Integration of Illness Management and Recovery within Assertive

Exciting Innovations in EvidenceBased Practices: Keeping the
Individual Front and Center
Susan Gingerich, MSW
[email protected]
Short History: SAMHSA EvidenceBased Practices
• Toolkit committees formed and began to meet
in 2000
• Toolkits piloted beginning in 2002
• Goal = make EBPs user-friendly and available
to a wide range of agencies and consumers
• Goal=Help consumers move forward in
recovery, improve their quality of life, and
accomplish life goals
Making SAMHSA Toolkits Available
First editions, based on pilot, online 2005
– Assertive Community Treatment (ACT)
– Integrated Dual Disorders Treatment
– Family Education (FE)
– Supported Employment (SE)
– Illness Management and Recovery (IMR)
Making EBP Toolkits Available
In addition, Social Skills Training is an EBP, with
structured manuals and curriculum, which has also
been the source of innovations and improvements.
How Evidence-based Practices
Evidence: Research
Client Factors
Clinical Experience
Evidence Based
Revisions on Line 2008
• Based on additional feedback from pilot
agencies and from wider community
• Example of a few changes in IMR
 Module 6 (Drug and Alcohol Use) added
 Group guidelines & handouts provided
 Modules divided into sessions
 Module 9 (coping w/ symptoms ) revised & expanded
Examples of 2011 IMR
• More time on identifying personally meaningful goals
& breaking into steps
• Goal-tracking sheet to be used throughout
• Systemic review of goals in individual & group
• Expansion of Practical Facts, Building Social Support,
Coping with Symptoms
• New Module: Healthy Lifestyles
Improvements in IMR, cont’d
• “Check-it-outs” to give more practice of
strategies and skills
• IMR scales (client and clinician version)
• Home practice sheets (Part A = use
something from session, and Part B = take
step towards your goal)
• Flexibility in order of modules and delivering
“targeted” skills
Overall Themes of Innovations and
Improvements to EBP’s
1. Increased emphasis on personal goals
2. Increased use of CBT and skills training
3. Multiple translations and cultural adaptations
4. Combinations of EBPs for multiple challenges
5. Novel methods of delivery (including technology)
6. New research on developing interventions to
address special needs of individuals
1. Increased Emphasis on Personal
Assertive Community Treatment (ACT)
Integrated Dual Disorders Treatment (IDDT)
Family Education (FE)
Supported Employment (SE)
Illness Management and Recovery (IMR)
Social Skills Training (SST)
--Remains extremely important to help people stay well
and out of hospital
--Also important to explore “Why?”
• “What would you be able to do if your life wasn’t
interrupted by hospitalizations?”
• “How would you like to be spending your time?”
• “Who would you like to be spending your time
• Essentially: How can we help you make your life like
you would want it to be?
• Remains important to help people with dual
disorders decrease or stop use
• Also important to explore “Why?”
• “What would your life be like if you weren’t
drinking or using drugs?”
• “What would you be able to do? Who would
you be able to spend time with?”
• “How can we help you start on some of those
changes now?”
Family Education and Support
• Remains important to involve whole family in
support of treatment.
• Also imp to explore “why” with individual
• “What would you like your family to
understand better about your experience?”
• “How might your life be better if you had
understanding & support from family?”
• “How could family help you w/ goals?”
• “How could you help your family?”
Family Education, cont’d
• Explore more of the “why” with family
• “What would you like to understand better
about your relative’s experience?”
• “What are your relative’s personal goals?”
• “How could family help w/ their goals?”
• “How could your relative help you with your
Example of innovation for
increasing family involvement
“Outcomes of a Brief Program, REORDER, to
Promote Consumer Recovery and Family
Involvement in Care”
by Lisa Dixon, Shirley Glynn, et al.
Psychiatric Services , Nov 2013.
Supported Employment
--Still important to help person get a job or go to
--Important to remember that the “why?” of a job or
school varies for each individual
• income and standing in the community
• way to introduce self to new people and potential
friends and romantic partners
• way of being around people and decreasing loneliness
• Keeping up with friends and/or family members
--Learning illness management strategies and skills
remains vital.
--The “why” is different for each individual and for each
module, depending on person’s goal
• More time is spent on module 1 (Definition of
Recovery and recovery goals)
• Development of Goal-tracking sheet
• Consistent review of personal goals
• Practice, role play, home assignments geared towards
IMR, cont’d
• Tailoring the modules to the clients, not vice
• Question, How could same module, “Coping
with Stress,” be helpful to people with
following goals?
 Getting a job
 Taking an art class
 Spending more time with my children
 Moving to my own apartment
Social Skills Training
• Important to help people develop social skills, but
not in a vacuum.
• The reasons people want or need social skills varies
based on their goals.
• Examples of changes to SST model used by VA
 Meeting individually to establish personal goals
Tailoring role plays around goals
Developing home practice assignments based on
taking steps towards personal goals
2. Increased Use of CBT and Active
Skills Training
Once people have identified goals, what next?
Develop skills to overcome challenges.
• ACT: Coping skills for persistent symptoms.
• IDDT: Skills for attending meetings
• FE: Skills for responding to Early Warning Sign
• SE: On-line job search, group interviews
Examples of Increased Use of CBT
Skills Training, cont’d
 Skills for Sharing your relapse prevention plan with
 Practicing elements of your relapse prevention plan to
increase preparedness
 Learning positive self-talk for specific voices
Applying skill to personal goal
3 role plays per person each session
Home practice tailored: Who do you want to give a
compliment to? What compliment? When? Where?
3. Multiple Translations and
Cultural Adaptations
Example: IMR translated into
Spanish (Mexican)
Spanish (Puerto Rican)
In progress: French, Russian,
Cultural Adaptations
Adaptations in process of IMR for
“Cultures within Cultures”
• Geriatrics
• Intellectually disabled
• Persons with co-occurring physical health
• Forensics
• Homeless
• Deaf community
4. Combination of EBPs for
Multiple Challenges
• Cognitive Remediation + IMR + Supported
Employment (Brooklyn Bureau)
• ACT+ IMR (University of Washington and
Places for People, St. Louis)
• IMR + Co-occurring Disorders (University of
5. Novel Methods of Delivery
High Tech
• Computers (Cognitive Behavioral Therapy for Voices
and Paranoia, Jen Gottlieb, Boston University)
• Smart Phones (App with 5 targets developed by Dror
Ben-Zeev, Dartmouth University)
• I-Pad (Rickard Fardig, Piper Meyer, Kim Mueser)
• PPT slides (Eddy Suarez at Sunrise Community
Mental Health Center, Everett, Washington)
Novel Methods, cont’d
Low tech
• Tanzanian model of IMR with whole family
attending, tea and lunch served, traditional
handclapping and singing included
• Japanese model of Relapse Prevention
Training for inpatients, with family attending
on the unit
6. Developing new interventions
• RAISE (Recovery After an Initial
Schizophrenia Episode)
• Health Technology Program (for individuals
who have recently experienced a
17 sites piloted the Navigate Program (including
St. Clare’s in NJ). Provides:
• Individualized medication management
• Individual Resiliency Training (IRT)
• Supported Employment and Education (SEE)
• Family Education Program (FEP)
Health Technology Program
9 sites piloting a Relapse Prevention Planning
(RPP) program that includes technology tools
• Core = 5 in-person RPP sessions
• FOCUS app for Smart Phone (targets = mood,
voices, medications, socialization, sleep)
• Daily Support Website for families and clients
• Computer CBT for Voice and for Paranoia
In HTP clients are already using
tech tools in creative ways
• Using smart phones to help remind selves of
appointments and leisure activities, keep lists
of steps towards goals, take photos of relapse
prevention plan, get in touch with people to
prevent isolation
• Using computer to search for jobs, e-mail
friends or family, locate activities in their
community, take on-line courses, download
budget templates, check hours of DMV
What can we take away from these
Look at the practices you are offering. Ask
yourselves these questions:
1. How are personal goals addressed in the
practice? Could this be strengthened?
2. What specific skills are being taught in the
practice to help people address their goals?
3. How are cultural differences addressed in the
practice? What translations might be helpful?
Take away, cont’d
4. Would it be beneficial to offer additional
practices (E.g., social skills training for
clients whose goals center around
relationships) or combined practices?
5. Would additional delivery systems be helpful
to your clients? E.g., posting educational
materials on-line? Using ppts?
6. Is your agency interested in learning more
about first episode Tx? About technologies?
Final comments
Let’s hear from clients themselves in this DVD
showing a graduation from IMR in St. Louis.

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