illness management

8/6/2019 Illness Management

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TrainingFrontline Staff

IllnessManagementand Recovery

U.S. DEPARTMENT OF HEALTH AND HUMAN SERVICES

Substance Abuse and Mental Health Services Administration

Center for Mental Health Serviceswww.samhsa.gov
http://www.samhsa.gov/http://www.samhsa.gov/http://www.samhsa.gov/


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TrainingFrontline Staff

U.S. Department o Health and Human Services


Center or Mental Health Services


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Acknowledgments

This document was prepared for the Substance Abuse and Mental Health Services Administration

(SAMHSA) by the New Hampshire-Dartmouth Psychiatric Research Center under contract number

280-00-8049 and Westat under contract number 270-03-6005, with SAMHSA, U.S. Department

of Health and Human Services (HHS). Pamela Fischer, Ph.D., and Crystal Blyler, Ph.D., served as

SAMHSA Government Project Ofcers.

Disclaimer

The views, opinions, and content of this publication are those of the authors and contributors and

do not necessarily reect the views, opinions, or policies of the Center for Mental Health Services

(CMHS), SAMHSA, or HHS.

Public Domain Notice

All material appearing in this document is in the public domain and may be reproduced

or copied without permission from SAMHSA. Citation of the source is appreciated. However,this publication may not be reproduced or distributed for a fee without the specic, written

authorization from the Ofce of Communications, SAMHSA, HHS.

Electronic Access and Copies of Publication

This publication may be downloaded or ordered at http://www.samhsa.gov/shin. Or, please

call SAMHSAs Health Information Network at 1-877-SAMHSA-7 (1-877-726-4727) (English

and Espaol).

Recommended Citation

Substance Abuse and Mental Health Services Administration. Illness Management and Recovery:

Training Frontline Staff. HHS Pub. No. SMA-09-4462, Rockville, MD: Center for Mental Health

Services, Substance Abuse and Mental Health Services Administration, U.S. Department of Health

and Human Services, 2009.

Originating Ofce

Center for Mental Health Services


1 Choke Cherry Road

Rockville, MD 20857

HHS Publication No. SMA-09-4462

Printed 2009
http://www.samhsa.gov/shinhttp://www.samhsa.gov/shin


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Training Frontline Sta

This our-part workbook will help Illness Management

and Recovery (IMR) leaders teach practitioners about the

principles, processes, and skills necessary to deliver eective

Illness Management and Recovery services. The workbook

includes the ollowing topics:

nBasic elements and core values;nCore processes;nRecovery and the Stress-Vulnerability Model; andnMotivational, educational, and cognitive-behavioral

strategies.

The CD-ROM included in this KIT contains the Practitioner Guides

and Handouts booklet which includes all o the guides, handouts,

and orms that practitioners use to provide Illness Management

and Recovery to consumers. Use both the CD-ROM and the

Training Frontline Stabooklet to train practitioners.


For reerences, see the booklet The Evidence.


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This KIT is part o a series o Evidence-Based Practices KITs created

by the Center or Mental Health Services, Substance Abuse and

Mental Health Services Administration, U.S. Department o Health

and Human Services.

This booklet is part o the Illness Management and Recovery KIT

that includes a DVD, CD-ROM, and seven booklets:

How to Use the Evidence-Based Practices KITs

Getting Started with Evidence-Based Practices

Building Your Program

Training Frontline Sta

Evaluating Your Program

The Evidence

Using Multimedia to Introduce Your EBP


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Whats in Training Frontline Staff

How Program Leaders Should Use This Workbook . . . .A

Decide on your program ormat . . . . . . . . . . . . . . . . . . . . . B

Prepare program-specifc inormation . . . . . . . . . . . . . . . . . B

Prepare agency-specifc inormation . . . . . . . . . . . . . . . . . . C

Visit an existing team . . . . . . . . . . . . . . . . . . . . . . . . . . . . C

Arrange or didactic training . . . . . . . . . . . . . . . . . . . . . . . C

Recruit a consultant . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . C

Cross-train . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . D

Module 1 . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 1

Basic Elements and Core Values . . . . . . . . . . . . . . . . . . . . . 1

What is Illness Management and Recovery? . . . . . . . . . . . . 1

Practice principles . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 3

Program standards . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 5

How we know that Illness Managementand Recovery is eective . . . . . . . . . . . . . . . . . . . . . . . . . . 5

Core components o Illness Management and Recovery . . . . 5

Core values in Illness Management and Recovery . . . . . . . . 6

Summary . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 8

Exercise: Explore the Benefts o Illness Managementand Recovery . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 9

Exercise: Identiy Consumers . . . . . . . . . . . . . . . . . . . . . . 11

Exercise: Introduce Your Program . . . . . . . . . . . . . . . . . . . 13

Module 2 . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 1

Core Processes. . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 1

Engaging consumers is a continuous process . . . . . . . . . . . . 2

Assess consumers knowledge and skill level . . . . . . . . . . . . 2



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Follow the curriculum . . . . . . . . . . . . . . . . . . . . . . . . . . . . 2

Use Practitioner Guides . . . . . . . . . . . . . . . . . . . . . . . . . . . 3

Use Handouts or consumers . . . . . . . . . . . . . . . . . . . . . . . 3

Pace your sessions . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 4

Consider the ormat o your sessions . . . . . . . . . . . . . . . . . . 4

Structure your sessions . . . . . . . . . . . . . . . . . . . . . . . . . . . . 5

Provide homework assignments . . . . . . . . . . . . . . . . . . . . . 5

Follow up on homework assignments . . . . . . . . . . . . . . . . . 6

Setting and pursuing goals . . . . . . . . . . . . . . . . . . . . . . . . 6

Involve other supporters . . . . . . . . . . . . . . . . . . . . . . . . . . 7

Complete Progress Notes . . . . . . . . . . . . . . . . . . . . . . . . . . 8

Participate in supervision . . . . . . . . . . . . . . . . . . . . . . . . . . 8

Summary . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 8

Exercise: Compare Assessment Procedures . . . . . . . . . . . . . . 9

Exercise: Complete a Progress Note . . . . . . . . . . . . . . . . . 11

Exercise: Involve Other Supporters . . . . . . . . . . . . . . . . . . 13

Exercise: Improve Your Program . . . . . . . . . . . . . . . . . . . . 15

Module 3 . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 1

Recovery and the Stress-Vulnerability Model . . . . . . . . . . . . 1

Recovery means more than just coping . . . . . . . . . . . . . . . . 2

Learn rom other perspectives . . . . . . . . . . . . . . . . . . . . . . 3

Think about recovery as a process . . . . . . . . . . . . . . . . . . . . 3

Convey hope. . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 4

Oer consumer-directed care . . . . . . . . . . . . . . . . . . . . . . . 4

Help consumers pursue personal goals . . . . . . . . . . . . . . . . 4

Understand the Stress-Vulnerability Model . . . . . . . . . . . . . 4

Change consumers biochemistry . . . . . . . . . . . . . . . . . . . . 6

Change consumers risk o exposure to stressors . . . . . . . . . . 6Conront some stressors . . . . . . . . . . . . . . . . . . . . . . . . . . . 6

Help consumers deal with hassles . . . . . . . . . . . . . . . . . . . . 6

Help consumers deal with hassles . . . . . . . . . . . . . . . . . . . . 7

Summary . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 7

Exercise: Reinorce Your Understanding o Recoveryand the Stress-Vulnerability Model . . . . . . . . . . . . . . . . . . . 9

Exercise: Practice What Youve Learned Aboutthe Stress-Vulnerability Model . . . . . . . . . . . . . . . . . . . . . 11

Exercise: Learn More About Recovery . . . . . . . . . . . . . . . . 13

Module 4 . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 1Motivational, Educational, and Cognitive-Behavioral Strategies . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 1

Motivational strategies . . . . . . . . . . . . . . . . . . . . . . . . . . . . 1

Educational strategies . . . . . . . . . . . . . . . . . . . . . . . . . . . . 2

Cognitive-behavioral strategies . . . . . . . . . . . . . . . . . . . . . . 3

Other clinical skills . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 7

Conclusion . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 8

Exercise: Practice What Youve Learned . . . . . . . . . . . . . . . . 9

Exercise: Review the Illness Managementand Recovery Curriculum . . . . . . . . . . . . . . . . . . . . . . . . . 11


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Training Frontline Sta A

Training Frontline Staff

How Program Leaders Should UseThis Workbook

Training Frontline Staffintroducespractitioners to the basic principles andskills they need to deliver eective Illness

Management and Recovery services.

Use this workbook with the PracticeDemonstration Video and the Englishor Spanish Introductory Video on theDVD in this KIT.

Since being part o a team and learning

how to process inormation together is anessential part o IMR, we recommendthat you conduct group training ratherthan simply giving IMR practitioners the

workbook to read on their own.

To make the content easy to manage, we

divided the training into our modules.

The Four Illness Management

and Recovery Modules in Training

Frontline Staff

1 Basics Elements and Core Values

2 Core Processes

3 Recovery and the Stress-VulnerabilityModel

4 Motivational, Educational, andCognitive-Behavioral Strategies

The ultimate purpose o this workbook isto have practitioners understand therecovery theory behind the IMR model,how IMR is delivered, and the skills

necessary to provide eective services.We have ound that practitioners preerto read one module at a time and then


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B Training Frontline Sta

discuss that module with colleagues as a group.Working through these modules as a group createsan opportunity to discuss and master the core

values and teaching principles that are essentialto eective IMR practice.

Decide on your program ormat

This workbook is designed to allow practitioners tooer IMR in either an individual or group ormat.Because the Practitioner Guides and Handoutsdier depending on which ormat you choose, youmust decide whether your agency will oer IMR

in a group or individual ormat beore training yourIMR sta.

For more inormation about the advantagesand disadvantages o oering IMR in a groupor individual ormat, see Building Your Programin this KIT.

Prepare program-specic inormation

In addition to using the materials in this workbook,give practitioners inormation about IMR policiesand procedures. These include the ollowing:

nCriteria or admitting consumers to the program;

nConditions under which consumers will bedischarged;

nIMR assessment orms and the timerame orcompleting them;

nCriteria or assessing the programs delity to theIMR model; and

nOutcomes that will be monitored.

For sample orms, see Building Your Programand Evaluating Your Program in this KIT.

How to Completethis Four-Session Training

n Arrange or IMR practitioners to meet at least

once a week or 4 weeks. You will cover up to

one module each week.

n In this workbook, on the page beore each

module, youll fnd Notes to the acilitator and

IMR leader. Review the notes to prepare or the

training.

n Copy and distribute the modules

reading materials so that

practitioners can read them beore

the training session. You will fnd

this booklet on the KITs CD-ROM.

n Copy the exercises or each module

so that you can distribute themduring each training session. You

will fnd the exercises in this booklet

on the KITs CD-ROM.

n For each session, ask a dierent group member

to acilitate.

n Begin each training session

by showing the corresponding

segments o the Practice

Demonstration Video.

n Discuss the inormation in the video and

workbook.

n Complete the suggested exercises or that

module.

n At the end o this training series, give each IMR

practitioner a copy o the Practitioner Guides

and Handouts in this KIT. Discuss a plan or

addressing issues and questions that may arise

as practitioners use the Practitioner Guides and

Handouts and provide IMR services.


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Training Frontline Sta C

Prepare agency-specic inormation

You should also develop a plan to train IMRpractitioners about other policies and proceduresthat may be relevant to the agency in which theIMR program operates. These might include theollowing:

nConsumers rights: Practitioners should beaware o the state and ederal consumer rightsrequirements.

nBilling procedures: Practitioners must knowhow to document and bill or IMR services.

nSaety: Many agencies with existing community-based programs will have materials about saety.I training in this area is not already available,plan or training in de-escalation techniques.

nMandated reporting: Practitioners must knowhow to report suspected abuse and neglect. Theymust also know what to do i they nd out aboutother illegal activity and threats o harm to selor others.

nOther policies and procedures:Consult youragencys human resources oce to learn o otherprogram, agency, or state policies that the stashould know.

Visit an existing team

Ater your IMR team completes this workbook,we suggest that new practitioners observe anexperienced, high-delity IMR program. I you

are amiliar with these materials beore your visit,your visit will be more productive. Rather thanusing time to explain the basics, the host program

will be able to show the new IMR practitioners

how to apply the basics in a real-world setting.

Arrange or didactic training

Ater using this workbook and visiting anexperienced IMR program, IMR practitioners willbe ready or a trainer who will help them practice

what they have seen and read. Some IMR leaderschoose to hire an external trainer to help their

team practice IMR principles, processes, and skills.The initial training should take 2 to 3 days.

Recruit a consultant

Once IMR practitioners begin working withconsumers, youalong with the IMR coordinator/directorare responsible or ensuring that they

ollow the evidence-based model. This task canbe challenging.

You must acilitate a sta development process,apply what you have just learned about IMR in

your own clinical work with consumers, and, at thesame time, ensure through clinical supervision thatIMR practitioners ollow the model.

It is very easy to stray rom the evidence-basedmodel and do something similar to but not quite

the same as IMR. Sometimes this happens becausepractitioners believe they are diligently ollowingthe IMR model, but they miss some o the moresubtle aspects o it. In other cases, IMR servicesstart well, but, as more consumers are admitted

to the program and pressure mounts, practitionersrevert to older, more amiliar ways o working.

To ensure that your team ollows the IMR model,work with an experienced consultant throughoutthe rst year o operation. A consultant can provide

ongoing telephone and in-person support to helpyou with your challenging leadership role.


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D Training Frontline Sta

Cross-train

It is important that sta throughout your agencydevelop a basic understanding o IMR. Cross-training will ensure that other sta memberssupport the work that the IMR team undertakes.

As discussed in Building Your Program, we alsorecommend that you use these materials to trainmembers o your IMR advisory committee.The more inormation that advisory committeemembers have about IMR, the better they willbe able to support the program and its mission.

Training is also an opportunity or IMRpractitioners and advisory committee membersto become amiliar with one another. Make surethat the advisory committee members and IMRpractitioners introduce themselves and that theyare amiliar with one anothers roles.

To help you conduct your training, we include thesemultimedia materials in the IMR KIT:

nIntroductory PowerPoint presentation;

nSample brochure; and

nIntroductory Video.

Once trained, you or your sta will be able touse these materials to present routine, inserviceseminars to ensure that all sta members withinthe agency are amiliar with the IMR program.


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Basics Elements and Core Values E Module 1

Module 1

Basics Elements and Core Values

Notes to the acilitator and IMR leader

Prepare or Module 1

nMake copies o Module 1. Your

copy is in this workbook; print

additional copies rom the KITs

CD-ROM.

nDistribute the material to the IMR practitioners

who will participate in your group session. Ask

them to read it beore meeting as a group.

nMake copies o these exercises:

oExplore the Benefts o Illness

Management and Recovery

o Identiy Consumers

o Introduce Your Program

Do not distribute the exercises until the group

training. Your copies are in this workbook;

print additional copies rom the KITs CD-

ROM.

Make copies o your agencys policies and

procedures or identiying consumers or IMR

and discharging them rom the program (i

available). Guidelines or developing these

policies are provided in Building Your Program

in this KIT. Do not distribute them until your

group training.

Conduct your frst training session

n When you convene your group,

view the Orientation session on

the Practice Demonstration Video.

Discuss the video and the content

o Module 1.

n Distribute the ollowing:

o Your agencys IMR admission policy

o Your agencys IMR discharge criteria

o The exercises or this module

n Review the distributed materials and complete

the exercises as a group.

Facilitating the dialogue: One o the roles

o a acilitator and IMR leader is to acilitate

the dialogue during group training sessions.

Some people have difculty speaking in a

group, perhaps because they are timid or

sot-spoken. Others may eel proessionally

intimidated by those with more experience

or higher degrees. Conversely, some

practitioners will be sel-confdent and

outspoken and will need to learn to listen

openly to what others have to say.

As you work together on each module,

encourage those who are more withdrawn to

express their views and make sure that more

vocal group members give others a chance

to speak. Group training also provides theopportunity to assess the anxiety that IMR

practitioners may eel about providing IMR

services. Use your group training time to

explore and address issues openly.


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Basics Elements and Core Values 1 Module 1


Module 1: Basics Elements and Core Values

Module 1 explains the basic elements o Illness Management and Recovery

(IMR), including the importance o recovery and the core values o the

evidence-based model. This module orients practitioners to the content

they will provide to consumers in either a group or an individual ormat.

What is Illness Managementand Recovery?

Serious mental illnesses such asschizophrenia, bipolar disorder, andmajor depression are widely accepted

in the medical eld as illnesses with well-established symptoms and treatment.As with other disorders such as diabetes

or hypertension, it is both honest and

useul to give people practicalinormation about their mental illnesses,how common they are, and how they canmanage them. Many people with mental

illnesses report that this inormation ishelpul because it lets them know thatthey are not alone and it empowers themto take control o their symptoms andtheir lives.


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Module 1 2 Basics Elements and Core Values

As one person with schizophrenia said:

I we do acknowledge and seriously study our

illnesses, i we build on our assets, i we work to

minimize our vulnerabilities by developing coping

skills, i we conront our illnesses with courage and

struggle with our symptoms persistentlywe will

successully manage our lives and bestow our talents

on society (Leete, 1989).

Illness Management and Recovery is an evidence-based, psychiatric rehabilitation practice.The primary aims o IMR are to empowerconsumers to do as ollows:

nManage their illness;

nFind their own goals or recovery; and

nMake inormed decisions about their treatmentby acquiring necessary knowledge and skills.

In the IMR program, practitioners meet weekly

with consumerseither individually or as agroupor 3 and 10 months. The inormationcovered in IMR sessions includes the ollowing:

nRecovery strategies;

nPractical acts about mental illnesses;

nStress-Vulnerability Model and treatmentstrategies;

nBuilding social support;

nUsing medication eectively;

nDrug and alcohol use;

nReducing relapses;

nCoping with stress;

nCoping with problems and persistent symptoms;and

nGetting your needs met by the mental healthsystem.

Critical components o these 10 topics aresummarized in educational Handouts that

practitioners may review and distribute toconsumers in the IMR sessions. See Modules2 to 4 o this workbook or an introduction to

the Handouts or these 10 topics and guidelinesor covering inormation in group or individualormats. A copy o these materials may be oundin Practitioner Guides and Handouts in this KIT.


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Practice principles

IMR is based on a core set o practice principles.These principles orm the oundation o theevidence-based practice and guide practitionersin delivering eective IMR services.

For an overview o the IMR principles, see theollowing chart.

Principle 1:

Recovery is dened

by the individual.

IMR Practice Principles

Helping consumers in the process o recovery is the ultimate goal o IMR. In

introducing the concept o recovery, consumers are encouraged to develop their

own defnitions o recovery and to cultivate their own strategies or taking steps

toward recovery.

IMR practitioners help consumers establish personally meaningul recovery goals

that are integrated throughout the practice. Specifcally, practitioners help

consumers in these ways:

n Helping them identiy important personal goals;

n Instilling hope that they can accomplish important personal goals;

n Helping them identiy and put into practice strategies that will acilitate

progress toward recovery; and

n Helping them develop specifc recovery plans.

For this reason, Topic 1 o the IMR curriculum is Recovery Strategies. For more

inormation about recovery, see Module 3 in this workbook.

Principle 2:

Education about mental

illnesses and their treatment

is the oundation o inormeddecisionmaking.

People are empowered by knowledge. The more consumers understand the basic

acts about mental illnesses, the better equipped they are to speak or

themselves and to take an active role in their treatment and recovery.

IMR provides the opportunity to answer some common questions consumershave about mental illnesses including these:

n How are mental illnesses diagnosed?

n What are the symptoms o mental illnesses?

n What are the treatments or mental illnesses?

n How common are mental illnesses?

n What does the uture hold or me?

For more inormation, see Topic 2: Practical Facts About Mental Illnesses on the

CD-ROM, Practitioner Guides and Handouts in this KIT.


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Principle 3:

The Stress-Vulnerability Model

provides a blueprint or illness

management.

IMR helps consumers understand the Stress-Vulnerability Model o mental

illness. It describes the actors that contribute to the onset and course o mental

illnesses.

Based on the Stress-Vulnerability Model, several dierent treatment options are

available to help consumers manage their mental illnesses and achieve recovery

goals. Knowing more about mental illnesses helps consumers make inormed

decisions and engages them actively in the treatment process.

IMR explains how stress and biological vulnerability contribute to symptoms

o mental illnesses. Furthermore, treatment based on the IMR model conveys

the message that consumers can reduce their symptoms and achieve their goals.

This understanding allows consumers to become amiliar with dierent

treatment options.

For this reason, Topic 3 o the IMR curriculum is the Stress-Vulnerability

Model and Treatment Strategies. For more inormation about the Stress-

Vulnerability Model, see Module 3 in this workbook.

Principle 4:

Collaborating with proessionalsand signicant others helps

consumers achieve recovery goals.

Many consumers beneft rom involving practitioners and other supporters

in helping them manage their mental illnesses and take steps toward

recovery. Involving other supporters may be helpul in several ways.

Specifcally, it may

n Provide accurate inormation about mental illnesses to clariy

misunderstandings;

n Reduce criticism o consumers who experience symptoms;

n Reinorce inormation and skills learned through IMR sessions; and

n Generate support to help achieve consumers personal goals.

The decision to involve other supporters in Illness Management and

Recovery is always the consumers choice.

For more inormation, see Topic 4: Building Social Supports on the CD-ROM,

Practitioner Guides and Handouts in this KIT.

Principle 5:

Relapse prevention planning

reduces relapses and

rehospitalizations.

IMR helps consumers examine their previous experience with relapse

in order to develop a Relapse Prevention Plan. IMR practitioners help

consumers identiy triggers, early warning signs, and steps they can take

to help prevent relapses.

For more inormation, see Topic 7: Reducing Relapses on the CD-ROM,

Practitioner Guides and Handouts in this KIT.

Principle 6:

Consumers can learn new

strategies or managing theirsymptoms, coping with stress,

and improving the quality o

their lives.

IMR afrms that consumers can use cognitive-behavioral, motivational,

and educational strategies to manage symptoms, stress, and relapses.

Using these strategies can signifcantly improve their lives.

For more inormation, see Topics 8: Coping with Stress and Topic 9: Coping

with Problems and Persistent Symptoms on the CD-ROM, Practitioner Guides

and Handouts, in this KIT.


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Program standards

One o the unique eatures o IMR is that theimportant characteristics o this evidence-basedmodel have been translated into program standardsto help programs replicate eective services.An instrument called the IMR Fidelity Scale

summarizes these characteristics. The delity scaleis available to help quality assurance teams assesshow closely their program ollows the evidence-based model (See Evaluating Your Program in thisKIT). Your IMR leader will distribute this scaleto you to review and discuss during training.

Basic Characteristics o Illness

Management and Recovery

nSmall number o people in session or group

n At least 3 months o weekly sessions

or the equivalent

n Comprehensive curriculum

n Provision o educational handouts

n Involvement o signifcant others

n IMR goal setting

n IMR goal ollowup

n Motivation-based strategies

n Educational techniques

n Cognitive-behavioral techniques

n Coping skills training

n Relapse prevention training

n Behavioral tailoring or medication

How we know that Illness Managementand Recovery is eective

IMR is based on research that shows that bylearning more about managing mental illness,people who have experienced psychiatric symptoms

can take important steps toward recovery.

Specically, IMR helps consumers do the ollowing(Mueser et al., 2002):

nLearn more about mental illnesses;

nReduce relapses and rehospitalizations;

nReduce distress rom symptoms; and

nUse medications more consistently.

Core components o Illness Managementand Recovery

IMR includes a variety o interventions designed tohelp consumers improve their ability to overcomethe debilitating eects o their illnesses on socialand role unctioning. The core components o IMRare as ollows:

nPsychoeducation;

nBehavior tailoring;

nRelapse prevention; and

nCoping skills training.


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Core Components

nPsychoeducation provides the basic

inormation about mental illnesses and

treatment options.

nBehaviortailoring helps consumersmanage daily medication regimes by

providing strategies or remembering

to take medications.

nRelapse prevention teaches consumers to

identiy triggers o past relapses and early

warning signs o an impending relapse and

develop relapse prevention plans.

nCoping skills training involves identiying

consumers current coping strategies

or dealing with psychiatric symptomsand either increasing their use o these

strategies or teaching new strategies.

To eectively teach these core components toconsumers, IMR practitioners use a variety otechniques including motivational, educational,and cognitive-behavioral strategies. IMRpractitioners can learn these strategies by readingand applying the inormation in Module 4 o

this workbook.

Core values in Illness Managementand Recovery

IMR is based on several core values that permeatethe relationship between the practitioner andconsumers. These values include the ollowing:

n

n

Building hope;Recognizing consumers as experts in their ownexperience o mental illness;

Emphasizing personal choice;

Establishing a collaborative partnership; and

Demonstrating respect.

n

n

n

Build hope

Primarily, the process o teaching IMR involvesconveying a message o hope and optimism.

The long-term course o mental illnesses cannotbe predicted, and no one can predict anyonesuture. However, studies suggest that consumers

who actively participate in their treatment andwho develop eective coping skills have the mostavorable course and outcome, including a betterquality o lie (Mueser et al., 2002). The ability

to infuence ones own destiny is the basis or hopeand optimism about the uture.

IMR practitioners convey hope and optimismto consumers. People who experience psychiatricsymptoms oten report that having another personbelieve in them is empowering and validating.

In providing IMR, practitioners presentinormation and skills as potentially useul toolsthat consumers can use in pursuing their goals.IMR practitioners retain an attitude o hope

and optimism, even when consumers maybe pessimistic.


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Recognize consumers as experts

While IMR practitioners have proessional

expertise in the treatment o mental illnesses,consumers have expertise in the experience omental illnesses. Consumers know what has beenhelpul and what has not.

Just as IMR practitioners share their expertiseabout inormation and skills or managing and

recovering rom mental illnesses, consumers sharetheir expertise about how they experience mentalillnesses and which strategies work or them.IMR practitioners seek each consumers uniqueexperience with mental illnesses and response totreatment. By paying close attention to consumersexpertise, IMR practitioners are more eective in

helping consumers make progress toward theirpersonal goals.

Emphasize personal choice

The overriding goal o IMR is to give consumersthe inormation and skills they need to makechoices about their own treatment. The ability andright o consumers to make their own decisions isparamount even when consumers decisions dierrom the recommendations o their treatment

providers. Certain rare exceptions to this principleexist, or example, when legal constraints such asan involuntary hospitalization to protect consumersrom themselves or others.

In general, IMR practitioners avoid placingpressure on consumers to make certain treatment

decisions. Instead they accept consumers decisionsand work with them to evaluate the consequencesin terms o their personal goals.

Establish a collaborative partnership

While IMR practitioners are teachers, they are alsocollaborators. IMR practitioners help consumerslearn how to cope with their illnesses and makeprogress toward their goals. The collaborative spirit

o IMR refects the act that practitioners andconsumers work side by side in a nonhierarchical

relationship.

Demonstrate respect

Respect is a key ingredient or successullycollaborating in IMR. IMR practitioners respectpeople who experience psychiatric symptoms asellow human beings, capable decisionmakers, andactive participants in their own treatment. IMRpractitioners accept that consumers may dierin their personal values and respect the right o

consumers to make inormed decisions basedon these values.

IMR practitioners also accept that consumers may

hold dierent opinions, and they respect consumersrights to their own opinions. For example, consumersmay disagree that they have a particular mental

illness or any mental illness at all.

Rather than actively trying to persuade consumersthat they have a specic disorder, IMR practitionersrespect their belies while searching or commonground as a basis or collaboration. Commonground could include agreement on issues such

as the ollowing:

nSymptoms and distress that consumersexperience (perhaps even conceptualizedgenerally as stress, anxiety, or nerve problems);

Desire to avoid hospitalization;

Diculties with independent living; or

A specic goal they would like to accomplish.

n

n

n

Rather than insisting that consumers accept aparticular point o view, IMR practitioners seek

common ground as a basis or collaborating, thusdemonstrating respect or consumers belies.


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Exercise: Explore the Benefts o Illness Management and Recovery

Studies that have explored what makes a dierence in whether practitioners adopt a new approach totreatment have ound that practitioners are more likely to adopt a practice i it addresses an area in whichthey eel they must improve. Share your experiences about where the traditional service delivery systemhas been inadequate and identiy aspects o IMR that address those inadequacies.

Some experiences where the traditional service delivery system has been inadequate:

n

n

n

n

n

n

How IMR may address those inadequacies:

n

n

n

n

n


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Exercise: Identiy Consumers

Answer the ollowing questions to help reinorce your understanding o your agencys IMR policiesand procedures.

1. What is your agencys IMR admission policy?

n

n

n

n

2. How will consumers be reerred to your IMR program?

3. Under what circumstances will consumers be discharged rom IMR?


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Recovery and the Stress-Vulnerability Model 13 Module 3

Exercise:Learn More About Recovery

nLearn from the National Empowerment Center (NEC)

The National Empowerment Centers web site has stories and articles written by people who haveexperienced mental illnesses. The articles give you a glimpse of what it is like to receive mental healthservices and include accounts of personal journeys to recovery.

Group Discussion: Download two articles or stories from http://www.power2u.org. Review and discussthe stories as a group.

nRead more about recovery

Much of the information on recovery in this module comes from a Substance Abuse and Mental Health

Services Administration (SAMHSA) report calledA Review of Recovery Literature by Dr. Ruth O. Ralph(2000). This report is available from the SAMHSA web site http://www.samhsa.gov.

Group Discussion: Download this report (about 30 pages). Review and discuss it as a group.
http://www.power2u.org/http://www.power2u.org/http://www.samhsa.gov/http://www.samhsa.gov/http://www.samhsa.gov/http://www.power2u.org/


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Core Processes 15 Module 2

Module 2

Core Processes


Prepare or Module 2

n Make copies o Module 2. Your copy

is in this workbook; print additional

copies rom the CD-ROM in the KIT.

n Distribute the material to those who are

participating in your group training. Ask them

to read it beore meeting as a group.

n Make copies o these exercises:

o Compare Assessment Procedures

o Complete a Progress Note

o Involve Other Supporters

o Improve Your Program

Do not distribute the exercises until the group

training. Your copies are in this workbook;

print additional copies rom the KITs CD-

ROM.

n Make copies o your agencys

policies and procedures or

assessing consumers and

documenting services provided by your IMR

program (i available). For a Model Assessment

Form and Progress Note, see Building Your

Program in this KIT.

Also, make copies o these documents ound

in Evaluating Your Program in this KIT:

o Illness Management and Recovery Fidelity

Scale

o General Organizational Index

o Outcome measures that your agency will

monitor (i available)

Do not distribute the documents until the

group training.

Conduct your second training session

n When you convene your group, discuss the

content o Module 2.

n Distribute the ollowing:

o Your agencys policies and procedures

or assessing consumers and documenting

IMR services

o The IMR Fidelity Scale

o General Organizational Index

o Outcome measures that your agency

will monitor (i available)

o Exercises or this module

Note: This module has no corresponding Practice

Demonstration Video component.


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Module 2: Core Processes

Module 2 introduces you to the core processes o Illness Management and

Recovery (IMR), including reerral and assessment procedures, the curriculum,

and the session ormat. This module also discusses key aspects or providing

eective services such as identiying, setting, and pursuing goals and using

homework assignments to apply educational material.

Core Processes o Illness Management and Recovery

nA consumer is reerred to your IMRprogram.

nThe IMR leader or practitioner introducesthe IMR program.

nIMR practitioner assesses the consumerusing the IMR Knowledge and Skills

Inventory.nThe consumer begins weekly or biweekly

IMR sessions in a group ormat, individual

ormat, or combination o the two.

nIMR practitioners teach consumersinormation presented in IMR curriculum.

nIMR practitioners help consumers applyknowledge and skills using exercises and

homework assignments.

nIMR practitioners help consumers set andpursue personal recovery goals using IMR

goal orms and exercises.

nIMR practitioners help consumers buildsupport by involving amily and othersupporters.

nIMR practitioners document consumersprogress using the IMR Progress Note.

nIMR practitioners meet weekly or groupsupervision and individually with an IMR

leader as needed.


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Module 2 2 Core Processes

Although you might think that integrating IMRcore processes and paperwork into your daily

routine is too time consuming and burdensome,these processes make IMR teams operateeectively and eciently.

Engaging consumersis a continuous process

Engaging consumers in the process o IMR startsthe moment that they are reerred to the program.It is dicult, i not impossible, to engage consumers

in a treatment process in any meaningul way unlessyou know their needs and goals and, at the sametime, also know that what is being done ocuses onreaching those goals. For this reason, whether your

agency oers IMR in a group ormat or individually,we suggest meeting individually with consumersto conduct your IMR orientation sessions.

To explain the IMR program during your rstmeeting, use the Handout, Orientation to IllnessManagement and Recovery introduced in Module1 and ound on the CD-ROM, Practitioner Guides

and Handouts in this KIT. Your next ew sessionsare dedicated to getting to know consumers better.

IMR practitioners meet with consumers and their

amily members or other supporters to urtherdescribe the program and learn about consumersimmediate needs and goals.

The engagement process never stops. Wheneveryou meet with consumers, you learn more abouttheir immediate needs and goals. I you wantconsumers to stay engaged, you have to continueto help them progress in a way that is meaningul

to them. It may take some consumers a while torealize that you are oering something dierentrom what they have received rom the mentalhealth system in the past.

Assess consumers knowledgeand skill level

In your second and third sessions, use the Knowledgeand Skills Inventory to assess consumers. Your IMRleader will distribute and review this orm during

your group training. This assessment orm ocuses

on consumers positive attributes rather than ontheir problems or decits.

It is important to gather inormation in a riendly,low-key manner, using a conversational tone. I youask questions too quickly, consumers may eel

interrogated. Allow time or discussion and donteel that every question has to be answered.Use consumers responses to connect them to waysthe IMR program can benet them. At the end oeach session, ask or eedback on the parts o theprogram that seem most interesting to themto continue the engagement process.

Follow the curriculum

Once you nish introducing consumers to the IMRprogram and assessing their knowledge and skilllevel, you are ready to begin oering weekly orbiweekly sessions based on the IMR curriculum.The IMR curriculum consists o these 10 topics:

nRecovery strategies;

nPractical acts about mental illnesses;

nStress-Vulnerability Model and treatmentstrategies;

nBuilding social support;

nUsing medication eectively;


nReducing relapses;

nCoping with stress;

nCoping with problems and persistent symptoms;and

nGetting your needs met by the mental healthsystem.


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Typically, the IMR curriculum can be ollowedin the order listed. However, or some consumers,it is important to tailor the program to respond to

their individual needs. For example, when specicsymptoms distress a consumer, address theproblem early using Topic 9: Coping with Problemsand Persistent Symptoms. We encourage you to

use your clinical judgment about the order otopics in the IMR curriculum.

Practitioner Guides and Handouts have beendeveloped to guide your work with the IMRcurriculum. See the CD-ROM, PractitionerGuides and Handouts in this KIT.

Use Practitioner Guides

Practitioner Guides are available or each topicin the IMR curriculum. The guides give you

a quick review o the topics overall goal andthe recommended structure or each session.The guides also give you reminders andrecommendations such as the ollowing:

nAlert you to upcoming exercises so that you mayallot time to complete them;

nPrompt you to make connections betweeninormation within the Handout and consumerspersonal recovery goals; and

nSuggest homework assignments thatappropriately reinorce knowledge and skills.

Practitioner Guides also include suggestions ormotivational, educational, and cognitive-behavioralstrategies that are tailored to the topic area. For amore detailed discussion o these strategies, seeModule 4 o this workbook.

Two sets o Practitioner Guides are in the booklet:

nPractitioner Guides or individual sessions; and

nPractitioner Guides or group sessions.

Each Practitioner Guide is marked with one o theollowing icons on the top right corner o the pageto identiy whether it was developed or use in the

individual or group ormat:

Individual session

Group session

I the Practitioner Guide can be used in eitherormat, both icons will appear.

Beore each session, select and review theappropriate Practitioner Guide or the topicthat you will be discussing. Use this materialto help comprehensively cover the topics inthe IMR curriculum.

Use Handouts or consumers

Handouts or each topic are also available or youto distribute and review with consumers during

your sessions. The Handouts have practicalinormation and skills that consumers can use inthe recovery process. They are written in simple,easy-to-understand language and includeinormative text, summary boxes, probing questions,and exercises to help consumers learn the materialin a number o dierent ways. They are not meant

to be stand-alone documents. It is important thatyou help consumers integrate the knowledge andskills presented in them.

Similar to the Practitioner Guides, some Handoutsmay dier depending on whether you arepresenting the material in an individual or group

ormat. Each Handout is also marked with oneo the ollowing icons on the top right corner toidentiy whether it was developed or use in theindividual or group ormat:

Individual session

Group session


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I a Handout may be used in either ormat, bothicons will appear.

During the rst IMR session, give each consumera three-ring IMR binder. Tell consumers to bringthe binders to every session and to insert theirHandouts ater completing them.

I consumers have diculty remembering to bring

their binders to the sessions or i they lack a secureplace to keep them, set up a storage area near thelocation o your IMR sessions. Have extra copieso the IMR Handouts available or consumers whoorget their binders. You can collect those extracopies at the end o your session.

Pace your sessions

Typically, IMR sessions are oered weekly and

last between 45 and 60 minutes. The length othe IMR program varies between 3 and 10 months.

The length o the IMR program and pacing o thesessions depend on a variety o actors, includingthe ollowing:

nConsumers prior knowledge and skill level;

nThe problem areas that they would like to workon; and

nThe presence o either cognitive dicultiesor severe symptoms that may slow thelearning process.

Use the inormation collected in the orientationsessions to help predict the pacing o the sessions.Some consumers may have limited attention spans,comprehension problems, or severe symptoms thatmake it dicult to ocus or more than 30 minutes.Consider taking breaks during sessions orconducting more requent, brie sessions, such

as meeting or 20 to 30 minutes two or threetimes a week.

Consider the ormat o your sessions

The IMR program may be oered in eitherthe individual or group ormat or a combinationo the two. The length o the IMR program andthe pacing o the sessions will dier dependingon the ormat that your agency chooses.

Ask your IMR leader which ormat your agencywill oer. Reer to the appropriate PractitionerGuide and Handout or each session.

Using a group ormat

When you oer IMR in a group ormat, establishgeneral group guidelines. Common guidelinesinclude the ollowing:

nWhat is said in the room stays in the room;

nTreat all group members and property withrespect; and

nRegular attendance is expected.

During the rst group session, tell consumersabout the general group guidelines. Ask them tonotiy you i they cannot attend the IMR group.

You can deal with violations to the guidelines invarious ways. Raise less serious ones in a general

way, not by conronting a specic consumer, butby reminding all consumers o the guidelines andasking or a recommitment to them. You can deal

with more serious violations by meeting separatelywith specic consumers. Only in the most extremesituations should you conront a consumer in ronto others in the group.


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Structure your sessions

IMR practitioners have ound that ollowingthe outline shown in the box helps them workthrough the IMR curriculum more eciently

with consumers. For this reason, the PractitionerGuides or each topic recommend that you ollow

this structure or your IMR sessions.

Suggested Structure for Individual

and Group Sessions

Individual

sessions

Group

sessions

Socialize inormally

and identiy any major

problems

13

minutes

13

minutes

Review previous sessions 13

minutes

13

minutes

Review homework 35

minutes

510

minutes

Follow up on goals 13

minutes

510

minutes

Set agenda or current

session

12

minutes

12

minutes

Teach new material orreview previously taughtmaterial

3040

minutes

2025

minutes

Agree on new homework

assignment

35

minutes

510

minutes

Summarize progressmade in current session

35

minutes

35

minutes

Provide homework assignments

Homework assignments are a critical vehicle orhelping consumers practice and apply what theylearn. With sucient practice, consumers canintegrate new skills to the point where theybecome automatic and can be used with little

or no orethought.

The Practitioner Guides include suggestions orhomework assignments. Suggestions may includethe ollowing;

nReviewing a section o the Handout;

nFinishing an exercise that was started during thesession; or

nActively practicing a newly acquired skill.

When homework involves practicing a new skill,

it is helpul i consumers make a specic plan orhow that will be accomplished. For example, iconsumers indicated that they would like topractice the strategy o exercising regularly, helpmake a plan about what type o exercise, how manyminutes, which days o the week, what time o day,and how to overcome anticipated obstacles.

Help consumers troubleshoot obstacles that might

interere with completing the homework. Thisgives consumers some options and helps themavoid becoming distressed.

Be aware that some consumers will be ne with

the term homework assignment, while others mayeel uncomortable with it. I this is the case, usedierent terminology, such assomething to follow

up with what we talked about today, anopportunity to practice what were learning,or recovery action steps.


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Follow up on homework assignments

Ask consumers to share their experiences o tryingto complete the homework assignment. Praiseconsumers or their eorts and accomplishmentson the homework. Explore the ollowing questions:

nWhat were you able to do?

nWhat were you unable to do?

nWhat might you do dierently in the utureto ollow through with homework?

I consumers did not complete a homework

assignment, identiy obstacles that they may haveencountered. Problem-solve ways that they mayovercome these obstacles. For example, i thehomework assignment was to attend a support

group meeting and they did not havetransportation, you could help identiy a busor subway that they could take to the meeting.

I consumers did not complete the homework,discuss reasons and collaboratively modiy theassignment to be more achievable. For example,i the homework was to attend a support groupmeeting, but consumers were very apprehensive

about being with people they dont know, amodied assignment might be to start by calling

the contact person or the support group andasking a ew questions.

It is important to tailor homework assignments toaddress consumers needs and interests. This may

be more challenging when providing IMR in agroup ormat. Use consumers responses to thereview questions at the end o each session toassess how much o the inormation and skills theyhave mastered. Tailor homework assignments tohelp consumers continue to pursue their goals.

Setting and pursuing goals

As mentioned in Module 1, setting and pursuingpersonal goals is an essential part o recovery.In IMR, consumers dene what recovery meansto them and identiy personal recovery goals.

The rst IMR topic, Recovery Strategies, containsspecic inormation about setting goals. However,throughout the entire program, IMR practitionershelp consumers set meaningul, personal goals andollow up on those goals.

Two exercises help consumers set and pursue goals:

nWorking on Goals identies one or two goals anda ew steps towards achieving them; and

nStep-by-Step Problem-Solving and GoalAchievement outlines more detailed goalplanning.

Although you can nd these exercises attached tothe IMR HandoutTopic 1: Recovery Strategies,use these exercises during any IMR session to helpconsumers dene or revise their goals and establishsteps or pursuing them.

Since it is expected that consumers will developand pursue multiple goals over the course o theIMR program, we developed a orm to helpconsumers track their goals and progress.Instruct consumers to insert the orm, Goals Set in

the IMR Program, in the ront o their IMR binderand update it weekly. This orm is also attached

to IMR HandoutTopic 1: Recovery Strategies onthe CD-ROM, Practitioner Guides and Handoutsin this KIT.

Practitioner Guides or each session will promptyou to ollow up on consumers progress towardtheir goals. I you are providing IMR in a group

ormat, ollow up on the goals o two or threeconsumers during each session. Focus on dierentconsumers each week to ensure that all groupmembers have an opportunity to reviewtheir progress.


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It is important to monitor several aspects oconsumers progress, including:

nBreaking goals down into small steps;

nRecognizing progress in achieving each step;

nHelping consumers adjust or revise goals; and

nSetting new goals when old ones have beenreached.

Consider rewarding consumers accomplishments.I you are oering IMR in a group, applaudconsumers achievements. You could also considergiving other rewards such as certicates ortoken gits.

Keep consumers goals in mind throughout the

IMR session. Make as many connections as

possible between consumers goals and how thetopic inormation and skills can help them meettheir goals.

Involve other supporters

Developing and enhancing natural supports isa goal o the IMR program. Family members

or other supporters who are involved in IMRare more supportive o consumers mental healthtreatment and recovery goals.

While IMR Topic 4: Building Social Supportsis dedicated to building a support network,

you should integrate this task into every IMRsession. During IMR orientation sessions, explore

the benets o developing support networks.Review dierent types o people that consumerscan consider including in their support network.

In addition to amily members, consumers mayinclude the ollowing people:

nFriends;

nSupport group members;

nLeaders o sel-help programs;

nBoyriends or girlriends;

nRoommates;

nClassmates;

nCase managers;

nSta members rom Supportive Housingor Supported Employment programs;

nCounselors rom other programs;

nFamily Psychoeducation program groupmembers;

nChurch members;

nOther spiritual group members; or

nOthers.

Look or ways to help consumers build their

support network. For example, you may encourage

amilies to participate in specic IMR sessions.

Other ways that amily members and othersupporters can be involved in the IMR programinclude the ollowing:

nHelping consumers review and masterinormation in the IMR curriculum;

nHelping consumers practice newly learned skills;

nTaking a role in implementing one or more steps

in consumers plans or achieving a personalrecovery goals; and

nTaking a role in consumers Relapse PreventionPlan, Plan or Coping with Persistent Symptoms,or Plan or Coping with Stress. For moreinormation about these plans, see Topics 7, 8,and 9 on the CD-ROM, Practitioner Guidesand Handouts in this KIT.

I consumers are uncomortable involving amilymembers or other supporters on their own, oer

to initiate contact with the people they choose.With consumers permission, oer to keep theamily member or other supporter inormed by

regularly calling or by sending them IMR handoutsor other relevant written materials.


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Another idea is to have a monthly support groupor consumers, amily members, and othersupporters. Support group members would review

the IMR Handouts and discuss ways to supportwhat consumers are learning in the IMR program.

Remember that the decision to involve a amily

member or other supporter is the consumerschoice. Thereore, it is important to listen to

consumers and respect their decisions aboutwhether and in what ways to involve amilymembers or other supporters.

Complete Progress Notes

Ater every IMR session, complete an IMRProgress Note to document the services that youprovided. The Progress Notes will help you trackthe ollowing inormation:

nConsumers personal goals;

nKinds o interventions provided (motivational,educational, cognitive-behavioral);

nEvidence-based skills that are taught (copingskills, relapse prevention skills, and behavioraltailoring skills); and

nHomework assignments.

Ask your IMR leader or a copy o the IMRProgress Note.

Participate in supervision

As part o an IMR team, you are expected to meetweekly with your IMR leader or individual orgroup supervision. Weekly supervision meetingsare critical or ensuring open communicationamong team members.

Discuss consumers goals and the progress thatthey are making toward their recovery. Talk with

your IMR leader and ellow IMR practitionersabout how to respond to issues that arise in yourIMR sessions.

Every 6 months, your IMR leader will also presentthe results and recommendations rom your IMRdelity assessment. Use this inormation to discussas a team how your IMR program may beimproved. For more inormation on the IMRdelity assessments, see Evaluating Your Programin this KIT.

Summary

In summary, this module introduced the coreprocesses o IMR, including reerral and

assessment procedures, the IMR curriculum, andthe ormat or IMR sessions. The next moduleintroduces the concept o recovery and the Stress-

Vulnerability Model.


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Exercise: Compare Assessment Procedures

Distribute and review your agencys IMR assessment orm. (For a model Knowledge and Skills Inventoryassessment orm, see Building Your Program in this KIT. For this exercise, use the version that your agencyhas adapted.)

nGroup discussion: Review your agencys IMR assessment orm and procedures or completing it. How doesit compare to assessment orms that you have used in the past?


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Exercise: Complete a Progress Note

Distribute and review your agencys IMR Progress Note. (For a model orm, see Building Your Programin this KIT. For this exercise, use the version that your agency has adapted.)

nGroup Discussion: Complete the orm, based on the role-play o the Orientation to Illness Managementand Recovery that you completed in your last training. Discuss your responses as a group.


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Exercise: Involve Other Supporters

nRole-play: Select two practitioners to play the roles o consumer and practitioner. Model howIMR practitioners will discuss with consumers the importance o building support networks.Provide options or dierent people who may be included and how they may participate.Show respect or consumers decisions.


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Exercise:Improve Your Program

nDistribute these documents:

nIMR Fidelity Scale

nGeneral Organizational Index (GOI)

nOutcome measures that your agency will monitor (i available)

nDiscuss how your IMR program will be evaluated.


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Module 3

Recovery and the Stress-Vulnerability Model


Prepare or Module 3

n Make copies o Module 3. Your

copy is in this workbook; print

additional copies rom the CD-ROM

in the KIT.

n Distribute the material to those who are

participating in your group training. Ask them

to read it beore meeting as a group.

n Make copies o these exercises:

o Reinorce Your Understanding

o Recovery and the Stress-

Vulnerability Model

o Practice What Youve Learned About

the Stress-Vulnerability Model

o Learn More About Recovery

Do not distribute them until the group training.

Your copies are in this workbook; print additional

copies rom the CD-ROM.

n Make copies o the materials

described in the exercise Learn

More About Recovery that you

wish to review during the training.

Also, make copies o the Practitioner Guides and

Handout or Topic 1: Recovery Strategies ound

on the CD-ROM in this KIT. Do not distribute

them until the group training.

Conduct your third training session

n When you convene your group,

view the ollowing three segments o

Practice Demonstration Video:

o Recovery Strategies

o Practical Facts About Mental Illnesses

o The Stress-Vulnerability Model and

Treatment Strategies

n Discuss the video and the content o Module 3.

n Distribute the exercises and related materials.

Discuss and complete them as a group.


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Module 3: Recovery and the Stress-Vulnerability Model

Two concepts are essential to understanding the goals and objectives o Illness

Management and Recovery (IMR):

n Recovery, especially in the context o serious mental illness, embraces a

hopeul vision or people who experience psychiatric disorders. Since theultimate goal o IMR services is to support consumers recovery processes,

it is important to ocus on this concept.

n The Stress-Vulnerability Model provides a useul ramework or

understanding mental illnesses and actors that infuence their onset and

course. The Stress-Vulnerability Model also oers a ramework or thinking

about inormation and skills that consumers need or recovery.


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Module 3 2 Recovery and the Stress-Vulnerability Model

Recovery means more than just coping

The idea o recovery rom serious mental illnessesmay be new to you i you came o age proessionallyin an earlier era when the mental health eldgenerally held low expectations or people withserious mental illnesses. Todayrecovery embraces

a more hopeul vision or people who experienceserious mental illnesses.

In a recovery ramework, the expectation is thatconsumers can live a lie in which mental illnessesare not the driving actor in their lives. Recoverymeans more than expecting people to simply cope

with mental illnesses or maintaining people withmental illnesses in the community. As an IMRpractitioner, you are called on to be a source ohope, support, and education, and to partner withconsumers on their journey through mental illnessand the accompanying social contexts.

Consumers are looking or the ollowing rom you:

nSupport and education so they can better managetheir symptoms;

nEncouragement to set personal goals and worktoward them; and

nInormation, skills, and support.

A Substance Abuse and Mental Health ServicesAdministration (SAMHSA) publication preparedby Dr. Ruth Ralph or the National TechnicalAssistance Center or State Mental Health Planning(NTAC) and the National Association or StateMental Health Program Directors (NASMHPD),describes recovery as ollows:

a process in which consumers learn to approach

daily challenges, overcome disability, learn skills,

live independently, and contribute to society

(Ralph, 2000).

Helping consumers in the process o recovery isthe ultimate goal o IMR.

The dictionary talks about recovery in terms oregaining something or getting something back.In consumers comments about recovery, they

repeat themes o regaining hope, motivation,sel-condence, meaning, and independence.Consequently, it is important or IMR to conveythe belie that consumers can achieve the ollowing:

nGet well and stay well or long periods o time;

nWork toward and meet personal goals; and

nLead happy and productive lives.

Consumers who were involved in developing thisKIT discussed the importance o goals in providingmeaning and instilling hope. As one consumer said:

I have to have goals. Thats what gives my lie

meaning. Im looking to the uture.

According to another consumer:

Its about motivation.

For another consumer, the issue is sel-esteem:

Recovery is about having confdence and sel-esteem.

There are things Im good at, and I have something

positive to oer the world.

Independence is also important:

The most important thing in my recovery is to be

as independent as possible. Im working at that all

the time.

IMR practitioners work with consumers to helpthem achieve maximum independence in manyareas including housing, nances, and medicationmanagement. IMR practitioners can also helpconsumers become more independent in theirrelationship with the mental health system by

educating them about mental illnesses andtreatment options and by relating to them as

partners in the treatment process rather thanas the subjects o treatment.


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Learn rom other perspectives

We are not suggesting that recovery means thatconsumers simply go back to where they werebeore the onset o illness. For one thing, we areall continuously changing, growing, and learning.Further, being diagnosed with a serious mental

illness can be a lie-altering experience. For thesereasons and others, some consumers preer to talkabout the experience o mental illness in termsother than recovery.

For a broader view o consumers thoughtsabout the experience o mental illness, consider

these quotes:

I am not recovered. There is no repeating, regaining,

restoring, recapturing, recuperating, retrieving.

There was not a convalescence. I am not complete.What I am is changing and growing and integrating

and learning to be mysel. What there is, is motion,

less pain, and a higher portion o time well-lived

(Caras, 1999).

Our lives seem not to ollow a traditional linear

path; our lives appear to be like advancing spirals.

We relapse and recuperate, we decide and rebuild,

we awaken to lie and recover/discover, and then we

spiral again. This spiral journey is one o renewal and

integration, the dynamic nature o this process leads

to what can only be described as transormation.Recovery and rehabilitation imply that someone

was once broken and then was fxed. Transormation

implies that proverbial making o lemonade ater lie

hands you lemons. It is the lesson, hard learned, o

the opportunity available in the midst o crisis that

evokes a substantive change within ourselves (Cohan

& Caras, 1998).

Think about recovery as a process

Recovery does not mean the same thing as cure.When we use the term recovery in this book, wedo not imply that consumers will never experiencepsychiatric symptoms again; we are talking aboutan ongoing process.

Consider the ongoing process o recovery as ajourney through mental illness to a place whereconsumers have the courage, skills, knowledge,and aspiration to struggle persistently withpsychiatric symptoms and the impairments thatcan limit them rom living independent and

meaningul lives (Ralph, 2000).

The process o recovery involves consumersexperiencing and processing their eelings abouthaving mental illnesses and the consequences othose illnesses in their lives. Consumers write andspeak o experiencing grie, rustration, loneliness,

despair, and anger at God, at the mental healthsystem, and at societys treatment o people withmental illnesses.

As you work with consumers, it is important toallow them to express their eelings about havingmental illnesses. Anger, grie, rustration,

hopelessness, and despair are all normal emotionsthat people who are diagnosed with major illnessesmight experience. Be careul not to ignore theseeelings as being merely symptoms o mentalillness, mood swings, or labile aect.

Listen and validate consumers eelings, without

discounting or minimizing their experiences.Help them reocus on what they are able to doand how they can decrease the symptoms theyexperience, prevent them rom recurring, and

become involved in meaningul adult activitiesthat interest them.


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Convey hope

It is easy or people who are diagnosed with seriousmental illnesses to lose hope. It can be very dicultto live with the symptoms o mental illnesses.Historically, we have sent a clear message thatconsumers are less valued members o our society.

Until recently, even the mental health proessionhas sent the message that the best consumersmight hope or is to cope.

While progress is slowly being made to changeattitudes and eliminate the stigma associated

with mental illnesses, consumers still receive many

negative messages, which are easy to internalize.Your job involves countering those negativemessages by showing the people you work withthe same respect and consideration you wouldany adult and by helping them envision socialroles or themselves other than those o patientor consumer.

Oer consumer-directed care

Through learning inormation about mentalillnesses and treatment, developing skills or

reducing relapses, dealing with stress, and copingwith symptoms, consumers can become empoweredto manage their own illnesses, to nd their own

goals or recovery, and to assume responsibilityor directing their own treatment.

Consumers are not passive recipients o treatment.The goal is not to make them comply with treatmentrecommendations. Rather, the ocus o IMR is toprovide consumers with the inormation and skills

they need to make inormed decisions about their

own treatment.

Help consumers pursue personal goals

Being able to set and pursue personal goals isan essential part o recovery. In IMR, consumersdene what recovery means to them and theyidentiy goals.

The rst IMR curriculum topic, RecoveryStrategies, has specic inormation about settinggoals. However, throughout the entire program,IMR practitioners help consumers set meaningul,personal goals and ollow up on those goals.As consumers gain mastery over their psychiatricsymptoms, they gain more control over their lives

and become better able to realize their visiono recovery.

In each IMR session, practitioners should ollowup with consumers progress toward their personalgoals. The IMR curriculum includes exercisesdesigned to help consumers set and pursue

personal recovery goals.

Understand the Stress-Vulnerability Model

The ultimate goal o IMR is to help consumers

reach a point where having mental illnesses isnot central in their lives. To help them reach thatpoint, you must understand something about the

onset and course o mental illnesses. The Stress-Vulnerability Model gives you a ramework orthinking about mental illnesses; it is a practicalschema or conceptualizing the objectiveso services.

According to some views o the Stress-Vulnerability

Model, an episode o serious mental illness such

as schizophrenia, schizoaective disorder, bipolardisorder, or major depression involves two actors(Mueser et al., 2002; Ingram & Luxton, 2005):

nPsychobiological vulnerability; and

nStress.


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For people to develop a mental illness, they musthave apsychobiological vulnerability. Researchersare not certain o the exact precursors o these

vulnerabilities, but some research suggestsgenetics, biochemical agents, and early biologicaldevelopment. The illness may then developspontaneously or it may develop when they

are exposed to stress.

Everyone is amiliar with stress. Some stressors aremajor, unpleasant lie events or traumas, such aslosing a loved one, being red, losing your home,being arrested, and being hospitalized. Stressorscan also be events and experiences that aregenerally considered positive or desirable.For example, being discharged rom the hospital,

being released rom prison, giving birth to a child,receiving a job promotion, getting an increase inpay, and starting a new relationship are experiencesthat would generally be considered changes or thebetter. The key is that they involve change. Even

when it is or the better, change can be stressul.

Stressors do not always have to be major events.Daily hassles such as trac jams, cranky children,rude people, or deadlines can also be stressul.At times, people may be particularly susceptibleto stress. Sometimes even little things thatnormally would not bother people can be stressul,

such as eeling hungry, tired, lonely, or ill (as shown

in Table 1).

Triggered by stress, the illness may recurperiodically. In some consumers, vulnerabilityappears to increase with repeated episodes oillness. Consumers who receive IMR services oten

have had multiple episodes o illness or experiencesymptoms that may not ully remit.

Some conditions and circumstances make it easieror people to cope with stress, such as when they aregetting exercise, proper rest, and good nutrition.Social supporthaving people who will listen and

oer support when things are not going wellcanalso make it easier or people to cope with stress.

Table 1: Stressors and Susceptibility to Stress

Stressors Susceptibility to stress

Major negative events Major positive events Everyday hassles Increase susceptibility Decrease susceptibility

n Major illness

n Hospitalization

n Serious injury

n Victimization

n Loss o your home

n Divorce or

separation

n Having a child

taken away

n Arrest or

incarcerationn Loss o a job

n Family crises

n A new home

n Hospital discharge

n A new baby

n Release rom jail

n A new relationship

n Getting married

n Starting a new job

n A promotion

n A pay raise

n Giving up addictive

drugs

n Deadlines

n Rude people

n Forgetting

something

important

n Trafc

n Cranky children

n Paying bills

n Not receiving

a check on time

n Not eeling well

n Being tired

n Being hungry

n Noisy living

environment

n Crowded living

environment

n Social isolation

n Negative or

pessimistic attitude

n Lack o meaningulstimulation

n Good health

n Adequate rest

n Adequate nutrition

n Adequate fnancial

resources

n Social support

n Opportunities

to relax

n Exercise

n Positive or

optimistic attitude


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Implications or intervention

Considering the basic premise o the Stress-

Vulnerability Model, you could conclude thatwhen people who are vulnerable to mental illnessesencounter stressors, they risk relapse. Logicallythen, interventions that change someonesbiochemistry, exposure risk, and actors thatinfuence susceptibility to stressors can avorablyalter consumers odds o experiencing

psychiatric symptoms.

For this reason, in addition to teaching consumersabout recovery and practical acts about mentalillnesses, the IMR curriculum includes theollowing topics:

nThe Stress-Vulnerability Model and strategies

or treatment;nUsing medication eectively;


nReducing relapses;

nCoping with stress; and

nCoping with problems and persistent symptoms.

For more inormation, see Practitioner Guidesand Handouts in this KIT.

Change consumers biochemistry

One way to alter the stress-vulnerability equationis to alter biological processes. Medications canalter the workings o chemicals within the brainto reduce or eliminate psychiatric symptoms.These medications can have substantial side eects

and using them eectively requires a close workingrelationship between consumers and their doctors.

Drugs and alcohol also aect the chemistry in thebrain and can worsen psychiatric symptoms.Eectively addressing psychiatric symptoms meansalso treating co-occurring substance use disorders.

Change consumers risk o exposureto stressors

Many consumers also ace major negative lieexperiences such as job loss, arrest, and injury.To change consumers exposure to stressors, you

must think ahead about what skills, support, and

resources consumers need to prevent such eventsrom occurring. For example, perhaps consumerscan avoid evictions i you help them devise andcarry out a plan to pay their rent on time or coachthem to keep their apartment clean. Perhaps

you can help consumers avoid arrest through

coordinated interventions that include helpingthem occupy their time with activities that providealternatives to using illegal substances.

Conront some stressors

Consumers may not want to avoid positivestressors, such as moving to a new apartment,being discharged rom the hospital, or nding

a new job. In these instances, you will want towork with them to nd ways to make the changesless stressul.

One approach to managing positive events is tobreak them into manageable pieces. For instance,moving to a new apartment might begin with the

consumer spending part o a day there with amiliarpeople. On the next visit, the consumers supportersmight stay or only part o the time. The next stepmight be or the consumer to spend time in theapartment alone, eventually spending a nightalone. Starting a new job might be done similarly.The consumer might spend increasing amounts

o time on the job, gradually reducing the amount

o immediate support until the consumer iscomortable in the situation. These types ointerventionsand the need or themwill varyrom consumer to consumer.


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Help consumers deal with hassles

Not all stressors are major events. Lie is ull ohassles that can be sources o stress. Some maybe easier to deal with i you can anticipate them;then you can plan to either avoid the hassles or

you can rehearse strategies or coping with them.

For example, i traveling to a job during rushhour is intolerably stressul or a consumer, you may

want to help the consumer plan to leave work at adierent time to miss the rush. Another alternativemight be to rehearse a conversation that theconsumer may have with a job supervisor aboutstarting work at a dierent time.

Summary

The topics within the IMR curriculum arebased on the concepts o recovery and the Stress-

Vulnerability Model. Inormation and exerciseswithin the IMR curriculum help consumersrecognize and manage a variety o problems and

stressors. For more inormation on these topics,see Practitioner Guides and Handouts in this KIT.


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Exercise:Reinorce Your Understanding o Recoveryand the Stress-Vulnerability Model

Complete the ollowing questions. Discuss your answers as a group.

1. What does the word recoverymean to you?

2. What advice would you give to someone with a mental illness who is discouraged about recovery?

3. According to the Stress-Vulnerability Model, what are the main actors that contribute

to psychiatric symptoms?

4. How can consumers reduce their biological vulnerability?

5. How can consumers cope with stress?


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Exercise:Practice What Youve Learned About the Stress-Vulnerability Model

Read the action steps developed with Mr. Jones and decide which step addresses each change shown.Check all that apply.

Action step

Check all that apply

A

Change the personsbiochemistry

B

Change the personsrisk o exposureto stressors

C

Change the personssusceptibilityto stressors

D

Other

See psychiatrist every 4 to 6 weeks or

prescriptions, symptom assessment,

supportive therapies

Attend weekly IMR group to learn about

mental illnesses and coping strategies

Schedule a one-to-one motivationalinterview three times a week with an

integrated treatment specialist

Attend weekly co-occurring

disorders group

Find sae, aordable housing

Meet monthly to review budget

and liaison with payee

Meet monthly with IMR practitionerand other supporter to identiy stressors

and their impact on personal goals.


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Exercise:Learn More About Recovery

nLearn rom the National Empowerment Center (NEC)

The National Empowerment Centers web site has stories and articles written by people who haveexperienced mental illnesses. The articles give you a glimpse o what it is like to receive mental healthservices and include accounts o personal journeys to recovery.

Group Discussion: Download two articles or stories rom www.power2u.org. Review and discussthe stories as a group.

nRead more about recovery

Much o the inormation on recovery in this module comes rom a Substance Abuse and Mental HealthServices Administration (SAMHSA) report calledA Review of Recovery Literature by Dr. Ruth O. Ralph(2000). This report is available rom the SAMHSA web site www.samhsa.gov.

Group Discussion: Download this report (about 30 pages). Review and discuss it as a group.
http://www.power2u.org/http://www.samhsa.gov/http://www.samhsa.gov/http://www.power2u.org/


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Motivational, Educational, and Cognitive-Behavioral Strategies 15 Module 4

Module 4

Motivational, Educational, andCognitive-Behavioral Strategies


Pr

illness management

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