatric Rehabilitation & Counseling Professions
21
What are the consequences
of substance use disorder for
individuals with mental illness?
Department of Psychiatric Rehabilitation & Counseling Professions
22
Consequences of Substance Use
Housing instability
(homelessness)
Symptom relapse
Treatment non-compliance
Violent behavior or threats of
violence
Social isolation and social
difficulties
Suicidal ideation or attempts




Cognitive impairments
Re-hospitalization
Difficulty budgeting funds
Hygiene and health
problems
 Serious infections (HIV and
hepatitis)
 Legal problems and
incarceration

 SAMHSA’s Co-Occurring Center for
Excellence, 2005
Department of Psychiatric Rehabilitation & Counseling Professions
23
Why Integrated Treatment?
• An estimated 45% of individuals with alcohol use
disorders had at least one co-occurring psychiatric
disorder
• In the National Comorbidity Study, approximately 78% of
alcohol-dependent men and 86% of alcohol-dependent
women men with criteria for a lifetime diagnosis of
another psychiatric disorder, including drug dependence
Brady &Sinha, 2005
Department of Psychiatric Rehabilitation & Counseling Professions
Increases
Integrated Treatment
-Relapse
-Hospitalization
-Incarceration
-Duplication of
services
-High service
costs
Department of Psychiatric Rehabilitation & Counseling Professions
Reduces
-Continuity of
care
-Consumer
quality of life
outcomes
-Stable
housing
-Independent
living
Integrated Treatment
• Helps people address both disorders at the same time—in the same
service organization by the same team of treatment providers
• Emphasizes that individuals achieve big changes like sobriety,
symptom management, and an increase in independent living
• Takes a stages-of-change approach to treatment, which is
individualized to address the unique circumstances of each person’s
life
• Is multidisciplinary and combines pharmacological (medication),
psychological, educational, and social interventions to address the
needs of consumers and their family members
(Center for Evidence-Based Practices)
Department of Psychiatric Rehabilitation & Counseling Professions
Core treatment components
Multidisciplinary
Team
Family
Psychoeducation
Participation in
Alcohol/Drug
Self-help
Stage-Wise
Interventions
Group
Treatment
Pharmacological
Treatment
Access to
Comprehensive
Services
Motivational
Interventions
Interventions to
Promote Health
Time Unlimited
Services
Assertive
Outreach
Substance Abuse
Counseling
Department of Psychiatric Rehabilitation & Counseling Professions Center for Evidence-Based Practices
STRATEGIES FOR
SUPPORTING PEOPLE WITH
CO-OCCURRING DISORDERS
Stage-wise Interventions
Department of Psychiatric Rehabilitation & Counseling Professions
Stages of Change
Prochaska & DiClemente 3
Department of Psychiatric Rehabilitation & Counseling Professions
What stage am I in?
“I have a problem but I don’t know what to do about it”
“I am working on it and it is difficult”
“I am working on it and it is getting easier”
“I messed up and…”
“I’m making a plan to help with my problem”
“I don’t have a problem”
Department of Psychiatric Rehabilitation & Counseling Professions
Stage-wise Interventions
Pre-contemplationEngagement
• Assertive outreach
Contemplation and
Preparation-Persuasion
• Education
• Practical help (housing,
entitlements, other)
• Goal setting
• Introduction to individual,
family, group, and selfhelp treatment formats
• Building awareness of
problem through
motivational counseling
www.samhsa.gov
Department of Psychiatric Rehabilitation & Counseling Professions
Stage-wise Interventions
• Counseling and
treatment
based on cognitivebehavioral techniques
Maintenance-Relapse
Prevention
• Continued counseling and
treatment based on
relapse prevention
techniques
• Skills training
• Skill building
• Support from families
and self-help groups
• Ongoing support
to promote recovery
Action-Active Treatment
www.samhsa.gov
Department of Psychiatric Rehabilitation & Counseling Professions
Motivational Techniques (OARS)
• Open-ended questions: Getting the person to do more
of the talking, exploring options
• Affirmations: Recognizing person’s strengths.
Statements that emphasize that change is possible.
• Reflective Listening: Making statements back to the
person about your view of what they are saying.
• Summarizing: Type of reflective listening. Reflect back
what the person has been saying, putting attention on
important points.
Department of Psychiatric Rehabilitation & Counseling Professions
Additional Strategies to Consider
• Engage with families
• Encourage involvement in self-help groups (e.g., AA, NA)
• Provide supports for housing/independent living
• Promote health and wellness
• Provide intensive outreach as needed
• Encourage people with co-occurring disorders to work
Department of Psychiatric Rehabilitation & Counseling Professions
Encourage People with Co-occurring
Disorders to Consider Employment
Stable recovery is associated with:
1.
Having a trusting relationship with a clinician who helps with
recovery from both illnesses;
2.
Having stable, safe, and substance-free housing;
3.
Having a social network of non-substance abusers;
4.
Having a meaningful daily activity such as work.
Becker, et al., 2005
Department of Psychiatric Rehabilitation & Counseling Professions
35
Employment as a Stepping Stone for
Recovery…
Work provides:
•
•
•
•
•
•
Structure to one’s day,
Meaningful goals,
Self-esteem,
Additional finances,
Sober friends,
Other changes that help people:
– Develop hope,
– Change their self-image, and envision a different life.
McHugo, et al., 2012; Becker, et al., 2005
Department of Psychiatric Rehabilitation & Counseling Professions
36
Employment as a Stepping Stone for
Recovery…
Work often helps people to:
1.
Become motivated to pursue abstinence,
2.
Cut down their use,
3.
Restrict their time of use.
Staff must instill hope and a belief that people can
recover and can work, even when they have given up
on themselves.
Becker, et al., 2005
Department of Psychiatric Rehabilitation & Counseling Professions
37
THE VARIETY OF PEOPLE WE
SEE
Some of the many characteristics of individuals for whom we
provide support and some strategies to consider
Department of Psychiatric Rehabilitation & Counseling Professions
An overview of some special circumstances we
encounter:
•
•
•
•
•
•
Individuals with cognitive difficulties
Individuals experiencing delusions/auditory hallucinations
Older adults
Individuals who abuse drugs/alcohol
Individuals from a variety of socio-cultural groups
Individuals with criminal justice involvement
Traumatic experiences-services need to be sensitive!
Bellack, et al., 2004
Department of Psychiatric Rehabilitation & Counseling Professions
Individuals with cognitive difficulties or those
experiencing symptoms
• These individuals often have a delayed response to questions
or requests.
–
–
–
–
–
–
Be patient! Give the individual the time to respond!
Speak slowly and clearly
Make only a few statements at a time
Check for understanding
Ask individual to repeat back what they’ve heard
If the individual doesn’t understand, repeat the information as
simply as possible; using fewer words
– Again ask the individual to repeat what was just said
Department of Psychiatric Rehabilitation & Counseling Professions
Older adults
• Mobility impairments
– allow extra time for individual to get where they need to be
• Transportation problems
– provide transportation in vehicles that accommodate difficulties in
boarding, etc.
• Visual impairments
– if providing materials, make sure there is extra large print; see if reading
glasses or magnifying glasses are needed
• Hearing Impairments
– speak loudly and clearly; avoid lengthy explanations
• Memory and attention problems
– provide repeated opportunities to check for understanding and
practicing skills learned; be sure to review information often
Department of Psychiatric Rehabilitation & Counseling Professions
Sociocultural Differences
• Our goal is to promote community integration and to use
communication and engagement skills to help individuals
accomplish this
– Providers cannot assume that each individual is bound by the
same norms, roles, values and beliefs
– Different cultural groups employ different verbal and non-verbal
patterns of behavior
– Providers must be sensitive to and able to accommodate
differences in lifestyles, values, norms and preferences
Department of Psychiatric Rehabilitation & Counseling Professions
Individuals Involved with Criminal Justice System
• Possible difficulty in expressing opinions or making decisions
– provide opportunities to practice and see others express opinions or
feelings without aggression; help them identify reasonable short term
goals
• Difficulty in expressing emotions constructively
– help individuals to develop a vocabulary for expressing emotions; and
identify situations that lead to common emotions
• Questioning authority and pushing limits
– be firm but kind in responding to challenges, avoid responding to
provocation, set clear guidelines for interactions
Department of Psychiatric Rehabilitation & Counseling Professions
Team Building Activity
• Lost at Sea activity
Department of Psychiatric Rehabilitation & Counseling Professions
Summary and Questions
• Illness Management and Recovery (IMR).
• Intervention strategies for individuals with the co-occurring
disorders of substance use and mental illness
– Motivational Interviewing (OARS)
– Employment planning
• Intervention strategies for special populations
• Team building strategies
Department of Psychiatric Rehabilitation & Counseling Professions
References
Becker, D.R., Drake, R.E., & Naughton, W.J. (2005). Supported
employment for people with co-occurring disorders. Psychiatric
Rehabilitation Journal, 28(4), 332-338.
Bellack, et al. (2004). Skills training for schizophrenia (2nd. Ed). New York:
Guilford Press:
Brady, K.T., & Sinha, R. (2005). Co-occurring mental and substance use
disorders: The neurobiological effects of chronic stress. The
American Journal of Psychiatry, 162(8), 1483-1493.
Center for Evidence-Based Practices (CEBP) at Case Western
Reserve University.(n.d.). Center for Evidence-Based Practices
(CEBP) at Case Western Reserve University. Retrieved April 28,
2014, from http://www.centerforebp.case.edu/practices/sami/iddt.
Department of Psychiatric Rehabilitation & Counseling Professions
References
Gingerich, S., & Mueser, K.T. (2005). Illness management and recovery:
Evidence-based mental health practice: A textbook, 395-424.
McHugo, G.J., Drake, R.E., Xie, H., & Bond, G.R. (2012). A 10-year study of
steady employment and non-vocational outcomes among people
with mental illness and co-occurring substance use disorders.
Schizophrenia Research, 138, 233-239.
Miller, W. R., & Rollnick, S. (2013). Motivational Interviewing (3rd ed.). New
York: Guilford Press.
Miller, W. R., & Moyers, T. B. (2006). Eight stages in learning motivational
interviewing. Journal of Teaching in the Addictions, 5 (1).
Prochaska, J. O., Norcross, J. C., & DiClemente, C. C. (1994). Changing for
Good. New York: Harper/Collins.
Department of Psychiatric Rehabilitation & Counseling Professions