Behavorial Health is Essential To Health Prevention works...illness (i.e. treatment packages that...
Transcript of Behavorial Health is Essential To Health Prevention works...illness (i.e. treatment packages that...
People Recover
Treatment is effective
Prevention works
Behavorial Health is Essential To Health
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Recovery-Oriented Cognitive Therapy:
Theory, Evidence, and Activating the
Adaptive Mode
Paul M. Grant, Ph.D. & Ellen Inverso, Psy.D.
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https://www.ncbi.nlm.nih.gov/pubmed/24079355
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https://jamanetwork.com/journals/jamapsychiatry/fullarticle/1107449
Background and Theory
Symptom, Side Effect, Secondary Diagnosis?N
egat
ive
Sym
pto
ms Decreased
emotional response
Decreased motivation
Reduction in socialization
Decreased speech and activity
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Of 7678 people diagnosed with schizophrenia• 41.0% had at least two “negative”
symptoms documented• Frequency:
Motivation 30.5% Affect 27.4% Eye contact 26.0% Emotional withdrawal 23.5%
South London and Maudsley NHS Foundation Trust (SLaM) Biomedical Research Centre (BRC) Case Register
Cognitive Model: Beck’s Cognitive Triad
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Negative views about the world
Negative views about oneself
Negative views about the future
Everyone hates me because I’m worthless.
I am worthless.I’ll never be good at anything because everyone hates me.
Dobson, K. S., & Block, L. (1988). Historical and philosophical bases of cognitive behavioral theories. Handbook of Cognitive behavioral Therapies. Guilford Press, London.
Beliefs about self, other, and the world
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Cognitive Triad 1Self
2External
3Future
SymptomSituations
Task Orientation
I am broken, inadequate, and inefficient
The task is too demanding
I will failAmotivation, Avoidance
PleasureI am incapable of having pleasure
Nothing out there is enjoyable
I won’t enjoy the activity
Anhedonia: inability to feel pleasure
Inter-personal
I am unlikeableOther people aren’t friendly
If I socialize I will be rejected
Asociality, Avoidance
EnergyI don’t have energy
The demand is too energy depleting
I won’t have energy to do it
Anergia: abnormal lack of energy
Connection
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Baumeister, R. F., & Leary, M. R. (1995). The need to belong: Desire for interpersonal attachments as a fundamental human motivation. Psychological Bulletin, 117(3), 497-529.http://dx.doi.org/10.1037/0033-2909.117.3.497
Basic Science: Constructs
• Understanding mechanisms informed by cognitive model to drive treatment
• Measure development and validation
• Self esteem scale
• Cognitive insight scale
• Uncertainty tolerance
• Excitement interest scale
• Self concept scale
• Other validated measures: community participation, functional outcome, neurocognition, symptomatology, and beliefs (e.g., hopelessness, avoidance, flourishing)
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Studies
• Association (path analytic/structural equation modeling/regression)
• Cross sectional• Longitudinal
• Experimental
• Experience Sampling
• Samples: Chronic, ultra-high risk, early episode
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Defeatist Beliefs
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Neurocognitive Performance
Defeatist Beliefs
Negative Symptoms
-.32* .41**
-.24*
Taking even a small
risk is foolish
because the loss is
likely to be a disaster.
Meta-Analysis
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Timothy R. Campellone, Amy H. Sanchez, Ann M. KringSchizophr Bull. 2016 Nov; 42(6): 1343–1352. Published online 2016 Mar 15. https://www.ncbi.nlm.nih.gov/pmc/articles/PMC5049520/
Asocial Beliefs
“I prefer hobbies and leisure activities that do not involve other people.”
“People sometimes think I am shy when I really just want to be left alone.”
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THE EXISTENCE of multiple pathways to community participation in a longitudinal model supports the utility of multi-modal interventions for serious mental illness (i.e. treatment packages that build upon individuals' strengths while addressing the array of obstacles to recovery) that feature Unproductive attitudes and motivation as treatment targets.
From neurocognition to community participation in serious mental illness: the intermediary role of dysfunctional attitudes and motivation.
Thomas EC, Luther L, Zullo L, Beck AT, Grant PMhttps://www.ncbi.nlm.nih.gov/pubmed/27884217
Pathway Paper*
Defeatist Performance
BeliefsMotivation
Community Participation
Asocial Beliefs
MotivationCommunity Participation
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* From neurocognition to community participation in serious mental illness: the intermediary role of dysfunctional attitudes and motivation https://doi.org/10.1017/S0033291716003019
Self-Concept
Delusions
Motivation
Self-Concept
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Cross Sectional: Defeatist Beliefs Results
Baseline Defeatist
Beliefs
Neurocognitive Performance
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p < .01
Defeatist Beliefs and Neurocognitive Performance
Baseline Defeatist Beliefs
Change in Neurocognitive
Performance
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p = .04
Changes in Defeatist Beliefs from Baseline to
6 months
Changes in Neurocognitive
Performance from 6-12 months
p = .034
Cognitive Insight and Neurocognition
Baseline Cognitive Insight
Change in Neurocognitive
Performance from Baseline to Follow up
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p < .01
Changes in Cognitive Insight from 12 to 18
months
Changes in Neurocognitive
Performance from 18 to 24 months
p < .01
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Negative Symptoms
Effort
Defeatist Beliefs Poor
Performance
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Social exclusion
?
Mood
Stress
Self-defeating attitudes
Reduced effort
Avolition
Decline in global defeatist beliefs
Improvement in social functioning
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Decline in work-specific defeatist beliefs
Better social functioning, self-esteem, and work
behaviors
Mervis, J. E., Lysaker, P. H., Fiszdon, J. M., Bell, M. D., Chue, A. E., Pauls, C., ... & Choi, J. (2016). Addressing defeatist beliefs in work rehabilitation. Journal of Mental Health, 25(4), 366-371.
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Social ExclusionDefeatist Beliefs and
Poor Performance
Reddy, F., Reavis, E., Polon, N., Morales, J. & Green, M. (2017b) The Cognitive Costs of Social Exclusion in
Schizophrenia. Schizophrenia Bulletin 43, S54-S54.
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Validation:
Clinical Trial of CT-R
http://www.mentalhealthexcellence.org/wp-content/uploads/2013/10/2011_ArchivesGeneralPsychiatry_doi-10-1001-archgenpsychiatry-2011-129.pdf
Summary of CT-R Clinical Trial
Compared to people with Standard Treatment (ST) only,
people who received both Cognitive Therapy (CT) and
Standard Treatment (ST) had:
• Better functioning (d = 0.56)
• Reduced avolition-apathy (d = -0.66)
• Reduced positive [active] symptoms (d = -0.46)
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(Grant et al., 2014, Archives of General Psychiatry)
Clinical Trial Follow-Up
Gains maintained over the course of 6-month follow-up in which no therapy was delivered:
• Better Functioning (d = 0.53)
• Reduced Negative Symptoms (d = -0.60)
• Reduced Positive Symptoms (d = -1.36)
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Six-Month Follow-Up of Recovery-Oriented Cognitive Therapy for Low-Functioning Individuals With Schizophrenia Grant, Bredmeier, Beck. https://ps.psychiatryonline.org/doi/abs/10.1176/appi.ps.201600413?af=R&
Clinical Trial Follow-Up
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NOTE: tp < .10, * p .05, ** p < .01
Mechanism of Therapy
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Importance of Positive Beliefs
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• 35 individuals with low neurocognitive scores and elevated negative symptoms
• Guided Success vs Control
• Changes in positive beliefs and mood most impact improvement in task performance
Translating Science to Practice
Access Energize Develop Actualize Strengthen
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Adaptive Mode
• Activating the adaptive mode• Ways to engage
• Beliefs increased
• Aspirations• Goals: valued, meaningful,
personal
• Meaning of accomplishing goal
• Obstacles• Current behaviors/obstacles
• Beliefs underlying obstacle
• Positive action• Current strategies and
interventions
• Symptom/behavior targeted
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Challenges to getting started
• Isolation
• Low energy
• Limited access to motivation
• Interpersonally lack of confidence
• Demoralized
• Hesitancy to connect and trust
• Really distressed
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When are people at their best?
• Birthday parties
• Big sports events like Super Bowl or NCAA Championship
• Picnics, gatherings with friends
• Movies or theater
• Listening to or playing music
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What do people look like at their best?
• Funny & Personable
• Knowledgeable
• Energized
• Warm
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Accessing the Adaptive Mode
• Shared interests• Talking• Doing
• What do we enjoy?
• What makes us happy?
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Accessing the adaptive mode
• Asking for advice• Problem solving
• I’m going to a potluck what should I make?• Binary questions
• This song or that song?• Curiosity about specific pockets of knowledge
• I’m trying to learn more about the sound of the city in the 60s – what should I know?
• Teach me…• About a specific skill set – dance move, recipes,
health tips
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Action Plan
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What do you want to try?1. _______________2. _______________3. _______________4. _______________
Questions DiscussionComments
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Thank you to our presenters
Paul Grant, PhDAaron T. Beck Psychopathology
Research Center
Ellen Inverso, PsyDDirector of Clinical Training
Beck Recovery Training Network
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SAMHSA’s
10 Principlesand
4 Dimensionsof Recovery in
Behavioral Health
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HomeHealth
CommunityPurpose
Recovery to Practice
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Through education, training,
and resources SAMHSA’s
Recovery to Practice (RTP)
program supports the
expansion and integration of
recovery-oriented behavioral
health care delivered in
multiple service settings
between multiple disciplines.
Want to continue your learning?
1Patel R, Jayatilleke N, Broadbent M, et al Negative symptoms in schizophrenia: a study in a large clinical sample of patients using a novel automated method BMJ Open 2015;5:e007619. http://bmjopen.bmj.com/content/5/9/e007619
2Rabinowitz J, Berardo CG, Bugarski-Kirola D, et al. Association of prominent positive and prominent negative symptoms and functional health, well-being, healthcare-related quality of life and family burden: A CATIE analysis. Schizophr Res 2013;150:339–42. http://dx.doi.org/10.1016/j.schres.2013.07.014
3Campellone TR, Sanchez AH, Kring AM. Defeatist performance beliefs, negative symptoms, and functional outcome in schizophrenia: a meta-analytic review. Schizophr Bull 2016;42:1343-52. https://www.ncbi.nlm.nih.gov/pmc/articles/PMC5049520
4Peuskens, J., Demily, C., & Thibaut, F. (2005). Treatment of cognitive dysfunction in schizophrenia. Clinical Therapeutics, 27 Suppl A, S25-37. https://doi.org/10.1016/j.clinthera.2005.07.015
5Choi, KH, Jaekal, E. Lee, GY. (2016). Motivational and Behavioral Activation as an Adjunct to Psychiatric Rehabilitation for Mild to Moderate Negative Symptoms in Individuals with Schizophrenia. - PubMed -NCBI. Retrieved November 11, 2017, from https://www.ncbi.nlm.nih.gov/pubmed/27895602
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RTP Companion Newsletter on
Recovery-Oriented Cognitive Therapy
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Sign up to receive the RTP quarterly newsletter by visiting our webpage:https://www.samhsa.gov/recovery-to-practice
2018 RTP webinar Series: Recovery-Oriented Cognitive Therapy
Discovering Meaningful Aspirations and Taking Action#2 of 4 on Wednesday, January 17, 2018 1:00 pm to 2:00 pm ET
Remaining Dates:
Feb 7th and Feb 21st
Click here to register: https://ahpnet.adobeconnect.com/ekfeiy0nl7qt/event/event_info.html
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