20 WAYS TO OVERCOME
BARRIERS TO RECOVERY
th
(20 Revision)
2012
Prof. Courtenay M. Harding
CourtenayHardingConsulting@gmail
Good Morning!

OVERALL GENERAL INFORMATION
FOR TODAY
 What’s in the folders?
 How to work with this information
 Breaks for lunch, phone &
bathroom
 Ask questions as we go along
 Evaluations and Certificates at end
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CourtenayHardingConsulting@gmail
THE PRESENTATION PLAN
Review 20 obstacles with
strategies to get some
answers or how to better
understand the
complications. Lots of
resources!
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ACKNOWLEDGMENT &
APPRECIATION
TO ALL THE CLINICIANS & FAMILIES
 WHO CARE
 WHO SPEND TIME PROBLEM
SOLVING
 WHO CHALLENGE THE STATUS
QUO
 WHO SPEND TIME GOING THE
EXTRA MILE
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CourtenayHardingConsulting@gmail
MORE STUDIES USING
WIDER DIAGNOSTIC CRITERIA

STUDY
#
Av. Years
%
Year & Place
of Ss
length
improvement
_______________________________________or recovery

HINTERHUBER 157

1973 AUSTRIA

KREDITOR

1977 LITHUANIA

MARINOW

1986 BULGARIA


30
74.8 %
115
20.2
84
%
280
20
75
%
THESE PROJECTS HAVE
STUDIED…..
 2400
plus people
 Across 2-3 decades after first
admission
 In intact samples
 Found surprising confluence of
findings
FINDINGS
o
46-68 % OF EACH COHORT
SIGNIFICANTLY IMPROVED AND/OR
RECOVERED
o
Recovered means:
o
o
o
o
o

No enduring symptoms,
No odd behaviors,
No further medication,
Living in the community,
Working, and relating well to others
Significantly improved –means
•
Recovered in all areas but one
Resources with More
of the Evidence

Harding, C.M.: Changes in schizophrenia across
time: paradoxes, patterns, and predictors. In:
Carl Cohen (ED.) SCHIZOPHRENIA INTO LATER
LIFE: Treatment, Research and Policy. APPI
Press, 2003, pp.19-42 ( a review of all ten studies)

Harding, C.M.; Zubin, J.; Strauss, J.S.; Chronicity
in schizophrenia revisited, BRITISH JOURNAL OF
PSYCHIATRY in Supplement entitled:
“Transactional Processes in Onset and Course of
Schizophrenic Disorders”. 1992, 161 (Suppl. 18):
27-37.
CourtenayHardingConsulting@gmail
More Evidence


Davidson, L, Harding, C.M., & Spaniol, L. (Eds.).
Research on Recovery from Severe Mental
Illness: 30 years of Accumulating Evidence and
Its Implications for Practice. (Vol. 1), Center for
Psychiatric Rehabilitation, Boston University,
2005 & (Vol.2) , 2006
Harding, C.M.: The interaction of
biopsychosocial factors , time, and the course of
schizophrenia: Time is the critical co- variate. In:
C.L. Shriqui & H.A. Nasrallah (Eds.)
Contemporary Issues In The Treatment Of
Schizophrenia. Washington, D.C., APA Press.
1995, pp. 653-681.
CourtenayHardingConsulting@gmail
More resources -3

Harding, C.M.: An examination of the
complexities in the measurement of
recovery in severe psychiatric
disorders. In: R.J. Ancill, S.
Holliday, & G.W. MacEwan (Eds.),
Schizophrenia: Exploring The
Spectrum Of Psychosis. Chichester,
J. Wiley & Sons, 1994, pp. 153-169.
CourtenayHardingConsulting@gmail
Base Papers for
Vermont Study

Harding, C.M.; Brooks, G.W.; Ashikaga, T.; Strauss, J.S.;
Breier, A.: The Vermont longitudinal study of persons with
severe mental illness: I. Methodology, study sample, and
overall status 32 years later. (lead article) AMERICAN
JOURNAL OF PSYCHIATRY, 1987, 144(6): 718-726.

Harding, C.M.; Brooks, G.W.; Ashikaga, T.; Strauss, J.S.;
Breier, A.: The Vermont longitudinal study: II. Long-term
outcome of subjects who retrospectively met DSM-III
criteria for schizophrenia. (lead article) AMERICAN
JOURNAL OF PSYCHIATRY, 1987, 144(6): 727-735.
CourtenayHardingConsulting@gmail
Base Papers for the MaineVermont Comparison Study

DeSisto, M.J.; Harding, C.M.; McCormick, R.V.;
Ashikaga, T.; Gautam, S.: The Maine-Vermont
three decade studies of serious mental illness: I.
Matched comparison of cross-sectional outcome.
BRITISH JOURNAL OF PSYCHIATRY, 1995, 167,
331-338.

DeSisto, M.J.; Harding, C.M.; McCormick, R.J.;
Ashikaga, T.; Brooks, G.W.: The Maine-Vermont
three decade studies of serious mental illness: II.
Longitudinal course comparisons. BRITISH
JOURNAL OF PSYCHIATRY, 1995, 167, 338-342.
CourtenayHardingConsulting@gmail
IF RECOVERY AND SIGNIFICANT
IMPROVEMENT ARE
POSSIBLE……….
 THEN
WHY ARE SO MANY
PARTICIPANTS NOT
GETTING BETTER?

SEVERAL MILLION PEOPLE
LANGUISHING IN US ALONE
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HOWEVER………..

If your participant seems to be
“stuck” on the path to recovery let’s
look at some possible reasons and
ways to change the Individual
Recovery Plan (IRP)……
Please note: these
questions are not just for
physicians to ask but also
for other clinicians, users,
and family members to be
curious and to raise
questions…
CourtenayHardingConsulting@gmail
YOU NEED TO LOOK AT A PERSON
TWICE…… once with your heart and
then with your head……..
FIRST TO SEE THE
SIMILARITIES
AND, ONLY THEN. CAN YOU
APPRECIATE THE
DIFFERENCES
From Dr. Candace Fleming, a Native American psychologist
CourtenayHardingConsulting@gmail
Learning to play a
detective !
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CourtenayHardingConsulting@gmail
Always important to
have some fun!
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LOOKING FOR THE
“PERSON UNDER THE
DISORDER”



COMPREHENSIVE RE-EVALUATION
NEEDED (based on history, careful
interview, lab findings & physical exam)
BIO-PSYCHO-SOCIAL-SPIRITUAL
APPROACH
SYSTEMATIC &
MULTIDISCIPLINARY
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QUESTION #1
HAVE
OTHER
POSSIBLE CAUSES
OF SYMPTOMS AND
BEHAVIORS BEEN
ELIMINATED?
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WHY IS THIS QUESTION
IMPORTANT?
e.g. Schizophrenia is a
diagnosis of exclusion. The
following differential diagnoses
should be eliminated BEFORE
giving the diagnosis of
schizophrenia. Not often done.
Wrong diagnosis = wrong
treatment
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CourtenayHardingConsulting@gmail
DIAGNOSIS OF EXCLUSION
(especially schizophrenia)
 26
other disorders (medical,
neurological, and psychiatric)
that masquerade with
schizophrenia-like
symptoms !
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DIAGNOSIS OF
EXCLUSION
(schizophrenia)
 Autism
(esp. Asperger’s
Syndrome)
 Temporal Lobe Epilepsy
 Tumor
 Stroke
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MORE THINGS TO EXCLUDE
Brain Trauma
 Endocrine & Metabolic Disorders
(e.g. acute intermittent porphyria
(liver enzyme)
 Homocystinuria (a disorder of amino
acid metabolism)

CourtenayHardingConsulting@gmail
MORE THINGS TO EXCLUDE
Vitamin Deficiency (e.g. B 12)
 Central Nervous System Infectious
Processes (e.g. AIDS, neurosyphilis,
or herpes encephalitis)
 Autoimmune Disorders (systemic
lupus erthymatosa)
 Heavy Metal Toxicity (e.g. Wilson’s
Disease – too much copper)

CourtenayHardingConsulting@gmail
EVEN MORE TO EXCLUDE:





Some Drug Induced States (e.g.
amphetamines, barbiturate withdrawal,
cocaine, digitalis, disulfram)
Mood disorders, schizoaffective disorder,
Personality disorders,
Brief Reactive Psychosis,
OCD
CourtenayHardingConsulting@gmail
Differential Diagnoses for Mood D/O
(based on history, careful interview, lab findings
& physical exam)









Multiple Sclerosis
Stroke
Hyper &
Hypothyroidism
Bereavement
Dementia
Cancer (esp. of
Pancreas)
Spinal Cord Injury
Peptic Ulcer
Mononucleosis








Huntington’s Disease
AIDS
End-stage Renal
Disease
Head Injury
Parkinson’s Disease
Lupus
Hyper & Hypo
parathyroidism
Hepatitis
CourtenayHardingConsulting@gmail
ANOTHER HELPFUL
STRATEGY
 Basis-24






“a leading behavioral health assessment”
Comprehensive
Cuts across diagnostic categories
Provides weighted average
Overall score plus 6 subscales
(sub abuse, symptoms and functioning,
relationships, self harm, emotional liability,
psychosis, and depression)
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SOURCE FOR BASIS-24

Developed by Dr. Susan Eisen
 www.basissurvey.org/basis24/
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HOW TO DO BETTER………
 Take
the time get
triangulated information
 Get the lab tests done
 Reassess over time
 Pay attention to comorbid
diagnoses
CourtenayHardingConsulting@gmail
Treat or refer other diagnoses




Establish links and a little black book with other
medical colleagues across the local community
Work with your colleagues in other fields to
understand what happened and how to
understand your participant who may still appear
to them to have only a psychiatric disorder
Networks of partnerships treating person in a
holistic way
Partners include hospital, primary care docs,
mental health and addiction services plus others
such as OB/GYN, eye specialists, hearing tests,
dental care, and legal aid.
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SUGGESTED
INSTRUMENTS
 To clarify a psychiatric
diagnosis
–THE STRUCTURED
CLINICAL INTERVIEW FOR
DSM-IV TR (CLINICAL VERSION)
 SCID
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OR IF PSYCHIATRIC DIAGOSIS IS
RE-ESTABLISHED
All diagnoses are cross-sectional
working hypotheses
 Not lifetime labels
 Not able to predict long-term
outcome
 Must write enough evidence to show
evidence of the diagnosis into the
case record (what is present/absent)

CourtenayHardingConsulting@gmail
REMEMBER TO LOOK FOR &
RECORD STRENGTHS


Strengths of your participant ( e.g.
insight? Manage meds? Manage S/S ?
Uses strategies to recognize oncoming
prodrôme? Uses coping to reduce
anxiety? Computer skills? Has driver’s
license? Etc………..
Working with the strengths rather than
deficits, problems and disabilities – that is
what helps people get better
CourtenayHardingConsulting@gmail
Interesting Resources
to Check out


Harding, C.M.: Re-assessing a person with
schizophrenia and developing a new treatment
plan. In: J.M. Barron (Ed). MAKING DIAGNOSIS
MEANINGFUL: ENHANCING EVALUATION AND
TREATMENT OF PSYCHOLOGICAL DISORDERS.
Washington, D.C. APA Press. 1998, pp. 319-338.
(source for this training changed many times)
CourtenayHardingConsulting@gmail
More Resources

Rosen, A. (2006) The community psychiatrist of
the future. Current Opinion in Psychiatry.
Lippincott Williams and Wilkins .

Ragins, M. Recovery With Severe Mental Illness:
Changing From A Medical Model to A
Psychosocial Rehabilitation Model
http://www.villageisa.org/Ragin%27s%20Papers/recov.%20with%20
severe%20MI.htm
CourtenayHardingConsulting@gmail
BATHROOM AND MOBILE
PHONE BREAK
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QUESTION # 2
 DOES
THIS PERSON
WITH A PSYCHIATRIC
DISORDER HAVE OTHER
MEDICAL PROBLEMS
ABOUT WHICH TO WORRY?
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WHY IS THIS QUESTION
IMPORTANT?
 Even
though a psychiatric
diagnosis may be correct, there
is a good chance that the person
may be experiencing a comorbid condition or two or three.
 If left untreated, he or she may
die unnecessarily early.
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CourtenayHardingConsulting@gmail
OVERVIEW OF
SITUATION





40-60 % with medical co-morbidity
Not recognized nor treated
Participants get “turfed” back to
psychiatry or not referred at all
Need primary care, eye & hearing exams,
OB/GYN etc
Need admission and annual physical by
nurse practitioner, a health history
questionnaire and basic lab tests
CourtenayHardingConsulting@gmail
A Resource (Old but Helpful)





Hosp Community Psychiatry. 1989
Dec;40(12):1270-6.
A medical algorithm for detecting physical
disease in psychiatric patients.
Sox HC Jr, Koran LM, Sox CH, Marton KI, Dugger
F, Smith T.
Source
Department of Medicine, Dartmouth-Hitchcock
Medical Center, Hanover, New Hampshire, USA
CourtenayHardingConsulting@gmail
LABORATORY TESTS
TO CONSIDER





BIOCHEM
TOX SCREEN
COMPLETE
BLOOD COUNT
URINALYSIS
THYROID PANEL
B-12
 FOLATE
 VDRL (for
syphilis)
 HIV
_______________
 CT or
 MRI (if
indicated)

CourtenayHardingConsulting@gmail
Other than the step-down MRI or
CT Scans, these tests cost less
than $100 ! Since many people
are entering the system of care
through community mental health
and not hospital stays, these tests
might be ordered as part of
admission to help with the
differential diagnostic process.
CourtenayHardingConsulting@gmail
Some Suggested Strategies
Collaboration and linkages
 Have a case manager (or other
person who knows person well) go
armed with information and written
questions and take notes with user
to another physician
 Rescheduling missed appointments
 Get outside prescriptions into record

CourtenayHardingConsulting@gmail
More Suggested Strategies



Offer preventive
programs: e.g.
Weight Watchers,
Jazzercise, other
exercise programs
Walking
Nutrition, cooking
and grocery
shopping skills


Meditation & other
relaxation
techniques
Other Health and
Wellness
Education Classes
on blood
pressure, weight,
and diabetes
monitoring.
CourtenayHardingConsulting@gmail
PAYING ATTENTION
GETS ………
 Finding
strengths in self
care management
 Healthier people
 Reduced mortality rates
 Avoids confounding
diagnosis
 And contraindicated
medications
CourtenayHardingConsulting@gmail
Resource to check out

Danson,D.,Jones, R, Macias, C.,
Barreira,P. J. , Fisher, W.H., Hargreaves,
W. A. & Harding, C.M. Prevalence,
severity, and co-occurrence of chronic
physical health problems of people with
serious mental illness. PSYCHIATRIC
SERVICES, 2004, 55: 1250-1257.
CourtenayHardingConsulting@gmail
QUESTION #3
Is
there an
additional
neurological
impairment?
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WHY IS THIS QUESTION
IMPORTANT?
There are groups of young men who
are withdrawn and sit quietly and are
mostly ignored because they cause
no trouble.
 If they qualify for the Deficit
Syndrome then they might do better
if they have a medication change,
cognitive remediation, and active
rehabilitation
CourtenayHardingConsulting@gmail

CourtenayHardingConsulting@gmail
THE DEFICIT
SYNDRÔME




+/- S/S of Schizophrenia Come and Go
(esp. + symptoms)
Attempts to find primary, enduring stable
negative symptoms
Subtype or Additional D/O
Neurological Impairments ( sensory
integration, stereognosis, graphesthesia,
right-left confusion, the face-hand test, &
audiovisual integration)
CourtenayHardingConsulting@gmail
THE DEFICIT
SYNDRÔME - 2




Poor premorbid social functioning
Reduced glucose uptake in the frontal
cortex, parietal & thalamic areas on PET
scans
Increased anhedonia and fewer psychotic
events
Earlier onset, seems to be unremitting,
suffer spontaneous movement d/o, severe
cognitive impairments
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THE DEFICIT SYNDRÔME - 3

Deficit PARTICIPANTs in comparison to
NonDeficit PARTICIPANTs show:
 Equal positive symptoms (hallucinations,
delusions, and formal thought d/o)
 Less severe dysphoric symptoms (e.g.
depressive mood, anxiety, guilt, & hostility)
 Less severity of suspiciousness
 Similar duration of illness
 Brain architecture seems to be more intact in
some areas
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THE DEFICIT
SYNDRÔME - 4




Need longitudinal information
Use SDS or PDS Criteria
Exclude: drug effect & demoralization
Need 2 of the following for more than a
year:





restricted affect,
diminished emotional range,
poverty of speech,
curbing of interests,
diminished sense of purpose and social drive
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THE DEFICIT
SYNDRÔME - 5
 USE
SCREENING TOOL: THE
Neurological Evaluation Scale
(NES)
 TRY:
 Atypical Neuroleptics
 Cognitive Remediation
 Other Aggressive Rehab
CourtenayHardingConsulting@gmail
Some Resources:
Brian Kirkpatrick et al, 1989, (SDS The Schedule for the Deficit
Syndrome), 1993, 2001
 PDS : Proxy for Deficit Syndrome
Kirkpatrick 1996 (core deficit + no
dysphoria)
 Robert W. Buchanan et al, 1990,
1993,1994, 1996

CourtenayHardingConsulting@gmail
Another Interesting
Resource

Strauss, J.S.; Rakfeldt, J.H.; Harding,
C.M.; Lieberman, P.: Psychological and
social aspects of negative symptoms.
BRITISH JOURNAL OF
PSYCHIATRY, 1989, 155 (Suppl. 7):
128-132.
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QUESTION #4
WHO
IS THIS
PERSON
UNDER A COAT
OF ILLNESS?
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WHY IS THIS QUESTION
IMPORTANT?
 Once
a person has been
labeled, he or she is often
hidden from view. Finding
and working with the real
person underneath is the key
to recovery.
CourtenayHardingConsulting@gmail
CourtenayHardingConsulting@gmail
ASSESSMENT OF ADULT
DEVELOPMENT





PSYCHIATRIC PROBLEMS DISRUPT A LIFE
NEED TO GRIEVE FOR LOSS OF TIME AND
OPPORTUNITIES
THE “REHABILITATION CRISIS” (McCRORY,
1982) which describes how clinicians can get in
the way of recovery process inadvertently
ASSESSMENT OF PREMORBID LEVELS OF
FUNCTIONING (peer relations, school
performance and dating etc)
Use LIFELINE (Harding, 2011)to get to know the
person and his or her patterns better
CourtenayHardingConsulting@gmail
What to do when people
deny they have an illness?





Can get better without any insight or
admission that they have a diagnosis
Usually aware that something is holding
them back from getting a life they want
If want to recapture their dreams and
accept some kind of help from others or
Focus on what the person thinks is
distressing or getting in the way of dream
Listening and engaging
– L. Davidson,
2012
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What If A Person Has No Goals?
L. Davidson & P. Ridgway






Is person demoralized and lost hope?
Is person socialized into learned helplessness?
Has person become risk aversive?
Does person have co-occurring depression?
Have you earned person’s trust?
Are there disabling symptoms and environmental
responses interfering with relationships and
participation?
CourtenayHardingConsulting@gmail
New Resource Questionnaire to get a handle
on what a person wants and needs to get
better



REFOCUS- Promoting recovery in
community mental health services
(Rethink recovery series: vol. 4) Bird, V. et al,
Institute of Psychiatry, Kings College London
Relationships, understanding values and
treatment preferences, assessing strengths, and
supporting goal-striving
Checklists, worksheets, strengths assessment
CourtenayHardingConsulting@gmail
Some resources to get to
know people better

www.researchintorecovery.com/refocus and
rethink.org/refocus

Harding, C.M. The Lifeline, 2011
CourtenayHardingConsulting@gmail.com
Davidson, L & Ridgway, P. What if a person has
no goals?
(dmh.mo.gov/docs/mentalillness/personwithnogo
als.pdf)
McCrory, D. (1980) The rehabilitation crisis: The
impact of growth. Journal of Applied
Rehabilitation Counseling, 11(3):136-139.


CourtenayHardingConsulting@gmail
Narrative Therapy
 Beels,
C. Christian (2001) A
Different Story: The Rise of
Narrative in Psychotherapy.
Phoenix Arizona. Zeig, Tucker &
Theisen, Inc.

CourtenayHardingConsulting@gmail
Question #5
WHAT
OTHER
THINGS HELP OR
HINDER
PROGRESS?
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WHY IS THIS QUESTION
IMPORTANT?



Often a person loses their psychiatric
symptoms but the clinician does not
understand that it has happened.
This is because the person may continue
to get in his or her own way because of
quirks in their personality or despair
It is important to separate out the signal
from the noise.
CourtenayHardingConsulting@gmail
CourtenayHardingConsulting@gmail
ASSESSMENT OF
CHARACTERLOGICAL
TRAITS





Can get in the way or aid progress
How did the person respond to crises
before mental illness?
Is the schizophrenia gone but not the
personality quirk, Axis II, or despair
Criteria under reconsideration for DSM 5
Look for evidence of problem-solving, a
sense of humor, a philosophical approach,
optimism, persistence and strengths in
functioning and resilience to build upon
CourtenayHardingConsulting@gmail
Consider rewarding positive behaviors
and not focusing on learned poor ones
Clinicians seem to pay attention to painin-the-neck behaviors and miss the
opportunity to reinforce healthy ones.
 Praise small congenial behaviors such as:
saying “Good morning”, or shaking
hands, or looking you in the eye, or
noticing when a hand is needed, etc. etc.

CourtenayHardingConsulting@gmail
Assessment of other things that get in
the way of recovery process



Need to assess
socialization into
participant (user,
consumer) role
Medication side
effects
Not provided with
educational or
work opportunities




Lack of other
rehabilitation
Extreme virulence
of illness (only
10%)
Lack of staff
expectations (very
important)
Loss of hope
CourtenayHardingConsulting@gmail
Resources



Benedict Carey : Thinking clearly about
personality disorders, New York Times
http://www.nytimes.com/2012/11/27/health/
clearing-the-fog-around-personalitydisorders
Ted Millon: Personality Disorders in
Modern Life, 2nd ed. (2004)
www.pearsonassessments.com/mmpi2.as
px
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QUESTION #6
ARE
THERE SPECIFIC
NEUROCOGNITIVE
DEFICITS BEING COPED
WITH BY THIS
PERSON?
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WHY IS THIS QUESTION
IMPORTANT?

Since we have been saying that this
is a “brain disease” for a couple of
decades, wouldn’t it be appropriate
for us to at least take a flash
neuropsychological picture of how
the brain is operating and depending
on what is found try to help
reprogram the wiring a little bit?
CourtenayHardingConsulting@gmail
SCHIZOPHRENIA &
NEUROCOGNITIVE DEFICITS







Attention
Vigilance
Executive functioning (reasoning,
judgment, problem-solving, anticipation,
planning, decision-making)
Learning
Memory
Ability to read affect on faces
Find cognitive strengths
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MUTLIMODAL APPROACH
 Tests
of laterality- prefrontal,
frontal, parietal, temporal
functioning
 Semantic, episodic & working
memory
 Expressive & receptive language
 Constructional skills
CourtenayHardingConsulting@gmail
MATRICS Consensus
Neurocognitive Battery (MCCB)





An NIMH initiative
Used “a broad-based
interdisciplinary
consensus process”
Originally designed
for pharmacological
research
Outcome measure for
cognitive remediation
Repeated measures of
cognitive change
•
•
•
•
•
And as a cognitive
reference point for
non-intervention
studies
Translated into 16
languages to date
Very short battery
better tolerated
Well known
neuropsych tests
www.matricsinc.org
CourtenayHardingConsulting@gmail
Components of MCCB




10 tests measuring
seven cognitive
domains
1)Processing
Speed
2) Attention/
vigilance
3) Working
Memory





4)Verbal Memory
5) Visual Learning
6) Reasoning &
Problem Solving
7) Social Cognition
www.matricsassessment@
gmail.com
CourtenayHardingConsulting@gmail
Suggested Cognitive Remediation
Efforts in Community Mental Health

Once a profile of strengths and
problems are documented try using
cognitive remediation computer
techniques! (see Alice Medalia’s
work at Columbia University and
Susan McGurk’s work at Boston
University)
CourtenayHardingConsulting@gmail
MUTLIMODAL APPROACH  GOAL
IS TO: MATCH
REHAB TYPE AND
INTENSITY TO CHANGING
NEEDS
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More Resources

Medalia, A. & Choi, J.(2009). Cognitive
Remediation in Schizophrenia.
Neuropsychology Review, 19:353-364.

McGurk, S.R. et al. (2007). A Meta-Analysis
of Cognitive Remediation in
Schizophrenia. American Journal of
Psychiatry, 164: 1791-1802.
CourtenayHardingConsulting@gmail
SOME MORE RESOURCES:
G.E. Hogarty - Cognitive
Enhancement Therapy – 2002Guilford Press
 G.E. Hogarty & S. Flescher (1999)
 H.D. Brenner et al, Hografe & Huber
Toronto, 1994
 W. Spaulding et al BJP, 1989
 Michael F. Green et al, Scz Res., 2004

CourtenayHardingConsulting@gmail
LUNCH BREAK
for one hour
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QUESTION #7
ARE
THE
MEDICATIONS
REALLY WORTH THE
TRADE-OFF?
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WHY IS THIS QUESTION
IMPORTANT?



For years, the field has accepted the idea
that the only thing that helps are
medications with everything as adjunct.
Data are showing that patients on meds
for a long time are dying 25 years earlier
than age-related cohorts.
We need to reconsider more “medication
optimization” approaches.
CourtenayHardingConsulting@gmail
CourtenayHardingConsulting@gmail
ASSESSMENT OF NEED FOR,
RESPONSE TO, AND SIDE
EFFECTS FROM MEDICATION
TAKE A THOROUGH HISTORY
 GET OLD RECORDS
 TALK TO OTHERS WHO KNOW
PERSON
 COLLABORATE, COLLABORATE,
COLLABORATE, COLLABORATE

CourtenayHardingConsulting@gmail
MORE ON SIDE EFFECTS





20-30 OTHER SIDE EFFECTS e.g.
DYSKINESIAS, DYSTONIAS,
PARKINSONISM
EVEN ATYPICALS CAN HAVE SIDE
EFFECTS – VERY DOSE DEPENDENT
NEED TO SYSTEMATICALLY CHECK
q.6 MOS WITH INSTRUMENTS
TRAIN PARTICIPANTS TO SELFMONITOR
ATTEND TO SEX DIFFERENCES
CourtenayHardingConsulting@gmail
CAUSES OF
MISINTERPRETATION




MUST LISTEN TO THE WAY MEDS MAKE
PEOPLE FEEL FROM THE INSIDE OUT
SOMETIMES CLIENTS CAN’T DESCRIBE
SUBTLE FEELINGS
E.g. Side Effect of Akathisia- being compelled
to be in motion- pacing, rocking, etc thought to
be agitation, elopement, need for seclusion,
acting out, and left untreated.
USE AIMS + EPS EXAM q.6 MOS
CourtenayHardingConsulting@gmail
DEFINITION OF THE WORD
“COMPLIANCE”
Not a great word in this era of
shared decision-making!
GIVING IN TO A REQUEST,
DEMAND, WISH;
ACQUIESENCE; A
TENDENCY TO GIVE IN TO
OTHERS
CourtenayHardingConsulting@gmail
Vs. “ADHERENCE”
(somewhat better)
 TO
STICK FAST
 TO BECOME ATTACHED
 TO GIVE ALLEGIANCE TO
 TO GIVE DEVOTION OR
SUPPORT
CourtenayHardingConsulting@gmail
MEDICATION MANAGEMENT
APPROACHES IN PSCYHIATRY
 Provides
a systematic &
structured plan for med
management
 Documentation is clearer and
more concise
 Objective measures of outcome
 Shared decision-making
CourtenayHardingConsulting@gmail
Discussions of Medications

“New developments in antipsychotic therapy” an interesting discussion report of a group of
psychopharmacologists J. Clin Psych Nov 2003

CATIE STUDY= Clinical Antipsychotic Trials of
Intervention Effectiveness
Results underscore need for access to full range
of medications” in www.szdigest.com and also
NEJM Sept 22, 2005 J. Lieberman et al

CourtenayHardingConsulting@gmail
“Meducation”
Provides understanding of social &
cultural issues involved in
medication adherence
 Can provide a list of critical
questions a user, consumer, patient
should ask his or her physician and
another one for the pharmacist
 Offers a tracking chart for client to
use
CourtenayHardingConsulting@gmail

Some helpful resources




www.mayoclinic.com/health/.../DSECTION=treatm
ents-and-drugs
www.nimh.nih.gov/health/...medications/complete
-index.shtml
What Your Patients Need to Know About
Psychiatric Medications by WC Jackson – 2007
www.ncbi.nlm.nih.gov › ... › v.9(4); 2007
Schrank, B.,Sibitz, I. Unger, A.& Amering, M.:
How Patients With Schizophrenia Use the
Internet: Qualitative Study. J Med Internet Res.
2010 Oct-Dec; 12(5): 70.
CourtenayHardingConsulting@gmail
Helpful to track down earliest
prodromal signs and symptoms




Work on finding usual
early warning sign
Describe mild,
moderate, and severe
versions
Experiment with
simple interventions
that work
Chart the status
Make emergency
plans

(R. Liberman)
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Morbidity & Mortality
CourtenayHardingConsulting@gmail
MORBIDITY AND MORTALITY
 The



Metabolic Syndrome
Abdominal obesity (excessive fat tissue in and
around the abdomen)
Atherogenic dyslipidemia (blood fat disorders —
high triglycerides, low HDL cholesterol and high
LDL cholesterol — that foster plaque buildups in
artery walls)
Elevated blood pressure
CourtenayHardingConsulting@gmail
MORBIDITY AND MORTALITY-2




More of The Metabolic Syndrome
Insulin resistance or glucose intolerance
(the body can’t properly use insulin or
blood sugar)
Prothrombotic state (e.g., high fibrinogen or
plasminogen activator inhibitor–1 in the
blood)
Proinflammatory state (e.g., elevated CReactive Protein in the blood)
CourtenayHardingConsulting@gmail
MORBIDITY AND MORTALITY-3

Increased risks of:
 Coronary heart disease
 Stroke
 Peripheral vascular disease
 Type 2 Diabetes
 Physical inactivity
 Hormonal Imbalance
 Expression of familial genetic profile
CourtenayHardingConsulting@gmail
MORTALITY- 4
Graded relationship between number
of neuroleptics taken and mortality
and dosage levels with…
 Fatal arrhythmias
 Sudden cardiac deaths
 Venus thrombosis
 Pulmonary embolism
 Asthma deaths

CourtenayHardingConsulting@gmail
(even after adjusting for known
risk factors of premature
death such as: smoking, lack
of exercise, BMI, B/P, serum
total and HDL cholesterol)!
CourtenayHardingConsulting@gmail
MORBIDITY AND MORTALITY-6
On 1st Generation drugs mortality risk =
2.84 and was just slightly reduced to 2.25
after adjusting for other factors such as:
somatic diseases, BMI, exercise, B/P, BMI,
alcohol intake and education.
 Relative risk for each new drug added 2.50
additional risk.
– Joukamaa et al, 2006
 Similar Findings for Atypicals and for
Antidepressants (both SSRIs and Tricyclic's)

CourtenayHardingConsulting@gmail
New Considerations for
optimization of medications
 Some
people seem to need no
medications;
 Some people seem to need
medications for a short while;
 A few people seem to need
medication for a longer period.
 Need research to help triage
CourtenayHardingConsulting@gmail
Support for optimization of
medications………….
Literature says that 1st episode
participants may need little or no
medications by adopting “wait and see”
 Nothing in the literature that says
everyone needs meds for a lifetime only
maybe a small group
 Taper, taper very very slowly if on for a
long time

CourtenayHardingConsulting@gmail
More Resources:
Personal Therapy – GE Hogarty et al
1997 helps adherence
 W. Fenton Psychiatric Times 2006
Combined therapy
 APA – 2004 Practice Guidelines
 Texas Medication Algorithm – No!
Was drug company sponsored.

CourtenayHardingConsulting@gmail
QUESTION # 8
WHY
IS THIS PERSON
TAKING STREET
DRUGS IN PLACE OF
OR IN ADDITION TO
PRESCRIPTIONS ?
CourtenayHardingConsulting@gmail
WHY IS THIS QUESTION
IMPORTANT?

Mental Health and Substance Abuse
systems of care need to be blended
and the work done simultaneously in
order for anything to work out.

Research has shown many different
reasons for use of substances
CourtenayHardingConsulting@gmail
CourtenayHardingConsulting@gmail
INFO ON USING
STREET DRUGS





At least 47% to 75% have co-occurring
disorders
Most costly to treat
Makes initial diagnosis difficult
Use of structured interviews helpful (SCID
subsection clinically useful or ASI – the
Addition Severity Index for research)
Info on street drug of choice may be
helpful to add into diagnostic process
CourtenayHardingConsulting@gmail
Co-Occurring or Dual Dx D/O
can lead to:






Symptom
Relapses
hospitalization
financial and
family problems
homelessness
suicide






Violence,
Sexual and
physical
victimization,
Incarceration,
HIV,
Hepatitis B and C
and early death.
CourtenayHardingConsulting@gmail
Some Reasons People Give

IS PERSON TREATING
DEPRESSIONS OR MEDICATION
SIDE EFFECTS (e.g. Akinesia) or
to ameliorate lack of motivation
and pleasure or to combat
loneliness or to get a social
group ? (see work of Prof. Mary
Ann Test and colleagues)
CourtenayHardingConsulting@gmail
EBP: Integrated Dual
Disorders Treantment (IDDT)
 Services
provided
concurrently
 Individualized assessment
and treatment planning in
heavy collaboration
 Use SCID-SA Screener
CourtenayHardingConsulting@gmail
EBP: Integrated Dual
Disorders Treatment

DUAL DISORDERS TREATMENT
IMPLEMENTATION RESOURCE KIT
 Information
 Training Materials
 Annotated Bibbs
 Refs
 http:://www.mentalhealthpractices.
org
CourtenayHardingConsulting@gmail
EBP: Integrated Dual
Disorders Treatment






Blending
Stage-wise Treatment
Motivational Interviewing
Substance Abuse Counseling
Involving all stakeholders
4 basic skills for clinicians
 Knowledge of substances & how they affect MI
 Assessment skills
 Motivational interviewing skills
 SA Counseling skills
CourtenayHardingConsulting@gmail
Some Lessons Learned
Standard confrontational models
might not work for people with
schizophrenia. Other models may
work better with less stress
 Blended funding streams and
integrated care more helpful
 Gender, age, ethnicity, geographic
residence, exposure to trauma, make
differences

CourtenayHardingConsulting@gmail
The Substance Abuse &
Mental Health
Administration in U.S. has a
wealth of publications on
research and treatment
strategies.
www.SAMHSA.GOV
CourtenayHardingConsulting@gmail
QUESTION #9
WHAT
ARE THE
RELEVANT SEX
DIFFERENCES?
CourtenayHardingConsulting@gmail
Why is this question important?






Not taught very often in med schools yet
Females metabolize drugs differently
Females often over medicated which cuts their
Estrogen protection
Females often have a later onset which provides
a stronger platform to return to
Males are more vulnerable and who struggle
more early on but eventually grow stronger in
outcome and
Females may lose their edge at menopause
CourtenayHardingConsulting@gmail
CourtenayHardingConsulting@gmail
SEX DIFFERENCES ACROSS
THE LIFE SPAN







NEURAL DEVELOPMENTAL GROWTH
BIRTH COMPLICATIONS
PEDIATRIC INJURIES
PUBERTY AND HORMONES
METABOLIC DIFFERENCES
MENOPAUSE
PRESCRIBING PRACTICES ARE
DIFFERENT
CourtenayHardingConsulting@gmail
SOME SEX DIFFERENCES AFECTING ILLNESS
EXPRESSION AND OUTCOME - 1
MALES

FEMALES
Early events may make brain
more vulnerable (e.g. slight
displacement of developing
cells by Mother’s flu, anoxia
due to cord around neck,
less temperature regulation,
and more risky playground
behaviors because of
increased exploration due to
testosterone)

Less events
CourtenayHardingConsulting@gmail
SOME SEX DIFFERENCES AFECTING ILLNESS
EXPRESSION AND OUTCOME-2
MALES


FEMALES
Quick metabolism of
food and medicine gets
into blood stream faster
May contribute to more
side effects


Slower metabolism of
food and medicine
means slowly entering
blood stream =
probably less side
effects
Meds cross blood/brain
barrier faster = drugs
more efficient
CourtenayHardingConsulting@gmail
Some Sex Differences affecting
illness presentation & outcome - 3
MALES


FMALES
Earlier onset often
in early to mid teens
– means less
education, less job
and dating
experience
Slow progress
toward recovery

More often later
onset with some
school completed,
dating and job
experience = much
stronger platform
for recovery and
initially stronger
CourtenayHardingConsulting@gmail
Some Sex Differences Affecting
Illness Presentation and Outcome - 3
MALES
 Often symptoms are
presented quietly
 Medications are often
less in number and
lower dosage
 Course improves more
slowly and matches
females later at trend
levels
FEMALES




Often symptoms are
presented in a boisterous
way
Medications are often more
in number and higher in
dosage
Cuts natural Estrogen
protection
Otherwise woman have
stronger outcomes until
menopause and loss of
Estrogen
CourtenayHardingConsurlting@gmai
Resources


Chiders, S.E.; Harding, C.M.: Gender,
premorbid social functioning, and longterm outcome in DSM-III schizophrenia.
SCHIZOPHRENIA BULLETIN, 1990, 16(2):
309-318.
Harding, C.M. & Hall. G.M.: Long-term
outcome studies of schizophrenia: Do
females continue to display better
outcome as expected? International
Review of Psychiatry, 1997, 9:409-418.
CourtenayHardingConsulting@gmail
QUESTION # 10
WHERE
IS THIS
PERSON IN THE
COURSE OF
ILLNESS?
CourtenayHardingConsulting@gmail
WHY IS THIS QUESTION
IMPORTANT?
Helpful
to track episode
information to see
when illness is
beginning to lift.
CourtenayHardingConsulting@gmail
CourtenayHardingConsulting@gmail
COURSE
INFORMATION
Instead of narrow medical model
(acute or chronic)
 Schizophrenia is virulent early and
tapers off later
 Similar to other general medical
disorders
 Mother nature is trying to help
 BURNT OUT vs. The Phoenix

CourtenayHardingConsulting@gmail
MORE ON COURSE
Also course of life, itself
 A lifeline or life history is helpful
 Mutual participation model
 Longitudinal patterns and trends
 Different uses of social relationships
 Build therapeutic relationships

CourtenayHardingConsulting@gmail
“The LIFELINE”






Quick and easy way to get a life history on
one line on one piece of paper
Builds a therapeutic and appreciative
relationship
Being used by clinicians across the world
Covers 12 areas of a life lived
Derived from the Life Chart – a research
instrument
Takes from 20 to 60 minutes
CourtenayHardingConsulting@gmail
Consider the differential effects of
rehabilitation in interaction with course
 Propose
that possibly ….
 Early rehabilitation interventions
from Day 1 forward may help
reduce disability
 Later
rehabilitation interventions
may help to increase ability
CourtenayHardingConsulting@gmail
Consider getting people back to school or
work as soon as possible.
Had calls from MDs, RNs, high school
teachers, college professors and engineers.
Each said, in effect: “I once had
schizophrenia but I don’t tell anyone.
Thanks for talking about recovery.”
How much do we underestimate what is
possible for people?
CourtenayHardingConsulting@gmail
Some Resources

THE LIFELINE – v. 2011 by C. M. Harding
(CourtenayHardingConsulting@gmail.com)

Strauss JS, Hafez H, Lieberman P, Harding CM. The
course of psychiatric disorder, III: Longitudinal
principles. Am J Psychiatry. 1985 Mar;142(3):289-96.

Harding, C.M.: Course types in schizophrenia. An
analysis of European and American studies.
SCHIZOPHRENIA BULLETIN. 1988, 14(4):633-643
CourtenayHardingConsulting@gmail
QUESTION # 11
WHAT
MYTHS AND
MISINFORMATION
ARE STRESSING
THE PERSON?
CourtenayHardingConsulting@gmail
Why is this question important?
Knowledge
transfers
power from the
illness and the care
system to the person.
CourtenayHardingConsulting@gmail
CourtenayHardingConsulting@gmail
ASSESSMENT OF
UNDERSTANDING THE ILLNESS
AND MEDICATIONS






Collaboration and education
Helps change the stressful valence – can
reduce relapse rates
Teaches how to manage symptoms
Never says more than we actually know
Promotes competency and empowers
Increases self-esteem
CourtenayHardingConsulting@gmail
EBP:WELLNESS MANAGEMENT
AND RECOVERY PROGRAM-1

CLINICIAN BENEFITS:
A comprehensive step by step
approach
 Ready-to-use materials
 Skill is using motivational ,
cognitive behavioral and
educational strategies
  Satisfaction to see  outcomes

CourtenayHardingConsulting@gmail
EBP: WELLNESS MANAGEMENT
AND RECOVERY PROGRAM-2

CLINICIANS RECEIVE:
 guide with practical tips
 handouts, checklists, planning sheets
 introduction video
 informational brochures
 fidelity scale
 outcome measures
CourtenayHardingConsulting@gmail
EBP: WELLNESS MANAGEMENT
AND RECOVERY PROGRAM-3
•
•
•
•
Recovery
strategies
Practical facts
about MI
StressVulnerability &
treatment
strategies
Building social
supports
•
•
•
•
•
•
•
•
•
•
reducing
relapses
using meds
effectively
coping with
stress
coping with
problems &
symptoms
getting your
needs met in the MH
system
CourtenayHardingConsulting@gmail
“HOPE CAN ARRIVE ONLY
WHEN YOU RECOGNIZE
THAT THERE ARE REAL
OPTIONS AND THAT YOU
HAVE GENUINE CHOICES.”
Jerome Groopman, MD (2004)
CourtenayHardingConsulting@gmail
More Resources

Wellness Self-Management & Plus by
Columbia University – Paul Margolies and
Tony Salerno

http://www,mentalhealth.samhsa.gov/cmhs/co
mmunitysupport/toolkit

http://www.mentalhealthpractices.org/imr_mlpl
. html
CourtenayHardingConsulting@gmail
More Resources




Liberman RL et al, describing UCLA Models,
Innovations & Research, Vol2(2), 1993
P.A. Garrety et al , Schiz Bull, 2000
WRAP Plan – Mary Ellen Copeland
Harding, C.M.; Zahniser, J.: Empirical
correction of seven myths about
schizophrenia. Acta Psychiatrica
Scandinavica. 1995:90 (Suppl. 384):140-146.
CourtenayHardingConsulting@gmail
BATHROOM AND MOBILE
PHONE BREAK
CourtenayHardingConsulting@gmail
QUESTION # 12
WHO
DEPENDS ON
THE CLIENT FOR
HELP?
CourtenayHardingConsulting@gmail
Why is this question important?
 Challenges
the assumption
that all the help is being
extended to the person with
the lived experience.
 Ask and you will find out
some surprising information!
CourtenayHardingConsulting@gmail
CourtenayHardingConsulting@gmail
What You Will Find Out…


Most people with the
lived experience have
people they help with
emotional support
during a crisis or with
Concrete help such as
the loan of bus money
or moving furniture or
providing
companionship
CourtenayHardingConsulting@gmail
SOCIAL SUPPORTS
CONNECTION BETWEEN KIND AND
AMOUNT OF SOCIAL SUPPORTS
AND RECOVERY FROM AND
PREVENTION OF ILLNESS OF ALL
KINDS
 NETWORKS = TYPE, AMOUNT,
DENSITY, SIZE, DEGREE OF
INTERDEPENDENCE, CLUSTERING,
DEGREE OF INTIMACY (M. Hammer,1981)

CourtenayHardingConsulting@gmail
SOCIAL SUPPORTS - 2

Social Skills Training (considered a Promising
Rehab Practice)
 Reading social cues
 Acting appropriately
 Practicing acceptable social behaviors
 (e.g. eye contact, small talk etc.)
 Decrease loneliness
 Increase possibility of finding friends
and significant others.
CourtenayHardingConsulting@gmail
Resources…………
Liberman’s Social &
Independent Living Skills
Modules at UCLA
 See Innovations & Research
 Vol2 (2) 1993
 Harding’s Star Chart (Social
Network) Harding & Keller,
1998
 Robert
CourtenayHardingConsulting@gmail
SOCIAL SKILL RESOURCES

1) Penn, D..L., Roberts, D.L., Combs, D., Sterne, A.: The development of the social
cognition and interaction training program for schizophrenia spectrum disorders.
Psychiatric Services, 56 (4):449-451, 2007.

2) Hogarty GE: Personal Therapy for Schizophrenia and Related Disorders: A Guide to
Individualized Treatment. New York, Guilford Press, 2002

3) Liberman, R. Liberman, R., DeRisi, W., & Mueser, K. : Social skills training for
psychiatric patients. New York: Pergamon Press, 1989.

4) Mueser, K.T. & Gingerich, S.: The Complete Family Guide to Schizophrenia. New
York, The Guilford Press, 2006.

5) Bellack, A.S., Mueser, K.T., Gingerich,S., Agresta, J.: Social Skills Training for
Schizophrenia: A Step by Step Guide (2nd Ed.). New York: Guilford Press, 2004.

6) Harding, C.M.: Curriculum – How to Get A Date: One More Way To Teach Social
Skills in PROS. V. 1, New York, Center for Rehabilitation and Recovery, The Coalition
of Behavioral Health Agencies, 2011
CourtenayHardingConsulting@gmail
Even More Resources



Beels, C. C. (1989) The invisible village. New
Directions for Mental Health Services, 1989: 27–
40.
Strauss, J.S.; Harding, C.M.; Hafez, H.;
Lieberman, P.: The role of the patient in recovery
from psychosis. In: J.S. Strauss, W. Böker and
H. Brenner (Eds.), Psychosocial Management of
Schizophrenia. Toronto: Hans Huber Publisher,
1987, pp. 160-166.
Hammer, Muriel ( 1981) Social Supports, Social
Networks, and Schizophrenia. Schiz Bull. 7(1):4557.
CourtenayHardingConsulting@gmail
QUESTION #13
WHAT
IS THE
PERSON’S
WORLD VIEW?
CourtenayHardingConsulting@gmail
Why is this question
important?
Working to understand cultural, ethnic,
religious, and other important factors in
the person’s world is absolutely critical
for individualized recovery planning.
 Everyone has a culture (even Northern
Europeans not just people of color)

CourtenayHardingConsulting@gmail
CourtenayHardingConsulting@gmail
CULTURAL SENSITIVITY






ONLY RECENTLY APPRECIATED
DIVERSITY IS HALLMARK OF WORLD
NEED TO UNDERSTAND AT INTAKE
ONWARD
WHAT IS IMPORTANCE OF RELIGIOUS
THINKING versus RELIGIOSITY?
SENSE OF TIME?
DISPLAYED AFFECT?
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CULTURAL SENSITIVITY-2
 Disorganized
sounding speech a linguistic variation?
 Importance of family,
community and church?
 Is the interpreter asking the
same questions you are? (see
Utah DMH video)
CourtenayHardingConsulting@gmail
CULTURAL SENSITIVITY-2







http://www.wiche.edu/archive/mh/cultural
CompetenceStandards
SAMHSA’s only approved standards for
anything
Benchmarks
Guidelines
Outcome Measures
Lit Review
For everyone for everyone and the major
4 minority groups
CourtenayHardingConsulting@gmail
More resources of interest

Tervalon, M. & Murray-Garcia, J. (1998)
Cultural Humility versus Cultural
Competence: A Critical Distinction in
Defining Physician Training Outcomes in
Multicultural Education. J. of HealthCare
for the Poor and Underserved., 9(2), 117125.
CourtenayHardingConsulting@gmail
Question # 15
IS
THERE ANY
COHESION IN THE
SYSTEM OF CARE?
CourtenayHardingConsulting@gmail
Why is this question
important?
 Complex
biopsychosocial
problems need integrated
comprehensive systems which
collaborate with users and
carers.
 It helps people if we have our act
together!
CourtenayHardingConsulting@gmail
CourtenayHardingConsulting@gmail
LINKAGES - 1
Coordination and linkage between all
the players are critical
 Need semi-permeable membranes for
information sharing, flexibility,
coordination, continuity and
integration
 Clear and consistent policies from
the top down

CourtenayHardingConsulting@gmail
LINKAGES - 2
Clear and consistent policies from
the top down
 Use community resource checklist
(community mental health, extension
services, consumer groups, natural
support)
 Again, the more we have our act
together the better the participants
become

CourtenayHardingConsulting@gmail
Some Resources

Principled Leadership. William A. Anthony & Kevin Ann
Huckshorn, Boston University, 2008.
www.bu.edu/cpr/products/books/titles/leadership.html

The Comprehensive, Continuous, Integrated System of
Care (CCISC) process (Minkoff & Cline, 2004, 2005) is a
vision-driven system “transformation” process ...
www.kenminkoff.com/ccisc.html

www.samhsa.gov/co.../topics/healthcare-integration/cciscmodel.aspx

www.who.int/entity/mediacentre/news/notes/2007/np25/.../in
dex.html
CourtenayHardingConsulting@gmail
Another resource

Harding, C.M.: The limited resources
debate: Changing the rules of the game to a
win-win scenario. AUSTRALASIAN
PSYCHIATRY, 1997, 5(6), 271-273.
CourtenayHardingConsulting@gmail
Training resources



Coursey, R. D., Curtis, L., Marsh, D. T., Campbell, J.,
Harding, C. M., Spaniol, L., Luckstead, A., McKenna, J.,
Paulson, R., Zahniser, J., Kelley, M., and other members of
the Adult Panel of the SAMHSA Managed Care Initiative:
Part I. Competencies for the direct service staff who work
with adults with severe mental illnesses in outpatient
public mental health/managed care systems. AND
Part II. Competencies for the direct service staff who work
with adults with severe mental illnesses: Specific
knowledge, attitudes, skills, and bibliography.
PSYCHIATRIC REHABILITATION JOURNAL. 2000, Spring
CourtenayHardingConsulting@gmail
More resources on training

Neligh, G.L.; Shore, J.; Scully, J.; Kort, H.; Willett, B.,
Harding, C.M.; and Kawamura, G.: The program for public
psychiatry: state-university collaboration in Colorado.
HOSPITAL AND COMMUNITY PSYCHIATRY, 1991, 42(1): 4448.


Zimet, C.N.; Harding, C.M.: Chapter 19 - The Colorado
postdoctoral training consortium: an innovative
postdoctoral program in public psychology. In: Wolford,
P., Myers, H.F., Callan, J.E. (Eds.), PUBLIC-ACADEMIC
LINKAGES FOR IMPROVING PSYCHOLOGICAL SERVICES,
RESEARCH, and TRAINING. Washington, D.C. APA Press,
1993, pp. 165-169.
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#14 – WHAT TO DO WITH AN
OUT OF CONTROL PERSON?
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Why this is an important
question?
Psychological
strategies can
go a long way to calm a
person without heavy
dosing
CourtenayHardingConsulting@gmail
CourtenayHardingConsulting@gmail
QUESTION # 14 – RISK
MANAGEMENT - 2
 Research
has found the
following risk factors for minor
and serious violence:
 PERSECUTORY IDEATION
 SUBSTANCE ABUSE
 CHILDHOOD CONDUCT D/O
 VICTIMIZATION
CourtenayHardingConsulting@gmail
RISK MANAGEMENT





Relapse Prevention Strategies for mental
health and substance abuse issues
Try Paul and Lentz Social Learning
Environments (behavioral)
Tony Menditto’s program for forensic
participants
Individualized Token Behavioral
Programs which tend to generalize to
other environments
Reduce Restraint and Seclusion with
psychological strategies first
CourtenayHardingConsulting@gmail
DIALECTICAL BEHAVIORAL
THERAPY



For persons diagnosed with Borderline
Personality Disorder
Effective for “…..reduces suicidal
behaviors, psychiatric hospitalization,
dropout from treatment, substance abuse,
anger and interpersonal difficulties.”
Always conducted within a team approach
CourtenayHardingConsulting@gmail
Resources

Marsha Linehan et al (2006) Two-year randomized
controlled trial and follow-up of Dialectical
Behavioral Therapy vs. Therapy by experts for
suicidal behaviors and Borderline Personality
Disorder. Arch Gen Psych, 63(7): 757-766.

Linehan, M. & Dimeff, L.A. Dialectical Behavior
Therapy Manual of Treatment Interventions for
Drug Abusers and Borderline Personality
Disorder. Seattle, Washington, University of
Washington, 1997.
CourtenayHardingConsulting@gmail
Other Resources




The Wellness Recovery Action Plan (WRAP)
Mary Ellen Copeland, 2011.
An Anger Management Training Package for
Individuals With Disabilities, H. Gulbenkoglu et al.
London, Kingsley Pubs., 2006.
Evidence-Based Practice of Cognitive-Behavioral
Therapy , Dobson, D & Dobson, K New York,
Guilford Press, 2009.
Paul, G. L., Stuve, P., & Menditto, A. A. (1997).
Social-learning program (with token economy) for
adult psychiatric inpatients. The Clinical
Psychologist, 50, 14-17.
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QUESTION #16
WHERE
DO THE
CLINICIAN AND
CONSUMER BEGIN TO
START BUILDING THE
RECOVERY PROCESS?
CourtenayHardingConsulting@gmail
Why is this question important?
 After
150 years of focus on
psychopathology, deficits,
damage and dysfunction, peer
advocates and rehabilitation
research has shown that
building on strengths helps
people reclaim their lives.
CourtenayHardingConsulting@gmail
CourtenayHardingConsulting@gmail
ASSESSMENT OF STRENGTHS



Rehab is built on strengths not problems or
deficits
Strengths of: person, system of care, family,
case manager, the doc etc
Sense of humor, drivers license, computer
skills, care of others, watering plants and even
the manipulation of systems
CourtenayHardingConsulting@gmail
Some Resources


Anthony, W. A. & Farkas, M. (2012) The
essential guide to psychiatric
rehabilitation practice. Boston MA: Boston
University.
Rapp, C. A. The strengths model: Case
management with people suffering from
severe and persistent mental illness. New
York, NY, US: Oxford University Press.
(1998).
CourtenayHardingConsulting@gmail
More Resources

Harding, C.M., Strauss, J.S., Hafez, H.,
Lieberman, P.L.: Work and Mental Illness:
1. Toward an integration of the
rehabilitation process. J. Nervous & Mental
Disease, 1987, 175 (6): 317-327.
CourtenayHardingConsulting@gmail
Question # 17. Has the person
ever experienced trauma in their
life?
CourtenayHardingConsulting@gmail
Why is this question important?
 It
is only recently that clinicians
have begun to acknowledge and
understand the role of trauma in
the impact on psychiatric
problems as well as challenges
for treatment.
CourtenayHardingConsulting@gmail
CourtenayHardingConsulting@gmail
Traumatic Experiences
AT SOME POINT WE NEED TO FIND
OUT ABOUT PREVIOUS
TRAUMATIC EXPERIENCES
 Effects: Avoidance, hypervigilance,
emotional difficulties, and recall
behaviors, anxiety, depression, problems
sleeping, and sometimes hopeless
 Use SCID-D for assessment

CourtenayHardingConsulting@gmail
Some Trauma Studies
50-60% of US have a traumatic
experience
 10% - 17 % Chronic PTSD (Galea et al, 2002)
 In community 1 in 10 women/girls and 1
in 20 men/boys have PTSD (Kessler et al, 1995)
 Most do not & do not display pathology!

(Bonanno et al, 2002)
CourtenayHardingConsulting@gmail
Predictors of the Emergence
of PTSD
LACK OF SOCIAL SUPPORT
 LACK OF EDUCATION
 TOUGH FAMILY BACKGROUND
 PRIOR PSYCHIATRIC HISTORY
 DISSOCIATIVE REACTION
• (Berwin et al 2000, Ozer et al, 2003)

CourtenayHardingConsulting@gmail
Psychophysiological Sequelae of
Stress and Trauma
Psychogenic Stress of all kinds can be
Genotoxic in Cellular Structures
 Changes in both internal and external
environments can lead to ± changes in
gene structures
 The Brain is a Plastic Organ as well
 Healing is possible

CourtenayHardingConsulting@gmail
CourtenayHardingConsulting@gmail
Mnemonic for PTSD
FEARS





Fears
Ego construction (numbing & withdrawal)
Anger
Repetition (Flashbacks & nightmares)
Sleep disturbance
• Jean Goodwin
CourtenayHardingConsulting@gmail
Mnemonic for COMPLEX PTSD
FEARS
Fugue & Other Dissociative states
Ego fragmentation
Antisocial Behaviors
Re-enactment
Suicidality & Somatitization
• Jean Goodwin
CourtenayHardingConsulting@gmail
SOME RESOURCES



Journal of Brain Behavioral and Immunity for
articles on psychoneuroimmunology
Trauma-Focused Cognitive Behavioral Therapy NREPP ...
www.nrepp.samhsa.gov/viewintervention.aspx?id
=135
Tips for survivors of a traumatic event.
www.samhsa.gov/MentalHealth/tips_survivors_m
anaging_your_stress
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# 18 – CAN THIS PERSON
READ?
CourtenayHardingConsulting@gmail
Why this question is so
important?
 People
coming for services
hardly ever get assessed for
level of literacy and yet we
pass out materials and
prescriptions expecting that
they can read.
CourtenayHardingConsulting@gmail
CourtenayHardingConsulting@gmail
Assessment of the level of
functional literacy




Realizing that admitting you can’t read is
more embarrassing to a person than
talking about symptoms!
Receiving information in the way a person
can understand
Learning to read might improve selfesteem and reduce symptoms
Helps close the gap in healthcare
disparities
CourtenayHardingConsulting@gmail
REALM-R
Rapid Estimate of Adult Literacy
in Medicine, Revised
(a 5 minute 11 word list for English
speakers which provides a quick
measure of literacy)
Bass et al 2003
CourtenayHardingConsulting@gmail
Ways to enhance understanding in
persons with low level literacy-1
 Slow
down speech fluency
 Use “living room” language
instead of medical
terminology
 Show or draw pictures to
enhance understanding and
subsequent recall
CourtenayHardingConsulting@gmail
Ways to enhance understanding in
persons with low level literacy-2



Limit amount of information given at each
interaction and repeat instructions
Use a “teach back” or “show me”
approach to confirm understanding
Be respectful, caring, and sensitive
thereby empowering people to participate
in their own health care.
– Williams, Davis, Parker & Weiss. Fam
Med. 2002, 34:387)
CourtenayHardingConsulting@gmail
# 19 Does this person believe in
something bigger than self?
CourtenayHardingConsulting@gmail
Why is this question so
important?

Belief in something greater than
one’s self is often helpful to survive
the challenges of psychiatric
problems. Sharing information about
this important area identifies a
strength.
CourtenayHardingConsulting@gmail
CourtenayHardingConsulting@gmail
USE OF SPIRITUALITY
Research shows that about half of every
sample relies on some sort of faith
(Western or Eastern formal religion,
informal beliefs , nature, art, music etc.)
to provide help and supports
 Need to ask and talk about it if person is
interested

CourtenayHardingConsulting@gmail
AND 20) “WHAT DOES THE
PERSON THINK HE OR SHE
IS RECOVERING FROM?”
CourtenayHardingConsulting@gmail
Why is this question important?
 If
you ask you may be surprised!
 Often
it has nothing to do with
diagnosis or symptoms
…………..
CourtenayHardingConsulting@gmail
CourtenayHardingConsulting@gmail
CHERYL GAGNE’S LIST
from peers:

! Loss of self, connection, & hope
Loss of roles and opportunities
devaluing and disempowering
programs, practices, and
environments
Prejudice and discrimination in
society
Internalized oppression and
shame
CourtenayHardingConsulting@gmail
WHAT MADE THE DIFFERENCE ACCORDING TO
THOSE INTERVIEWED FROM VERMONT STUDY?




Decent food,
clothing and
housing
People with whom
to be
A way to be
productive
A way to manage
s/s and meds




Individualized rx
Case
management
Psychoeducation
Integration back
into the
community
CourtenayHardingConsulting@gmail
WHAT DID THE VERMONTERS ALSO
SAY MADE THE DIFFERENCE?
Hope!
“Someone believed in me”
 “Someone told me that I had a
chance to get better”
 “My own persistence”
 Hope connects with natural selfhealing capacities

CourtenayHardingConsulting@gmail
“To hope under the most extreme
circumstances is an act of
defiance that….permits a person
to live his [her] life on his [her]
own terms. It is the part of the
human spirit to endure and give
a miracle a chance to happen.”
Jerome Groopman, MD (2004)
CourtenayHardingConsulting@gmail
Another Resource

Strauss, J.S.; Harding, C.M.: Relationships
between adult development and the
course of mental disorder. In: J. Rolf, A.
Master, D. Cicchetti, K. Nuechterlein, and
S. Weintraub (Eds.), RISK AND
PROTECTIVE FACTORS IN THE
DEVELOPMENT OF PSYCHOPATHY. New
York, Cambridge University, 1990.
CourtenayHardingConsulting@gmail
AS A CLINICIAN BEING
SYSTEMATIC CREATIVE, &
STRUCTURED IN YOUR
APPROACH
YOURSELF AND YOUR
RELATIONSHIP ARE THE BEST
TOOLS IN YOUR KIT BAG
CourtenayHardingConsulting@gmail
MANY THANKS
FOR PARTICIPATING.
HOPE SOME OF THIS
INFORMATION WILL BE
HELPFUL.
CourtenayHardingConsulting@gmail
Presenter Information


Courtenay M. Harding, Ph.D., recently retired as a professor in the department of
psychiatry at the College of Physicians and Surgeons of Columbia University. She
was trained at the University of Vermont and Yale. She also just retired as the
director of the Center for Rehabilitation and Recovery at the Coalition of Behavioral
Health Agencies in NYC. Dr. Harding moved to New York from Boston where she
was the Senior Director of Boston University’s well-known Center for Psychiatric
Rehabilitation under William Anthony. Among her research endeavors, Dr. Harding
participated in two three-decade NIMH studies of schizophrenia and other serious
illnesses and found that many once profoundly disabled persons could and did
significantly improve and/ or even fully recover. These findings, similar to nine other
long-term studies from across the world, helped to create the Institute for the Study
of Human Resilience in order to investigate ways in which people reclaimed their
lives including getting back to work. To date, she has received 52 federal, state, and
foundation grants and contracts for schizophrenia research and studies of mental
health services. She has been the recipient of over 46 awards and honors including
the Alexander Gralnick Research Investigator Award from the American
Psychological Association’s foundation for “exceptional contributions to the study of
schizophrenia and other serious mental illness and for mentoring a new generation of
researchers” Dr. Harding has published extensively about schizophrenia,
rehabilitation, and recovery and has presented findings from her studies and clinical
work in over 500 state, national, and international meetings. She has worked with 30
states, Australia, New Zealand, 11 European, and 9 Asian countries including China to
redesign their systems of care.
CourtenayHardingConsulting@gmail