CEP Workshop Series 2013 Module 7:Integrated Care Fraser Todd and Michelle Fowler 2013 Workshop Introduction Workshop Agenda Mihi and introductions Housekeeping exercise Introductory Mindfulness exercise overview of the Case of Rachel - Integrated Care Exercise 1: Mindfulness Introduction Integrated care Key Concepts in Intagrated Care: A response Lo healLh care fragmenLauon many dlnerenL approaches verucal and horlzonLal lnLegrauon Some models sLrong
Original Description:
Original Title
7. Integrated Care and CEP Workshop 2013 (NXPowerLite)
CEP Workshop Series 2013 Module 7:Integrated Care Fraser Todd and Michelle Fowler 2013 Workshop Introduction Workshop Agenda Mihi and introductions Housekeeping exercise Introductory Mindfulness exercise overview of the Case of Rachel - Integrated Care Exercise 1: Mindfulness Introduction Integrated care Key Concepts in Intagrated Care: A response Lo healLh care fragmenLauon many dlnerenL approaches verucal and horlzonLal lnLegrauon Some models sLrong
CEP Workshop Series 2013 Module 7:Integrated Care Fraser Todd and Michelle Fowler 2013 Workshop Introduction Workshop Agenda Mihi and introductions Housekeeping exercise Introductory Mindfulness exercise overview of the Case of Rachel - Integrated Care Exercise 1: Mindfulness Introduction Integrated care Key Concepts in Intagrated Care: A response Lo healLh care fragmenLauon many dlnerenL approaches verucal and horlzonLal lnLegrauon Some models sLrong
Fraser Todd and Michelle Fowler 2013 Workshop Introduction Workshop Agenda Mihi and Introductions Housekeeping Workshop overview Review of last workshops action planning exercise Introductory Mindfulness Exercise Overview of Integrated Care Specific Transdiagnostic Factors Collaboration Review of the Case of Rachel Integrated Care Exercise 1: Mindfulness Introduction Integrated Care Integrated Care Key Concepts in Intagrated Care: A response Lo healLh care fragmenLauon Many dlerenL approaches verucal and horlzonLal lnLegrauon Some models sLrongly person-cenLred. ... 8uL noL many! Mental Health Corrections AOD Physical Health Education running an efficient system Financial Workforce Policies/Procedures The Spirit of Te Ariari Systems Integration: Servlce MP hyslcal sychosoclal ACu running an efficient and coherent service Treatment Integration: The Spirit of Te Ariari SocleLy CommunlLy lamlly erson enhancing wellbeing of people and their and families Integrated Care: The Spirit of Te Ariari Integrated Care Dual Diagnosis Treatment Integration: Mlnko's rlnclples of lnLegraLed uual ulagnosls 1reaLmenL 1. uual dlagnosls ls Lhe rule noL Lhe excepuon 2. lndlvlduals wlLh dual dlagnosls dler - lour CuadranLs Model 3. LmpaLhlc hopeful, lnLegraLed LreaLmenL relauonshlps 4. Case managemenL balanced wlLh empaLhlc deLachmenL, conLracung, consequences and conungenL learnlng 3. MenLal healLh and alcohol and drug problems should boLh be consldered prlmary 6. hllosophlcal framework of dlsease and recovery models wlLh parallel phases of recovery 7. lnLervenuons musL be lndlvlduallsed accordlng Lo: CuadranL, dlagnosls, level of funcuonlng, exLernal consLralnLs, phases of recovery/sLages of change, level of care 8. Cllnlcal ouLcomes musL be lndlvlduallsed MosL 'dual dlagnosls' approaches focus on Lhe merglng of sLandard subsLance use and menLal healLh 1reaLmenLs wlLhln a slngle Leam or across Leams LhaL collaboraLe closely WlLh Lhls approach fragmenLauon wlll remaln especlally wlLh Leams LhaL don'L collaboraLe closely or wlLh Agencles ouLslde addlcuon and menLal healLh servlces. Integrated Care The Effectiveness of Treatment Integration: 1reaLmenL lnLegrauon wldely clLed as evldence-based pracuce Powever, evldence ls very weak Chow eL al meLa-analysls of LreaLmenL lnLegrauon sLudles CL wlLh alcohol = small eecL slze CL wlLh drug use = no beneL from resldenual care = small eecL slze for ouLpauenL care prevlous revlew arucles no sLudles show lmprovemenLs ln boLh ACu and MP condluons Integrated Care Person-centred Integrated Care: 1. SLarL wlLh Lhe "#$%&': Crganlze care around Lhe needs of Lhe lndlvldual/famlly/whanau ldenufy core values, sLrengLhs, personal denluon of well-belng 2. CbLaln ()*+"*# %&)$,#% &- .'-&$(/+&' from ()*+"*# *.-# 0&(/.'% Lo. 3. ldenufy 1/$$.#$% Lo well-belng and "/234/5% Lo 4#**61#.'7 and. 4. Conslder '&(&23#+, (dlagnosuc)8 .0.&7$/"3., (lndlvlduallzed) & /#+&*&7.,/* perspecuves 3. lnLegraLe Lhe above lnformauon wlLh an /#+&*&7.,/* 9,/)%/*: -&$()*/+&' 6. negouaLe managemenL 7&/*% /'0 "*/' based on Lhe oplnlon, across "3/%#% &- 2$#/2(#'2 7. use personal values and vlslon of well-belng Lo engage and mouvaLe 8. lnLegraLe LreaLmenLs uslng a ()*+0.%,."*.'/$5 2#/( 9. Where Lhe Leams capaclLy ls exceeded, lnLegraLe Lhrough eecuve ,&**/1&$/+&' Timelines & Ecograms Multiple paradigms Screening & Assessment Multiple sources Multiple domains Opinion & *Multidimensional Case Formulation MDT *Collaboration Multiple perspectives Multiple skills *Wellbeing Perspective Integrated Care Points of Integration: Key Transdiagnostic Factors Brief Psychological Interventions Psychological Transdiagnostic Factors: Self-esLeem and self-emcacy Auenuon conLrol lmpulslvlLy negauve urgency negauve emouonallLy ;&7'.+<# /'0 /=#'+&'/* 1./% Lmouon regulauon >)(.'/+&' ?#$-#,+&'.%( AvoldanL coplng sLyle lnsomnla Key Transdiagnostic Factors Rumination: uenluon: asslve, repeuuve LhoughLs 8elauvely unconLrolled and maladapuve locused on negauve conLenL and sympLoms of dlsLress As opposed Lo: o Worry (problem solvlng, buL ouLcome uncerLaln or poLenually negauve o Self-reecuon (adapuve) o roblem-solvlng (adapuve) Causes: Auenuonal conLrol problems ulscrepancy beLween acLual sLaLe and deslred sLaLe 8elnforced by poor coplng skllls and problem solvlng skllls AbsLracL Lhlnklng raLher Lhan concreLe Lhlnklng Why raLher Lhan whaL ConcreLe Lhlnklng focuses on whaL and how - supporLs problems solvlng Key Transdiagnostic Factors Rumination: Consequences: A ma[or facLor ln Lhe aeuology of depresslon when rumlnaung on negauve cognluons MedlaLes neurouclsm on depresslon lncreased rlsk of depresslon, soclal anxleLy, CAu, CCu, bullmla, subsLance use, aggresslon when uslng alcohol lemales rumlnaLe more Lhan males 8umlnauon explalns much of Lhe assoclauon MedlaLes role of perfecuonlsm ln depresslon Lxplalns much of anxleLy ln depresslon uepresslon AnxleLy >)(.'/+&' Key Transdiagnostic Factors Rumination: AssessmenL: 8umlnauon ulary - A8C's (1rlggers, conLenL, lmpacL on mood) 8umlnauon Scale 1reaLmenL. Exercise 2a: Rumination and Perfectionism Scales Culckly compleLe Lhe 8umlnauon Scale for yourself Key Transdiagnostic Factors Rumination: 1reaLmenL: SLop lL! does noL work ulscrlmlnaLe beLween helpful and unhelpful repeuuve LhoughLs normallse - we all do lL" 1houghL sLopplng and dlsLracuon - Lemporary Lemng go of Lhe goals and deslres may reduce rumlnauon locus on changlng Lhe "$&,#%% of Lhlnklng raLher Lhan Lhe conLenL lmprove auenuonal conLrol (Cognluve 8las Modlcauon), mlndfulness ConcreLeness Lralnlng o locus on Lhe deLalls ln Lhe momenL o nouce speclc and dlsuncuve deLalls of Lhe conLexL of Lhe evenL o noLe 3&4 evenLs unfolded e.g. lmaglne lL as a movle o roblem solvlng skllls Mlndfulness n8 Lhe key Lo rumlnauon ls Lhe focus on absLracL processes and Lherefore Lhe fallure Lo solve Lhe problem (dlscrepancy beLween acLual and deslred sLaLe) drlvlng Lhe rumlnauon. Key Transdiagnostic Factors Perfectionism: A conunual sLrlvlng Lo achleve demandlng sLandards LhaL are self-lmposed and relenLlessly pursued May be adapuve Maladapuve when: o Self crluclsm for sLandards noL belng meL o Self-worLh based on meeung hlgh sLandards o Conunued sLrlvlng Lowards sLandards desplLe negauve eecLs Mulu-dlmenslonal consLrucL: o Concern over mlsLakes o arenLal expecLauons & arenLal crluclsm o ersonal sLandards o Crganlsauon Key Transdiagnostic Factors Perfectionism - Causes: Muluple causes and malnLalnlng facLors erfecuonlsm oen rewarded o Soclally condoned o Clves sLrucLure Lo Lhe day o Clves a sense of conLrol o Leads Lo achlevemenL o Allows avoldance of feared slLuauons o Allows avoldance of dlscoverlng feared aspecLs of Lhe self Transdiagnositic Factors Perfectionism maintaining factors: Self-worLh dependenL on sLrlvlng for achlevemenL CounLer-producuve behavlours & self- crluclsm 1emporarlly meeLs sLandards Avolds Lrylng Lo meeL sLandards lalls Lo meeL sLandards lnexlble sLandards erformance- relaLed behavlour Cognluve blases 8eappralse sLandards as lnsumclenLly demandlng Key Transdiagnostic Factors Perfectionism - Consequences: LlevaLed ln & conLrlbuLes Lo Lhe aeuology and malnLenance of muluple condluons: o uepresslon - perfecuonlsm scores elevaLed, especlally self-orlenLed perfecuonlsm o anlc, = lncreased CM, S and soclally prescrlbed perfecuonlsm o Soclal anxleLy = lncreased CM and soclally prescrlbed perfecuonlsm o CCu = lncreased uA scores - uA used as a measure of CCu severlLy by may o Laung dlsorders o SLrongly assoclaLed wlLh sulcldal ldeauon and behavlour (soclally prescrlbed perfecuonlsm especlally erfecuonlsm also leads Lo a range of unhelpful behavlours: Avoldance rocrasunauon erformance checklng CounLerproducuve behavlours - e.g. llsL maklng or llng paper ln order Lo enhance Lo ensure hlgh performance may become excess and ume consumlng, acLually lmpedlng performance. lf perfecuonlsm ls presenL and noL addressed, ouLcomes for Lhese dlsorders are poorer Key Transdiagnostic Factors Perfectionism - Treatment: ldenufy perfecuonlsuc LhoughLs (screenlng, LhoughL dlary) ldenufy maladapuve LhoughLs = cognluve resLrucLurlng o 'people wlll noL llke me lf l am noL perfecL' o 'l am lnadequaLe, whaLever l achleve ls noL good enough' sycho-educauon SeL reallsuc goals AccepL 'good enough' Challenge all or noLhlng/black and whlLe Lhlnklng WaLch for lndeclslon and procrasunauon Exercise 2: Rumination and Perfectionism Scales Key Transdiagnostic Factors Cognitive and Attentional Bias: Auenuonal blas 1he Lendency for cerLaln Lypes of lnformauon Lo capLure auenuon o AnxleLy - lncreased focus on LhreaL and anger o uepresslon - lncreased focus on negauve sumull - e.g. sad faces o SubsLance use dlsorders - cues and Lrlggers for subsLance use o Soclal anxleLy - focus on soclal lnLeracuons Auenuon 1ralnlng Cognluve 8las Many Lypes Some closely relaLed Lo auenuonal blas lnuence Lhe lnferences people make e.g. aurlbuuon errors, bellef blas lncludes cognluve dlsLoruons and maladapuve core bellefs Cognluve 8las Modlcauon o Cen onllne/compuLer based o 8eLralns cognluve and auenuonal blases o Plghly promlslng lnLervenuons Key Transdiagnostic Factors Anger and Hostility: 1. Plgh levels of anger and hosullLy slgnlcanLly lmpede engagemenL 2. Lssenual Lo address assoclaLed MenLal PealLh problems 3. Conslder problems commonly underplnnlng anger conLrol problems lallure Lo recognlse physlologlcal slgns of anger negauve urgency oor execuuve conLrol Cognluve mlsaurlbuuons e.g. mlsLrusL Low self-esLeem, proLecuon from humlllauon 8umlnauon Avoldance of Lrlggers oor coplng skllls Key Transdiagnostic Factors Anger and Hostility Common Maladaptive Thoughts: 1houghLs and Lmouons Commonly AssoclaLed wlLh Anger: o 1hreaL o lnvalldauon o ln[usuce o Crluclsm o Pumlllauon o lmporLanL rules vlolaLed Maladapuve 1houghL rocesses Commonly AssoclaLed wlLh Anger: o All or noLhlng Lhlnklng o !umplng Lo concluslons o 'Should' sLaLemenLs o 8lamlng o Labellng o Cver-generallzauon o Cognluve blas - 'seelng Lhe bad Lhlngs ln a slLuauon' o Magnlcauon o Lmouonal reasonlng - 'l feel angry, you musL have wronged me' Key Transdiagnostic Factors Anger and Hostility: ldenufy key Lrlggers and conLexLs lan sLraLegles Lo cope wlLh anger ln Lhese slLuauons o lmplemenLauon lnLenuons 8ecognlse physlologlcal sympLoms of anger - body scan mlndfulness 'CaLch" Lhe lmpulse Lo acL - mlndfulness uefuslon C81 - lndenufy and challenge maladapuve LhoughLs o anger dlary, cognluve resLrucLurlng Coplngs skllls 1each skllls Lo deal wlLh rumlnauon and poor problem-solvlng Address avoldanL coplng (mlndfulness) Key Transdiagnostic Factors Anger and Hostility: 1rlgger 1houghL 8ehavlour leellng @'7#$ roblem: CosL > 8eneL 1hlngs LhaL ! Anger 1hlngs LhaL " Anger Useful Websites self-directed or therapist Mood Gym: hups://moodgym.anu.edu.au/moodgym Get Self Help: hup://www.geLselmelp.co.uk/selmelpasslsL.hLm Useful Websites self-directed or therapist Therapist Aid: hup://www.LheraplsLald.com Useful Websites self-directed or therapist CCI: hup://www.ccl.healLh.wa.gov.au/resources/consumers.cfm Useful Websites self-directed or therapist Collaboration Collaboration Six Principles of Effective Collaboration: 1. 8ecognlse and accepL Lhe need for parLnershlp 2. uevelop clarlLy and reallsm of purpose 3. Lnsure commlLmenL and ownershlp 4. uevelop and malnLaln LrusL 3. CreaLe clear and robusL parLnershlp arrangemenLs 6. MonlLor, measure and learn Collaboration Emotionally Intelligent Teams: - Comprlsed of emouonally lnLelllgenL Leam members - key aurlbuLes o Self-awareness o Self-managemenL o Soclal awareness o 8elauonshlp managemenL - CoverL norms made overL o SubLle, oen unsLaLed bellefs, hablLs and behavlours of a Leam LhaL subLly buL powerfully lnuence lLs behavlour Collaboration Barriers to Collaboration: SLakeholders unwllllng Lo work LogeLher - Compeuuve culLure or splrlL - arochlal amLudes - ulerlng values and culLures - ersonal reslsLance Lo change - Lack of shared agenda Collaboration Resistance: - laclng personal needs ahead of Lhose of LangaLa whalora - lear of loss of power and lnuence - Peavy lnvesLmenL ln currenL goals and pro[ecLs - ldenuLy bound ln currenL posluon - !ourney Loo hard - uesunauon worse Lhan currenL posluon - ower ln reslsung change - MlsLrusL ln Lhose asklng for change - e[orauve amLudes beLween Leams and servlce Collaboration Strategies to Enhance Collaboration: - Make shared goals and values expllclL- e.g. person-cenLredness! - Allow ume for Lhe developmenL of personal relauonshlps - LxpllclL supporL from key people ln each servlce or agency - CClnS Exercise 3: Collaboration Review: Rachel Integrated Care Rachel - Integrated Care Person-centred Integrated Care: 1. SLarL wlLh Lhe "#$%&': Crganlze care around Lhe needs of Lhe lndlvldual/famlly/whanau ldenufy core values, sLrengLhs, personal denluon of well-belng 2. CbLaln ()*+"*# %&)$,#% &- .'-&$(/+&' from ()*+"*# *.-# 0&(/.'% Lo. 3. ldenufy 1/$$.#$% Lo well-belng and "/234/5% Lo 4#**61#.'7 and. 4. Conslder '&(&23#+, (dlagnosuc)8 .0.&7$/"3., (lndlvlduallzed) & /#+&*&7.,/* perspecuves 3. lnLegraLe Lhe above lnformauon wlLh an /#+&*&7.,/* 9,/)%/*: -&$()*/+&' 6. negouaLe managemenL 7&/*% /'0 "*/' based on Lhe oplnlon, across "3/%#% &- 2$#/2(#'2 7. use personal values and vlslon of well-belng Lo engage and mouvaLe 8. lnLegraLe LreaLmenLs uslng a ()*+0.%,."*.'/$5 2#/( 9. Where Lhe Leams capaclLy ls exceeded, lnLegraLe Lhrough eecuve ,&**/1&$/+&' From Formulation to Treatment Planning Step 3: Goal Planning: Barriers to Well-being Finances Accommodation Unemployment Mental Illness Family tensions etc Relationships Substance Use Pathways to Well-being Pleasure Character Strengths +ve Activities Enabling Institutions +ve Relationships Optimism etc Rachel Personal Values and Character Strengths : A&" B ;3/$/,2#$ C2$#'723%D 1. lalrness 2. klndness 3. CurloslLy ?#$%&'/* E/*)#% FG#$,.%# 1. lamlly 2. Self-accepLance 3. urpose Rachel WHOQOL-BREF : Pow would you raLe your quallLy of llfe = 3 (nelLher poor nor good Pow saused are you wlLh your healLh = 2 (ulssaused) (ouL of 3) uomaln 1: hyslcal PealLh 36 uomaln 2: sychologlcal 31 uomaln 3: Soclal relauonshlps 44 uomaln 4: LnvlronmenL 30 (ouL of 100) - norms around 70, sd's around 12-13 Rachel Vision of Well-being : H#%2 ?&%%.1*# C#*- 9I J#/$%: Close relauonshlp wlLh her daughLer, avallable as a supporuve lovlng moLher Pave a happy supporuve lovlng famlly leellng relaxed and generally overall wlLhln myself Mood sLable, good sleep, healLhy llfesLyle Worklng ln a [ob LhaL was sausfylng and had purpose Smokefree, cannabls free, Lo be drlnklng less and ln conLrol of Lhls llnanclally sLable SLable relauonshlp wlLh a lovlng, supporuve and communlcauve parLner ComforLable ln soclal slLuauons Pobbles LhaL l en[oy Supporuve frlends Rachel Flourishing or Languishing? Flourishing or Languishing? : ;$.2#$.&' 3.738 *&4 &$ K 9'#)2$/*: 1 osluve aecL low 2 Llfe sausfacuon 0 3 Self-accepLance low 4 Soclal accepLance low 3 ersonal growLh low 6 Soclal acLuallzauon 0 7 urpose and meanlng ln llfe 0 8 Soclal conLrlbuuon 0 9 LnvlronmenLal masLery 0 10 Soclal coherence 0 11 AuLonomy 0 12 osluve relauons wlLh oLhers low 13 Soclal lnLegrauon 0 From Formulation to Treatment Planning Step 1: Rachels Opinion Diagnoses, Problems and Strengths: @G.%L Ma[or uepresslve ulsorder osL-Lraumauc sLress dlsorder Alcohol dependence wlLh physlologlcal dependence Cannabls dependence wlLh physlologlcal dependence nlcoune dependence wlLh physlologlcal dependence ?$&1*#(% /'0 C2$#'723% negauve rumlnauons Pyper-arousal and lnLruslve memorles from rape lmpulslvlLy AvoldanL coplng sLyle SLressful relauonshlp wlLh parLner SLress of carlng for young chlld Lack of asseruveness ln relauonshlps (dependenL LralLs) From Formulation to Treatment Planning Step 1: Rachels 4x4 Grid: See age 10 of Workbook Rachel Standard Treatments: M#0.,/+&' SS8l, 8lsperldone aL nlghL for 1Su, conslder nalLrexone for alcohol ?%5,3&*&7.,/* N'2#$<#'+&'% Coplng skllls lncludlng mlndfulness, dlsLress Lolerance 8elapse prevenuon lmaglnal denslusauon O23#$ lamlly educauon and supporL Rachel Further Interventions for Rachel : racuce AC responses - daughLer, parLner, famlly, frlends Meanlng and urpose ln Llfe -lasL lorward Lxerclse CharacLer SLrengLhs apply your sLrengLh of curloslLy ln a new way, each day for a week 8andom AcLs of klndness each day for a week, Lake Lhe opporLunlLy Lo do someLhlng klnd for anoLher person wlLhouL expecung lL Lo be reclprocaLed Lovlng klndness MedlLauon lorglveness (lncludlng self-forglveness) From Formulation to Treatment Planning Step 4: Treatment Planning: Apply speclc LreaLmenLs Lo each problem 10-olnL sLrucLure for each phase of LreaLmenL: 1. Semng 2. lurLher lnformauon 3. 1reaLmenL of medlcal condluons 4. sychopharmacology 3. sychologlcal lnLervenuons 6. lamlly/Whanau and soclal lnLervenuons 7. SplrlLual lnLervenuons 8. Lducauon of LangaLa whalora and famlly/whanau 9. Soclal needs 10. Self-help groups From Formulation to Treatment Planning Step 4: Treatment Planning: Larly Mlddle LaLe AuLonomy 1. Semng 2. lurLher lnformauon 3. 1reaLmenL of med condluons 4.sychopharmacology 3. sychologlcal 6.lamlly/whanau 7. SplrlLual 8. Lducauon of cllenL and whanau 9. Soclal needs 10. Self-help From Formulation to Treatment Planning Step 4: Treatment Planning - Psychological Interventions: lndlvldual Croup Self-dlrecLed sycho-educauon Mouvauon ulagnoses & problems Well-belng, recovery & sLrengLhs key sychologlcal lnLervenuons: sycho-educauon Mouvauon ueclLs (dlsorders, problems Well-belng, recovery and sLrengLhs lormaLs: lndlvldual Croup Self-dlrecLed From Formulation to Treatment Planning Step 4: Treatment Planning - Psychological Interventions: MaLch psychologlcal lnLervenuons Lo sLages of LreaLmenL LngagemenL ersuaslon Acuve 1reaLmenL 8elapse prevenuon lnLegraLe key sLraLegles lnLo follow-up/Lherapy sesslons Motivational Framework for Session Structuring: 1 1ake opporLunlues Lo reecL & summarlse Change Lalk Well-belng Lalk 3a 2 3b 4 8elnforce commlLmenL Lalk SeL Agenda SplrlL of mouvauonal lnLervlewlng In the next episode Management Structure Structured Follow-up Session Planning Template: