Recovery-Oriented Cognitive Therapy: Team-based CT-R for Building Empowerment and ResilienceOn August 18, 2019 by Raul Dinwiddie
Good afternoon, everyone. We are so glad that
you can be with us on this Wednesday morning. I know that in parts of the country it’s
snowing, and in other parts there is ice. Hopefully some of you have some sun and are
quite comfortable and warm wherever you are. Thanks for being here.
We are bringing you this Recovery to Practice webinar based on funding from SAMHSA, Substance
Abuse and Mental Health Services Administration. My name is Melody Riefer, and I am going to
be your moderator today. I’m going to give you a couple of quick
hints about how to navigate the room if you are looking at a computer screen or a tablet
screen. You probably need to know that the views and
opinions and content in this presentation don’t necessarily reflect the exact views,
opinions, and policies of the Center for Mental Health Services of the Substance Abuse Mental
Health Services Administration or the U.S. Department of Health and Human Services. However,
we do have experts presenting information to you.
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reason at all, this would be real-time captioning, it’s available by clicking the link in the
pod just below the presenters’ pictures. A separate window will open and provide that
information for you. This is the third webinar in a series looking
at recovery-oriented cognitive therapy. And we have two great presenters who are – who
have been with us for the whole series. Paul Grant and Ellen Inverso, who are from the
Perelman School of Medicine at the University of Pennsylvania. Both of these people have
spent a great deal of time working on recovery-oriented cognitive therapy and developing the trainings
that are associated with that intervention. So they will continue to educate us on CTR,
and I would like to turn the webinar over to them at this point.
So Paul, Ellen, thanks again for being here, and we look forward to learning from you today.
Thank you very much, and – Thank you.
We really appreciate it. Since we – we were last on the webinar, there has been some kind
of change in – in the country. Our home city has been destroyed by a Super Bowl victory,
so it’s – it’s a pretty interesting time for us. We’re happy to be joining with
all of you. And we’re happy to see that there is so
– there’s a lot of familiar faces – sorry, Paul – there’s a lot of familiar faces
to us in folks that we have worked with and see who I see are joining us today, and so
we want to say hi to everyone who we know. Glad to have everyone here. And those who
are joining us for the first time, we’re excited.
Yeah. So today what we want to do is we want to pick up sort of from where we’ve been
and sort of more forward into – to this point in time we’ve really been talking
about the adaptive mode, and really talking about the ways that we can sort of meet up
with the people that we are collaborating with to have, you know, their lived experience
and some of the challenges that they are facing. How we can really meet up with them and really
sort of start to energize and really help them build up their best self.
And so we spent the first two times talking about that, especially a focus on developing
this adaptive mode and, you know, best self in terms of what does the individual want,
what are they really looking to get in their life, including making sure that that is kind
of richly expressed for them, and then really helping them actualize that with actual things
they are doing so they have the feeling of the feelings. And then they see also the meaning,
whatever the meaning is of volunteering, or going back to school, or, you know, getting
a girlfriend or boyfriend, that kind of thing. All that kind of stuff. Really realizing it.
And then we also focused some on really how it is we can help – help with really drawing
conclusions around, sort of strengthening these positive beliefs, and making the positive
message more frequent and really the life being – the sort of life the person really
wants to be having as they develop more and more autonomy and more, you know, just more
of the life that they really want to have. And we talked also in that context about shifting.
So today what we want to – want to shift to is really talking about some of the challenges
that often have gotten the person into a particular level of care and the challenges that often
come with – with – you know, go under the categorization of a symptom by a psychologist
or a psychiatrist might put it in that category. But for the sake of what we are going to talk
about, these are challenges to moving forward. And really, the focus with respect to any
of the challenges is going to be around resiliency – sorry, empowerment. Real empowerment is
what we’re going for. What we want to do towards the end of this
session is really talk about how teams, treatment teams, community teams, hospital teams, can
really sort of collaborate with an individual to really bring about some real impressive
recovery and resiliency. Ellen?
So I want to introduce for folks who are joining for the first time and to remind those who
have been with us for the previous webinars, I want to introduce you to the mechanism by
which we organize a lot of the ideas that we’ll be talking about.
So in the download materials, in your reference materials, you will find a recovery map. And
what that does is it is a tool for organizing exactly what Paul was just describing. And
so the area of the recovery map – so, in general, it’s about developing an understanding
of how an individual is at their best and the beliefs that are really activated when
someone is in a really great adaptive mode. But also it’s a way of understanding when
somebody is having a challenging time. Kind of what are the beliefs that are more activated
in that time. And that gives us a really meaningful target for what we are going to be – what
we can do as far as interventions do. So this is a tool we’ll reference at different
points and kind of the point where we’re going to be focusing on part of today is the
– the challenges and thoughts. So what are the current things that are getting in the
way of moving toward aspirations, and then what are some of those beliefs that are underlying
those. Now, one of the things that we’ll be doing
today is we want to try and provide a kind of light touch, for – with the amount of
time we have, a light touch on the recovery-oriented cognitive therapy formulation for some specific
and common challenges. And those are going to include lack of access to motivation, so
when an individual has a really difficult time kind of accessing motivation. And also
when somebody is expressing delusions and it’s getting in their way of achieving the
– their aspirations, things that are really important to them. When hallucinations are
the obstacle as well as aggression and self-injury. Those are some of the topics we are going
to try and do a light-touch formulation on. And then we’ll provide some recommendations
for strategies and interventions that are rooted in the CTR model.
And then as we talk about the treatment teams, we’ll really emphasize how those can be
addressed in a really recovery-oriented cognitive therapy and aspirations-oriented teaming or
milieu at all the levels of care. So as I was saying, obstacles – challenges
that people experience are really only a problem if they are getting in the way of, you know,
forming relationships, pursuing the things that are meaningful, or if they are contributing
to other ways in which a person gets stuck. So the experience of what might traditionally
be labeled as a symptom is not in and of itself – if we have a – quote/unquote – symptom,
that is not, in and of itself, an obstacle, and neither are similar factors such as not
having insight into mental illness or things like that. A person doesn’t have to identify
it as a challenge to – identify a diagnosis or a symptom as a challenge in order to live
a rich life. Right? So we really see that the obstacles come into play when they are
exactly that, getting in the person’s way. And so we really want to think about how the
obstacles work. And really that is going to be in terms of thinking about the beliefs.
If you were present in the first session that we had, we talked about some of the beliefs
that people have about themselves about being capable, incompetent or weak. Beliefs about
others in terms of others being sort of malicious, or rejecting, or, you know, not understanding,
that kind of thing. Really what we want to do is see sort of how
these – how these obstacles come up. Or challenges as we like to call them. Then really
this is greatly about empowering the individuals to be able to really – really be able to
not have that get in the way of really the life they want to be having, but that – that
is sometimes what has happened. And so we will really try to be focusing on it in those
terms. But a lot of the understanding is really – is really where a lot of – where the
work is going to be. And I would really say, too, that when we
are working on understanding the obstacles, it’s really going to involve enhancing the
experience of the beliefs that can be activated when someone is at their best or in the adaptive
mode. A lot of times those are personal things that counter the beliefs underlying obstacles.
Similarly, the – as we’re doing things that support the meaning of achieving aspirations,
those are going to be the things that will really bring somebody into the – into more
adaptive mode and can help to undercut the challenges, the beliefs that are underlying
the challenges. Yeah. And one other thing, too, we would say
is that also this can help avoid unwitting sort of conflicts you might have with – with
people. Because ultimately the challenges are going to be in the context of the life
they want to be having, which can really minimize conflicts in terms of handling them. And I
think this will be especially obvious when we are talking about things like anger and
self-injury. So we always like to start things as exciting
as possible when we can. So negative symptoms are certainly the most exciting thing we run
into. You know, sort of lack of things. So – and – but as I said on the first day,
I think the negative symptoms are actually much more associated with disability and really
a lack of getting the life they want than they might initially seem. You know, oftentimes
somebody who has a lot of negative symptoms and not a lot else, just – just can fly
under the radar a lot of times. Because they don’t really have a lot of motivation, they
might sit by themselves all the time. They often don’t do a lot that really draws attention
to them. So, the people that we are talking about that might be leading lives of quiet
desperation. It might people who have a lot of this without some of the other challenges
being present. And what we found is – and what our work
has shown, and our research has shown, is that there are beliefs that are connected
to the negative symptoms. Which are publicly, you know, mis-named because they sound a little
bit absolute, like no motivation, no sociality, no pleasure, no speaking, that kind of thing.
But it really – it’s really – I mean, the no motivation I think is really about
a lack of access. Harder to access it. Social stuff is really about feeling really just
wary about socializing so sticking to yourself instead. And with finding pleasure, it’s
really not engaging in pleasurable activity or finding low-level pleasurable activities
don’t give a lot of feedback. You need something a little bit stronger.
So this slide just illustrates some of the beliefs that we see as really proximal factors
to the negative symptoms, so, like in the first – first box, you know, why bother?
You know, partly the same feelings all the way. If you really have these beliefs and
you endorse them firmly, you’re probably not likely to engage in a lot of things that
might be leading you towards the girlfriend, or leading you towards the volunteering, or
that kind of thing. Similarly, with the sociology, similar kinds
of things. You don’t expect people to like you. You don’t expect to enjoy social experiences.
So you might not – you might choose to just stay to yourself. And I think we see a lot
of that. And it’s similar to hopelessness and not expecting to enjoy things.
In terms of the limited speech, there’s some pretty good research that shows that
people over the age span, this one actually seems to grow the longer the person has, gotten
– had the diagnosis, the more likely it is there is a deficit in speech. And I do
worry – I think that maybe illustrates the language doesn’t seem like other people
care. And they just feel people aren’t interested in what they have to say. So – so single-word
answers are indicators of care about the social challenge.
May I have the next slide? So the – what we’ve been talking about
in terms of how to address language symptoms is really through experientially countering
the beliefs that the people have that are – that are – that are keeping them quiet
but ultimately isolated. We all might have beliefs about things that we don’t well
or that won’t work out for us. But those – those are just limited to that area whereas
for the individuals we’re working with, it’s often global. Everything.
So real key to countering the a – what is called the a-motivation is really to help
the person experience success. See that they really are capable of doing things.
Similarly, you know, have beliefs about not being able to be socially successful. So having
a positive experience with a staff member, and ultimately with other people, and then
the community, where you see that it is better to do things with other people than do things
by yourself. You like it better. That you can succeed. And if you can succeed at this
particular task, you might be able to succeed in another kind of task. And then ultimately
it leads up to sort of positive beliefs that – that I am a good person, I’m a capable
person, and I have a future. And the resiliency comes in really when we’re talking about
sort of initially when you might feel like – and I think we all might have days like
this – where you just don’t feel like doing stuff, you don’t feel like getting
started. You realize, well, initially I don’t feel like starting, but then I can really
get going, and – and – and then it is much better than I expect I can be. That kind
of thing. Anything you would add to that, Ellen? Okay.
All right. In terms of – we told you this was going
to be a quick – quick trip here, but you can pick up some stuff in the classroom.
And in terms of delusion, the way that – the way that we conceptualize delusions is that
they really are sort of standing in for something that is deeper for the person. So, somebody
who feels they are being poisoned. Or they might have the experience of conspiracy and
things like that. It seems like they really care about safety. And they feel vulnerable.
And they don’t miss it, so they always feel like they’re not going to be able to keep
themselves safe. So, safety is an important value for them.
Similarly, somebody who – who might sort of boast and tell you that they own the hospital,
or that they own the organization, all these kinds of things, it might be the case that
they – that they don’t feel like they are important. Or they don’t feel like people
are listening to them. Or something like that. Similarly, some of the delusions can be related
to really not having any sense of control. And the belief itself, the belief that you
might – that you have power, that you’re talking to important people, things like this
might counter the sense that in your personal life you don’t have a sense of control.
And at the end of the day, a lot of delusions can be about are connections. I’m going
to ask Ellen to illustrate with an example or two.
Sure. We have some examples coming up. I’ll actually just
go ahead. So, yeah, we’ve got a couple of examples.
We’ll do a couple examples coming up I think after we break down some of the understandings
if that sounds okay. Sure.
Cool. So there are some – what we’re trying to do, is we’re trying to get an understanding,
right, of when it is that some of these experiences are more likely to come up than not. And that
can give us a lot of good information as to what the beliefs are that a person is actually
experiencing at that time. So these are just some common times when we
see delusions be more likely to show up. And I think that many of us can relate to the
experience of social gatherings and in some of these situations we may have different
reactions, that don’t always get us closer to the things that we want.
So increased stress situations such as being in treatment. Those can be really stressful
situations, you know, working with a team of providers, regression, all the different
contexts. Rejection. So, you know, in the pursuit of
work, or pursuit of relationships. Even just in general interactions the perception of
rejection can really stoke up a lot of vulnerability. Disappointment.
Situations where I don’t feel like I have a lot of control or freedom. And a lot of
times we’ll see that in situations of, you know, involuntary hospitalization or the approach
of court dates can really stoke up a lot of those beliefs.
And then in times when someone is particularly isolated or feeling maybe really lonely, that
can bring up a lot of beliefs like paranoia and maybe focusing a lot on kind of cues in
the environment that contribute to just different feelings of vulnerability and so forth.
And these are – this is a very – it’s not an exhaustive list, but when we are thinking
about the common beliefs that underlie solutions, there are a lot of – these are kind of the
more common ones, the things – this is where the cognitive model helps inform what we do
and the interventions we’ll ultimately decide to pursue. So beliefs about the self-esteem,
you know, I’m helpless, or weak, or vulnerable, can really bring up a bit of these beliefs.
Similarly, if I don’t find that other people are trustworthy, or that people are going
to take advantage of me, I may want – I may kind of compensate for that by, you now,
really giving myself a very important status or role, something to that extent.
And similarly for the future, the world being dangerous, or, you know, that I have to always
be prepared for what’s going to happen can really be – those can be some of the beliefs
that underlie this. And so what we want to try and do is figure
out which of these beliefs are maybe most activated for somebody so that we can select
an accurate target and intervention. And that’s going to include a lot of action, and here
is where we can give you some – some examples. So one of the things that we want to do to
try and better understand which of the beliefs it is that is – that is really activated
for a person is we want to – we want to really be curious and develop a good understanding.
So we want to try to see things from the person’s perspective. And get a really good sense for
the meaning of what it is that a person is communicating.
So, for example, if somebody is sharing that they are a, you know, the owner of a hospital,
for example, or the owner of an organization or a – a – a – has a particular status,
I might want to find out, what’s the best part of that? What’s good about that? And
when we ask somebody what’s good about that, we get a – we get a really good sense for
just what is it that the person is trying to achieve.
So if we all think about, and, you know, if you feel free to put this in the Chat box
if you want, think about what would be good about, you know, owning a hospital? Or what
would be good about, you know, being a rock star? There are a lot of things that we can
get from that that inform us about what a person may feel like they are missing or lacking
in their life. So maybe it’s that I have control, or maybe that I have status, that
people respect me. There’s a lot of different beliefs that we can learn about getting an
understanding – pop – rock stars are popular and have a lot of fun. That’s a perfect
possibility that someone might say to someone else – that someone might say that gives
us a lot of good information about what is it that they feel like they might be lacking
in their life and what is it that we can help target. Being in control of your life, or
when you are getting discharged, things like that. These are – these are excellent.
So, you really want to ask questions that are going to get us – be curious enough
to get us an understanding, what is the person looking for and what are they hoping to get.
Similarly, when we have individuals who are experiencing – we have individuals who are
experiencing more kind of concerns about their safety and other people, or fear about being
injured in some way, we can ask similar questions to get a good understanding, you know, what
lets you know that this is happening? Help me understand so that I can hear – so that
I can get an understanding from your perspective. So, for example, we’ve had folks who believed
that things were happening to them at night, or they were sharing that they were getting
hurt throughout the night, and we would ask them, you know, what lets you know that that
is happening and help me understand? And we would learn a lot about things like physical
pain that they were experiencing. They were unexplained where when people come in and
out of the room to do checks at night that I’m feeling really – that that’s a really
vulnerable position. I can hear them coming in. I’m experiencing physical discomfort.
And I put those two things together. So we want to get an understanding from the
person because that’s the – that’s the target. That is something that we can then
work with. And what we want to do to help with the empowerment
key is collaboratively engage the individuals in activities that are going to provide that
exact meaning that someone might be looking for. Whether that’s to feel valued, connected,
safe, or in control, right? And so a couple examples. So we are – a couple of you guys
put some great comments about these in the comments already, but we – there’s an
individual – a couple of individuals we work with I want to illustrate these points
with. We’re going to talk a little bit about what it looks like, some of the beliefs targeted,
and then how the intervention came out of those beliefs.
So we did have, you know, an individual who often stated that he was a famous rock star.
And was a famous rock star who would put on concerts regularly. And so when we asked him,
you know, what’s the best part of that or what would be good about that, we learned
some really important information. We learned that for him the best part would be helping
other people. That as a rock star performing, he would have money to give and help other
people. And, actually, I’m going to hit on this. We’ve got a great question from
Doug about – I want to – and I’m going to make sure I hit on it about inadvertently
colluding with the collusion. I’m going to hang onto to that though and make sure
I say it before this slide is up. That’s a great question.
So, we learned that it would be – it would be something that he would be helpful with,
that he would be important and connected to other people were the beliefs that seemed
to be underlying that – that statement that he would make. So that became our target because
there are things that we can all do together on the day to day to be helpful, to have an
important role, and to be connected to other people.
So the intervention for this particular individual involved helping staff organize a clothing
drive to help people in the town in which they lived. And so by having a role in a project
like that, the experience and the statement about being a rock star really didn’t come
up so much as he was involved in that because of having an important and meaningful role
within that context. Another example. We have several individuals
that we have worked with who have indicated that they own the program in which they are
in. And so the – the beliefs that were targeted in that case were the sense of being important
and having control, as you guys – several of you commented on that might be an important
part if you own – own the organization. And so the intervention was providing an opportunity
for the individual to have an important role where he also had a sense of choice and control
in his experience, and that, for this person, involved being a – the resident tour guide.
He gave tours of the residence to new people coming in as well as to new staff and helped
to orient staff, which helped to also level a bit of the playing field between staff and
the residents of the – the place. Less of a power struggle. Because they – they – you
know, this person was able to share his expertise. And similarly he had some – would perform
some work on the unit in a janitorial kind of context that he was very proud of and would
direct other people in how to keep the place clean and – and – and how to run things
well. And so in that – within the context of that role, it actually helped him to connect
more to other people and participate in a lot of the different events within the community
in which he could really connect more with the broader community.
And then finally I want to share with you about an individual who frequently believed
that he was being poisoned, and the beliefs that were targeted about that were really
around disconnection and really perceiving that he was being rejected, and really focusing
on that. And so the intervention there then hits on
those targeted beliefs of helping him to connect and the way in which he connected was to teach
other people. Teach other people. He taught things like chess. Taught things like exercise.
There were a variety of things that he taught to other people which helped him to expand
his connections and be – not experience the rejection so much. And also he was able
to really be a part of the community, and that really reduced his feel – feeling for
being threatened or that people were out to get him.
So to quickly touch on that question about the difference between collusion and – and
getting more information is we really want to understand we’re not asking about the
details of the delusion per se. So not getting a lot of details about, well, you know, where
do you perform your concerts, and what songs do you plan, things like that. And then it’s
really more about, hey, what’s good about that? What would be the best part about that?
And hitting up the meaning underneath. So instead of kind of getting down that – that
path where we can really spiral into focusing on the belief itself, instead we’re focusing
on what is the meaning for the person, and we’re kind of going – circumventing that.
Yeah. What I would say, and it’s just assumptions, but really what we’re doing is we’re figuring
out what the – what the – what the delusion tells us what the person’s need is. What
they really want. Whether it’s safety, importance, belonging, what that is.
And then what we think of – the approach we’re talking about like for safety therapy.
We’re hoping that he gets that need into the light in a way that is actually much more
concrete and immediate for them. And at least that’s what really matters. It’s not – well,
we’re going to the meta level – we’re certainly not colluding. We’re figuring
out what matters. And the delusion has come up because their needs aren’t being met.
So, whether it be for safety, for importance, or both.
So that’s how I would answer that. It’s not so much that we’re – we need to know
what the delusion means to the person so that we can really help them communicate that meaning
better. And one of the things I would like to illustrate
is you don’t need to have something grandiose to replace a grandiose belief. And so there
is still simple ways in which you are connected to other people in making a difference. Like
that gentlemen who is using money within the community to go on outings and things of that
source, can go a long way. Hallucinations are the perceptions – perceptions
of things that aren’t there. And they are often really distressing and upsetting. They
are also one of the – one of the experiences that we see that can lead to some of the dangerous
behaviors because, of course, people can comply with what the voice is saying or similarly
by what they are seeing and act on in it that kind of way.
I’m thinking we don’t have on the slide but that could be useful to keep in mind is
that hallucinations are something that brings to you and pretty much polls – Gallup-like
polls from even all over the world will show pretty much 80% of people will say that they
have heard persons when there’s something not there or seen something when there is
nothing there. And that 88% of people have hallucinations without having a diagnosis
of any sort. And one of the features that seems to differentiate – oh, and you might
find this interesting, too. People who are psychic often report hearing voices in the
way that they see the future. So what’s different with the people we work
with is on the slide. It’s really their beliefs about the voices that seems to really
lead to their distress and sometimes their compliant behavior. And the biggest one, I
think, is that sense of control. The experience really seems like it’s out of control. It
seems like something comes and goes when it pleases. And oftentimes this is the reason
that people who have hallucinations and go through lots of treatment are so demoralized.
And so hallucinations in particular are associated with depression quite a lot and demoralization
in a way that – that the users are more likely to be associated with anxiety for example.
The other really important issue is the credibility. Because physically there are all kinds of
things in the world that they are talking about. But a lot of times the individuals
believe what the voice has to say, and they think it is credible, and that’s more of
those fears that – or they will really be upset at what it’s telling them, that other
people are going to hurt them, or that they should do this, that, or the other thing to
make the world a better place, and that kind of thing.
And, on to the next slide. So empowerment, again, is a belief. And think
of if hallucinations, I think that it’s really a straightforward thing.
Sorry, I’m told I’m being muffled. I’m speaking directly into my thing. Sorry.
So, empowerment can be, I think, for the person, being able to refocus. Because a lot of times
people feel like the hallucinations are keeping them away from the life that they want to
be having or the stuff they want to do. So, if we can identify the aspirations and the
things that you want to be having, then what you can do is you can start to focus away
from the hallucination onto the things that you want. Oftentimes, and it’s pretty easy
to illustrate, if you do some kind of activity with someone that throws stuff back and forth,
you might have a conversation, or you might play a game. And you might notice that during
that time you can’t hear the voices as much. And that what you are doing will help guide
the person to see that what they are doing that actually makes it different.
I would advise, I’m a little bit wary about having people listen to headphones on their
own, only because I think that really a lot of the power of recovery, and the power of
what people want to be doing is with other people. And listening to headphones kind of
isolates you a little bit. So, it might defeat the purpose a touch. But we’ll see in a
second a little exercise how you can utilize and other things that distort sort of once
you understand, but basically it’s really hard to talk and listen at the same time.
And there’s some neuroscience behind all of that. So any kind of activity really engaging
the person outside themselves, emphasizes the fact that they have control. And that
control is something they can draw upon at other times, and that’s what we’re really
referring to. So let me have the next slide. All right.
This one is for you. So this is just an example of an intervention
that can be used to help draw someone’s attention to the fact that they can actually
have control over the experience of distressing voices. So I like to distinguish between it’s
not a tool for distraction, it is a tool – our mission isn’t distraction, our mission is
really about control. So that this isn’t an obstacle so that you can then go do more.
So refocusing and kind of moving – getting over the hump, so to speak, and then moving
towards something else. So this is an intervention called Look, Point,
Name. And it involves kind of guessing a really rough gauge for how distressed somebody is.
And this is something that can be used with folks who don’t describe the experience
as voices. It can just be described as if you’re feeling stressed. You know, it seems
like you are feeling stressed out. Would you say you’re a little stressed, a lot stressed,
somewhere in between? You can adapt it to the individual that you are working with.
But what you do is you say, you know, I’ve got this kind of trick that some folks have
used to help them feel a little bit less stressed, and, you know, what do you say we try it out.
And Look, Point, Name involves looking at something, pointing to it, and saying the
name out loud. It helps to really interfere with those processes that Paul was just describing.
So you go back and forth and back and forth. Now step three here says you keep going until
you run out of objects. My tip for you guys is you want to keep going until we see the
person is really involved in the activity with you and not – and, you know, it’s
just really like, you know, animated. The affect is brighter. They’re going a little
bit faster. That’s a good cue that someone has control in that moment, and so that’s
a great time to say, hey, how you feeling now? Better? Worse? You know, stress low,
medium, high? And they give you the rating again. When they indicate that they feel better
or they feel less stressed, or they are hearing voices less, depending on what they use, you
can say, huh, you know, so do you have more or less control than you thought you did?
Or, wow, doing something likes this really helps you get control over that stress you’re
feeling. I wonder if there are other times you can do this to help feel less stressed.
So it’s a simple intervention that can be modified to an abundance– many difference
ways, but it’s really a test for trying to get some more control over those experiences.
And the importance is that the person notices that they were the one who chose to engage
in the activity which really gives them that control. And you can say, “you helped me,
you did it.” Go ahead, Paul.
Yeah, that’s right. And that’s right exactly. And so then they can see that they have the
control and they can take it with them. Yes.
Here’s some of the conclusions, right, that we talked about. And they are similar to what
we talked about last time. Just a little bit more in terms of sort of posing the questions
to help them see that they are getting what they want and they are doing what they are
hoping to be able to achieve. They are sort of strengthening their sense of control and
efficacy. So you want to move to the next one?
Um hmm. Oh, it should be – oh – Twenty. Yeah. So – so we don’t have a lot of time
to talk about this, which it could be a whole webinar in and of itself talking about anger
and self-injury. And I’m not seeing this slide by hopefully you are.
So – so essentially these are ones that really challenge staff in terms of really,
you know – they are the things that really consume a lot of the resources and that kind
of thing. And so we think – we think that if you look at these two things together,
they are often quite similar. And a lot of the aggressive behavior, the hitting and other
things that we see, often is really reactive kinds of things to these kinds of beliefs
that are underneath what the individual, you know, what the individual walks through the
world seeing. They are looking to not be – it’s like they are expecting to be rejected. They
are expecting others not to like them. They are also in a situation where they are worried
they are going to be weak. A lot of the examples are about being weak and that kind of thing.
So these are kind of really useful beliefs to think about in these situations. So these
often lead to these really kind of – often, often really sort of challenging situations
that we might see. And sometimes the same person has those.
I don’t know if we want to illustrate that with a quick example or if not.
I think that we probably don’t have enough time. I want to be sure we get to teams.
Okay. All right. Okay, so you want to move on to 21?
Okay. And so what we’ve found is that this is where the recovery image is really useful.
And so – so the person who really has an image of themselves in the future, and we
see them working as a nurse, or also – or in that kind of – they can bring that to
bear when they are feeling challenged. And the key to self-injury, it’s often they
get an urge to hurt themselves when they feel rejected or they feel like social things are
not working right. And they can bring that to bear as a way of sort of martialing the
positive emotions that they feel and then the resiliency that they have to be able to
do something different and wait until the urge passes. And we had somebody say that
to us. I know if I sort of focus on my art for a little while, the urge will pass and
then I’m going to be moving more towards the job that I want to have.
And we find it – the positive beliefs, the more we get them activated, the better because
in terms of really being able to help them not engage in these things which are ultimately
getting in the way of what they really want to be doing.
So, go on to the next one. So when we talked last time about resiliency,
these seem to be factors we find over and over again that really seem to lead to these
situations. So feeling rejection, disappointment, actual or – actual disappointment or things
not working out right. Or just feeling overwhelmed. So the feeling overwhelmed often shows us
exactly when somebody is going through some kind of transition, like into a new job, or
into a new living situation, or that kind of thing. That’s when resiliency comes to
bear. If you would show me the next slide.
This is – this is something you might think about in terms of how to work with somebody
to really develop their confidence and their resiliency with regard to any number of challenges
that we have. One of the things that we know is that a lot of times people are having a
lot more success than they report. We often focus on the things that don’t work so well.
And so this is – this is a way to get them to sort of notice things that they could help
other people with, item one. Two, maybe you look at places where they could do that themselves.
And then look at some of the minor stressors they might be facing and them in doing role
plays with them to sort of see how they could – how they could handle it when it comes
up. And this can really prepare them for some real successful movement into whatever it
is that they want to be doing. So in terms of thinking about teams and things
like this, this is a network of care we have been involved in. I’ll talk more about this
tomorrow with Arthur Evans tomorrow. Next slide.
But we did just sort of looked at the levels of care where teams – you can find teams.
These are some of the places we’ve worked. Perhaps you want to jump into a little bit
of a discussion of teams. And ultimately the approach we’ve used, we’ve really been
able to promote the continuity of care with it. I was hoping Ellen could illustrate with
maybe a couple of examples. Oops, sorry. I was muted.
One of the things we have really been able to do with this approach is improve the continuity
of care within the system, and that involves using tools such as the recovery map as a
way to share understanding and have the things that we’ve learned about – about individuals
that help bring them into the adaptive mode, or that really help them have a meaningful,
valuable role. And also just even identifying – knowing what the meanings are behind their
aspirations. Those are things that we have seen successfully communicated across providers
and treatment teams to help support continuity from hospitals and into communities as well
as from residences into new supported independent housing. And these kinds of things are also
really useful and helpful in connecting with the families as well because they can be a
really valuable resource for when is a person at their best? How do we understand it? And
can share a continuity between loved ones and treatment providers as well.
So some of the ways that we have seen this translated across the different types of programs,
we’ve been able to really help to develop programming that then meets the meanings that
people are looking to experience and help them to experience steps so lead them toward
the aspirations that they want. And this is kind of a cross setting. We’ve seen this
in residential settings. We’ve seen this on act teams. We’ve seen this in hospitals
as well and in outpatient providers who have really integrated activities for individuals
to pursue interests, engage in aspiration-oriented activities, have meaningful roles, and really
become a part of the community. And we have really found that there are a lot of beautify
ways that people have connected in activities that they do in the treatment-oriented setting
to activities that actually exist in the community. For example, people who have joined book clubs,
and Bible studies, and building clubs. Things that might occur in any community. They can
begin at any stage of this. So we have really worked with teams to knowing this formulation
and this way of understanding individuals, really incorporate their individualized programming
to provide the opportunity in-house, which provides the confidence and success to then
lead into just living a really rich, full life. I do think that that actually summarizes
kind of the next several slides of stuff. And everyone, we do have access to the slides.
I know we’re up against time here, but everyone will have access to the slides for the details.
That was kind of my summary. Paul, do you want to end?
Yeah, sure. I was going to say, we didn’t get a chance to really cover so much the treatment
team. The treatment teams follow the same approach in the sense that you started off
by accessing the person’s adaptive mode. Then you sort of switch over to what aspirations
that they are working on, and really how they are dealing with them. And then you can in
some of the challenges towards the – as you move along, which really leads to a really
productive and dynamic conversation which is ultimately one that they really want to
be – be having anyway, and it really avoids a lot of the conflict, and I think becomes
a better experience for everyone because treatment teams can be a little daunting.
So maybe at that point we should wrap up what we’re talking about. And we can – we can
address some of the concerns that we didn’t discuss just now in the questions-and-answers
if that would be helpful. Thanks, you guys. I know there were both some
technical difficulties and there’s just such rich information here that I think any
one slice of this could be talked about for a long time, which is why you have a full
training available. And so I want to, you know, be sure and make note of that. That
we – we know we’re just sticking our toes into the water on this topic, and I appreciate
your working with us in this format. I do have some questions that were presented
and sent by the audience. One of the questions was, I find that there
is some resilience in the delusion that supports survival and often harkens back to early childhood
trauma or other toxic stress. What are your thoughts about this?
Um, yeah. I think that – I’m thinking of several examples. Within the delusion,
you can see some strengths, and I do think the person is often doing as well as they
can do. Obviously sometimes the delusion creates a social liability for the person because
a lot of other people don’t really – don’t really, you know, appreciate it. They don’t
see it as true and things like that. But I do see that there’s often some real – some
real strength in there. And what we’re really trying to do is to try to see if we can harness
that so that the person can actually get more of what they want. Because certainly when
you are really paranoid and afraid, it’s very hard to really make a difference in the
world, which is what a lot of people want to do.
Similarly, if you are really thinking that you have billions of dollars or think you
are a deity, it’s much harder for you to actually concretely do some of that stuff.
But I do think that – I do think that even within the other – the other – some of
the other challenges that we’ve discussed, there’s usually some real strengths there
that you can grab onto. I don’t know, Ellen, if you want to say
anything about that. No, I think that’s great.
Another question was kind of trying to get a little clearer about how you select the
intervention based on the type of hallucination, perhaps, that someone is hearing. So if someone
is hearing voice commands, for instance, would you select a different intervention versus
another type of – of voice they were hearing? Sure. I think that it really – that’s
where the formulation and understanding kind of what might be stoked up for a person is
really helpful. So I think that there are – excuse me – I think that for some, like
we talked about where it’s maybe that they are just hearing a lot of negative things
or hearing very distressing things and it’s not necessarily commanding them to do anything
but it’s – it’s – it’s just a really stressful experience. Getting a sense of control
and also interventions that will help with maybe having – giving that person successful
experiences to demonstrate that the voices are not actually credible, they don’t tell
the truth. Then for someone who might be experiencing
a command hallucination, I think of an example of a gentleman who heard voices that he needed
to – he needed to hit someone. But the reason that he needed to hit one person was because
if he didn’t hit that person, then several other people would be hurt. So that right
there gives us a clue that the desire to comply with that voice might be because the person
actually really wants to help other people. And that maybe he was afraid or that people
are in danger. And so I think that that would inform the intervention in a way that how
can we maybe counter some of the beliefs that a person is having that would stoke some of
those voices up in a way. I don’t know if that’s a helpful explanation.
But it’s absolutely right that you want to target it and tailor it to whatever either
belief seems to be especially activated and provide an experience that was going to counter
that. Um hmm.
But I also think it’s really important to emphasize that we want to do that in the context
of their aspirations. Aspirations.
Really the kind of things that they want to be doing. It’s – it’s getting rid of
the stress is only part of the equation. You want to do it – it’s easiest, I think
– not easiest, but it’s much more effective if you do it in the context of helping the
person really get to some meaningful life experiences, that they really are connecting
it with their values and their aspirations. And so I would want to take this opportunity
to remind people who perhaps weren’t on sessions one or two that they can learn more
about the role of aspirations in those earlier webinars. And that it does really build on
itself. And so just the same way successes build on themselves for us to be able to do
more and more, the – the content for these webinars do the same.
The other part that I was reminded of is how much, and how important it is that – that
any intervention be seen as an art rather than a science. I mean there’s a – there’s
a – there’s a structure, and you all have done a fabulous job, like with the recovery
map and things like that, to identify a structure to hold things up. But that the nuances are
art. And so the – the more you know someone, the more you are able to determine if you
should pursue a voice command or not. And I’m afraid that leaves us with our need
to close up, and in doing so, what I want to do is first of all thank you all. I want
to remind the audience that we will be back on – not tomorrow – but in two weeks,
on February 21st, with Dr. Grant. And we will have Dr. Arthur Evans joining us for the final
session of this webinar series. Ellen, it has been great to get to know you
through these first three sessions, and I look forward to having you kind of hanging
out in the wings next week as well. We couldn’t do any of this without the support
of SAMHSA, and that it’s SAMHSA’s recovery-oriented practices that are the foundation of everything
that Recovery to Practice does. And so practices like these and our other webinars are designed
to help the whole field, regardless of discipline, become better at what we do. And for all of
us to become better in our own recovery. So Recovery to Practice, if you don’t know,
is an initiative that is designed to help the various disciplines come together and
put into practice the principles of recovery. And have it not just be something that is
theoretical or intangible, but to make it very tangible and that we can act on it.
We want you to be able to continue your learning, and so with that we have available some additional
resources as well as additional resources provided by the trainers, and so I hope you
will take the time to check out these links, and read the articles, educate yourselves
as providers. We also have a newsletter that is published
roughly quarterly, and we would want you to know that there is additional information
specific to recovery-oriented cognitive therapy in our most-recently released version of the
newsletter. If you do not already get that, you can by
visiting the samsha.gov website and going to Recovery to Practice.
As our mentioned, our final webinar in this series will be presented on February 21st,
1:00 Eastern Time. Please adjust for your time zone. You can click on this link to register,
and we hope that you do. These have been in high demand, and so registering early, and
calling in early, is well advised. If you would like to get your continuing education
credit, and I know that there are a lot of you who do want that, you will be able to
click on this link, and you will be taken to a page where you will complete a very brief
questionnaire, and you can then take the quiz to get your continuing education credit. This
credit is brought to you by NADAC (SP) and is approved for a number of disciplines. So
know that it is likely to cover yours. I hope that you will take the time to pursue this
continuing education credit, and also let people know about this webinar series. And
we have a great year coming up, and we want you to be able to get the kind of support
that you need. If you cannot make the actual time, you can still register, and that way
you will get a link for when the recording is available.
So with that, Paul, Ellen, thanks for your wisdom, your education, your science, and
providing that to us. We will see you all in a couple of weeks. Everybody, have a great
day. That concludes this webinar. Thank you.