1. Rutgers, The State University of New Jersey ICMS Training Session 6

2. Department of Psychiatric Rehabilitation & Counseling Professions 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

3. 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)

4. Department of Psychiatric Rehabilitation & Counseling Professions What is RECOVERY?

5. 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...

6. 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/

7. Department of Psychiatric Rehabilitation & Counseling Professions ILLNESS MANAGEMENT AND RECOVERY (IMR) GINGERICH & MUESER, 2005

8. 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

9. 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

10. Department of Psychiatric Rehabilitation & Counseling Professions 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

11. 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

12. Department of Psychiatric Rehabilitation & Counseling Professions ModuleTopics 1Recovery Strategies 1. Defining Recovery 2. Exploring Areas of Life You Would Like to Improve 3. Identifying A Personal Recovery Goal 4. Breaking Down Your Goal 5. Following Up on Your Goal and Solving Problems 2Practical Facts About Mental Illnesses 1.Understanding the Disorder and its Diagnosis 2.Learning What Happens after People Develop Symptoms 3.Taking Positive Steps to Manage the Disorder 4.Dealing with Negative Attitudes and Beliefs about Mental Illness (Stigma) Department of Psychiatric Rehabilitation and Counseling Professions Overview of Modules

13. Department of Psychiatric Rehabilitation & Counseling Professions Overview of Modules ModuleTopics 3The Stress- Vulnerability Model 1.Understanding the Causes of Mental Illnesses 2.Learning What Improves Symptoms and Reduces Relapses 3.Understanding Treatment Options 4.Reducing Relapses 4Building Social Support 1. Recognizing the Importance of Social Support 2.Connecting with People 3.Having Enjoyable Conversations 4.Sharing Personal Information 5.Understanding Other People 6.Developing Closer Relationships Department of Psychiatric Rehabilitation and Counseling Professions

14. Department of Psychiatric Rehabilitation & Counseling Professions Overview of Modules ModuleTopics 5Using Medications Effectively 1.Learning about the Role of Medication in Managing Symptoms 2.Identifying and Dealing with Side Effects 3.Making an Informed Decision about Medication 4.Getting the Best Results from Medication 6Drug and Alcohol Use 1. Identifying Common Reasons People Use Drugs and Alcohol 2.Recognizing Problems that Alcohol and Drugs Can Cause 3.Weighing Pros and Cons of Sobriety 4.Identifying Personal Reasons for Sobriety 5.Finding New Ways of Getting your Needs Met 6.Making a Personal Sobriety Plan Department of Psychiatric Rehabilitation and Counseling Professions

15. Department of Psychiatric Rehabilitation & Counseling Professions Overview of Modules ModuleTopics 7Reducing Relapses 1.Identifying Triggers of Relapse 2.Recognizing Early Warning Signs of Relapse 3.Developing a Relapse Prevention Plan 4.Putting your Relapse Prevention Plan into Practice 8Coping with Stress 1.Learning What Causes Stress 2.Identifying the Signs of Stress 3.Preventing and Coping with Stress 4.Using Relaxation Techniques 5.Making a Plan for Preventing and Coping with Stress Department of Psychiatric Rehabilitation and Counseling Professions

16. Department of Psychiatric Rehabilitation & Counseling Professions Overview of Modules ModuleTopics 9Coping with Persistent Symptoms 1.Identifying Persistent Symptoms 2.Coping with Depression 3.Coping with Anxiety 4.Coping with Hallucinations and Delusions 5.Coping with Sleep Problems and Low Energy 6.Coping with Anger Problems and Concentration 7.Making a Plan for Continuing to Use Coping Strategies 10Getting your Needs Met in the Mental Health System 1.Overview of Community Mental Health Services 2.Financial and Health Insurance Benefits 3.Advocating for Yourself in the Mental Health System Department of Psychiatric Rehabilitation and Counseling Professions

17. Department of Psychiatric Rehabilitation & Counseling Professions Overview of Modules ModuleTopics 11Healthy Lifestyles 1.Diet, Part I 2.Diet, Part II 3.Exercise 4.Personal Hygiene 5.Sleep Department of Psychiatric Rehabilitation and Counseling Professions

18. 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?

19. Department of Psychiatric Rehabilitation & Counseling Professions INTEGRATED TREATMENT FOR CO-OCCURRING DISORDERS

20. 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//SMA11-4629/01- FullDocument.pdf 20

21. Department of Psychiatric Rehabilitation & Counseling Professions 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//SMA11-4629/01- FullDocument.pdf 21

22. Department of Psychiatric Rehabilitation & Counseling Professions 22 What are the consequences of substance use disorder for individuals with mental illness? What are the consequences of substance use disorder for individuals with mental illness?

23. Department of Psychiatric Rehabilitation & Counseling Professions 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 23

24. Department of Psychiatric Rehabilitation & Counseling Professions 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

25. Department of Psychiatric Rehabilitation & Counseling Professions Integrated Treatment -Continuity of care -Consumer quality of life outcomes -Stable housing -Independent living -Relapse -Hospitalization -Incarceration -Duplication of services -High service costs Increases Reduces

26. Department of Psychiatric Rehabilitation & Counseling Professions 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)

27. Department of Psychiatric Rehabilitation & Counseling Professions Core treatment components Multidisciplinary Team Stage-Wise Interventions Access to Comprehensive Services Time Unlimited Services Assertive Outreach Motivational Interventions Group Treatment Family Psychoeducation Participation in Alcohol/Drug Self-help Pharmacological Treatment Interventions to Promote Health Substance Abuse Counseling Center for Evidence-Based Practices

28. Department of Psychiatric Rehabilitation & Counseling Professions STRATEGIES FOR SUPPORTING PEOPLE WITH CO-OCCURRING DISORDERS Stage-wise Interventions

29. Department of Psychiatric Rehabilitation & Counseling Professions Stages of Change Prochaska & DiClemente 3

30. 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”

31. Department of Psychiatric Rehabilitation & Counseling Professions Stage-wise Interventions Pre-contemplation- Engagement Assertive outreach Practical help (housing, entitlements, other) Introduction to individual, family, group, and self- help treatment formats Contemplation and Preparation-Persuasion Education Goal setting Building awareness of problem through motivational counseling www.samhsa.gov

32. Department of Psychiatric Rehabilitation & Counseling Professions Stage-wise Interventions Action-Active Treatment Counseling and treatment based on cognitive- behavioral techniques Skills training Support from families and self-help groups Maintenance-Relapse Prevention Continued counseling and treatment based on relapse prevention techniques Skill building Ongoing support to promote recovery www.samhsa.gov

33. 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.

34. 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

35. Department of Psychiatric Rehabilitation & Counseling Professions 35 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

36. Department of Psychiatric Rehabilitation & Counseling Professions 36 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

37. Department of Psychiatric Rehabilitation & Counseling Professions 37 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

38. Department of Psychiatric Rehabilitation & Counseling Professions THE VARIETY OF PEOPLE WE SEE Some of the many characteristics of individuals for whom we provide support and some strategies to consider

39. 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

40. 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

41. 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

42. 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

43. 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

44. Department of Psychiatric Rehabilitation & Counseling Professions Team Building Activity Lost at Sea activity

45. 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

46. 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 (2 nd. 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.

47. 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.