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CEP Workshop Series 2013

Module 7:Integrated Care

Fraser Todd and Michelle Fowler
Workshop Introduction
Workshop Agenda
Mihi and Introductions
Workshop overview
Review of last workshops action planning exercise
Introductory Mindfulness Exercise
Overview of Integrated Care
Specific Transdiagnostic Factors
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!
running an efficient system
The Spirit of Te Ariari
Systems Integration:
running an efficient and coherent service
Treatment Integration:
The Spirit of Te Ariari
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 &
Multiple paradigms
Screening & Assessment
Multiple sources
Multiple domains
Opinion &
Case Formulation
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
negauve urgency
negauve emouonallLy
;&7'.+<# /'0 /=#'+&'/* 1./%
Lmouon regulauon
AvoldanL coplng sLyle
Key Transdiagnostic Factors
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)
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
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
Key Transdiagnostic Factors
8umlnauon ulary - A8C's
(1rlggers, conLenL, lmpacL on mood)
8umlnauon Scale
Exercise 2a: Rumination and Perfectionism Scales
Culckly compleLe Lhe 8umlnauon Scale for yourself
Key Transdiagnostic Factors
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
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
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
behavlours & self-
meeLs sLandards
Avolds Lrylng Lo
meeL sLandards
lalls Lo meeL
lnexlble sLandards
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:
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'
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
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
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:
CosL >
1hlngs LhaL
1hlngs LhaL
Useful Websites self-directed or therapist
Mood Gym:
Get Self Help:
Useful Websites self-directed or therapist
Therapist Aid:
Useful Websites self-directed or therapist
Useful Websites self-directed or therapist
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
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
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
- 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
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
Mental Illness
Family tensions
Substance Use
Pathways to Well-being
Pleasure Character
+ve Activities
+ve Relationships
Personal Values and Character Strengths :
A&" B ;3/$/,2#$ C2$#'723%D
1. lalrness
2. klndness
3. CurloslLy
?#$%&'/* E/*)#% FG#$,.%#
1. lamlly
2. Self-accepLance
3. urpose
Pow would you raLe your quallLy of llfe = 3 (nelLher poor nor good
Pow saused are you wlLh your healLh = 2 (ulssaused)
(ouL of 3)
uomaln 1: hyslcal PealLh 36
uomaln 2: sychologlcal 31
uomaln 3: Soclal relauonshlps 44
uomaln 4: LnvlronmenL 30
(ouL of 100) - norms around 70, sd's around 12-13
Vision of Well-being :
H#%2 ?&%%.1*# C#*- 9I J#/$%:
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$/*:
1 osluve aecL low
2 Llfe sausfacuon 0
3 Self-accepLance low
4 Soclal accepLance low
3 ersonal growLh low
6 Soclal acLuallzauon 0
7 urpose and meanlng ln llfe 0
8 Soclal conLrlbuuon 0
9 LnvlronmenLal masLery 0
10 Soclal coherence 0
11 AuLonomy 0
12 osluve relauons wlLh oLhers low
13 Soclal lnLegrauon 0
From Formulation to Treatment Planning
Step 1: Rachels Opinion Diagnoses, Problems and Strengths:
Ma[or uepresslve ulsorder
osL-Lraumauc sLress dlsorder
Alcohol dependence wlLh physlologlcal dependence
Cannabls dependence wlLh physlologlcal dependence
nlcoune dependence wlLh physlologlcal dependence
?$&1*#(% /'0 C2$#'723%
negauve rumlnauons
Pyper-arousal and lnLruslve memorles from rape
AvoldanL coplng sLyle
SLressful relauonshlp wlLh parLner
SLress of carlng for young chlld
Lack of asseruveness ln relauonshlps (dependenL LralLs)
From Formulation to Treatment Planning
Step 1: Rachels 4x4 Grid:
See age 10 of Workbook
Standard Treatments:
SS8l, 8lsperldone aL nlghL for 1Su, conslder nalLrexone for alcohol
?%5,3&*&7.,/* N'2#$<#'+&'%
Coplng skllls lncludlng mlndfulness, dlsLress Lolerance
8elapse prevenuon
lmaglnal denslusauon
lamlly educauon and supporL
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
3. sychologlcal
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
ulagnoses &
recovery &
key sychologlcal lnLervenuons:
ueclLs (dlsorders, problems
Well-belng, recovery and sLrengLhs
From Formulation to Treatment Planning
Step 4: Treatment Planning - Psychological Interventions:
MaLch psychologlcal lnLervenuons Lo sLages of LreaLmenL
Acuve 1reaLmenL
8elapse prevenuon
lnLegraLe key sLraLegles lnLo follow-up/Lherapy sesslons
Motivational Framework for Session Structuring:
1ake opporLunlues Lo reecL
& summarlse
Change Lalk
Well-belng Lalk
3b 4
8elnforce commlLmenL Lalk SeL Agenda
SplrlL of mouvauonal lnLervlewlng
In the next episode
Management Structure
Structured Follow-up Session Planning Template: