Transcript Mount Sinai ACTT in Practices and Actions

How to Improve ACTT Practices
Based on Criticism
Wendy Chow, MSW RSW
Assistant Professor, Dept of Psychiatry,
University of Toronto
Head, International Education, Dept. of Psychiatry, University of Toronto
Program Manager, Assertive Community Treatment and Mental Health Court Support Program
Vice President, Ontario ACT Association
Dr. Joel Sadavoy, M.D., F.R.C.P (C)
Professor and San and Judy Pencer and Family Chair in Applied General Psychiatry, University of
Toronto
Director, the Cyril and Dorothy, Joel and Jill Reitman Centre for Alzheimer Support and Training
Head Geriatric and Community Psychiatry Program, Mount Sinai Hospital
Ontario ACT Association 2012 Workshop
April 19-20, 2012
Outline
• Who are the clients treated in ACT?
• Addressing clients criticisms of ACT
• Intervention & techniques to form better
therapeutic relationships
Schizophrenia is a complex
illness.
• Integrated medication, psychosocial and
rehabilitative approaches are necessary
for effective treatment (APA guidelines for Rx of patients
with Schiz 1997)
The Perfect System
• Based on the nature of the disease/dysfunction
rather than traditional institutional organizations
• Integrates the full array of necessary servicessocial and medical
• Addresses the social breakdown in families,
work, friendships, physical health needs etc
• Addresses the inevitable need for intermittent
acute institutional care
Schizophrenia is not a hopeless
disease but takes special skills to
manage it
• 1/3 do well over time
• 1/3 do moderately well (i.e. stabilized even
though symptomatic)
• 1/3 do poorly with relapses and poorly
controlled symptoms- they never really get
better (these are the clients usually treated
by ACT teams) (Wahlbeck et al Cochrane Database of
systematic reviews, 3, 2003)
Factors in Poor Outcome Group
• Inherent nature of the disease
• Treatment failures- medication non-compliance;
medication is essential
• Client’s Isolation, homelessness, family/social
rejection, unemployment, and loss of sense of
self
• Under treated medical illness, especially
culturally diverse populations
• MH systems are not well structured to deal with
this problem.
ACT Studies
• ACT extensively studied in RCT’s
• Reduced hospital use in 74% of studies (eg.
McGrew et al 1995, Tibbo et al 1999,Lehman et al 1997 )
• Housing stability -67% of studies
– E.g.. Reduces homelessness – (Lehman et al 1997)
• Improved QOL in 58%
• Very good client satisfaction in 88% of
studies
One yr/6month Reduction in IP Hospitalization After Admission
MSHACT/ KACTT
120
100
104
97
One year before
MSHACTT
80
One year after
MSHACTT
60
60
52
40
One year before
KC ACTT
45
20
21
One year after
KC ACTT
23
17
14
14
8
7
0
mean number of
hospitalized days
per patient:
MSHACTT 78%
KUINA 71 %
reduction
total number of
admissions:
MSHACTT 57%
KUINA 47%
reduction
number of patients
with at least one
inpatient admission:
MSHACTT 56%
KUINA 47%
reduction
Reduction in Inpatient Hospitalization After Admission into Mount
Sinai Hospital Assertive Community Treatment Team
Three Year Follow Up Study ( n=61)
6939
7000
One year prior to ACTT
6000
One year after ACTT
5000
two years after ACTT
4000
three years after
ACTT
3000
2000
1314
781
1000
0
total number of hospitalized days
664
Client Criticisms of ACT (1)
• Very Little literature on satisfaction
McGrew J., Wilson R, Bond G.
An Exploratory Study of What Clients Like Least About
Assertive Community Treatment Psychiatry Serv 2002; 53:761763
Client Criticisms about ACT (2)
• McGrew et al 2002
• N=182
• Results :
– No complaints - 44%
– Home visits, intrusiveness, overemphasis of
medications - 21%
– Service frequency, availability of staff - 16%
– Insufficient financial support, inconvenient
location of program - 19%.
Overemphasis of Medication
What are the reasons clients
resistant to medication?
• Medication sometimes does not work
• Side effects lead to impaired function and self
perception
• Poor alliance with and trust of team/clinicians
and mental health workers impairs compliance
• Medication experienced as stigma, external
control, symbol of failure
• Failure to develop a concept of medication as
an ally
Medication is essential to good
outcome
• High relapse group- one year relapse rates in
responsive clients: 45-70% with placebo, 2030% with typical antipsychotic (atypical may be a
little better)
– Medication maintenance appears essential (although
not sufficient on its own) (e.g. Tran et al 1998; Ohmori
et al 1999 Deliva et al 1998; Carpenter 1996)
– 2.5-10 fold decrease in relapse rate with medication
(Davis 1985)
Clients Criticisms of ACT
Frequency of contact
Recommend minimum of 2/week
Flexibility is essential and tailored to needs of the
client and symptoms
Clients Criticisms of ACT
Availability of Staff
Availability of Staff
24/7 model has many challenges: e.g. staff
willingness, funding, burnout; team management
is essential in this model
Clients Criticisms of ACT
Location
ACT program offices need to be
close to clients in the
community
But the office is not the primary location of service
provision; overemphasis on office management
defeats ACT model
Clients Criticisms of ACT
Intrusiveness
Intrusiveness emerges when there is poor
alliance with the client and failure to allow
maximum autonomy based on functional
capacity
Six important elements to reduce
sense of intrusiveness
•
•
•
•
Empathy as the core of the alliance
Uncover the person within the illness
Understand the Trauma of illness
Learn the client’s internal experience of their
illness
• Understand the impact of chronic illness
• Understand client’s self perception as it relates
to Medication- Compliance and attitudes to
medication
Evidence for the Importance of the
Psychological Perspective
• Clinical - Clients tell us: what they experience as
positive and negative in therapy
• Frequent failure to establish an empathic alliance
– Desire to avoid treating this population- frequent
relapse and little improvement (Parker et al)
– Failure to establish empathy is related to high
staff/clinician and mental health worker burnout rates
(Astroem et al)
• Evidence for psychotherapeutic efficacy
– Adjunctive therapy in combination with medication
(Meuser)
– Effectiveness of CBT (Tarrier et al, Sensky et al)
Regardless of presentation the
Psychological therapeutic tasks
remain the same
• Establish relationship and therapeutic alliance to
the greatest extent possible- engage with the
healthy remaining part
– Client almost always has double bookkeeping
• Develop a psychological understanding of the
client
– Based on the idea that the client’s illness occurs in an
inner psychological context that interacts with the
outside world
– Clinicians and mental health workers’ task is to
understand this context and use it for the client’s
welfare
Empathy
• The degree to which an individual can mentally
identify with another and see ( and feel ) the
world as they do. Trial identifications while
attempting to understand
• Much more challenging with experiences that
are highly unusual or repugnant
eg. Hallucinations or delusions
• May be enhanced by a shared group experience
among clinicians and mental health workers
Uncovering the person within the
illness: Who is the client?
• Client often feels like a diagnosis not a person
• The illness exists in the context of the client’s life
and development
• The client’s psychic reality
– Dreams, ambitions, loneliness, isolation, rejection,
hopelessness, self-perceptions
– Sources of happiness and creativity
– Cognitive distortions about the illness and its
treatment
Internal Experience 1
• Cognitive Distortions
– I am incurable
– I am shameful
– Others cannot love or care about me
– My drugs are dangerous/will harm me
– Nobody understands/believes me
– People think I am crazy/bad/dangerous
symptoms
Internal Experience 2
• Impact of hallucinations on function and
concentration
• Experience of delusions
• Not being believed/labeled crazy
• Fear and panic
• Desire
• Grandiosity
• Responsible for bad events
Trauma of the Illness
• Emergency/police/hospitalization
experiences- force and compulsion
• Medication side effects- contribute to
negative symptoms
• Societal reactions/ violence/ living on the
street
• Family rejection
• Harsh clinicians and mental health
workers
Chronicity
• Chronic maladaptive beliefs and patterns
of interaction with others
• Chronic impaired or maladaptive social
interactions- friendships within the “misfit”
community
• Substance abuse
• Inadequate living/economic arrangements
• Fears - eg. Robbery, violence, illness
• Chronic illnesses- inadequate medical
care
Medication and Self perception
• Compliance related to alliance with clinicians,
mental health workers and trust
• Mistrust of the system - authorities and health
workers reinforced by paranoid thought patterns
• Negative side effects lead to impaired self
perception and function
• Medication as visible stigma
• Medication as symbol of external control
• Medication as symbol of failure
• Developing a concept of medication as an ally
Goals and Tasks of Psychological
Intervention 1
• Engaging the client and connecting with them
• Understanding and therapeutic
relationship/alliance
• Translating behavior into meaning
• Communicating- finding a common language
• Destigmatizing
• Dealing with shame, loss, identity, relationships
and sexuality
• Setting realistic goals
Goals and Tasks of Psychological
Intervention 2
• Maintaining a therapeutic stance - limit setting
• The holding environment - containment/reducing
alienation/therapeutic haven
• Tolerating uncertainty confusion, not knowing
and sometimes anxiety or fear
• Hopelessness/nihilism- the client cannot form a
therapeutic alliance at first; suicide ( 50 times
higher in Scf )
• Managing Therapeutic isolation
• Frustration - transference and how not to take it
personally
Creating and Sustaining a
Relationship
Factors
• “Know” the client
• Establishing trust (uncertain course and vicissitudes)
• Persistence and re-finding the relationship
• Fluctuations in the relationship
• Boundary issues
• Managing one’s own feelings
– Guilt, anger, anxiety, tension, fear, confusion, tolerate ambiguity
(to know and not know at the same time)
– How not to take it personally
– The hopeless therapist/ clinicians/ and mental health workers
Knowing the client: what does this
mean?
• Ask about their life and create a narrative
• Inquire about the client in a manner that
creates an emotional understanding- not
just facts
The Role of History and
Developmental Factors
• Early life experience- family dynamics
• Effects of adult life experiences including
culture and immigration
• Traumatic events
• Character and personality evolve over
time
Techniques 1
Creating a safe space
• No physical contact
• Absolute confidentiality, but within the team structure
• Non-judgmental
• Reliable - I do what I say
• Containing client
• Consistent - regularity and predictability of contacts
• Available - personal vs. team
• Don’t retaliate or withdraw- deal with own feelings without them
coming out in the therapy- client takes advantage of you or client
who seems to take advantage of you (client is 2 hours late and you
are really busy and then they are mad at you) - how not to take it
personally
• Inquiring and seek to understand
Techniques 2
• Creating an alliance means determining
what part of the client remains healthy ie.
Is there a part of the client that remains
intact and capable of insight or
understanding
• Some healthier parts almost always
present to some degree
Techniques 3
Explore clients experience of their illness convey to client your desire to understand
• Impact of illness on their relationships
• Impact of illness on their self esteem
• Practical effects- job, money living situation
• Effect on family and acceptance by society
Techniques 4
• Understand the client first from their own
perspective without imposing your own at
first
• How do they see their situation, the
causes of their illness, the best treatments
• Collaborate instead of confrontation
Techniques 5
• Set mutually agreed on goals to the extent
possible
• Goals should be practical and realistic
• Sometimes necessary for the clinicians
and mental health workers to set limits
– Non-judgmental and not angry limits - ie nonpunitive limit setting
Techniques 6
• The process does not go in a straight lineups and down
• Recognize and tolerate client’s need for
elements of control
Techniques 7
• Ambivalence- inherent in the illness
• Thought disorder- unusual associations; learn
clients mode of communication and use of
language, distortions and symbolism
• Look for subtle clues to what the client is
experiencing when his affect is inappropriateeg. laughter when anxious or sad
• Understand client’s need for distance and nature
of unusual emotional expression
• Attend to what triggers hallucinations
• All this emerges in the course of the therapeutic
encounter
Techniques 8
• Group Activities
-
Life skills group
Line dancing group
Music group
Baking group
Noodle group
• Groups address the needs of our clients
References
• Tarrier N et al randomized controlled trial of intensive cognitive
behavioural therapy for patients with chronic schizophrenia BMJ
1998;317:303-307
• Sensky T et al A randomized controlled trial of cognitive-behavioral
therapy for persistent symptoms in schizophrenia resistant to
medication Arch Gen Psychiatry 2000;57:165-172
• Packer S et al Psychiatric residents’ attitudes toward patients with
chronic mental illness Hosp Comm Psychiatry 1994;45:1117-1121
• Woodside H et al Hope and Schizophrenia: exploring attitudes of
clinicians Psychosoc rehab J 1994;18:140144
• Astroem S et al Staff burnout in dementia care: Relations to
empathy and attitude Int j Nursing Studies 1991;28:65-75
• Fox V. Empathy : the wonder quality of mental health treatment
Psychiatric rehab J 2000;23:292-293
• Meuser K et al Psychosocial treatment approaches for
schizophrenia Curr Opinion in Psychiatry2000;13:27-35