Wellness Management & Recovery Coordinating Center of Excellence

Kelly Wesp, PhD, Stephanie Ozbun, LSW, and Deborah Wilcox, PhD, Confluency Consultants & Associates

Goals of the WMR Program

  • Identify and achieve personal recovery and wellness goals
  • Develop informed collaborative approaches to selecting and managing treatment
  • Embark upon a journey to wellness

Hallmarks of WMR in Ohio

  • Participants in WMR Program set their course for recovery and wellness and find support from others with similar experiences
  • Based on Social Cognitive Theory (Bandura, 1986) with an emphasis on skill development, self-efficacy, and modeling
  • Recovery and Wellness are viewed from the participant’s experience (not the facilitator’s)

WMR Program Sessions

  • Mental Health Recovery
  • Wellness
  • An Understanding of Mental Health
  • The Role of Medication in Recovery and Wellness
  • Learning to Manage Symptoms and Side Effects
  • Effective Communication
  • Communicating with Your Providers
  • Coordinating Your Care
  • Building Social Supports and Involving Others
  • Planning for Wellness

Building Collaborative Relationships

doctorWMR provides opportunities to learn and practice new skills.  These skills assist participants in making better choices about their healthcare and to form collaborative partnerships with their providers.

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

Unique Aspects of WMR

  • Peer centric
  • Transformative
    • Promotes system change
    • Creates and supports peer and professional leaders
  • Promotes communication and collaboration
    • Between peers and providers
    • Inter-agency (COS, CMHC, Vocational, & State Hospitals)
  • Builds relationships across differences
  • Demonstrates Multicultural Competency
  • Implementation is Adaptable/Flexible

Peer Leadership is the Magic of WMR

  • Challenges the stigma associated with psychiatric and co-occurring illnesses
  • Provides new information on collaboration and partnership in healthcare service delivery
  • Develops ongoing wellness and advocacy outside of the behavioral healthcare setting

WMR Groups:  Building Communities of Wellness

  • Creating a safe space and place through the use of psycho-educational group process.
  • Uses the multicultural framework to ultimately enhance group effectiveness
  • Based on Yalom’s (1985) vision where true universality can occur within the context of psycho-education groups, members can discover the deeper connections between people based on their existential experiences and struggles, rather than on surface level similarities.

WMR Groups: Engagement in Deliberative Dialogue

  • Deliberative Dialogue not a debate it is engagement in collective learning; everyone in the group participants simultaneously as a learner and teacher.
  • Each group member is an expert on how the issues of wellness & recovery impacts there lives; group members share their stories.
  • Everyone is encouraged to participate in the group in the manner that works best for them .
  • Group members are encouraged to “share the oxygen” and not to dominate during the dialogue.
  • “Active Listening” and providing one another with feedback and support during the group process fosters safety and authentic engagement.
  • Exploration of holistic wellness and recovery occurs throughout the WMR group process and within the curriculum activities. Each participant is supported in the construction of their personal wellness and recovery goals and encouraged to share them with members of the group via the “ Wellness Wheel Goal setting process.

The Growth and Expansion of WMR

  • 26 Diverse Organizations involved
  • 350 Persons Trained on the WMR Model
  • Of the 350, 195 are Persons in Recovery
  • Over 125 individuals have completed the WMR Program more than once
  • Alumni Clubs have been developed in multiple communities to sustain ongoing wellness and recovery goals

Measuring Recovery Outcomes in WMR

  • Where does the “EVIDENCE” come from that supports a clinical practice as “Evidence-Based” ?
  • It comes in the form of feedback from practitioners and recipients of services about whether, or how well, the clinical practice is working
    • is there concrete evidence that the practice is really doing what it is supposed to do?
  • This feedback is collected in the form of data that measure possible recovery outcomes

Measuring Recovery Outcomes as We “Transform the System”

  • The recovery paradigm guides and directs the policies and practices of our mental health system, and is the primary goal of the “transformed system”
  • And yet…“Mental Health Recovery” as an “outcome” is a tough theoretical construct to measure
  • So, we often don’t…we tend to measure institutional outcome variables (hospital days, CSP use, medication adherence, symptoms, or NOMs), rather than personal change outcomes (such as enhanced self-efficacy, empowerment, quality of life, learning and personal growth, or spirituality)

WMR uses a Multidimensional Assessment of Individual Recovery

  • Mental Health Recovery Measure (MHRM)

a consumer derived recovery measure that includes 8 conceptual domains of the recovery process: Overcoming Stuckness, Basic Functioning, Self-Empowerment, Learning and Self-Redefinition, Overall Well-Being, New Potentials, Spirituality, Advocacy / Quality of Life

  • WMR Client Self-Rating Scale – curriculum-focused measure includes:
    • Knowledge Increase (learning)
    • Better Coping with Symptoms
    • Use of Wellness Planning
    • Progress towards Personal Goals

Measuring Individual Recovery Outcomes: What role does participation in the Wellness Management and Recovery (WMR) program play in promoting “social connectedness” or in helping people get relief from trauma symptoms through the promotion of resilience ?

  • WMR Social Support Questionnaire
  • Resiliency Questionnaire
  • PTSD

WMR Research Design

  • Ongoing Open Clinical Trial / Longitudinal Design
    • Pre, Post, and 6-month Follow-up assessment
  • Current Sample Sizes (as of 10/11/10)
    • N = 867 with Pre-WMR Data
    • N = 469 with Pre & Post-WMR Data
    • N = 113 with Pre, Post, & Follow-up Data
  • Multiple WMR groups run per site
    • Over 125 persons have gone through WMR more than one time (current outcomes look only at 1st time through).

WMR Research Design: Data Analysis

  • Quantitative data
    • Nomothetic: Analyze group average changes pre-WMR, post-WMR, and 6 month follow-up
    • Idiographic: Analyze individual results for reliable change (improvement / deterioration)
  • Qualitative data
    • Open-ended questions and individual interviews to uncover commonly expressed themes of the change process related to WMR participation

Two Key Questions

  1. Are there significant improvements in WMR Knowledge, Use of WMR Skills, and Mental Health Recovery?
  2. Do the Gains Last Over Time?

Pre, Post, and Follow-up Outcomes for the
WMR Client Self-Rating Total Score (N=75)

F(2, 148) = 14.3, p <.001

wmr-client-self-rating-graph

WMR Client Self-Rating: Item Level Analysis

Top 5 Areas of Change

  1. Knowledge Increase (of symptoms, treatment, coping strategies, medications)
  2. Use of a Wellness Plan
  3. Use of Relapse Reduction planning
  4. Progress towards personal goals
  5. Making healthy life-style choices

Pre, Post, and Follow-up Outcomes for the
Mental Health Recovery Measure (MHRM)
N = 113  F(2, 224) = 13.97, p <.001

MHRM-total-score

Qualitative Analysis:  How has participating in the WMR program helped you in your recovery?

The Alpha and the Omega themes

  • In the Beginning => Fear, Isolation, Doubt, Inhibition, and Feeling Stuck
  • In the End => Growth, Learning, Renewed Energy, Socialization, Overcoming Prejudice and Stigma

Qualitative Feedback

“If it weren’t for this program (WMR), I’d probably ended up back in the hospital.”

-WMR Graduate, Lorain

“I’m in more control of my illness than I ever have been in my life.”

- WMR Graduate, Cincinnati

Qualitative Feedback

"Personally, it was a powerful experience because it allowed me to undergo a period to reaffirm, rediscover and gain awareness of my gifts, talents, attributes, characteristics, challenges, victories and skills. Often times, we do not take time out to self-discover who we are and what we possess and what we want to achieve. In addition, I was able to appreciate the experience of others as they underwent a transformation process of self-evaluation and self-discovery.”

- WMR Facilitator, Toledo

Working Toward Improved Physical Health for WMR Participants

Brittany Tenbarge, M.A., Wesley Bullock, Ph.D.,
Janet Hoy, Ph.D., Alisha Lee, M.A., & David Medved, B.S.

University of Toledo
Department of Psychology

Special acknowledgement is given to the WMR participants, the WMR CCOE, and staff at Southeast, Inc. in Columbus, Ohio for their support and assistance.

Physical Health of People Living with SPMI

  • High rates of comorbid medical conditions:
    • Obesity
    • Hypertension
    • Diabetes mellitus
    • Heart Disease
    • Lipid Disorders
    • Chronic Respiratory
    • Renal & Liver Disorders
  • Higher mortality rates
    • Mean age of death = 47.7±15.3 years
    • Approx. 32.0±12.6 years of potential life lost per patient
    • Schizophrenia - 20% shorter life span than general population

Physical Health of Persons with SPMI

  • Comorbid medical conditions have been found to be associated with:
    • Lifestyle factors (e.g., tobacco use; diet high in fats & low in fiber; sedentary)
    • Metabolic & neurological side effects of psychiatric medications
    • Socioeconomic factors (e.g., access to physical activity & healthy foods)
    • Psychiatric symptoms
    • Poor health behaviors/Inadequate health care

Health Care

  • Less likely to report having a PCP: In the WMR research, 61.5% did not have a PCP upon intake at the CMHC
  • More likely to receive medical services through emergency care or psychiatric treatment team
  • Less adequate or appropriate health care (e.g., lower intensity of health services; fewer medical visits; poorer medical care following MI)

~ 50% of adults with SPMI have known physical disorders
~ 35% have undiagnosed physical disorders
~ 20% have medical conditions that may be causing or exacerbating their psychiatric symptoms (Kennedy et al., 2005)

What is Integrated Health Care (IHC)?

  • A way of organizing and de-fragmenting a health system
  • Includes different types of health providers & supports improved communication between providers
  • Involves both preventative and curative services
  • Way of organizing health services needed – usually targets a specific population and their needs – a “one-stop shop” of appropriate interventions
  • Easier to navigate
  • Minimizes the # of visits
  • Better approximates awareness of the whole person

The Relationship between the WMR Program and Physical Health

Method

  • Participants
  • 192 WMR participants from Southeast, Inc.
  • Measures
  • Mental Health Recovery Measure
  • Psychiatric treatment team documentation

Purpose

  • Better understand the physical health needs of WMR participants
  • Better understand whether physical health conditions are related to attrition from the WMR program.
  • Guide additions or revisions to the WMR curriculum

Proportions of Physical Health Conditions (N = 192)

Physical Health Condition

Percentage of WMR Participants

Hypertension

22.4%

Chronic Respiratory Disorders

19.3%

Obesity

17.7%

Gastrointestinal Disorders

16.7%

Arthritis

15.6%

Diabetes

14.1%

Lipid Disorders

13.0%

Infectious Diseases

11.5%

Seizure Disorders

7.8%

Heart Disease

6.3%

Cerebrovascular Disease

0.5%

Physical Health & Health Care Providers

  • 72.4% were documented as having at least one physical health condition
  • 44.3% were documented as having two + physical health conditions
  • These findings are likely to underestimate the prevalence of these physical health problems in WMR participants
  • 61.5% reported they did not have a primary health care provider at intake

Last Physical Health Assessment

  • Information on date of last physical health assessment was not available or not used for a portion of the participants.
  • Within the portion for which this information was available (N=56), date of last physical examination:
    • Mean = 1.82 years (SD = 1.66) prior to participation in the WMR program
    • Range = .03 to 6.36 years
    • 41% within one year prior to WMR
    • 16% between 1 to 2 years prior to WMR
    • 43% more than 2 years prior to WMR

Physical Health, WMR, & Recovery Gains

  • The total # of physical health conditions was significantly related to completion of the WMR program
    • As the total # of conditions increased, WMR participants’ likelihood of completing the WMR increased
    • WMR participants who had 1+ condition were more likely to complete WMR (N=66) than those with no conditions (N=15)
  • No significant relationship between physical health conditions and MHRM gains
    • WMR participants with 1+ condition made similar recovery gains to those with no conditions

Summary

  • WMR participants experience a high rate of comorbid physical health conditions and obesity
  • WMR participants appear to access health care in a suboptimal manner: Less likely to have usual source of care; Slightly less likely to obtain an annual physical exam
  • Having physical health conditions does not deter WMR participants from making mental health gains
    • People with more physical health conditions were more likely to complete the program despite their physical health conditions
    • Suggests people who would benefit most from the holistic approach of WMR are even more likely to do so

TRAUMA RECOVERY AND WMR: AVOIDANCE IS NOT AN OPTION

Alisha Lee, M.A.; Wesley A. Bullock; Ph.D.

Janet Hoy, Ph.D.

Brittany Tenbarge, M.A.

David Medved, B.A.

Special thanks to the WMR sites and peers who were willing to complete the surveys and make this research possible

WMR and Trauma Recovery

  • Given the impact of PTSD symptoms on individuals living with mental illness and the lack of attention given to these symptoms: What is WMR’s association with trauma recovery?
  • We asked individuals participating in WMR to complete measures assessing their self-reported levels of recovery and PTSD symptoms both at pre- and post-WMR
  • Sites for this study included:
    • Zepf Center
    • Wernert Center
    • Maumee Valley Guidance Center
    • Southeast Mental Health Recovery Inc
    • The Counseling Center of Columbiana County

Assessment of PTSD and Recovery

  • Measures
    • PTSD Checklist (PCL) (Weathers, Litz, Herman, Huska, & Keane, 1993)
      • Assesses the extent to which individuals have experienced PTSD symptoms in the past month
    • Mental Health Recovery Measure (MHRM; Young & Bullock,2003)
      • Self-report measure of recovery

Expected Results

  1. Individuals will report significantly lower levels of PTSD symptoms from pre- to post-WMR.
  2. Individuals will report significant gains in recovery from pre- to post-WMR.

Changes in Self-reported PTSD Symptoms and Recovery

  • At Pre-WMR, 48.5% of participants met criteria for PTSD.
  • At Post-WMR, 27.3% of participants met criteria for PTSD.

self-reported-ptsd

Individual Changes in PTSD Symptoms Levels

  • Reliable change on the PTSD Checklist
    • Improvement: 48.4%
    • Deterioration: 15.2%
  • Clinical change on the PTSD Checklist
    • Improvement: 27.3%
    • Deterioration: 6.1%

Recap

  • Individuals who participate in WMR report rates of PTSD that are three times the rate of the general population
  • The results provide support for WMR’s ability to effectively address trauma symptoms in participants
  • Individuals also reported significant gains in recovery following participation in WMR

Why are these results important?

  • A treatment program that effectively promotes the mental health recovery process can serve as good trauma treatment
  • It provides a treatment option for people who want to address their trauma symptoms but do not want explicitly discuss their personal trauma experiences

Sustainability: Individual and System Outcomes

  • Building individual capacity
  • Leadership development
  • Civic Engagement
  • Giving back to the community
  • Building Communities of Care / Wellness
    • Broadening access
  • Continuity of Care
    • Collaborative partnerships across organizations (CMHC, State Hospitals, COS, etc.)