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Evidence-Based Practices: Shaping Mental Health Services Toward RecoveryIllness Management and Recovery WorkbookChapter 1The Basics of Illness Management and Recovery
An Overview of the Illness Management and Recovery Program The Illness Management and Recovery Program consists of a series of weekly sessions where mental health practitioners help people who have experienced psychiatric symptoms to develop personalized strategies for managing their mental illness and moving forward in their lives. The program can be provided in an individual or group format, and generally lasts between three and six months. In the sessions, practitioners work collaboratively with people, offering a variety of information, strategies, and skills that people can use to further their own recovery. There is a strong emphasis on helping people set and pursue personal goals and helping them put strategies into action in their everyday lives. Materials for Providing the Illness Management and Recovery Program In the Practitioners’ Workbook (this document) there are two sets of materials for Illness Management and Recovery: the Practitioners’ Guide (Chapters 1-10) and Educational Handouts. The educational handouts contain practical information and strategies that people can use in the recovery process. The handouts are not meant to stand alone. Practitioners are expected to help people select and put into practice the knowledge and strategies that are most helpful to themselves as individuals. The following topics are covered in nine educational handouts:
Chapter 1 of the Practitioners’ Guide contains overall strategies for conducting the program, and Chapters 2-10 contain practitioner guidelines for using each of the educational handouts to conduct sessions. The guidelines contain specific suggestions for using motivational, educational, and cognitive behavioral techniques to help people use strategies from the handouts in their daily lives. They also provide tips for developing homework assignments and for dealing with problems that might arise during sessions. Getting started First, practitioners are advised to familiarize themselves with the format, content and tone of the program. This can be accomplished by first reading the following:
It is optimal for practitioners to read the remaining educational handouts and accompanying practitioners’ guidelines before beginning to work with people. Practitioners are advised to review specific handouts and guidelines prior to addressing these particular topic areas with people. Preparing For Sessions The first session is usually spent on orientation, using the “Orientation Sheet” (see Appendix 1) as a guide. The second (and sometimes third) session is spent on getting to know the person better, using the ”Knowledge and Skills Inventory” (see Appendix 2) as a guide. This inventory is focused on the person’s positive attributes rather than their problems or “deficits.” It is important to gather information in a friendly, low- key manner, using a conversational tone. The remaining sessions are focused on helping people to learn and practice the information and strategies in the educational handouts and to set and pursue their personal goals. Each session should be documented, using the “Progress Note for Illness Management and Recovery” (Appendix 3). The format of the progress note helps practitioners to keep track of the person’s personal goals, the kinds of interventions provided (motivational, educational, cognitive-behavioral), the specific evidence-based skill(s) that are taught (coping skills, relapse prevention skills and behavioral tailoring skills) and the homework that is agreed upon. Before beginning each educational handout, the practitioner is encouraged to review the contents of the handout and the practitioner guidelines of the same title in the Practitioners’ Guide. Most educational handouts will require two to four sessions to put the important principles into practice. Preparation for sessions is most effective when practitioners review the educational handout and the corresponding practitioners’ guidelines side-by-side, noting the goals of the handout, the specific topic headings, the probe questions, the checklists, etc. As noted above, sessions should be recorded on the form “Progress Note for Illness Management and Recovery” (Appendix 3). Although for many people it is most helpful to go through the handouts in the order they are listed, it is important to tailor the program to respond to individual needs. For example, when a person is very distressed by the symptoms he or she is experiencing, it would be preferable to address this problem early in the program using Educational Handout #8, “Coping with Problems and Symptoms. ” Practitioners need to be responsive to people’s concerns and use their clinical judgment regarding the order and pacing of handouts. There is widespread acceptance of the importance of recovery as a guiding vision for helping people who experience psychiatric symptoms to achieve personal success in their lives. The term recovery means different things to different individuals. Each person is free to define it in his or her terms. For some individuals, recovery means no longer having any symptoms or signs of a mental illness. For others, recovery means taking on challenges, enjoying the pleasures life has to offer, pursuing personal dreams and goals, and learning how to cope with or grow past one’s mental illness despite symptoms or setbacks. Regardless of the personal understanding each individual develops about recovery, the overriding message is one of hope and optimism. The recovery vision is at the heart of the Illness Management and Recovery Toolkit. Through learning information about mental illness and its treatment, developing skills for reducing relapses, dealing with stress, and coping with symptoms, people can become empowered to manage their own illness, to find their own goals for recovery, and to assume responsibility for directing their own treatment. People who experience psychiatric symptoms are not passive recipients of treatment, and the goal is not to make them “comply” with treatment recommendations. Rather, the focus of Illness Management and Recovery is providing people with the information and skills they need in order to make informed decisions about their own treatment.
Importance of Helping People Set and Pursue Personal Goals Being able to set and pursue personal goals is an essential part of recovery. At the same time that information and skills are being taught in the Illness Management and Recovery Program, people are also helped to define what recovery means to them and to identify what goals and dreams are important to them. The first educational handout, “Recovery Strategies,” contains specific information about setting goals. However, throughout the entire program, practitioners help people set meaningful personal goals and follow up regularly on those goals. As people gain more mastery over their psychiatric symptoms, they gain more control over their lives and become better able to realize their vision of recovery. In each session of the program, practitioners should follow up on the participants’ progress towards their goals. “Goals Set in the Illness Management and Recovery Program” (Appendix 5) helps practitioners to keep track of a person’s goals. Another form, “Step-By-Step Problem-Solving and Goal Achievement” (Appendix 6) is useful for helping a person plan the steps for achieving a goal (or solving a problem). The content and teaching methods used in the Illness Management and Recovery
Program are derived from multiple studies of professionally based illness management
training programs for people who have experienced psychiatric symptoms. Information
is taught using a combination of motivational, educational, and cognitive-behavioral
teaching principles. Critical information is summarized in educational handouts
that are written for people who experience psychiatric symptoms but are also
suitable for distribution to anyone with a professional or caring relationship
with a person who experiences psychiatric symptoms (such as a case manager or
a family member). Each topic is taught using a combination of motivational, educational, and cognitive behavioral methods. Also, in order to help people apply the information and skills that they learn in the sessions to their day-to-day lives, the practitioner and the person collaborate to develop homework assignments at the end of each session. These homework assignments are tailored to the individual, to help him or her practice strategies in “the real world.” Because developing and enhancing natural supports is a goal of Illness Management and Recovery, people are encouraged to identify significant others with whom they can share the handout materials and who may support them in applying newly acquired skills or completing homework. The amount of time required to teach Illness Management and Recovery depends on a variety of factors, including people’s prior knowledge and level of skills, the problem areas that they would like to work on, and the presence of either cognitive difficulties or severe symptoms that may slow the learning process. In general, between three and six months of weekly sessions of 45 to 60 minutes may be required to teach Illness Management and Recovery. Following the completion of the nine topic areas, people may also benefit from either booster sessions or participation in support groups aimed at using and expanding skills. These following sections discuss different topics related to the logistics of teaching Illness Management and Recovery. Included is information about the teaching format, session structure, session length, location, use of educational handouts, selection of program participants, involvement of significant others, and practitioner qualifications. Selection of Participants for the Illness Management and Recovery Program Who is most likely to benefit from Illness Management and Recovery? While many people will be familiar with at least some of the information and skills taught, almost everyone who experiences psychiatric symptoms will find they can learn something new from the program. Educational handouts have been written covering three common diagnoses: schizophrenia, bipolar disorder and major depression. Therefore, people with these diagnoses are most likely to benefit from participation in the program. However, because much of the information presented in Illness Management and Recovery is not specific to any one mental illness, people with other psychiatric diagnoses may also benefit. In such cases, people may benefit from the brief review of their symptoms with the practitioner, guided by the DSM-IV or educational handouts from other sources (see references, Appendix 7). People who experience psychiatric symptoms may benefit from training in Illness Management and Recovery regardless of how long they have had their mental illness. For anyone who has recently had a relapse, or is under extreme stress due to personal life circumstances, it may be preferable to wait until his or her symptoms have stabilized and undue life stresses have been resolved before beginning the program. Some people are often in crisis, due to problems such as homelessness, substance abuse, medical illness, or poverty. Rather than postponing Illness Management and Recovery for long periods of time (or perhaps forever), it is preferable to engage the person in the program. When people learn more about their symptoms and develop skills for coping with problems, they often feel more confident and can be more effective at resolving some of their life stresses. Format of the program Illness Management and Recovery can be taught using either an individual or group format. Each format has its advantages. The primary advantages of the individual format are that the teaching of material can be more easily paced to meet the person’s needs, and more time can be devoted to addressing his or her specific concerns. The main advantages of the group format are that it provides people with more sources of feedback, motivation, ideas, support, and role models. Teaching in a group may also be more economical. One option that combines the advantages of both individual and group formats is to teach the core material in an individual format, and then provide an optional support group that serves as a vehicle for providing social support, sharing coping strategies, and encouragement for people to pursue their personal recovery goals. The practitioner guidelines provided in this manual are based on an individual format, which practitioners can adapt if they choose to teach the materials in a group format. Structure of the sessions The practitioner should structure the sessions of Illness Management and Recovery
to follow a predictable pattern. The following structure is recommended:
Session Length Sessions generally last between 45 and 60 minutes. The most critical determinant of session length is the person’s ability to be engaged and learn the relevant material. Some people may have limited attention spans, comprehension problems, or severe symptoms that make it difficult to focus for more than 30 minutes. It may be desirable to take breaks during a teaching session or to simply have brief sessions. Another option is to conduct more frequent, brief sessions, such as meeting for 20 to 30 minutes two or three times a week. Location Teaching sessions can be conducted in almost any location that is convenient for the person. Examples of possible locations include the mental health center, the person’s home, the home of a family member, or a public setting (e.g., coffee shop). The setting should also have ample lighting (to read the handouts), comfortable seating, and some privacy. Regardless of the location, the practitioner should strive to create an environment that is quiet, free of unnecessary distractions, and conducive to learning and practicing the material. Educational Handouts The educational handouts are written in simple, easy-to-understand language, and include informative text, summary boxes, probe questions, checklists, and planning sheets for each topic. There are nine topic areas, which were noted earlier. These handouts can be used to help people learn the material in a number of different ways. First, it is important to review the contents of the handout. There are different ways to do this, depending on the individual. Practitioners can present the material in a conversational tone by summarizing the key points and providing relevant examples. Practitioners can offer to take turns reading paragraphs or ask people to read the material on their own and use the sessions for discussion. It is important to make reviewing the contents of the handout an interactive process, by pausing frequently to ask questions to check for understanding and to learn more about the person’s point of view. At all times communication should be a “two-way street” between the person and the practitioner; it must never seem like a lecture. Second, it is important for people to have a chance to personalize the information from the handout. Practitioners should allow time for people to answer the probe questions provided in each topic section of the handout and to complete the checklists and questionnaires. There are also planning sheets that people can use to strategize how they might use the information in their own situation. Third, homework assignments can be developed that involve reviewing some of the handout information or putting it into practice. Many of the checklists in the handouts involve helping people to select the strategies they are most interested in trying out. These checklists can then be used to develop homework assignments to help people put their strategies into action between sessions. Fourth, the person can give selected educational handouts to family members or other supporters to inform them about Illness Management and Recovery. This will often lead to a discussion of the material in the handout, which furthers the learning process. Practitioners must keep in mind that while some people may enjoy reading aloud, others may have minimal reading skills and may be embarrassed to do so. Practitioners can either simplify each of the main points without reading them directly from the handout or they can alternate reading certain sections out loud and summarizing others. Involvement of Significant Others Many people benefit from the involvement of significant others in helping them manage their mental illness and take steps towards recovery. Involvement of significant others may be helpful in several ways. By providing accurate information to significant others who may be misinformed about mental illness, it may reduce their criticism of the person who experiences symptoms. When people inform significant others about the goals they are working on as part of Illness Management and Recovery, it can generate support and help in achieving those goals. In addition, when people choose to ask significant others to help them practice newly learned skills outside of teaching sessions, it can increase the chances of the practice being successful. Significant others can be involved in the Illness Management and Recovery Program in several ways. People can share their educational handouts with significant others. People can request help from them in practicing specific skills. People can invite significant others to participate in some of the sessions. Significant others are especially helpful in sessions which involve developing a relapse prevention plan (using Educational Handout #6). Practitioners should make a special effort to encourage the person to include significant others in this process. The decision to involve significant others in Illness Management and Recovery
is always the person’s choice. When discussing the involvement of significant
others, the practitioner should explore with the person the benefits of involving
them, and respect the person’s decision about whether and in what ways
to involve them. Appendix 4 contains a list of significant others that people
may want to consider asking to become involved in the Illness Management and
Practitioner Qualifications Practitioners who teach Illness Management and Recovery must be warm, kind, empathic individuals who are knowledgeable about mental illness and the principles of its treatment. Good listening skills are important, including the ability to reflect back what the practitioner has heard and seek clarification when necessary. Good eye contact, a ready smile, and a good sense of humor are additional skills that can put people at ease. Specific teaching skills are also important. Practitioners must have the ability to structure sessions so that they follow a predictable pattern. They must also be able to establish clear objectives and expectations and to set goals and follow through on them. Another important practitioner attribute is the ability to take a “shaping” approach to increasing a person’s knowledge and skills. Shaping means that practitioners recognize that it often takes people a significant period of time to learn new information and skills, and that it is important to give positive feedback for their efforts and small successes along the way (see more on this in VI, under Cognitive-Behavioral Strategies). A shaping attitude towards setting and pursuing goals means that even very small steps are acknowledged and valued, which encourages people to continue in their efforts towards achieving their personal goals. Core Values in Illness Management and Recovery Teaching people how to manage their mental illness and make progress towards recovery is predicated on several core values that permeate the relationship between the practitioner and the person who experiences psychiatric symptoms. These values include hope, personal choice, collaboration, respect, and recognizing people as the experts in their own experience of mental illness. Hope is the key ingredient First and foremost, the process of teaching Illness Management and Recovery involves conveying a message of hope and optimism. The long-term course of mental illness cannot be predicted, and no one can predict anyone’s future. Studies have shown, however, that individuals who actively participate in their treatment and who develop effective coping skills have the most favorable course and outcome, including a better quality of life. This ability to influence one’s own destiny is the basis for hope and optimism about the future. Practitioners must first have hope and optimism themselves in order to convey these beliefs to the people they are working with. People who experience psychiatric symptoms often report that having another person believe in them is an empowering and validating experience. In teaching Illness Management and Recovery, practitioners present information and skills as potentially useful tools that they have confidence that people can use in pursuing their goals. It is vital that the practitioners retain an attitude of hope and optimism, even when the people they are working with may be pessimistic. The person is the expert in his or her own experience of mental illness Practitioners have professional expertise in their knowledge about mental illness, the principles of its treatment, and in strategies for dealing with stress, coping with symptoms, and pursuing goals. People who experience psychiatric symptoms have expertise in the experience of mental illness, how others react to them, and what has been helpful and what has not. Just as practitioners share their expertise regarding information and skills for managing and recovering from mental illness, people who experience psychiatric symptoms share their expertise with the practitioner about how they experience mental illness and what strategies work for them. It is important seek out the person’s expertise, because each individual has a unique experience with mental illness and a unique response to treatment. By paying close attention to people’s expertise, practitioners will be more effective in assisting them in making progress towards their goals. Personal choice is paramount The overriding goal of Illness Management and Recovery is to give people the information and skills they need to make choices regarding their own treatment. The ability and right of people to make their own decisions is paramount, including instances when they make decisions that differ from the recommendations made by their treatment providers. There are certain rare exceptions to this principle, as when there are legal constraints such as an involuntary hospitalization to protect the person from himself/herself or others. In general, practitioners should avoid placing pressure on people to make certain treatment decisions, and must instead accept their decisions and work with them to evaluate the consequences in terms of their personal goals. Practitioners are collaborators While practitioners are teachers, they are also collaborators in helping people learn how to cope with their illness and make progress towards their goals. The collaborative spirit of Illness Management and Recovery reflects the fact that the practitioner and the person who experiences psychiatric symptoms work together side-by- side in a non-hierarchical relationship. The practitioner can think of himself or herself as a consultant with expertise in the topic of Illness Management and Recovery. Practitioners demonstrate respect for people who experience psychiatric symptoms Respect is a key ingredient for successful collaboration in Illness Management and Recovery. Practitioners need to respect people who experience psychiatric symptoms as fellow human beings, capable decision-makers, and active participants in their own treatment. Practitioners need to accept that individuals differ in their personal values, and must respect the right of people to make informed decisions based on these values. Practitioners must also accept the fact that people may hold different opinions and that these opinions should be respected. For example, people sometimes disagree that they have a particular mental illness, or any mental illness whatsoever. Rather than actively trying to persuade people that they have a specific disorder, the practitioner should respect their beliefs, while searching for common ground as a basis for collaboration. Such common ground could be symptoms and distress experienced by the person (perhaps even conceptualized generally as “stress,” “anxiety,” or “nerve problems”), desire to avoid hospitalization, difficulties with independent living, or a specific goal that the person would like to accomplish. Rather than insisting that the person accept his or her point of view, the practitioner should seek common ground as a basis for collaborating, thereby demonstrating respect for the person in his or her belief. Several core teaching principles are incorporated into helping people learn information and skills for Illness Management and Recovery. These principles include motivational strategies, educational methods, and cognitive-behavioral techniques. In addition, to help people apply information and skills in their own day-to-day lives, homework assignments are included that involve review and practice outside of the session. Motivational Strategies Motivational strategies address the fundamental question of why a person should be interested in learning the information and skills that are included in Illness Management and Recovery. If a person does not view learning certain information or skills as relevant to his or her needs or desires, that person will not be motivated to invest the necessary effort in learning. Motivation to learn information and skills about Illness Management and Recovery should never be assumed. Developing motivation to learn information and skills is critical for teaching each of the modules of Illness Management and Recovery. Motivational strategies involve helping people see how learning information and skills will help them achieve short and long-term goals. Some of the goals for Illness Management and Recovery pertain to the reduction of distress due to symptoms and symptom relapses, while other goals may involve improving relationships, finding work or other meaningful activity, social and recreational activities, independent living, or other desired changes. Developing motivation for learning the information and skills contained in Illness Management and Recovery is an ongoing and collaborative process that occurs throughout the program. Motivation often needs to be rechecked or rekindled in the midst of teaching information or skills for which motivation may have been established. Motivation can wax and wane over time, especially if people perceive their goals to be distant and difficult to achieve. To help people sustain their motivation, practitioners need to convey their own confidence that they can accomplish goals, and to support people’s optimism, self-confidence, and self-efficacy. Educational Strategies An important goal of Illness Management and Recovery is to provide people with basic information about the nature of mental illness, the principles of treatment and strategies for preventing relapses and coping with symptoms. In order to be effective in teaching basic information, and to ensure that people understand its relevance in their own lives, several educational techniques are useful. First, education must be interactive, not didactic, to be effective. People learn information by actively processing it in a discussion with someone else. Interactive learning involves frequently pausing when presenting information to get the person’s reaction and perspective, talking about what the information means, and clarifying any questions that may arise. Teaching in an interactive style makes learning an interesting, lively activity, and it avoids the monotony of just one person speaking. In addition, an interactive teaching style conveys to the person that he or she has important contributions to make to the learning process, and that the practitioner is interested in what he or she has to say. In order for the practitioner to know whether he or she is successful in teaching information, frequent checks must be made to evaluate the person’s understanding of information. How often such checks need to be made will vary from one person to another, but at least some checking for understanding should be done on a routine basis. It is preferable to ask consumers to summarize information in their own language rather than asking yes or no questions, such as, “Did you understand?” Hearing the person explain his or her understanding of basic concepts enables the practitioner to know what areas have been understood and what areas need clarification. It is also helpful to ask “Is there anything that you disagree with?” when reviewing information in an educational handout. When information is presented, it should be broken down into small chunks to make it as easy to understand as possible. The pace of education will vary, with some people absorbing the information faster than others. Some mental illnesses cause impairment in cognitive functioning which can result in a slower rate of processing information and the need to present information in very small chunks. By presenting small amounts of information at a time, and frequently pausing to check understanding, everyone can learn information about Illness Management and Recovery at his or her own pace. When educating people about mental illness and recovery, it is helpful to periodically review information that has been previously covered. A number of strategies are helpful in reviewing information. First, the practitioner can summarize information after it has been discussed. For example, after talking about several symptoms of depression, the practitioner could say, “We’ve just talked about several symptoms of depression. These symptoms included a low mood, lack of energy, and sleep problems. Let’s talk about some other symptoms of depression…” Second, the practitioner can prompt the person to summarize previously discussed information and fill in additional information. It is important to begin each session with a brief summary and discussion of the topics covered in the previous session. By asking people to summarize what they remember, it is possible to both check on the person’s retention of information and to reinforce topics that were previously discussed. Third, homework assignments can be given to people to review the educational handouts. People may find it helpful to review the handouts on their own and/or with a significant other. Fourth, it can be helpful to review information when an opportunity presents itself at a later point and time. Helping people recognize and apply information to their own experiences is an important educational strategy. Fifth, when providing information to anyone it can be helpful to adopt their language whenever possible in order to facilitate communication. Individuals have their own ways of understanding their experiences, thinking about their lives, and looking into the future. The more the practitioner can “speak the same language,” the easier it will be to make a connection and avoid unnecessary misunderstandings. Cognitive-Behavioral Strategies Research shows that educational techniques alone are insufficient to improve the ability of people to manage their mental illness. Cognitive-behavioral techniques involve the systematic application of learning principles to help people acquire and use information and skills in Illness Management and Recovery. A number of different cognitive-behavioral techniques are employed in helping people master the material covered in Illness Management and Recovery, including the following: reinforcement, shaping, modeling, practice, and cognitive restructuring. Each of these approaches is briefly described below. Reinforcement Reinforcement can be broken down into two types: positive reinforcement and negative reinforcement. Positive reinforcement refers to an increase in something that is pleasant. For example, a nice meal, money, a hug, praise, and working at an interesting job are examples of positive reinforcement. Negative reinforcement refers to a decrease in something that is unpleasant. Examples of negative reinforcement include reduced feelings of anxiety, anger, and boredom; lower symptom distress; and reduced rates of relapse or rehospitalization. Negative reinforcement should not be confused with punishment, which is when something undesirable happens. The principles of reinforcement play an important role in teaching Illness Management and Recovery, because its core goals (to improve management of the psychiatric illness, to reduce the stress due to the illness, and to increase a person’s ability to achieve personal goals) are by their very nature reinforcing. Therefore, as people learn and apply the information and skills that are taught in Illness Management and Recovery, their use is reinforced to the extent that desired changes are accomplished. That is, as people experience the benefits of learning Illness Management and Recovery skills, these skills are reinforced and become a part of their day-to-day living. Reinforcement is used in the teaching of Illness Management and Recovery in two fundamental ways. First, the practitioner uses positive reinforcement in the form of praise, smiles, interest, and enthusiasm to encourage and help people learn information and skills during teaching sessions, and to help them review information and to practice newly acquired skills on their own for homework assignments. This type of social reinforcement is important because it acknowledges people’s efforts and makes them feel good about themselves. Second, as people learn to use skills taught for managing their illness and making progress towards recovery, they experience the naturally reinforcing effects of these skills, including reductions in distress, increases in self-sufficiency, and attainment of personal goals. Practitioners need to work closely with people and monitor progress towards goals to ensure that these positive outcomes of Illness Management and Recovery are attained. Shaping Shaping refers to reinforcement of successive approximations to a goal. The expression “Rome wasn’t built in a day” summarizes the concept of shaping. Similar to Rome, the information and skills taught in Illness Management and Recovery take time to learn, with each person learning at his or her pace. As people work on learning complex skills, such as identifying their early warning signs of relapse and developing a relapse prevention plan, it is important for the practitioner to recognize the steps taken along the way and to provide ample positive feedback and encouragement. Even when the pace of learning is quite slow and each step forward is small, practitioners can acknowledge these gains pointing them out, praising efforts, and letting people know they are making progress. Taking a “shaping attitude” means that practitioners understand the time and effort required to learn the information and skills in Illness Management and Recovery, and provide frequent reinforcement to people as they progress. Modeling One of the most powerful methods for teaching someone a skill is to demonstrate it for him or her. Modeling refers to the demonstration of skills for the purposes of teaching. Modeling has an important role to play in teaching Illness Management and Recovery, especially in helping people learn new skills. When modeling a new skill, it is useful for the practitioner to first describe the nature of the skill and then to explain that the skill will be demonstrated to show how it works. The practitioner then models the skill, and when completed, obtains feedback from the person about what he or she observed, and how effective the skill appeared to be. Modeling can be used to demonstrate a wide range of different skills, including those used in social settings as well as those used alone. When modeling a skill to be used in a social situation, practitioners can show how they might use the skill. For example, while working with the handout “Building Social Support” the person might want to work on the skill of starting a conversation. The practitioner might demonstrate how he or she might start a conversation with someone. The practitioner could also demonstrate the skill by arranging to take the role of the person experiencing psychiatric symptoms, and asking the person to take the role of someone that he or she might have social contact with. For example, the practitioner might demonstrate how the person might try starting a conversation with a relative at the next family holiday dinner. When the practitioner models a skill that a person can use alone, he or she can talk out loud to explain what he or she is thinking, and then demonstrate the skill. For example, the practitioner could demonstrate how a person could use a relaxation skill when feeling nervous and tense by first talking out loud about those feelings, then deciding to use the exercise, and then practicing the exercise itself. Practitioners can explain that they will model a skill by saying something like, “Now that we’ve talked about this particular skill, I’d like to demonstrate it in a brief role play. I’d like to show you how I might use the skill, and I’d like you to watch me to see what I do.” Modeling is especially useful when it is followed by the person practicing the skill, both in the session and outside of the session (see below). Practice and role play The expression, “practice makes perfect” is well suited to learning Illness Management and Recovery. In order to learn new skills, they need to be practiced, both in the sessions and outside of the sessions. Practice helps people become more familiar with a new skill, identifies obstacles to using the skill outside of teaching sessions, and provides opportunities for feedback from the practitioner and others. It is only by practicing skills outside of the sessions that people can improve their ability to manage their symptoms and make steps towards recovery. Practice of skills in sessions is especially effective when it is combined with modeling by the practitioner, although it may be done without such modeling as well. One of the best methods to help people practice a new skill is for the practitioner to set up a role play that will allow the person to try using the skill in the kind of situation that may come up in his or her life. For example, when talking about building social support in educational handout #4, the practitioner can help the person set up a role play where he or she practices starting a conversation with someone at work. After a skill has been practiced, the practitioner should always note some strengths of the person’s performance, and strive to be as specific as possible. The practitioner may also choose to give some suggestions to the person about how the skill may be done even more effectively, and additional practice in the session may be helpful. Homework assignments Homework assignments are a critical vehicle for helping people practice skills on their own. Specific assignments to practice skills are often helpful soon after a skill has been taught. The person should be familiar with the skill and have some specific plans for when and where to practice it. If the skill involves someone else, the person should select someone with whom to practice the skill. It is important that the person be involved in planning the homework assignment and to have confidence that he or she will be able to perform the skill successfully. Practicing within the session is one strategy for building up confidence about using a skill outside of the session. In the session following a homework assignment to practice a skill, the practitioner should follow up to find out how it went. It is sometimes useful to ask the person to demonstrate how the skill went instead of just talking about it. When the skill worked as planned, positive comments about using the skill can be elicited, and the practitioner can give additional praise. When a problem was encountered in using the skill, the practitioner can explore what went wrong, make and practice necessary modifications, and develop another homework assignment to practice the skill. With sufficient practice, people can learn new skills to the point where they become automatic and they can be used with little or no forethought. Cognitive restructuring People’s beliefs about themselves and the world and their personal styles for processing and understanding information shape how they respond to events. People’s beliefs and cognitive processing styles can be influenced by a variety of factors, including personal experience, mood, and what they have been told by others. Sometimes beliefs or cognitive processing styles may be inaccurate or based on distorted reflections of the world around them; in some cases, beliefs about the world may have been accurate at one time, for a person under one circumstance, but are no longer accurate. At other times, beliefs or processing styles be unhelpful, while not necessarily accurate or inaccurate. Cognitive restructuring is a cognitive-behavioral strategy that involves helping a person develop an alternative, more adaptive, and often more accurate, way of looking at things. There are many opportunities to employ cognitive restructuring in teaching Illness Management and Recovery. In the earliest sessions, practitioners may help people challenge the assumption that having a mental illness means not being able to pursue and achieve goals. This can be done by introducing the concept of recovery, and encouraging people to define recovery in terms of their own goals. During sessions focused on understanding the nature of mental illness, practitioners may provide people with a different way of thinking of the origins of their mental disorder. For example, rather than viewing it as a sign of personal weakness or faulty upbringing, the stress-vulnerability model suggests that a biological vulnerability is involved, which interacts with stress and coping skills. This model may provide a useful conceptualization to people by suggesting that vulnerability to relapses may be reduced by biological factors (taking medication effectively and avoiding drugs and alcohol), environmental factors (increased social support and decreased stress), and personal factors (increased coping skills, meaningful structure). When teaching the rudiments of relapse prevention, people’s beliefs that relapses happen randomly or that they cannot be prevented may be effectively corrected by providing information about the recognition of early warning signs of relapse and developing a relapse prevention program. During the process of teaching strategies for coping with symptoms, practitioners may help people develop an adaptive way of looking at troubling symptoms. For example, rather than symptoms being seen as intrusions into people’s well-being, they may be viewed as bothersome experiences that require the development and practice of coping strategies that can minimize their disruptive nature. Cognitive restructuring often occurs in the process of providing basic information to people, understanding their personal conceptualizations, and working with them to develop more adaptive ways of looking at things. While cognitive restructuring may occur informally, it may also be taught more formally as a coping skill for dealing with negative emotions. In such circumstances, cognitive restructuring involves helping the person describe the situation leading to the negative feeling, and then making a link between the negative emotions being experienced and the implicit thoughts and feelings associated with those feelings. Then, the person can be helped to evaluate the accuracy of those thoughts, and, if they are found to be inaccurate, to identify an alternative way of looking at the situation that is more accurate. The process of helping people evaluate the accuracy of their thoughts is sometimes facilitated by teaching them about “common cognitive distortions” people use when interpreting events around them, such as overgeneralization, jumping to conclusions, “black and white thinking,” catastrophic thinking, and selective attention (i.e., paying attention to only one piece of information while ignoring others). The essence of teaching cognitive restructuring as a strategy for dealing with negative emotions is to convey the message that feelings are the byproduct of thoughts, that such thoughts are often inaccurate, and that people can decide to change their thoughts based on an examination of the evidence. There are many opportunities to employ cognitive restructuring in teaching Illness Management and Recovery. In the earliest sessions, practitioners may help people challenge the assumption that having a mental illness means not being able to pursue and achieve goals. This can be done by introducing the concept of recovery, and encouraging people to define recovery in terms of their own goals. During sessions focused on understanding the nature of mental illness, practitioners may provide people with a different way of thinking of the origins of their mental disorder. For example, rather than viewing it as a sign of personal weakness or faulty upbringing, the stress-vulnerability model suggests that a biological vulnerability is involved, which interacts with stress and coping skills. This model may provide a useful conceptualization to people by suggesting that vulnerability to relapses may be reduced by biological factors (taking medication effectively and avoiding drugs and alcohol), environmental factors (increased social support and decreased stress), and personal factors (increased coping skills, meaningful structure). When teaching the rudiments of relapse prevention, people’s beliefs that relapses happen randomly or that they cannot be prevented may be effectively corrected by providing information about the recognition of early warning signs of relapse and developing a relapse prevention program. During the process of teaching strategies for coping with symptoms, practitioners may help people develop an adaptive way of looking at troubling symptoms. For example, rather than symptoms being seen as intrusions into people’s well-being, they may be viewed as bothersome experiences that require the development and practice of coping strategies that can minimize their disruptive nature. Cognitive restructuring often occurs in the process of providing basic information to people, understanding their personal conceptualizations, and working with them to develop more adaptive ways of looking at things. While cognitive restructuring may occur informally, it may also be taught more formally as a coping skill for dealing with negative emotions. In such circumstances, cognitive restructuring involves helping the person describe the situation leading to the negative feeling, and then making a link between the negative emotions being experienced and the implicit thoughts and feelings associated with those feelings. Then, the person can be helped to evaluate the accuracy of those thoughts, and, if they are found to be inaccurate, to identify an alternative way of looking at the situation that is more accurate. The process of helping people evaluate the accuracy of their thoughts is sometimes facilitated by teaching them about “common cognitive distortions” people use when interpreting events around them, such as overgeneralization, jumping to conclusions, “black and white thinking,” catastrophic thinking, and selective attention (i.e., paying attention to only one piece of information while ignoring others). The essence of teaching cognitive restructuring as a strategy for dealing with negative emotions is to convey the message that feelings are the byproduct of thoughts, that such thoughts are often inaccurate, and that people can decide to change their thoughts based on an examination of the evidence. Using Cognitive-Behavioral Strategies in Behavioral Tailoring, Relapse Prevention, and Coping Skills Enhancement The cognitive-behavioral strategies described above are used in combination in several of the evidence-based practices incorporated into the Illness Management and Recovery Program, including behavioral tailoring for taking medication, developing a relapse prevention plan, and teaching skills to enhance coping with persistent symptoms. Each of these practices is briefly described below, with a particular focus on the cognitive-behavioral methods used to teach each skill area. Behavioral Tailoring Behavioral tailoring involves helping people to develop strategies that incorporate the taking of medication into their daily lives. The rationale behind behavioral tailoring is that building medication into an existing routine will provide people with regular cues to take their medication, thereby minimizing the chances that they will forget. Interest in taking medication is usually established by motivational techniques, including eliciting and reviewing the advantages of taking medication, such as reduced symptoms, relapses, and rehospitalizations, and making progress towards personal goals. When using behavioral tailoring, the practitioner first explores the person’s daily routine, including activities such as eating meals (where and at what times) and personal hygiene (brushing teeth, showering, use of deodorant, contact lenses, etc.). Then, the practitioner and person identify an activity that can be adapted to include taking medication. For example, the person may choose to take medication when he brushes his teeth in the morning and evening. In order to create a cue for taking medication at these times, the person may elect to attach his toothbrush to his medication bottle with a rubber band, and choose to take the medication before brushing his teeth. In order to ensure that this plan is carried out, the practitioner may first model the routine for the person (attaching the toothbrush to the medication bottle, taking medication, brushing teeth, refastening the toothbrush to the rubber band), and then engage the person in a role play of the same routine. After rehearsing the routine in a session, the practitioner and the person could establish a homework assignment to implement the plan. Other people could be involved in helping to implement or follow up on the plan to make sure that it is working well, and a home visit could be scheduled with the practitioner as part of the follow-through plan. Successful implementation of the behavioral tailoring plan could be reinforced by praising the person for following through. Relapse Prevention Relapse prevention involves helping the person develop a plan that is aimed at identifying the early warning signs of a relapse, and responding to those signs in order to take the steps necessary to avert a relapse or to minimize the severity of a relapse. Developing effective relapse prevention plans requires the smooth integration of a combination of motivational, educational, and cognitive-behavioral teaching strategies. These plans are often most effective when they involve someone else who is supportive to the person, such as a family member or friend. When developing a relapse prevention plan, the practitioner first engages the person in a discussion of past relapses, and the advantages of preventing or minimizing the severity of future relapses. The practitioner then explains the nature of relapses, including their gradual onset and the emergence of early warning signs of an impending relapse (or the first symptoms of relapse), and leads a discussion of the person’s most recent relapse (or previous relapses) in order to identify possible early warning signs. When these signs have been noted, the practitioner and the person (and significant other, when involved) select several of the most prominent signs to monitor as part of the relapse prevention plan. When these signs have been selected, the practitioner works with the person to determine a set of steps for how to respond to these signs of a possible relapse. Once the steps for responding to the signs of a possible relapse have been established they are written down. Role plays can be used to familiarize the person with the steps of the relapse prevention plan, and to make any needed modifications. Homework assignments can involve additional role playing with any other people involved in the plan, and sharing the plan with other important people. With some people, the development of the plan may take place over several sessions, with the practitioners providing encouragement as the different steps of the plan are formulated. Coping Skills Enhancement Coping skills enhancement is aimed at helping people develop more effective strategies for dealing with distressing and persistent symptoms, ranging from depression to anxiety to hallucinations to paranoia. Similar to behavioral tailoring and relapse prevention, coping skills enhancement is primarily based on cognitive-behavioral strategies, while also employing motivational and educational strategies. When conducting coping skills enhancement, the practitioner helps the person to identify a problematic symptom to work on, and then conducts a behavioral analysis to determine situations in which the symptom is most distressing. The practitioner then collaborates with the person to identify coping strategies he or she has used to deal with those symptoms and to evaluate their coping efficacy. Strategies that the person has found to be effective, but insufficiently used, may be targeted for increased usage to deal with the problematic symptom. Then, an additional coping strategy is selected to add to the person’s repertoire of coping skills. After the person has chosen a coping skill that he or she would like to try, the practitioner models it for the person, who then practices it in a role play. As a homework assignment, a plan is made for the person to practice the coping strategy on his or her own. A significant other may be involved in helping the person remember to use the coping strategy or may play a role in the strategy itself (for example, taking a walk with the person as part of a coping strategy of using exercise to distract oneself from auditory hallucinations). Based on the person’s feedback about the effects of using the coping strategy, additional tailoring may be done to better adapt the coping strategy to the person’s situation. Finally, when the person has successfully learned the strategy, an additional assessment is conducted to evaluate whether another coping strategy should be taught, or whether the person’s current repertoire is sufficient. Conclusion of Teaching Principles Teaching Illness Management and Recovery involves the smooth integration of motivational, educational, and cognitive-behavioral teaching strategies. Motivational strategies are paramount, as they are necessary to ensure that people view learning information and skills as relevant to their own needs and goals. Educational strategies are oriented to providing people with basic information about the nature of recovery, mental illness and its treatment, and methods for coping with or reducing problematic symptoms. Cognitive-behavioral strategies are critical to helping people develop effective methods for setting and achieving personal goals related to recovery, using medication effectively, preventing relapses, and developing coping skills for dealing with symptoms. While the specific mix of strategies will differ from one person to the next, most teaching sessions will include a combination of each. Appendix A: Orientation Sheet for the Illness Management and Recovery Program The goals of the program are:
The mental health practitioner will:
The program includes:
The person participating in the program will:
Both the practitioner and the person participating in the program will strive for:
Appendix B: The Knowledge and Skills Inventory for the Illness Management and Recovery Program Collect information for this inventory in a low-key conversational manner. Avoid an “interrogating” tone. This form contains sample probe questions. NOT EVERY QUESTION HAS TO BE ANSWERED. Name: _____________________________________________________________ Address: ____________________________________________________________ Phone #: ____________________________________________________________ Date of Birth: _________________________________________________________ Talents, Abilities , Skills 1. Daily Routine 2. Educational and Work Activities 3. Leisure Activities/Creative Outlets 4. Relationships 5. Spiritual Supports 6. Health Knowledge 7. Previous Experience with Peer-Based Education or Recovery Programs 8. Previous Experience with a Practitioner-Based Educational or Recovery
Program 9. Knowledge About Mental Health
10. Questions Related to the Illness Management and Recovery Program Do you have any specific questions that you would like to have answered in
the Illness Management and Recovery program? What would you like to gain from the Illness Management and Recovery Program? What outcome would you like to see? Appendix C: Progress Note for Illness Management and Recovery Name:_________________________ ID #_________ Date ______________________ Name of significant other(s) involved in session:_________________________________ Problem or goal that is the focus of the person’s treatment: ________________________ _______________________________________________________________________ _______________________________________________________________________
Motivational interventions (check all that apply): __ connect info and skills with personal goals __ promote hope & positive expectations __ explore pros and cons of change __ re-frame experiences in pos. light Educational interventions (check the topic(s) that were covered): __ Recovery strategies __ Practical Facts about Mental Illness __ Stress-Vulnerability model __ Social Support __ Using Medication __ Reducing relapses __ Coping with Stress __ Coping w/ Symptoms & Problems __ Mental Health system Cognitive-behavioral interventions (check all that apply): __ reinforcement __ shaping __ modeling __ role playing __cognitive restructuring __ relaxation training Specific evidence-based skill(s) taught (specify which one(s)): ____________________ coping skill for dealing with symptoms: _____________________________________ relapse prevention skill: __________________________________________________ behavioral tailoring skill: _________________________________________________ Homework that was agreed upon: __________________________________________ _____________________________________________________________________ _____________________________________________________________________
Appendix D: Significant Others Information Sheet Note: The practitioner should discuss with the participant the importance of involving significant others for increasing their understanding and support and highlight how significant others can be helpful in reducing relapses. The practitioner can encourage the participant to identify one or more individuals that he or she considers to be significant others. If the participant decides to include one or more significant others, he or she can either contact the significant other(s) or ask the practitioner to do so. It is suggested that the practitioner obtain the participant’s written permission to contact significant others. Individuals who can be included as “significant others” re the Illness Management and Recovery Program:
How significant others can be involved in the Illness Management and Recovery Program at the request of the participant:
Appendix E: Goals Set in the Illness Management and Recovery Program Participant’s Name ____________________________________________ Practitioner’s Name ____________________________________________
Appendix F: Step-by-Step Problem-Solving and Goal Achievement 1. Define the problem or goal as specifically and simply as possible.
a. b. c. 3. For each possibility, list one advantage and one disadvantage.
a. b. c. 4. Choose the best way to solve the problem or achieve the goal. Which way has the best chance of succeeding?
a. b. c. d. e. f. Selected References for Illness Management and Recovery Summary of research supporting the components of Illness management and Recovery Mueser, K, Corrigan, P, Hilton, D, Tanzman, B, Schaub, A, Gingerich, S, Essock, S, Tarrier, N, Morey, B, Vogel-Scibilia, Herz, M. Illness Management and Recovery: A Review of the Research. Psychiatric Services, in press. Studies showing that education increases knowledge about mental illness Goldman, CR, Quinn, FL. Effects of a patient education program in the treatment of schizophrenia. Hospital and Community Psychiatry 39:282-286, 1988. * Macpherson, R, Jerrom, B, Hughes, A. A controlled study of education about drug treatment in schizophrenia. British Journal of Psychiatry 168:709-717, 1996. Bäuml, J, Kissling, W, Pitschel-Walz, G. Psychoedukative gruppen für schizophrene patienten: Einfluss auf wissensstand und compliance. Nervenheilkunde 15:145-150, 1996. Studies showing that behavioral tailoring improves taking medication as prescribed *Boczkowski, J, Zeichner, A, DeSanto, N. Neuroleptic compliance among chronic schizophrenic outpatients: An intervention outcome report. Journal of Consulting and Clinical Psychology 53:666-671, 1985. *Azrin, NH, Teichner, G. Evaluation of an instructional program for improving medication compliance for chronically mentally ill outpatients. Behaviour Research and Therapy 36:849-861, 1998. *Cramer, JA, Rosenheck, R. Enhancing medication compliance for people with serious mental illness. The Journal of Nervous and Mental disease 187:53-55, 1999. Kelly, GR, Scott, JE. Medication compliance and health education among outpatients with chronic mental disorders. Medical Care 28:1181-1197, 1990. Studies showing that relapse prevention training reduces relapses and rehospitalizations Buchkremer, G, Fiedler, P. Kognitive vs. handlungsorientierte Therapie (Cognitive vs. action-oriented treatment). Nervenarzt 58:481-488, 1987. * Herz, MI, Lamberti, JS, Mintz, J et al. A program for relapse prevention in schizophrenia: A controlled study. Archives of General Psychiatry 57:277-283, 2000. Perry, A, Tarrier, N, Morriss, R et al. Randomised controlled trial of efficacy
of teaching patients with bipolar disorder to identify early symptoms of relapse
and obtain treatment. British Medical Journal 318:149-153, 1999. Studies Showing That Teaching Coping Skills Reduces Severity of Symptoms * Leclerc, C, Lesage, AD, Ricard, N et al. Assessment of a new rehabilitative coping skills module for persons with schizophrenia. American Journal of Orthopsychiatry 70:380-388, 2000. *Lecomte, T, Cyr, M, Lesage, AD et al. Efficacy of a self-esteem module in the empowerment of individuals with schizophrenia. Journal of Nervous and Mental Disease 187:406-413, 1999. *Schaub, A. Cognitive-behavioural coping-orientated therapy for schizophrenia: A new treatment model for clinical service and research, in Cognitive Psychotherapy of Psychotic and Personality Disorders: Handbook of Theory and Practice, Vol . Edited by Perris, C, McGorry, PD Chichester, John Wiley & Sons, 1998. Schaub, A, Mueser, KT. Coping-oriented treatment of schizophrenia and schizoaffective disorder: Rationale and preliminary results. Presented at the 34th Annual Convention of the Association for the Advancement of Behavior Therapy, New Orleans. References for Practitioners Seeking More Information Related to Providing the Illness Management and Recovery Program Bipolar Disorder Fawcett, P, Golden, B, Rosenfeld, N. New hope for people with bipolar disorder. Prima Publishing, 2000. Miklowitz, D. The bipolar survival guide: What you and your family need to know. New York: Guilford, 2002. Cognitive-Behavioral Techniques for Psychotic Disorders Fowler, D. Cognitive behavioral therapy for psychosis: From understanding to treatment. Psychiatric Rehabilitation Skills 4(2): 199-215, 2000. Rector, N, Beck, A. Cognitive behavioral therapy for schizophrenia: An empirical review. Journal of Nervous and Mental Disease 189:278-287, 2001. Tarrier, N, Haddock, G. Cognitive-behavioral therapy for schizophrenia: A case formulation approach. In SG Hoffman and MC Tompson (Eds). Treating chronic and severe Mental Disorders: A handbook of empirically supported interventions (pp 69-95). New York: Guilford Press, 2002. Depression Copeland, ME. The depression workbook. Oakland: New Harbinger, 1999. DePaulo, JR. Understanding depression: What we know and what you can do about it. Wiley, 2002. Family Interventions MacFarlane, W. Multifamily groups in the treatment of severe psychiatric disorders. New York: Guilford Press, 2002. Mueser, K & Glynn, S. Behavioral family therapy for psychiatric disorders. Oakland, New Harbinger Publications, 1999. First Person Account of Illness Management Leete, E. How I perceive and manage my illness. Schizophrenia Bulletin (15)2: 197-200, 1989. Motivational Interviewing Miller, WR, Rollnick, S. Motivational interviewing: Preparing people to change. 2nd edition. New York: Guilford, 2002. Recovery Research Ralph, R. Recovery. Psychiatric Rehabilitation Skills (4)3: 488-517, 2000. Schizophrenia Herz, M, Marder, S.. The comprehensive treatment and management of schizophrenia. Baltimore, Lippincott, Williams, and Wilkins, 2002. Mueser, K. & Gingerich, S. Coping with schizophrenia: A guide for families. Oakland, New Harbinger Publications. 1994. Social Skills Training Bellack, A, Mueser, K, Gingerich, S, Agresta, J. Social skills training for schizophrenia: A step-by-step guide. New York: Guilford Press, 1997. Gingerich, S. Guidelines for social skills training for persons with mental illness. In Roberts, A and Greene, G. Social workers desk reference, pages 392-396, 2002. Liberman, R.P. Social and independent living skills (SILS) modules (trainers’ manuals, client workbooks, video packages, etc.) can be found at www.mentalhealth.ucla/edu. Stigma Corrigan, P. & Lundin, R. Don’t call me nuts: Coping with the stigma of mental illness. Chicago: Recovery Press, 2001. Wahl, O. Telling is risky business: Mental health consumers confront stigma. New Brunswick, NJ: Rutgers University Press. 1999. Substance Abuse and the Stages-of-Change Model Connors, G, Donovan, D, DiClemente, C. Substance abuse treatment and the stages of change. New York: Guilford Press, 2001. Velasquez, M, Maurer, G, Crouch, D, DiClemente, C. Group treatment for substance abuse: A stages-of-change therapy manual. New York: Guilford Press. Working Collaboratively With People Who Do Not Believe That They Have a Psychiatric Disorder Amador, X., Johanson, A. I am not sick: I don’t need help. Petonic, NY: Vida Press, 2000. Amador, X, Gorman, J. Psychopathologic domains and insight in schizophrenia. The Psychiatric Clinics of North America 21:27-42, 1998. |
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