No. 18, Summer BC s Mental Health Journal. Self-Management. artist: Annie Wilkinson

Transcription

1 No. 18, Summer 2003 BC s Metal Health Joural Self-Maagemet artist: Aie Wilkiso

2 2 BC s Metal Health Joural is a quarterly publicatio produced by the Caadia Metal Health Associatio, BC Divisio. It is based o ad reflects the guidig philosophy of the CMHA: the Framework for Support. This philosophy holds that a metal health cosumer (someoe who has used metal health services) is at the cetre of ay supportive metal health system. It also advocates ad values the ivolvemet ad perspectives of frieds, family, service providers ad commuity members. I this joural, we hope to create a place where the may perspectives o metal health issues ca be heard. To that ed, we ivite readers commets ad cocers regardig the articles ad opiios expressed i this joural. Please sed your letter with your cotact iformatio to: Mail: Visios Editor, CMHA BC Divisio Melville Street Vacouver, BC V6E 3V6 Tel: or (604) Fax: (604) office@cmha-bc.org The opiios expressed i this joural are those of the writers ad do ot ecessarily reflect the views of the Caadia Metal Health Associatio, BC Divisio or its brach offices. Editorial Board Na Dickie, Dr. Rajpal Sigh, Dr. Raymod Lam, Victoria Schuckel Executive Director Bev Gutray Editor Eric Macaughto Productio Editor / Desig / Advertisig Sarah Hamid-Balma Editorial Support Cythia Row Pritig Advatage Graphix CMHA is grateful to the Miistry of Health Services for providig fiacial support for the productio of Visios. editor s message Illess maagemet, self-care, or just self-maagemet: all of these are terms that describe essetially the same thig. But just what is it? As you read through this issue of Visios, some of you may feel that the material souds familiar, ad that we re ot talkig about aythig particularly ew. Others may believe that for health coditios as dautig as metal illesses ca be, that a perso ca t really maage or cotrol their illess i ay sigificat way. Still others may worry that what self-maagemet implies might be a excuse for govermets to reduce fudig (after all, if people are self-reliat, the they do t really eed services or so we may worry). Self-maagemet is a term that comes from other health coditios which, like metal illess, may be recurrig ad perhaps life-log coditios (e.g., diabetes, arthritis, asthma etc.). But the cocepts of self-maagemet are embedded i may areas of metal health care, uder differet ames. Whether you re ivolved i the self-help movemet, i psychosocial rehabilitatio or with the field of cogitive-behavioural therapy, all of you will recogize the uderlyig cocepts ad approaches that we ll talk about i this editio of Visios. The value of the self-maagemet cocept, the, is ot ecessarily that it s ew, but that it provides a uifyig framework for a umber of complemetary ideas ad a framework for haressig them i the same directio. What is the purpose, the? As the articles ad the guest editorial by Dr. Da Bilsker suggest, self-maagemet meas, first of all, havig a basic level of kowledge or literacy about metal health ad illess, ad a degree of kow-how whe it comes to accessig help whe a metal health problem presets itself i oe s midst. Next, it ivolves some more advaced kowledge about the particular health coditio i questio, the kid of kowledge that ca facilitate beig able to work i partership with a health professioal to fid a approach that works. Kowledge is also a buildig block for the skills ecessary for maagig symptoms outside the metal health professioal s office. The kid of skills we re talkig about here iclude the ability to maitai a healthy lifestyle ad to maage stressful situatios, i order to decrease the chaces of a repeat episode. While prevetio is the ideal, the skills we re talkig about iclude the ability to recogize early warig sigs of relapse, ad to develop a pla of actio for addressig these if they do appear. As poited out i more tha oe article, kowledge leads to skills, but actual selfmaagemet abilities deped o cofidece ad hope that these are actually possible ad the belief that they ca make a differece. We believe that self-maagemet is possible; ad that it does t mea that a perso with metal illess has to go it aloe, but istead is a way for the idividual to get more out of the services they use. Overall, we see self-maagemet as a powerful framework for a umber of complemetary approaches that ultimately lead to the same goal: that people with metal illess ca cotrol their illess ad live the kid of lives they wat. We hope you agree. Eric Macaughto correctios from last issue Visios apologizes for the followig oversights ad iaccuracies: Re: the article Psychiatric Disabilities Program by Kathy Smith, o p. 21. We wish to add cotext to a quote from the oted article, which icluded the phrase: people have difficulty maitaiig academic stadards due to their situatio. Eid Weier wishes to stress that with creative accommodatios, studets with metal illess do succeed academically. Re: the article Supported Educatio by Jill Newma. The setece: Supported educatio ivolves the itegratio of people with severe metal health disabilities ito post-secodary educatio ad the provisio of the supports that these idividuals require i order to be successful i a educatio eviromet should have bee attributed i a footote as a direct quote from a article by Dr. Kare Uger. The author s ame was also misprited. subscriptios ad back orders Visios subscriptios are $25 for four issues. Back issues are available to read o our website at Or call us to order hard copies at $7 apiece. Back issue themes iclude: Supported Educatio Mood Disorders Commuity Iclusio Eatig Disorders/Disordered Eatig Housig What is Metal Health? Seiors Metal Health Cross Cultural Metal Health Wome s Metal Health Axiety Disorders i Childre/Youth Sexuality, Itimacy & Relatioships Rehabilitatio ad Recovery Employmet Poverty, Icome & Uemploymet Early Itervetio Spirituality ad Recovery Metal Health Accoutability

3 table of cotets 3 backgroud 2 Editor s Message Eric Macaughto 4 Self-Maagemet i the Metal Health Field (guest editorial) Da Bilsker 7 How Families Ca Help i Self-Maagemet of a Metal Disorder Nicole Chovil 8 Health Literacy ad Maagemet of Chroic Health Coditios Irvig Rootma 9 Self-Efficacy ad the Chroic Disease Self- Maagemet Program Patrick McGowa 11 Mid vs. Matter: Perceptio ad Recovery Coralie McCormick 12 Self-Maagemet ad Addictios Lisa Dive 13 Carig for Self ad Others: Cosumer Board ad Committee Participatio Deborah MacNamara experieces ad perspectives 14 The Challege to Maage Na Dickie 15 Limitatios ad Complexities of my Self- Maagemet Sarah Hamid-Balma 17 My Brother s Nightmare: Comig to Terms with ad Learig to Maage Halluciatios M.C. Wog 18 Self-Maagemet of Psychosis ad Schizophreia Daa 19 Valuable Advice Jim Gifford 20 O the Morig Tides: Hope i Self- Maagemet of Metal Illess Scott Whyte 21 Self-Cotrol ad Bipolar Mood Disorder Erika 22 My Path to Welless: From Psychotic Depressio to Recovery Debbie Sesula alteratives ad approaches 24 Tips for Self-Maagemet of Eatig Disorder Symptoms Tais Hugill 25 Practical Midfuless: Tedig the Mid ad Spirit to Med the Mood Victoria Maxwell 26 Bipolar Self-Maagemet Program Review Daa 27 Hearig Voices that are ot Real Cythia Row 28 Checkig Thigs Out Pukaj Bhusha 29 Evidece-Based Treatmets for Alcohol Problems: Brief Itervetios Julia M. Somers 30 Stepped Care: Movig Beyod the Visio to the Evidece Joh F. Aderso regioal programs ad resources 32 Buildig Metal Health Literacy: The Metal Illess First Aid Course Joatha Oldma 33 Do t Trust Ayoe Over 30 : Youth Net Facilitates Metal Health Literacy by Youth for Youth Amada Walker 34 Visioig Recovery i a Day Program: Schizophreia Rehabilitatio Day Program Otto Lim 35 Early Psychosis Itervetio: Group Therapy Marie Nightigale 36 Survey of Chroic Disease Maagemet i BC: Focus o Self-Maagemet of Metal Illess withi Primary Care Mykle Ludvigse 38 BC Cliical Guidelies for the Diagosis ad Maagemet of Depressio Raymod W. Lam 39 Chroic Disease Self-Maagemet: Program Effective Over the Log Haul Kathy Smith 40 Turig Over a New LEAF: A Self-Maagemet Program for Adults with Paic Disorder Sarah Newth 43 LEAF Participat Profile Mykle Ludvigse 44 Gettig from Where We Are to Where We Wat To Be Debbie Sesula 45 My BRIDGES Diary Tracy May 47 RESOURCES letter to the editor I was very iterested i readig your Visios joural this sprig i regards to supported educatio. This issue has bee of great cocer to may of us i the Fraser Health Authority over the last few years. I a attempt to meet this idetified eed, our clubhouse, Friedship House, i collaboratio with New Westmister School District No. 40 ad Douglas College applied to the Natioal Literacy Secretariat ad HRDC ad was grated a award to develop ad supply a program to assist metal health cliets to access existig educatioal services. To accomplish this, we established a advisory committee ad delivered two twohour literacy sessios weekly at Friedship House durig the school year. Idividualized ad small group istructio was provided i Math, Eglish, Sciece, Social Studies, ad Learig ad Life Skills. A teacher from the Columbia Square Adult Learig Cetre i New Westmister provided the services i-house from November 2000 to Jue Of the 21 cliets erolled, may atteded o a regular basis ad beefited positively from the experiece. The project also had a positive impact o the attitude of may of the teachers at the Learig Cetre as they became aware of the challeges faced by metal health cliets as studets. Ufortuately, further fudig was ot available to cotiue this worthwhile edeavour ad it is our hope that this emphasis ca be reewed i the future. Jill Bloom, RN Director of Couselig ad Metal Health Services Fraserside Commuity Services Society New Westmister, BC

4 4 GUEST EDITORIAL Self-Maagemet i the Metal Health Field Da Bilsker, PhD Da is a psychologist who works i the Psychiatric Assessmet Uit at Vacouver Hospital ad also serves as a cosultat with the Metal Health Evaluatio ad Commuity Cosultatio Uit, a metal health services research group at UBC. His publicatios have bee i the areas of evidece-based metal health practice ad emergecy psychiatry. He is the co-author of the Self- Care Depressio Program Self-maagemet refers to a active egagemet of the health care cosumer i dealig with his or her disorder, meaig that the perso with the disorder is a active participat i care, rather tha someoe who simply follows recommedatios ad complies with the treatmet pla developed by a health professioal. Accordig to a orgaizatio that promotes care for chroic disorders, self-maagemet is defied as follows: Patiets must take better care of themselves to keep their chroic illesses uder cotrol, ad eed to be traied i prove methods of miimizig complicatios, symptoms ad disability But effective selfmaagemet meas more tha tellig patiets what to do. It meas givig patiets a cetral role i determiig their care, oe that fosters a sese of resposibility for their ow health. Usig a collaborative approach, providers ad patiets work together to defie problems, set priorities, establish goals, create treatmet plas ad solve problems alog the way. I order for self-maagemet of a disorder to be possible, the perso eeds access to appropriate iformatio so that he or she ca be sufficietly welliformed to participate actively i maagig the disorder. This emphasis o access to health iformatio cotrasts with the older model i which the perso relies etirely upo the health professioal s uderstadig of the disorder. The health care cosumer, icludig those with metal illess, eeds to lear ot oly the beefits associated with a particular treatmet, but also iformatio about potetial costs icludig fiacial cost ad the effort ad skills that may be required i order to achieve those beefits. Fiacial Costs Costs iclude ay fiacial outlay associated with this treatmet, as well as the relative expese of this treatmet compared to others of equivalet effectiveess. Although a sigificat proportio of metal health cliets have the cost of medicatios covered by govermet plas, it remais true that a substatial umber of idividuals receivig treatmet from the metal health system, especially those receivig treatmet for depressive or axiety disorders, must themselves cover all or most of their medicatio costs. Furthermore, most of the cost of psychotherapeutic treatmets such as cogitivebehavioural therapy are covered by idividuals receivig the treatmet. Therefore, a frak discussio of relative costs of therapeutically-equivalet treatmet alteratives is ecessary for patiets to be able to actively participate i maagemet of their disorder. Ratioal decisio-makig relies o balacig the costs ad beefits of a course of actio. Skills or Practices Needed to Self-Maage Disorder Effective self-maagemet is ot merely a matter of takig i cliical facts, but of acquirig particular behaviours required to maage a illess. Oe ca readily see this for a illess like diabetes, where the patiet must ofte lear how to self-admiister tests of blood glucose levels. But a similar reasoig applies to metal dis-orders. There are skills ad practices that have bee show i research to sigificatly ehace maagemet of various psychological ad psychiatric disorders such as relapse prevetio i bipolar disorder, structured problem-solvig i major depressio, ad relaxatio traiig i geeralized axiety disorder. I order for a perso to be a truly active participat i the disease maagemet process, he or she must also be iformed about the ratioale for a give optio, which etails a clear explaatio as to why this particular treatmet or, these treatmet alteratives is likely to be effective. Providig the perso with a plausible explaatio, eve oe that ackowledges gaps i our evidecebased kowledge, allows the idividual to be a active participat i decisio-makig ad gives a message of respect for this idividual s capacity to make importat decisios about his or her ow health. The role of the health professioal i this regard is to give the perso reasos to actively participate i treatmet, rather tha merely to elicit passive compliace with a treatmet regime. Self-Maagemet Strategies Self-maagemet strategies are well developed for some metal health problems: the pro-fusio of self-help books for depressio ad axiety reflects the umber of research trials showig that self-maagemet strategies ca be very helpful for these disorders. I the area of alcohol addictio, research has show the utility of self-maagemet approaches for those with milder forms of alcoholism. For disorders such as schizophreia ad bipolar disorder, the developmet of self-maagemet techiques are less developed, but there is a emergig recogitio that idividuals sufferig from these severe disorders have a importat role to play i maagemet of the disorder. I particular, a promisig approach is to work with affected idividuals to idetify strategies for recogizig the oset of relapse at a early stage ad implemet a pla to avert the episode or miimize its severity ad impact. For example, a perso sufferig from bipolar disorder who realizes from warig sigs that a maic episode is begiig ca mobilize cliical or social support ad substatially reduce the egative impact of this episode o his or her life. Self-maagemet is a crucial compoet of a approach to health care kow as chroic disease maagemet. This approach has become very ifluetial over the past decade. It was iitially developed to improve the care of chroic disorders such as diabetes, arthritis or asthma, disorders for which the traditioal cure model was iadequate. These are disorders where it is ot simply a matter of makig a diagosis, applyig the appropriate treatmet, curig the illess ad fially sedig the patiet o her way; istead, these chroic disorders

5 guest editorial 5 ivolve recurret episodes of illess, ofte with residual symptoms betwee acute episodes. Chroic disorders require a ogoig maagemet pla that icludes a coordiated respose by health professioals, the patiet ad their family. Oly i the last few years has the chroic disease maagemet (CDM) model bee applied systematically to metal disorders. The first metal disorder to be approached i CDM terms has bee major depressio, but it ca oly be a matter of time before the CDM model is applied to axiety disorders, bipolar disorder ad schizophreia. A umber of metal disorders show the characteristics typical of chroic illesses: recurret episodes, residual symptoms, maagemet rather tha cure, ad the eed for active self-maagemet by cosumers ad family members. Perhaps the CDM model will evetually become the domiat framework for metal health itervetio. But metal health problems raise a particular questio from a CDM/self-maagemet perspective: are idividuals with psychiatric disorders able to participate meaigfully ad effectively i self-maagemet practices? Ca they itegrate the ofte-complex iformatio that is available about metal disorders, make coheret ad ratioal decisios regardig treatmet optios ad acquire the self-care skills eeded to maage the disorder? I particular, cocer has bee raised that idividuals with psychological or psychiatric disorders might refuse effective treatmets whe these treatmets would beefit them because of the impact the metal disorder has o their cogitive ad emotioal fuctio. Cocers of this type have motivated a icrease i the availability of ivolutary treatmet mechaisms such as compulsory commuity treatmet (where a idividual sufferig from a metal disorder is required to comply with specific treatmets i the commuity). Oe ca argue that recourse to compulsory commuity treatmet lies at the other ed of a care cotiuum from self-maagemet iitiatives. My view is that we must first ackowledge that idividuals i the throes of a acute metal health crisis such as severe depressio or paraoid psychosis may be icapable at that time of graspig relevat iformatio or balacig the costs ad beefits of treatmet optios; furthermore, certai idividuals experiece a degree of ogoig psychiatric/psychological disturbace that substatially impairs their capacity to actively participate i maagemet of the disorder. However, oe must ot go too far i doubtig the capacity of idividuals with metal disorders to egage i self-maagemet. Most people with metal illess, most of the time, are quite able to comprehed clearlyexplaied iformatio, apply this iformatio to makig ratioal decisios ad acquire skills eeded to maage their disorders. Idividuals with metal disorders have cosiderable ad largely-utapped capacity to egage i self-maagemet practices, to fuctio as a itegral part of the disease maagemet process. I order to show what selfmaagemet looks like i practice, let me describe a selfmaagemet tool for depressio that has bee i developmet for the past two years. The Self- Care Depressio Program is a selfhelp maual for depressed idividuals writte by two psychologists (Dr. Rady Paterso ad me), as a way of providig depressed idividuals with kowledge of depressio ad Idividuals with metal disorders have cosiderable ad largely-utapped capacity to egage i selfmaagemet practices, to fuctio as a itegral part of the disease maagemet process. strategies to gai better cotrol of depressive symptoms. It was developed as a project of the Metal Health Evaluatio ad Commuity Cosultatio Uit at the Uiversity of British Columbia. The self-maagemet strategies explaied i this maual ca be used as a sole approach by idividuals with mild to moderate depressive symptoms or used i combiatio with evidece-based depressio treatmets, such as atidepressat medicatio or cogitive-behavioural therapy, for more seriously depressed persos. The Self-Care Depressio Program was desiged to be cocise, clearly writte, evidece-based, ad fairly straightforward to apply i a step-by-step maer. Besides clearly explaiig the biopsychosocial model of depressio, the Self-Care Program provides istructio i applyig the skills of: Activity Schedulig Depressed idividuals typically reduce their levels of activity i the areas of self-care, social ivolvemet, persoal projects ad fitess. This ca be chaged by learig to set actio goals that are feasible, specific ad gradually icreased. Problem-Solvig Depressed idividuals ofte have difficulty with effective problem-solvig, tedig to overestimate barriers, uderestimate persoal resources, ad to pla actio i a usystematic way. This ca be chaged by learig to apply a structured problemsolvig strategy. Cogitive Restructurig Depressed idividuals usually thik about themselves, their curret situatio ad their future prospects i a urealistically egative ad ufair maer. This ca be chaged by a method kow as cogitive restructurig, through which oe lears to idetify these distorted beliefs, challege them systematically ad replace them with more fair ad realistic beliefs. We did ot wat ay depressed perso to lack access to this selfmaagemet tool because of cost barriers, so we made the maual available free-of-charge ad accessible via PDF at Furthermore, we ecourage ay idividual or health professioal to copy this maual ad distribute it as widely as possible. I predict that someday all idividuals with psychological or psychiatric disorders will be offered self-maagemet traiig delivered through mauals or workshops. Whe idividuals who have suffered from metal disorders ad their families discover the potetial beefits of active participatio i care, they may come to expect self-maagemet support from the metal health system. This kid of expectatio from cosumers of metal health services, combied with gradual implemetatio of a chroic disease maagemet model, may well revolutioize the delivery of metal health care i this provice.

6 6 Importat Notice to Visios Readers Dear readers ad supporters, I would like to thak you for your support of Visios: BC s Metal Health Joural, ad to let you kow about some chages that we hope will make our publicatio eve stroger tha it has become over the past few years. It was back i 1997 that we started the joural as a small, four-page isert to our ewsletter. With the completio of this oe, we will have completed 18 issues, with a average legth of 40 pages per editio. The support we have received over this time, both from our ever-expadig readership ad from our cotributors, has bee truly amazig, ad I would like to thak all the people that have helped us to keep goig: subscribers, sposors, writers, ad our Editorial Board. The joural has bee a very key part of the Caadia Metal Health Associatio throughout BC, ad we appreciate the support of the Miistry of Health Services over the last several years as the mai fuder of the publicatio. We look forward to cotiued support from our mai fuder ad all of those who have kept us goig i the past, as we evolve ito a ew format as of the ext issue. As you may recall from our the isert i the last issue of Visios (#17), we have formed a partership with other provicially-fuded metal health ad addictios agecies to provide accurate, stadard, ad timely iformatio o metal health, metal disorders, ad substace use disorders ad to provide iformatio o evidece-based services, supports ad self-maagemet i a BC cotext. I keepig with this madate, ad with our ew partership, the joural will be reamed Visios: BC s Metal Health ad Addictios Joural ad will be produced uder the baer ad logo of BC Parters for Metal Health ad Addictios Iformatio. This reflects both a chage ad a cotiuatio of the previous madate of Visios. Our audiece cotiues to comprise a wide sector of people with metal illess, their sigificat others, ad metal health professioals from various disciplies. Some of the ew words you ll otice i our madate, such as evidece-based ad self-maagemet, are priciples that have always bee reflected i our joural. Upcomig issues will reflect a cotiued ad stroger commitmet to these cocepts as well as a stroger focus o a importat issue that so ofte goes alog with metal illess: substace use problems. I additio, Visios will keep you updated as to ew iitiatives udertake by the partership (as we have doe o page 41 of this issue). Please feel free to cotact us with ay feedback you may have o future iitiatives ad with ideas for topics to be covered uder the ew joural. With the chages, the joural becomes the first publicatio of its kid i Caada with such a broad madate ad partership, ad we are pleased to be part of it. Most importatly, we hope you will cotiue to be part of it, ad that you will cotiue to read Visios ad pass it o to colleagues ad frieds. The joural will cotiue to be available o our website ( ad sigle issues will also be free of charge to ay idividual withi our madate s target audieces who wishes to receive a hard copy. Subscribers will be receivig a letter with their ext issue as well as a commitmet to reimburse the remaider of their subscriptio, should they ow qualify for a complimetary subscriptio uder this ew madate. Oce agai, thak you for your support over the past years. I am cofidet that you will fid the ew Visios eve more comprehesive ad helpful as we move forward i this ew partership. Sicerely, Bev Gutray Executive Director Caadia Metal Health Associatio, BC Divisio

7 How Families Ca Help i Self-Maagemet of a Metal Disorder BACKGROUND 7 Families of people with serious metal disorders ca be a ivaluable source of support i maagemet of metal disorders. May people with serious metal illess either live with their families (icludig parets, spouses, sibligs ad childre) or have regular ogoig cotact with their family. 1,2 Family members are ofte the first to recogize behavioural chages that accompay a metal disorder ad ca aid a perso i gettig coected with metal health services. Families of idividuals diagosed with a metal illess also ofte serve as iformal case maagers, providig ad coordiatig care for their relatives. Family members ofte see the sigs of relapse ad ca ecourage their relative to seek help early. I order to effectively self-maage a metal disorder, cosumers may eed traiig i skills to deal with their illess, icludig takig medicatios as prescribed, dealig with commuity ad hospital services, learig ew ways to cope with symptoms such as auditory halluciatios, axiety, etc. Skill learig may also be eeded i relatio to maitaiig a healthy lifestyle, icludig good eatig habits, exercise, maitaiig a apartmet, work, ad social life. Other skills that may eed to be developed iclude the ability to deal with emotios ad the impact of the illess o their lives. Families ca assist by learig what is ivolved i self-maagemet as well as by learig what they ca do to help the perso. The followig areas have bee idetified as ways i which families ca assist i maagemet of metal disorders: 1 Learig about metal illess ad services available. Families ad their ill relative ca beefit from educatio that helps them to uderstad the ofte-cofusig ature of metal illess. Educatio should iclude learig about: behaviours/symptoms that create problems for the idividual (ad which may be frighteig ad bizarre to other family members) why a perso may ot see that there is aythig wrog with them why the perso may refuse to seek help (e.g., go to a doctor or metal health cetre) self-maagemet skills that a perso ca use to maage their illess why certai medicatios are used ad their side-effects a uderstadig of the reasos ad implicatios of ot takig medicatios as prescribed or followig through with recommeded treatmet how to determie what services are eeded by their relative, what is available i their commuity, ad how they ca assist their relative i accessig these services artist: Chatal Lefebvre Egagig perso i a treatmet pla Nicole Chovil, PhD learig how to commuicate with a perso i ways that will ecourage them to seek help Nicole is Director of alterative steps families ca take (legal procedures uder the BC Metal Health Act) whe a perso does ot agree to seek help Programs ad Support Services for the British Columbia Schizophreia Society. She is also Idetifyig warig sigs or symptoms of relapse Project Maager for the learig how to give feedback to their relative about symptoms/sigs that idicate a possible relapse Caadia Family Educatio Program, a idetifyig ad miimizig situatios that may place too much stress o the perso ad icrease chaces of relapse ew educatio program beig developed by the Schizophreia Society of Caada. Nicole is happy to report that her brother, Ia, is successfully maagig his schizophreia. Maagig medicatio helpig their relative to develop a medicatio routie iformatio o ways to facilitate takig of medicatio o a regular basis learig about ways to deal with side-effects assistig the perso i workig with their doctor aroud side-effects Workig with their relative to develop a crisis pla for relapse 5 foototes it is recommeded that this emergecy pla also kow as advace directives or Ulysses Agreemets iclude steps to follow whe the perso feels the oset of illess or episode: these might iclude icrease i medicatio, cotactig the family doctor (or psychiatrist) or takig time off work. The emphasis should be o developig a actio pla that eables the situatio to be hadled as safely as possible the pla should also iclude iformatio about curret treatmet, the ames ad cotact details of health professioals ad the local psychiatric facility, ad a series of steps to follow. It should also ote the idividuals who comprise the perso s support etwork ad the role that each should play i the evet of a crisis 1 Clark, R.E. (1996). Family support for persos with dual disorders. I R.E. Drake & K.T. Mueser (Eds.), Dual diagosis of major metal illess ad substace abuse: Volume 2 Recet research ad cliical implicatios. (pp ). Sa Fracisco: Jossey-Bass. 2 Goldma, H.H. (1984). The chroically metally ill: Who are they? Where are they? I M. Mirabi (Ed.), The chroically metally ill: Research ad services. (pp ). Spectrum Publicatios.

8 8 backgroud 6 issue related to self-maagemet of chroic health coditios, whatever their ature, is literacy, or health literacy. This article will attempt to describe this relatioship ad cosider its implicatios for people who are copig with chroic diseases as well as those who are tryig to help them help themselves. But first, what do we mea by literacy ad health literacy? Ufortuately, there are may defiitios of both cocepts, oe of which ejoy uiversal acceptace. However, the defiitio of literacy that is closest to beig uiversally accepted is the oe that is used i the Iteratioal Adult Literacy Survey which defies it as the ability to uderstad ad employ prited iformatio i daily activities at home, at work ad i the commuity to achieve oe s goals ad develop oe s kowledge ad potetial. 1 This implies that literacy has to do with how oe is able to fuctio i the world ad seems to be re the pla should also idetify who will take care of fiacial ad other aspects of the perso s life should they eed to be hospitalized or be uable to care for themselves Helpig to foster a lifestyle coducive to recovery ad maiteace of good metal health providig social support to relative ecouragig idepedece ecouragig egagemet i exercise, social activities, work, school, etc. Metal illess is much like may other illesses: with proper medical care, maagemet ad strog support, people ca recover. Families ca play a valuable role i supportig persos with metal illess. related resources for families Illess self-maagemet strategies Corriga, P.W. (2002). Behavioral Health Recovery Maagemet Project. Illiois. Family services for severe metal illess Mueser, K.T. (2003). Behavioral Health Recovery Maagemet Project. Illiois. Evidece-based practices: A primer New York State Office of Metal Health. (2001). Expert cosesus treatmet guidelies for schizophreia: A guide for patiets ad families (1999). Joural of Cliical Psychology, 60(suppl 11). gl-treatmet_of_schizophreia_1999.html Dealig with cogitive dysfuctio associated with psychiatric disabilities: A hadbook for families ad frieds of idividuals with psychiatric disorders Medalia, A. & Revheim, N. (2002). New York State Office of Metal Health. y.us/omhweb/cogdys_maual/cogdyshdbk.htm How to maage 5 commo symptoms of schizophreia Jaffe, D.J. Abbreviated versio of article by P. Weide & L. Haves that appeared i May 1995 issue of Hospital ad Commuity Psychiatry. Psychosocial maagemet of ocompliace Weide P. (1997). Joural of Practical Psychiatry ad Behavioral Health, 3, weide ho.pdf Health Literacy ad Maagemet of Chroic Health Coditios A Irvig Rootma Irvig is Professor ad Michael Smith Foudatio for Health Research Distiguished Scholar at the Uiversity of Victoria stricted to uderstadig ad usig the writte word. Others however, suggest that it goes beyod the writte word to iclude the ability to speak meaigfully ad uderstad oral commuicatios. With regard to health literacy, a defiitio that is gaiig icreasig iteratioal credibility is the followig oe icluded i the World Health Orgaizatio Glossary o Health Promotio which defies it as the cogitive ad social skills which determie the motivatio ad ability of idividuals to gai access to, uderstad, ad use iformatio i ways which promote ad maitai good health. 2 I this case, the sets of skills are wider tha those suggested i the defiitio of literacy ad are related to the cotext of health, broadly defied. There is however some debate over whether or ot health literacy is a distict type of literacy with its ow skills or whether it is simply literacy withi the health cotext. I persoally take the view that there are some uique skills associated with the health cotext (such as the ability to iterpret health cocepts ad to avigate the health care system) that go beyod the basic literacy skills which are eeded as well. I ay case, it is clear that at the preset time at least, health literacy is a icreasigly-used cocept ad oe that applies to self-maagemet of chroic health coditios. Kate Lorig, a well-kow researcher i the field of self-maagemet, suggests that illess self-maagemet ivolves three separate compoets: basic illess maagemet, emotio maagemet, ad role maagemet. 3 But how does this relate to literacy or to health literacy? With regard to basic illess maagemet, it is especially clear that it is related to both, but particularly health literacy give that it meas uderstadig the illess ad various strategies of maagig symptoms ad stressors. 3 That is, it is obvious that it is difficult, if ot impossible, to uderstad a complex illess ad strategies for addressig it without havig basic readig, writig ad oral commuicatio skills as well as more advaced skills to iterpret medical cocepts ad iformatio. With regard to emotio maagemet which ivolves comig to terms with the diagosis, adjustig life expectatios i healthy ways, ad i the case of metal illess, addressig stigma issues, 3 the relatioship with literacy ad health literacy is less clear. However, it strikes me that havig basic literacy skills as well as health literacy skills is helpful i obtaiig iformatio ad support eeded to maage or cope with the emotioal aspects of the illess. Fially, i relatio to role maagemet which meas developig the ability to fuctio effectively i valued social roles, 3 we kow that basic literacy is fudametal to beig able to play critical social roles such as studet or worker

9 backgroud 9 ad health literacy is importat i playig such roles withi the health care cotext where may people work. Thus, there is o doubt i my mid that literacy ad health literacy are importat foudatios for self-maagemet of chroic health coditios. Moreover, there is growig evidece that promotig health literacy is a effective strategy for improvig self-maagemet i health 4 ad that limited health literacy impedes appropriate self-maagemet for chroic disease. 5 A implicatio of this for people with chroic health coditios is that they eed to try to improve their literacy ad health literacy skills at the same time as, or before they become ivolved i, self-maagemet programs. A implicatio for practitioers is that they eed to be aware of the literacy requiremet of self-maagemet programs ad ecourage their cliets to upgrade their literacy ad health literacy skills. For those of you who are iterested i learig more about literacy ad health literacy, I suggest that you check out the website for the Natioal Literacy ad Health Program coordiated by the Caadia Public Health Associatio 6 as well as liks from that site. If you would like to become more ivolved i these issues i British Columbia, I suggest you cotact the Health Literacy Network of BC. 7 I additio, if you are iterested i research o the topic, you may wish to joi the Literacy ad Health Research Network which is curretly uder developmet. 8 Self-Efficacy ad the Chroic Disease Self-Maagemet Program The Chroic Disease Self-Maagemet Program (CDSMP) is a layperso-led patiet educatio program delivered to groups of oce a week for twoad-a-half hours for six cosecutive weeks. The leaders, who have chroic health coditios themselves, complete a four-day traiig workshop where they lear how to deliver the program. People who take the CDSMP lear ew iformatio but most importatly, they lear from each other. People lear ew skills ad have opportuities to practice ew skills, amely: ways of gettig started with importat behaviours such as exercise ad healthy eatig (people usually kow what they are supposed to do but it is difficult gettig started ad maitaiig these behaviours) how to problem-solve (people with chroic health problems are cotiually faced with problems) how to commuicate effectively with family, frieds ad health care professioals how to effectively work with health care professioals how to deal with the ager, fear ad frustratio that commoly accompay havig a chroic health coditio how to deal with depressio how to deal with fatigue how to evaluate treatmet optios (media, frieds ad family members are costatly suggestig ew medicies or treatmets to try) foototes 1 Statistics Caada. (1997). Iteratioal adult literacy survey, readig the future: A portrait of literacy i Caada. Ottawa: Special Survey Divisio, Cat. 89F0093XIE. 2 Kickbusch, I. & Nutbeam, D. (1998). Health promotio glossary. Health Promotio Iteratioal, 13, Macaughto, E. (2003). Illess self-maagemet, early itervetio ad supported educatio. Visios: BC s Metal Health Joural, 17, Levi-Zamir, D. & Peterberg, Y.D. (2001). Health literacy i health systems: Perspectives o patiet self-maagemet i Israel. Health Promotio Iteratioal, 16(1), Williams, M.V., Baker, D.W., Parker, R.M. & Nurss, J.R. (1998). Relatioship of fuctioal health literacy to patiets kowledge of their chroic disease. Archives of Iteral Medicie, 158(2), A website is curretly beig developed. I the meatime, you could cotact the author irootma@uvic.ca. The skills taught i the CDSMP are very helpful for persos livig with chroic health coditios, but i the CDSMP, people also icrease their cofidece i beig able to maage their health coditio. This cofidece is referred to as self-efficacy a cocept first described by psychologist Albert Badura i I his 1986 ladmark publicatio etitled Social foudatios of thought ad actio: A social cogitive theory, he defies self-efficacy as: Patrick McGowa, PhD Patrick is Program Coordiator for the Chroic Disease Self- Maagemet Program i BC. He is also Research Affiliate with the Uiversity of Victoria s Cetre o Agig. People s judgemet of their capabilities to orgaize ad execute courses of actio required to attai desigated types of performace. It is cocered ot with the skills oe has but with judgemets of what oe ca do with whatever skill oe possesses. 2

10 10 backgroud I other words, self-efficacy depeds o the way we thik about our abilities to perform some activity i this case, i relatio to maagig a ogoig health coditio ot o the abilities themselves. As Badura goes o to suggest, this meas that people ted to avoid tasks ad situatios they believe exceed their capabilities, but udertake ad perform assuredly activities they judge themselves capable of hadlig. He maitais that a powerful way of improvig a idividual s cofidece i relatio to performig a certai skill or behaviour (e.g. a copig skill) is to observe a successful performace of it carried out by someoe else who appears to be similar. As was discussed earlier, this pheomeo learig ad gaiig cofidece from others is a major stregth of the group or social aspect of the CDSMP. Research has show that there is a strog associatio betwee health outcomes ad how oe perceives his or her selfefficacy to perform a specific activity. For example, if someoe experieces severe back pai i the eveig, by just kowig strategies he or she could use to reduce the pai somehow reduces the pai experieced. People s belief i their persoal efficacy is a cetral mechaism mediatig the effects of psychosocial ifluece. Uless people believe they ca produce desired effects by their actios, they have little icetive to act. The Chroic Disease Self-maagemet Program uses four differet strategies to icrease people s level of self-efficacy. It provides mastery experieces that help participats gai a sese of cotrol over their health-related fuctioig through ehaced self-efficacy. As explaied below, these iclude guided mastery experieces, acquisitio of skills ad ehacemet of self-cofidece through peer modelig, reiterpretatio of physiological symptoms, ad social persuasio. Skills Mastery A importat strategy used to ehace self-efficacy is skills mastery. I the CDSMP, participats thik of a goal they would like to achieve i three to six moths ad the thik of small, achievable steps they ca take toward that goal. Each week, they are asked to form a actio pla to try a behaviour that leads to attaiig their goal. Subsequet CDSMP sessios iclude time for feedback o achievig their actio pla ad a discussio of problems. Peer Modelig Course leaders have chroic health coditios themselves, which ehaces assumed similarity betwee participats ad leaders. Assumed similarity ehaces the impact of modelig. The program offers structured opportuities for participats to support each other with problem-solvig. Thus, participats model for each other ad by servig as self-models, ehace their selfefficacy. Fially, program members check i with each other betwee the sessios to see how each is progressig with his or her idividual self-maagemet pla. Reiterpretig Symptoms A perso s adaptatios to disease are iflueced by his or her beliefs about the illess ad its symptoms. For example, if a perso who experieces fatigue believes this to be a symptom of the disease process, the idividual will rest. If it is explaied that fatigue ca also be due to de-coditioig, poor utritio, stress or depressio, participats have a ratioale for tryig ew behaviours to maage fatigue. As each symptom or problem is discussed, the multiple possible causes are idetified ad a set of maagemet techiques suggested. This allows participats to choose techiques that fit withi their cultural belief system. For example, participats who have ever exercised or who work at physically demadig jobs may ot accept the idea of exercisig to help cotrol their disease. However, if exercise is liked to dacig, for istace, it becomes fu ad more easily adopted. Social Persuasio I each commuity, family ad commuity relatios are very importat. These social supports are icorporated i the program by havig family members ad frieds atted ad assist participats i their ew self-maagemet activities. Aother form of persuasio comes from peer leaders ecouragig participats to do more tha they are doig ow. For example, if participats are walkig fewer tha three times a week, the leader might suggest walkig oe more time each week or a little farther each time. These examples ot oly help to guide the participats, but also support them as they begi makig lifestyle chages. Fidigs from diverse lies of research reveal that perceived self-efficacy affects every phase of health behaviour chage: whether people eve cosider chagig their health behaviours, how much they beefit from treatmet programs, how well they maitai the chages they have achieved, ad their vulerability to relapse. 3,4,5 As discussed throughout this article, evidece exists that selfefficacy is a key factor that mediates the effects of psychosocial programs (such as the CDSMP) o the health status of idividuals, icludig those with chroic health coditios. 6,7 The structure ad activities of the CDSM program is desiged with this kowledge i mid, ad with the recogitio that people s ability to maage their health depeds ot oly o their relevat skills, but most importatly o their cofidece i their abilities to carry out those skills. foototes 1 Badura, A. (1977). Self-efficacy: Toward a uifyig theory of behavior chage. Psychological review, 84(2), Badura, A. (1986). Social foudatios of thought ad actio: A social cogitive theory. Eglewood Cliffs: Pretice-Hall. (p. 391). 3 Schwarzer, R. (1992). Self-efficacy i the adoptio ad maiteace of health behavior: Theoretical approaches ad a ew model. I R. Schwarzer (Ed.), Self-efficacy: Thought, cotrol ad actio. (pp ). Washigto: Hemisphere. 4 Holma, H., & Lorig, K. (1992). Perceived self-efficacy i self-maagemet of chroic disease. I R. Schwarzer (Ed.), Self-Efficacy: Thought cotrol of actio. (pp ). Washigto: Hemisphere Publishig Corporatio. 5 Maddux J.E. (1995). Self-Efficacy, adaptatio ad adjustmet: Theory, research ad applicatio. New York: Pleum. 6 O Leary, A. (1985). Self-efficacy ad health. Behavioral Research ad Theory, 23(4), O Leary, A., Shoor, S., Lorig, K. & Holma, H.R. (1988). A cogitive-behavioral treatmet for rheumatoid arthritis. Health Psychology, 7(6),

11 Mid vs. Matter Perceptio ad Recovery backgroud 11 Life is ot easy ad it ca demad our complete attetio, but the ability to avigate life s daily difficulties relies o perceptios; perceptios dictate actio. Humas have the distict ability to edure hardships for the sake of future reward i a way other members of the aimal kigdom do ot. This allows us to desig bridges, pla surprise parties, ad tie our shoelaces. Perceptios are powerful, ad the power of huma perceptio is uprecedeted. Our perceptios have allowed us to reshape the world through sciece, literature, ad art, allowig us to successfully execute what we imagie. Imagiig how a buildig will look is ot eough; we must also be able to perceive how best to costruct it. Perceptio also has a meas of actig o our health i a way that is ot completely uderstood by sciece, but we ca gai some isights by describig two pheomea: the placebo effect, ad the relatioship betwee perceptio ad edurace. The placebo effect eables a illess treatmet that would otherwise have o medical value whatsoever to affect recovery or alleviatio of symptoms. If a patiet is give a treatmet with o medical value ad believes that it will work, it sometimes will. This belief ca be supplied by cultural beliefs, persoal beliefs, religio, or eve through trust i the perso who admiisters this treatmet. It is so remarkable a pheomeo that research studies evaluatig the efficacy of differet treatmets must go through elaborate cotrols to esure that positive results are ot i fact the same improvemets that could have bee oted had subjects bee give a iert placebo treatmet rather tha a active treatmet. Perceptio also eables people to edure discomfort to a greater extet if they are led to believe that this discomfort is temporary. Brezitz 1 ivestigated this pheomeo by askig subjects to keep their hads i ice-cold water, a paiful prospect. The experimeter told oe group that the test would last four miutes, but did ot give the iformatio about a time limit to the other group, eve though the test was to last four miutes for both. It tured out that participats i the secod group were 50% less likely to keep their hads i the water for the full four miutes tha the group that had bee told the test would last four miutes. The group who had bee told about the timeframe were better able to withstad the discomfort, sice they saw a limit to it. This effect was first oted durig the Secod World War, whe flight crews o missios over Germay were oted to be sufferig from stress-related illesses. Almost daily they would fly ito dager ad suffer terrible casualties; their morale was uderstadably low. A team of psychologists was the cosulted, ad the problem of stress-related illesses was reduced through their advice. It was their opiio that crew members could perceive o ed to their ordeal ad this was feedig their stress; so the psychologists suggested chagig this The success of illess maagemet strategies for metal illess ca be said to hige o perceptio, i the sese that their success requires the belief that oe will i fact succeed. perceptio by specifyig a defiite limit to the umber of missios each crew member had to fly. Each crew member was the iformed that their tour of duty would ed after forty missios. The icidece of illess declied. I both cases, illess-related pheomea (pai, stress-related illess) were show to be iflueced by psychological processes, ad i both of these cases, the primary active aget could be loosely defied as hope. The success of illess maagemet strategies for metal illess ca be said to hige o perceptio, i the sese that their success requires the belief that oe will i fact succeed. Success also higes o a visio of the self havig a active role i recovery. Exercisig perceptual power i this fashio ca put mid over matter. The oly problem is, of course, perceptio itself. With the oset of metal illess, the world o loger seems the same as it did before illess. This ca udermie metal health cosumers ability to iteract with the world ad achieve goals, large or small. If, for example, someoe who is depressed perceives a grumpy cashier s maer as persoal dislike, this ca further fuel symptoms of depressio; by cotrast, someoe without depressio is better able to excuse ad/or igore the cashier s maer. Hope for recovery is hard whe faced with log-term illess. Upo diagosis, cosumers are ofte told that their illesses are likely to be lifelog, ad therefore they must struggle with a sese of veryreal-yet- ivisible boudaries. This cocept of iteral barriers is such a abstract ad implacable cocept that ofte cosumers ca feel defeated by it. Therefore, people with metal illess caot perceive ay evetual improvemet, or geerate the motivatioal eergy ecessary to embark o a strategy for maagig the illess. It is i huma ature to hope. Oe ca be persuaded to hope by ay umber of meas, either by oeself or through frieds, family, observatio or caregivers. Oe psychologist, Nicholas Humphrey, claims that this hope ca come from three differet meas of persuasio: persoal experiece (observig somethig yourself), ratioal argumet (relyig o logical argumet), ad exteral authority (the ifluece of a respected authority figure). 2 Coralie McCormick Coralie is Employmet Database Admiistrator ad Isurace Project Research Assistat at CMHA BC Divisio foototes 1 Brezitz, S. (1999). The effect of hope o pai tolerace. Social Research, 66, Humphrey, N. (2000). How to solve the mid-body problem. Charlottesville: Imprit Academic.

12 12 backgroud Everythig that is doe i the world is doe by hope. Dr. Marti Luther Kig Jr. Ay oe or combiatio of these factors ca ehace (ot guaratee) the success of a illess maagemet strategy. Perhaps observig the recovery of someoe with a similar diagosis o a documetary ca aid someoe i evisioig recovery. Perhaps a therapist or psy- chiatrist ca fuel this hope by describig the likelihood of success of a treatmet regime. Believig i the logic of a wellresearched illess maagemet strategy ca also work. Buildig belief takes work ad maitaiig that belief i spite of ievitable setbacks ca be crucial to learig to live with illess. Successfully chagig perceptios chagig the way you look at yourself ad the world ca be pivotal to the success of illess maagemet ad recovery. Lisa Dive PhD (cadidate) Lisa is Marketig Assistat for the Kaiser Foudatio, a BC addictios charity foototes 1 McLella, A.T., Lewis, D.C., O Brie, C. P., & Kleber, H.D. (2000). Drug depedece: A chroic medical illess. Joural of the America Medical Associatio, 284, Committee o Addictios of the Group for the Advacemet of Psychiatry. (2002). Resposibility ad choice i addictio. Psychiatric Services, 53(6), Apodaca, T.R. & Miller, W.R. (2003). A meta-aalysis of the effectiveess of bibliotherapy for alcohol problems. Joural of Cliical Psychology, 59(3), Self-Maagemet ad Addictios A icreasig body of literature supports treatig addictio as a chroic relapsig disease, a move which is paralleled by similar shifts i our uderstadig of several metal disorders. Self-maagemet is recogized as providig a appropriate framework for the treatmet of a wide rage of chroic illesses. It ecourages idividuals to take resposibility for their ow recovery ad to utilize available resources effectively to achieve healthier lives. There are may parallels betwee addictios ad coditios where self-maagemet approaches have bee effective, such as adult oset diabetes, asthma ad hypertesio: 1 multiple factors cotribute to the oset of the disorder: geetic, biological, behavioural ad evirometal behavioural choices play a part i both the oset ad severity of the disorder, regardless of whether a biological or geetic predispositio exists rates of successful treatmet are similar across all disorders (as with other chroic diseases, the success of addictios treatmets is measured i terms of improvemet rather tha complete recovery) rates of compliace with pharmacological or behavioural treatmet regimes are comparable across all disorders factors such as low socio-ecoomic status, comorbid psychiatric coditios, ad lack of family or social supports are most commoly associated with lack of treatmet compliace ad relapse after treatmet for all disorders. I treatig a chroic disease, supportig the perso s self-maagemet ability is a importat factor, ad ivolves a umber of aspects. The perso must be iformed about their coditio, ad they must lear strategies for improvig their health ad avoidig a relapse. Ofte there is a treatmet regime that must be followed, ad the patiet must uderstad the importace of maitaiig it. These priciples ca be applied to addictios, to various metal disorders, ad to other chroic diseases. For istace, a asthma sufferer must take daily prevetative medicatios, exercise regularly, esure they always have emergecy ihalers with them, ad avoid aggravatig situatios (such as dusty eviromets or a park i sprigtime). Similarly, a recoverig addict must comply with a treatmet regime, such as regular cousellig, daily methadoe doses, or icotie patches. Improvig other areas of their lives, for istace, spedig time with family ad exercisig regularly, are also valuable i the course of recovery. Like the perso with asthma, ad like a idividual with diabetes who must avoid sugary foods, recoverig addicts may also eed to avoid potetial aggravatig situatios, such as frieds they used with or situatios that may make them wat to use agai. I each of these examples, self-maagemet allows idividuals with a chroic relapsig coditio to take a active role i their recovery. Applyig self-maagemet priciples to problem substace use has the added beefit that it fits with a harm reductio approach. This philosophy recogizes the value of achievig improved overall health, reduced use, a stabilized livig situatio, a improved employmet situatio, ad other gais that work towards the idividual s stabilizatio ad reitegratio ito society. Self-maagemet allows ad ecourages idividuals to participate i settig their ow goals ad determiig the type of itervetio that is likely to be helpful for them. A variety of goals are supported uder this approach, which is a advatage sice the same goals may ot be appropriate for everyoe. For istace, oe problem driker may adopt strategies to limit their use to withi-moderate drikig guidelies, while aother may fid that abstiece is their preferred goal. The questio of competece or capability is a importat cosideratio whe applyig self-maagemet priciples to addictios treatmet. A addicted idividual s competece varies over time; it is ot costat. There are a rage of factors that ca costrai the choices available to a idividual at a give time. 2 Examples of such costraiig factors iclude: poverty past or preset abuse lack of a supportive home eviromet udesirable peer or social iflueces uemploymet physical or psychological cravigs psychiatric problems The more such factors are preset, the more difficult (although ot impossible) it may be for the idividual to make healthier choices. Whe a idividual s ability to choose is costraied by circumstaces such as these, self-maagemet ca be more challegig. If there are too may costraits limitig the choices

13 backgroud 13 available to the idividual, a great deal of support will be required. I some situatios, for example, whe a perso is overdosig, they may be icapable of ay actio ad require professioal itervetio. However, if all itervetios are iformed by a self-maagemet approach, they ca work with the aim of supportig the perso ito a more empowered positio ad improvig their ability to make healthy choices. There is evidece that specific self-maagemet techiques are valid ad effective i addressig the problem of addictios. A recet study foud that providig people with self-help materials i a writte format was as effective as more itesive cousellig i reducig at-risk ad harmful drikig amog problem drikers who self-referred, as opposed to those who were referred to treatmet by others. 3 While this particular itervetio is oly oe amog may self-maagemet techiques, this fidig reiforces the idea that self-maagemet approaches, i geeral, may be a cost-effective way of addressig substace use problems. While extesive research has ot yet bee udertake ito the effectiveess of such techiques for addictios of varyig type ad severity, it appears a promisig route to pursue. After all, may people with substace use problems have bee successfully self-maagig to a more healthy state. Nevertheless, there is a eed for both the developmet of a rage of self-maagemet tools for addictios ad for broad evaluatios of their efficacy. Carig for Self ad Others Cosumer Board ad Committee Participatio Cosumer represetatio ad participatio o boards ad committees has bee a importat step i improvig the metal health system. A research study aimed at uderstadig cosumers experieces o boards ad committees highlighted importat issues i relatio to self-care ad participatio. The study icluded cosumers who were active members of boards ad committees i the metal health field i British Columbia for at least a oe-year period. The cosumers became ivolved with boards ad committees due to a desire to make the metal health system better for other cosumers. Oe perso said, If I ca help oe perso to keep from experiecig what I experiece, it makes it all worth it. Overall, board ad committee membership posed a umber of challeges ad beefits i relatio to self-care. Cosumers stated the mai reaso they were asked to participate o boards ad committees was to use their firsthad kowledge of the metal health system to iform policy ad practice. Cosequetly, i meetigs they would sometimes share persoal experieces, which could be paiful ad distressig. The cosumers were strogly attached to their views of the metal health system but these views were ot always recogized or validated by other committee members. Cosultatio did ot mea agreemet, which was stressful give the persoal ivestmet of the cosumers. The majority of cosumers iterviewed reported a high degree of stress ad frustratio due to relatioships with other board members ad the board process i geeral. Oe cosumer said, It takes a lot of eergy, a lot of aalytical sort of eergy to be doig board work, ad a lot of political sort of thigs... It s really a uusual kid of stress. Some cosumers reported feelig bured out, that they were metally ad emotioally exhausted because they were spread too thi due to a shortage of cosumers who were willig to participate o boards ad committees. At times, they felt disempowered, isolated, ad resposible for speakig o behalf of all cosumers. This resposibility icreased the pressure they felt to perform: I just thik it feels more ucomfortable whe you re a cosumer because you feel the weight of all these people who eed help, who eed assistace like that. I do t wat to act as some kid of iterpreter. Sometimes cosumers were itimidated give the power differetial they experieced with o-cosumers o their board or committee. It s ot oly ot equal, it s slated ad it s threateig ad very omious at oe ed, ad that s the ed the cosumers are playig at. Differeces i power ofte traslated ito differeces i recogitio ad status. Furthermore, membership o boards ad committees sometimes placed the cosumer i a coflict of iterest i relatio to his or her ow metal health care. They were sometimes i the positio of receivig services from the agecy of which they were a board member, forcig them to make alterative arragemets for their metal health care. Despite a umber of challeges posed to self-care, the cosumers stated board ad committee membership also brought umerous beefits. Deborah MacNamara Deborah is a cousellor at Kwatle Uiversity College ad assists studets with career, academic, ad persoal issues. She is curretly completig a doctorate i Iterdiscipliary Studies at the Uiversity of British Columbia

14 14 EXPERIENCES AND PERSPECTIVES The Challege to Maage Na Dickie Na is author of A Map for the jourey: Livig meaigfully with recurrig depressio. You may purchase her book by ig her at a-dickie@shaw.ca. Na is offerig a course Not Just the Blues: Maagig Major Depressio through North Shore Cotiuig Educatio o Thursday, November 13, Phoe (604) ; Course umber: HE As a perso with a 40-year history of recurrig depressio (uipolar mood disorder), I am ecouraged by the ew laguage ad strategies that have recetly etered the realm of treatmet for people with metal illess. For may years, the term self-help has bee used to describe various ways by which people with metal illesses ca best coted with the symptoms of metal illess. Numerous selfhelp books (of varyig applicability) lie bookstore shelves; a growig umber of useful self-help groups exist. Today, we talk about illess self-maagemet. This term challeges oe to be eve more resposible for his or her life. Self-help, though a proactive term, seems to imply copig with, dealig with, or livig with a illess. Self-maagemet, o the other had, as used today, goes oe step further; it requires that people with metal illesses be resposible, ot simply to help themselves, but to: lear everythig they ca about their illess, its usual ad abormal symptoms, ad the wide rage of traditioal ad alterative treatmets Carig for Self ad Others (cot d from prev. page) Through their board or committee, cosumers ofte leared of metal health services ad resources that could beefit them directly. They also developed friedships, felt empowered, experieced greater self-esteem ad cofidece, which all served to ehace oe s self-care. Oe cosumer said participatig o boards ad committees, chaged my attitude, my whole self cocept, this board I was always ashamed of my disease, very ashamed ad kid of paraoid, almost to the poit of hysteria of people fidig out that I was a metal patiet. Good self-care accordig to cosumers meat fidig a balace betwee takig care of themselves ad their resposibilities as board ad committee members. Havig a strog support etwork of frieds ad family helped them cope with the stress ad pressure. I order to survive metally ad emotioally, some of the co- sumers chaged the expectatios they had of themselves i relatio to their board ad committee work. Oe perso said, certaily sice I ve started, my defiitio of what could be accomplished has chaged you kow, I feel that I had to really chage my expectatios to survive because, or else I would have just exploded with frustratio I thik. Like ay job, board ad committee membership requires attetio to self-care ad maagig oe s stress ad workload. The iroy of board ad committee membership is that i the process of tryig to take care of other cosumers ad make a differece, cosumers face icreased challeges to their ow self-care. Give the importace of cosumer participatio o boards ad committees there is merit for cosumers ad ocosumers to cosider how to better support participats with these challeges. artist: Carolie Deri with this kowledge, devise a persoalized, comprehesive ad well-thought-out actio pla for their etire life of repeatig mood cycles whe possible, employ applicable self-maagemet strategies ad/or self-help strategies fid the ecessary outside resources (persoal ad professioal) to truly maage the illess throughout their lives, ad use these resources effectively ad optimally. Everyoe ca, ad sometimes ought to, be challeged beyod their preset capabilities. That is a requisite for growth. Whe people with metal illess accept the term self-maagemet, chaces are that they will strive, ad sometimes hopefully ofte succeed i goig beyod what they had previously bee able to do, ad perhaps eve beyod what was thought to be possible. Self-maagemet strategies must ot be oerous or complex, for if they are, oe may well face failure, somethig people with metal illesses are too familiar with already. Nor should self-maagemet be assumed to ecessarily ease symptoms of a episode, or haste recovery from it. Wise self-maagemet strategies may do so, but there is o guaratee. However, whe oe employs self-maagemet strategies o a ogoig basis, oe may discover, over time, that the quality of life durig all phases of a cycle may be ehaced. For self-maagemet to work, strategies must be realistic, ad customized for each perso, as o two people experiece episodes i exactly the same way, with idetical symptoms, or to the same degree of severity. Ofte the most oe ca do o the descet ito a episode, ad durig a episode, is to employ self-help techiques which have worked i the past, as well as some they may have leared about sice their last episode. For istace, durig a particularly dreadful episode of depressio, a perso s self-help may be limited by the grip of the symptoms, to esurig persoal safety ad eatig

15 experieces ad perspectives 15 properly. This beig the case, it is best to establish, implemet, reiforce, ad if ecessary, revise self-maagemet strategies durig remissio (that is, good metal health), ad durig the log road to recovery whe oe regais self-cofidece, a self-cocept beyod the illess, ad a sese of hope ad optimism. A questio facig a perso with metal illess is: what strategies beyod those of self-help ca I employ to maage my episodes, ad the rest of my life with the metal illess? Here are a few suggestios: Make Iformed Decisios About Treatmet Discuss all medicatios with your doctor or psychiatrist, ad perhaps as well, your pharmacist. What are the iteded effects ad likely side-effects of a medicatio, or combiatio of medicatios? You may choose to examie alteratives to covetioal medicatios What other treatmets are available other tha medicatio? What types of therapy are available? Would it be wise for you to pursue oe of them? Educate Yourself Fid out the causes of your illess: exactly what is happeig i your body whe you eter ad recover from a episode? Might there be a geetic compoet to your illess? Seek out courses or workshops offered o copig with ad maagig metal illess Determie aspects of your illess that are differet tha those of other people ad seek ways of dealig with them. Cosider joiig a self-help group, a safe eviromet i which to explore a wide rage of metal health ad illess issues Pla for the Future Make wise career or educatio choices, takig ito accout that you may have episodes of your metal illess for your whole workig life Pla strategies for maagig future episodes, based o what works best for you ow Tell supporters (family, frieds, colleagues) how they may cotribute to your illess maagemet program durig each phase of your mood cycle By implemetig ad practicig illess self-maagemet strategies durig every phase of our mood cycles, we who have mood disorders (or other metal illesses) ca lead productive, challegig ad meaigful lives. Limitatios ad Complexities of my Self-Maagemet I 1 recetly leared that my metal disorder (uipolar depressio) will be a life-log battle. It was hard to hear, after seve years o medicatios ad still i my mid-20s, that the reaso the weaig-off process ever seemed to work well for me was because I probably eeded to be o meds for life. Of course, over the course of these past seve years ad the relapses ad setbacks ad successes alog the way I have leared a whole host of techiques ad skills, ad pursued various alteratives that help keep me well: from relatioships with doctors, to goig through couselig, to makig lifestyle chages ad urturig social supports. These skills ad processes for participatig i my ow recovery are what academics ad others ow call self-maagemet. I call it takig care of myself. Still, I sometimes feel the whole cocept of self-maagemet is t great for self-blamig perfectioists like me. I kow it is t tryig to suggest I ca fix my coditio myself, but I do kow a lot of thigs that ca help. Ad that help ca feel awfully powerful sometimes. But there are a few barriers that I, ad may others I imagie, ievitably come across: Although takig some cotrol away from this beast of a disorder iside me has bee very therapeutic, ot everythig about my coditio is withi my direct cotrol (if it were, it s probably a sig of a trasiet depressed mood, ot the illess of depressio). So I ca be maitaiig a healthy lifestyle, ad takig my meds faithfully ad I ca still crash ad ot prevet it. This happeed recetly, ad it ca be really hard to cope with because I feel I have failed somehow. I start to thik, well, self-maagemet has helped prevet relapse before, why ot this time? is there somethig I could have doe? forgot to do? After all, usig self-maagemet priciples, I ve bee able to cut dow my setbacks to twice a year; whe I igore those priciples, I ca easily have symptoms retur half a doze times a year. So self-maagemet ca be powerful medicie, but it s ot a cure-all; it has its limitatios. Ad that s hard to remember sometimes because it has bee so helpful to me. Sarah Hamid-Balma Sarah is Visios Productio Editor ad Public Educatio ad Commuicatios Coordiator at CMHA BC Divisio

16 16 experieces ad perspectives 2 The priciples of self-maagemet are ofte the hardest thigs to brig myself to do whe I m eve slightly low. Whe I m depressed, I feel like broodig, oversleepig ad eatig all the wrog foods eve though I kow better! But I m ot aloe here. Thik about it: most North Americas kow that exercisig or eatig lots of fruits ad vegetables is good for you, but plety of folks still sit o the couch eatig potato chips. My poit is that kowig is oe thig; doig is quite aother. There are a lot of health-promotio priciples, metal illess self-maagemet icluded, that make sese, soud good, feel good, ad we kow them itellectually to be true. But it takes somethig else altogether to make them resoate emotioally ad that s where true behavioural chage ad motivatio come from. As a couselor of mie oce told me, The trip from the head to the heart is the logest sevetee iches i the world. Log ideed. 3 a Havig ay co-occurrig coditios ca make self-maagemet that much more difficult. So imagie what happes i these two commo scearios for me: I have a disablig sleep disorder that is urelated to my depressive illess. As a result of the sleep disorder that leaves me urefreshed upo wakig, I have a tedecy to feel sleepy ad lethargic a lot. That sleepy feelig I carry with me all day is frustratig ad ofte depressig. It eve feels like depressio, which it is t, which, i tur, makes it harder to fight off ay real symptoms of depressio that do ever retur. I have chroic allergies to a whole slew of evirometal allerges, ad although I get two weekly allergy shots, symptoms are still a real bother. However, I ca t take atihistamies to relieve them, because they always iteract with my atidepressats ad trigger a depressive episode. The ear-ose-throat cogestio that goes urelieved the bothers me durig my sleep makig my sleep disorder worse (see a above!) ad the cycle cotiues. The figure below should further shed light o the complexities of self-maagemet i my world. b Ayway, you probably get the idea. Self-maagemet does t happe i a vacuum. You ca cotrol oly certai variables ad have to take the rest as they come. figure 1 a glimpse ito my depressio self-maagemet world Everyoe ca draw a map like this, whether you have a metal illess or ot. The differece is oe of degree. The cosequeces of each arrow require that I pay much more attetio to these iterrelatioships, oly a few of which I ve show here.

17 My Brother s Nightmare Comig to Terms with ad Learig to Maage Halluciatios experieces ad perspectives 17 People who caot distiguish reality from illusio may be worse off tha those who are termially ill. We ofte hear of the mid s great power to overcome a physical ailmet, eve oe that s cosidered icurable. But what if the ailmet is part of the mid itself? Ulike those who suffer from diseases such as cacer or AIDS or those who are physically challeged, people who suffer from halluciatory ad delusioal symptoms of schizophreia have o idea where the problem is, sice the mid itself is playig tricks o them. What metal aguish do these people feel as they go through this cotiuous ightmare? How ca family ad frieds help, if at all? My brother was a ormal teeager, bright, coscietious, ad academically brilliat. Five years ago, a few moths after we arrived as high school studets from Hog Kog, my brother became very sesitive towards oise. Oe day we were o the bus o the way home from school; he tured to me ad said, Did you hear what other people aroud us are mumblig about? Not oly was he starig at the perso he believed was talkig about him, he also started respodig to what he heard by mumblig to himself. He earestly told me that people were followig him aroud all day ad were mockig ad ridiculig him. Iitially, I thought it was some kid of a joke ad replied like most people would: What do you mea? I have bee with you all day ad have ot see or heard the people you are talkig about. Of course you would t otice. They re after me. They belog to a group that s targetig me oly, he said. Though he let the coversatio drop, over the ext few moths such coversatios would occur agai ad agai. As time wet o, he became more ad more obsessed with the voices i his head. He was always ready to give me detailed, seemigly-logical aswers wheever I questioed what he saw or heard. With my limited kowledge of psychological illesses, oe day I had a talk with him ad told him how I thought we could approach the problem. We started out by doig some research o the iteret together. Everythig we read seemed to poit i the directio of schizophreia. I was still hopig that I would be wrog. However, after we cosulted with a psychologist, my brother was tetatively diagosed with schizophreia. A few weeks after seeig the psychologist i Buraby, oe day my brother sobbed desperately at school that he wated to kill himself. Not kowig what to do, we wet to a istructor we kew for help. He suggested we go to Vacouver Geeral Hospital immediately. By the time we arrived at VGH, he was gettig desperate about the voices i his head, I hear a lot of voices all aroud me. People are mockig ad jeerig at me o-stop. I ca t take it ay more. I feel like... After some eight hours of examiatio by doctors ad psychiatrists at the hospital, my brother was hospitalized i the metal health ward for the ext few weeks. Durig his stay i the hospital, he was put o differet medicatios ad dosages every two weeks as the doctor was tryig to fid out what worked best for him. Each medicatio brought o differet side-effects: dry mouth ad fatigue, for example. But regardless of what medicie he took, sideeffects ievitably came with it, although some less severe tha others. O the medicatio with the least side-effects, my brother looked happier ad more relaxed, ad heard o voices. I wet to see him after school every day. However, whe I took him out of the ward for a walk, the voices would come back to haut him, especially i crowded areas. After a moth or so, he was released from the hospital. As the days passed, he became icreasigly more upset ad worried about how he could cotiue with his life, especially with school, whe he foud out that the medicatio could oly reduce halluciatory symptoms, but could ever be able to elimiate them all. I additio to my brother s difficulty i acceptig this fact, our parets, who live i Hog Kog, were also stued to lear of his metal illess ad of its icurable coditio. Moths after he was released from the hospital, a fried itroduced my brother to a woma i her 60s who d bee sufferig from schizophreia for the last 20 years. She had it so bad that she could t hold dow a job, left her family, ad was homeless for may years livig o skid row. Whe my brother spoke to her, eve though she was still o medicatio, her life had ormalized. He spoke to her at legth i a restaurat o Commercial Street. Askig very few questios, he was listeig to her most of the time learig from her experiece. Ispired after listeig to how she survived the illess, he told me that he wated to overcome this illess with as much courage as she. For a few moths, he did demostrate courage i fightig this illess. Wheever the voices started to cram ito his head, he would first ask me whether I heard those voices as well. If ot, he would try to covice himself that the oises were ot real. But, whe the voices got too umaageable, he would lear to tell me about them istead of mumblig to himself. For a while, it did appear that he was o top of thigs. With more cofidece i livig with ureal voices, his illess became more stable or so it seemed to us. However, his icreased cofidece also prompted him to skip dosages. I did t kow util the uiversity cousellor set him to the hospital agai. He fightigly said, I heard a lot of oises aroud me agai. A lot. Nostop. I ve forgotte to take medicatio a few times i the last M.C. Wog M.C. is a 3rd year iteratioal psychology major at Simo Fraser Uiversity ad voluteer i the Chiese metal health promotio program at CMHA Vacouver/ Buraby brach

18 18 experieces ad perspectives two weeks. I did t mea to do that. I just forgot. You ca t uderstad. I ca t focus i class after takig the medicie. Every time he skipped his medicatio, he had to start with a ew medicatio pla that doubled his origial dosage. He was also forced to go back to the ward agai for the ext couple of weeks. He said he deeply regretted what he had doe. Beig re-hospitalized must have taught him to be more vigilat i takig his medicatio. Rather tha beig apathetic ad frustrated, he was more zealous tha ever i fightig the halluciatios. Not oly was he willig to go out aloe, he also improved his strategy i dealig with the voices. Wheever he heard too may voices, he would try to go to a quiet place to empty his mid. He also tried to covice himself that those voices were ureal. But if he felt he was losig self-cotrol, he would try to reach me, frieds or eve our parets to distract himself from the voices. Sometimes, he would brig a CD player alog with him wherever he wet, so whe disturbed by voices, he would just put o his headphoes ad try to igore them. Though small, these pro-active techiques did help my brother cope with the symptoms. The voices would appear ad disappear like waves risig ad subsidig. A couple of years ago, whe aother wave of symptoms came crashig i, he made a difficult decisio to quit school ad retur to Hog Kog. Uder the care of a psychiatrist there, he is ow i his last year of uiversity. The waves still come ad go, but he fids the symptoms more maageable livig at home. Though I could t, ad perhaps ever will, uderstad the metal hell he has goe through ad is goig through, there are a few thigs I have foud effective i helpig him cope. First, tellig him what is exactly happeig i reality ca help him make a distictio betwee what is real ad what is ot. This is crucial i helpig him actively fight the voices. For my brother, ad I suspect for most people i a similar situatio, acceptig the illess seems to be the most challegig task, because a passive attitude would lead him to be completely depedet o the medicatio ad reduce ay effort i dealig with the illess. But oce he accepts his coditio, he will lear to deal with the symptoms actively. Secod, family support is aother big resource i dealig with schizophreia, especially at the begiig of treatmet. His cofusio, as well as the egative side-effects of the medicatio, ca easily lead to passivity. Family support gives him the stregth for positive thoughts. I a phoe coversatio with him last week, my brother ow seems to be livig a fairly ormal life. He kows that this is a challegig ad difficult jourey, but he tells me that he wo t allow the voices to iterfere with his life. The more oise I hear, the more I am goig to fight it, he added. Self-Maagemet of Psychosis ad Schizophreia Daa Daa is a Master s Studet i Political Sciece at Simo Fraser Uiversity ad Brach/ Public Commuicatios Support at CMHA BC Divisio foototes 1 Chapma, R.K. (1997). Elimiatig paraoid delusios ad telepathy-like ideas i schizophreia: A persoal accout. I C.T. Mowbray, et al. (Eds.), Cosumers as providers i psychiatric rehabilitatio. (pp ). Columbia: Iteratioal Associatio of Psychosocial Rehabilitatio Services. 2 Marty, D. The experieces ad views of self-maagemet of people with a schizophreia diagosis. Lodo: Self- Maagemet Project. self-maagemet To some it might soud like a oxymoro, but may believe it possible that people with schizophreia ca maage this illess i a way that will eable them to lead fulfillig lives. I preset three accouts i favour of this approach. Oe is by Caadia Robert Chapma, who recovered from this illess ad ow speaks to others about his jourey to recovery. Aother presets excerpts from UK s Rethik Project. Ad the last oe is my persoal look at this issue as someoe who has bee hospitalized ad recovered from psychosis. Robert Chapma s Approach Robert s Chapma accout of his fight with schizophreia is oe of determiatio to coquer delusioal beliefs by replacig them by others that are based o reality. At first, Chapma became agry at the illess, a turig poit o a slow path to recovery. He says that there ought ot be a race i tryig to recover. 1 Although it is a illess that is usually braded o people as a termial oe, he did ot wat to accept that fate, ad by applyig method to his madess, developed ways of cotrollig it. What started Chapma dow this path was whe someoe told him that his ideas were part of a iteral process related to his disease, rather tha somethig exteral. This allowed him to develop his method for testig out his oftedelusioal ideas agaist reality. Chapma s three-step strategy worked as follows: The first step was to recogize the delusioal scearios. Evidece for delusioal ideas were foud to cotai doubt. Secod, I developed couter-argumets ad explored alterative iterpretatios [for my delusioal iterpretatio]. The third step was to replace the delusio with reality, truth ad ratioality. He developed the method over the course of several years. After that, he wet public with his fidigs, to share this jourey with others o TV, i ewspapers, cofereces ad i books he has writte. Ufortuately at preset, his books are hard to obtai i libraries or bookstores sice they are out of prit. However, his website, describes the approach i more detail. Rethik: Self-Maagemet Project for Schizophreia Whe cosiderig self-maagemet, we should t just focus o elimiatig the egative impacts that the illess has o our lives. The orgaizatio kow as Rethik, based i the UK, coducted a study that asked people with schizophreia their views o self-maagemet. 2 Ad as the study showed, a focus o the positives of the illess experiece is also a importat aspect of self-maagemet. For istace, oe perso iterviewed i the study oted the positives of havig a feelig for souds of words ad seeig pus i what people say lovig music ad

19 feelig at oe with ature ad the uiverse beig strogly affected by beauty i a positive way ; aother felt that he was a much better perso for havig suffered ad may facets of my persoality have developed as a result. The Self-Maagemet Project fids that self-maagemet is a idividual jourey, but oe with commo themes such as: acceptace of experieces strugglig agaist societal stigma joureyig through differet uderstadigs of illessrelated experieces, icludig the psychiatric, social ad spiritual over a period of time, developig hard-wo copig strategies havig to choose betwee fittig ito ormal society ad redefiig what ormal is ad givig value to differece The self-maagemet strategies i this approach ad i the oe discussed above ivolve more tha medicatio. They also ivolve commuicatio with the perso about the illess experiece, as well as developig ways of evaluatig ad couterig uhelpful ideas, such as delusios, paraoia or egative ideas about oeself. My Persoal Experiece From my persoal experiece of psychosis, I foud that the turig poit i my hospitalizatio came at a time whe I was thikig that I could ot trust aybody, that everybody wated me dead, ad that there was o other escape other tha suicide. Gradually, I started rememberig my childhood ad the times whe I was loved ad whe I trusted people. I the made a decisio to trust someoe that I kew ad felt good about. Ad that s how I started climbig up the ladder from the pit of delusios ad halluciatios. Aother turig poit was whe I was fially provided iformatio about schizophreia: the first diagosis my doctors gave me. I asked them repeatedly for it, but for some reaso they were reluctat to give it to me util almost the ed, whe they deemed I was ready. Oce I held this iformatio i my hads ad was able to read academic text just like I used to for my classes at uiversity I realized that all the delusios of gradeur, paraoias ad halluciatios I experieced had also bee shared by may others before me. I also realized that I was ot as special as I thought I was, i the grad scheme of thigs, ad that I would be able to lead the ormal life I wished. After that, I had to relear how to look at people ad to walk the streets i the same way as other people do. It was hard because I was still fightig my delusios ad was ashamed of what had happeed to me. But slowly, withi weeks, my ratioal thikig ad determiatio brought me out of my previous frame of mid. My sese of humour helped too, i tacklig the embarrassmet of returig to places where my psychosis happeed. For that quality, ad for all of the stregths that eabled my recovery, I am very grateful to my upbrigig, ad to my woderful family, frieds ad therapists. Before I came back to SFU, where I was studyig at the time, I flew back home to recuperate for the summer, ad got excellet care at the Cetre for the Treatmet of Psychosis, where I received help from a psychiatrist, psychologist ad cogitive therapist. I thik all of these thigs have bee a importat part of my recovery ad my ability to self-maage, ad I would recommed them to ayoe. experieces ad perspectives Valuable Advice Lately, to my elderly ad blid mother, I have bee readig aloud The right words at the right time by Marlo Thomas. Famous ad well-kow persos such as fighter Mohammed Ali, TV host Katie Couric, ad writer Tom Wolfe, offer up stories. They tell of momets, for them, whe somethig someoe said motivated them to move ahead ad achieve success. As a metal health cosumer, I too recall valuable advice, accepted from metors, that helped me to cope with life. Four special commets played a vital role whe directio was much eeded. Comig at crucial poits durig my psychological growig pais, they gave pause for reflectio. I tur, they eabled a greater degree of itegrity ad balace to take place. My late father s wisdom fostered i my heart ad soul the ability to carry o ad edure my mood swigs. Ofte, i the early years of my illess, he would joi me i my basemet suite i the family home. Durig those eveigs, we d liste to ispirig sogs like Pick yourself up, High hopes ad The impossible dream. But oe thig he said, touched me deeply. Cocerig my extreme highs ad lows, he remarked Nothig is ever as good as you hope or as bad as you fear. Like dad, my brother is fiercely loyal ad, i his busy schedule, has always foud quality time to sped with me. Oe day over luch, I shared my little pearl that there are o aswers. He looked me i the eye ad, smilig, said Jim, there are o questios! A light lit up i my head. It was t ecessary to ask the who, what, why, where ad whe of the mystery of life. Just live spotaeously i the momet ad, as the Beatles sig, Let it be. Droppig out of law school whe I had my breakdow, my itellectual drive was chaeled ito serious works of philosophy ad psychology. I became full of ideas ad theories that had o relevace to my day-to-day fuctioig i the world. Oe day I was expoudig to my mother. She sat quietly ad patietly, listeig. Whe I came up for air, she poetically said let the muddy waters settle. It dawed o me that I eeded to stop readig so deeply ad clear my mid, allowig the kerels to separate from the chaff. The last isight I d like to discuss came from the Merv Griffi Show o televisio. Oe of the guests was a actress, the appearig o a popular sitcom. She preached that everyoe i the world must meditate as the ed was ear. Merv asked his other guest, siger-sogwriter Roger Miller, if he had aythig to say. Roger simply said I m goa plat i the sprig. Jim Gifford Jim is the editor of I A Nutshell, a publicatio of the Metal Patiets Associatio 19

20 20 experieces ad perspectives O the Morig Tides Hope i Self-Maagemet of Metal Illess Scott worked for the RCMP, where he served as a costable for 23 years. I BC, he was statioed i Quesel, Fraser Lake, Alert Bay, Fort St. Joh, 100 Mile House, Price Rupert, ad o the PV Pearkes, a patrol vessel workig o BC s West Coast. He retired to Price George, where he ow works as Educatio ad Projects Coordiator for CMHA Price George brach Scott Whyte It seems like a log time ago ad so far away. I am speakig of my ear breakdow ad diagosis of bipolar disorder, or maic depressio. I say ear breakdow, because successfully breakig aythig owadays usually would spell its ed. We may live i a fastpaced world of disposable goods, but I am oe good that wo t easily be tossed. Not so may years ago i the history of psychiatric treatmet, our role as beig a part of the team would have bee scoffed at ad uiversally resisted. I more recet times, success stories are validatig today s growig evolutio toward psychosocial rehabilitatio practices, where cosumers are beig draw ito active participatio, becomig a itegral part of our ow treatmet plas. There are still some of the old time thikers i positios of authority, but thakfully there is a ew wave of belief, kowledge ad hope arrivig o each morig s tide. I believe that with each floodig tide comes atural erosio for a positive chage. I recogize milestoes regularly withi my ow recovery ad there ca be o doubt that I am self-maagig my illess. I eeded to kow my illess ad get reacquaited with myself o very itimate terms. I had to idetify triggers, lear to recogize ad moitor how I felt every day. This led me to a uderstadig that my triggers were all related to stress. Extreme stress had bee a very dagerous elemet i my life. I am stuck with a metal illess, but I ca do somethig positive with my stress. I bega to research stress maagemet. What did I fid out? Do t let ayoe tell you that you ca resolve stress with oe pill, or that you will be freed by laughter; it s more complicated tha that. While researchig, I was also impressed by the apparet ifluece that stress seems to have over may differet metal disorders. Effectively maagig stress higes upo a healthy lifestyle makeover. I have sice discovered that by effectively maagig my ow stress, the effects of my illess have dimiished sigificatly. I will be hoest ad admit that self-maagemet is plety of work ad it is timecosumig. It has ivolved my complete commitmet to the followig life chages: Medical Compliace Like ayoe else iitially caught up i the psychiatric soup, I had to experimet with ew medicatios. I remember that these were the bad times, ad I edured may setbacks before fidig the right mix, at least the oe that is workig for ow. After all that work, it oly makes sese for me ow to stick with the program. I have had to accept that I will be takig pills util the day that I die. Maybe the, I ll be afforded the time for a break from routie! Regular Exercise Stress pumps us up with very powerful agets, givig us the abilities to fight ad/or ru for our lives. These stress hormoes are produced with the itetio that they be used, so to do othig with them will leave them i our systems for too log, where they will become uhealthy ad evetually toxic. I ow vigorously exercise two to three times a week so that I ca bur off these chemicals i a socially acceptable maer because fightig or ruig away is usually iappropriate these days. My re- wards have bee fairly simple, too. I ed up feelig pretty good afterwards, both physically ad emotioally. Regular Relaxatio I have foud that deep muscle relaxatio, visualizatios, ad meditatio allow me to attai a relaxed state very quickly ad, most importatly, o demad. Learig to relax was essetial for me. I have become skilled at takig the 10-miute vacatio. Healthy Diet Eatig good food has made a real differece for me as well. Problem-Solvig Skills There is a momet i time betwee ay stimulus ad our reactio to it. We ca lear to recogize that momet ad use it to our advatage. We ca chage our iteractios with the thigs that are botherig us. Now that s eviable cotrol! Strog, Idividualized Support Networks The people i my etwork are those who I ca trust ad cofide i completely. They kow me whe I am well ad outwardly recogize chages i me that might be sigalig early trouble. I my old life, I was ill prepared for the toll that stress takes. I have sice leared how to haress that stress ad i tur, selfmaage my illess. I am oce agai happy ad gaifully employed. I am ow able to reach out ad offer help to others seekig chage; either before or after their ow ear breakdows.

21 experieces ad perspectives 21 We have diagosed you with bipolar mood disorder so bega the doctor s first words to me upo our secod meetig. His words were both a revelatio ad a double-fisted puch i the face. O the oe had, the discovery of this illess meas it partly explais why I had progressed through so may jobs. O the other had, it was iitially a shock to my idetity. While I wo t go ito embarrassig details, it appears to me that my erratic behaviour ad poor judgemet led to some job losses. The good ews is that after several years of struggle, I have bee correctly diagosed ad ca ow take steps to deal with the illess. Bipolar illess or maic-depressive illess is a disorder i which a idividual experieces extreme mood swigs. The idividual ca be happy or experiece elevated moods, ad also experiece low ad depressive states. It is estimated that oe to two per cet of the populatio suffers from some form of bipolar disorder. 1 The most extreme cases of elatio ad icreased activity are described by the term maia. Some symptoms of maia are: euphoric or elevated mood icreased eergy decreased eed for sleep irritability lack of ihibitios accelerated thikig, usually accompaied by lack of judgemet gradiose thoughts 2 While we caot be i complete cotrol of how we behave, I believe we ca be i better cotrol of our emotios. Some ways that help me maitai self-cotrol are: Reducig stressors that trigger symptoms. Stressors ca be ay umber of variables that ca trigger a icidet: coffee, the amout of work that has to be doe daily, time limits, Self-Cotrol ad Bipolar Mood Disorder God, grat me the sereity to accept the thigs I caot chage, the courage to chage the thigs I ca, ad the wisdom to kow the differece. Reihold Niebuhr ad so forth. Takig medicie regularly ad i the correct dosage. May relapses occur because the perso stops takig the medicie! Whe I first startig takig lithium, I was tempted ot to take it because of that first phase of feelig flat or drugged out. However, after a moth o lithium, I foud that my ormal emotios retured ad the robotic mood subsided. Recogize the symptoms ad take appropriate actio. Have a emergecy pla ready to implemet whe you are becomig ill. Sice I have bee diagosed with bipolar disorder, I have read several books ad umerous pamphlets o this subject. I speak to doctors, urses ad social workers as well as frieds ad family, i order to get their sese of my mood. I also moitor my ow mood. For istace, I sometimes experiece a mixed mood where I feel irritable ad sappish to people, almost to the poit of rage. Kowig this, whe I speak to someoe i perso, I try to look them i the eye ad speak calmly. I try to see a huma beig rather tha a target for my rage. Mostly, this actio succeeds, for the rage is oly a temporary feelig. Also, I speak to the doctor about gettig my medicatio adjusted. Aother way to maitai self-cotrol that s worked for me is to liste to motivatioal tapes, such as the oes by Og Madio, Athoy Robbis ad Steve Covey. The latter i his tape, The power of the seve habits, otes that a effective perso is proactive ad takes resposibility for their life. Oe is ot a product of their geetic makeup, eve though it may be a powerful ifluece. I summary, there ca be a umber of ways to maage bipolar disorder. Drug therapy, couselig ad mood disorder support groups are oly some of the ways to combat this illess, but bipolar illess ca be effectively maaged usig the kids of strategies that have worked for me. foototes 1 DePaulo, J. R. (2002). Uderstadig depressio. Baltimore: Johs Hopkis School of Medicie. 2 Bartha, C., Kitche, K., Parker, C. & Thomso, C. (2001). Depressio ad bipolar disorder: Family psychoeducatioal group maual. Toroto: Cetre for Addictio ad Metal Health. Erika Erika is i her early fourties, from the Lower Mailad, ad has recetly bee diagosed with bipolar disorder

22 22 experieces ad perspectives My Path to Welless From Psychotic Depressio to Recovery thigs that are ot true. I lived i a haze of medicatios ad othig was helpig. I was obsessed with takig my life. As a last resort, they gave me shock treatmet. I was ot ready to face the outside world. I was terrified. I had lost my etire idetity. There was o me; I did t exist, but I must have existed to suffer so. This cofused, disorieted state of depressio mixed with psychosis wet o ad o. I was quite heavily medicated, but the psychotic states did fially come to a ed. Actually, the craziess of psychosis was easier to hadle tha the hell of depressio because I was t coected to reality ad reality hurt. Reality cotiued to hurt for seve years as the depressio ligered o. There were periods of relief every so ofte. It was t o-stop tormet aymore. Debbie Sesula BA, RTC Debbie is Presidet of the White Rock/South Surrey brach of the Caadia Metal Health Associatio Part 1: Eslaved by Metal Illess The year is I was just your average uiversity studet strugglig through, determied to get my Bachelor of Arts (BA) degree. Beig i my last year, I had high hopes for the future ad othig was goig to get i the way. Or so I thought. Life was about to chage drastically. I bega to fid it almost impossible to face aother day. The ier pai was gettig worse. I felt so iadequate, uworthy ad uwated. It was all so overwhelmig. I barely atteded classes, I was doig lousy o my exams, ad I did t eve bother doig my oral presetatios. I was totally uable to express how I felt; all I could do was cry ad withdraw. I felt so aloe. That aloeess was the most paiful - that gap betwee me ad the rest of the world. The fear of beig aloe like this forever was agoizig. I was trapped. It was all so hopeless. Exhaustio overtook me, as it took every ouce of stregth I had just to do the simplest thigs like takig a shower or brushig my teeth. Nobody kew the tormet that was goig o iside of me; outwardly, I appeared perfectly ormal. I did t care aymore ad I certaily did t feel like livig. I became more ad more withdraw. If I was t cryig, I was tossig ad turig, tryig to sleep. I was o edge ad everythig irritated me. There was so much turmoil iside that I thought I would go crazy. My mid was dyig ad I wated to die with it. Despite the turmoil I was experiecig, I did graduate ad received my BA degree i Psychology. After a series of usuccessful suicide attempts, I was hospitalized a umber of times. The turmoil cotiued. The suicidal thoughts did t ed. The depressio ad axiety just kept gettig worse ad worse. I the wet ito a psychotic depressio. Psychosis basically meas discoectig from reality. I suffered from halluciatios, which is seeig or hearig thigs that are t really there, ad I suffered from delusios which is believig i Part 2: Freedom Through Self-Maagemet Gradually, I started to thik ad feel i a more ratioal way. Maybe life did have some possibilities; maybe there was hope after all. I felt ready to get goig i life ad to fight to get over ay obstacles that got i my way. It started feelig like the war was comig to a ed. Life was worth livig after all. How did I ever get to this state of thikig that life was ow worth livig? It s hard for me to say what really helped. Oe thig I do kow: time was the most importat healer. I kow, that s what people always say, Oh, you ll be fie, just give it time. But that is so true; it was vital that I was allowed time. The there were the coutless talks, the ecouragig words, people reachig out to me, beig firmly challeged, a lot of hard work o my behalf. Most importat was that people did t give up ad they cotiued to believe i me eve though I did t. Therapy, support groups, psychiatric outpatiet programs, clubhouse activity ad medicatio also played a importat role i my recovery. Durig the crises, havig respite i a residetial facility kow as CRESST (Commuity Residetial Emergecy Short Stay ad Treatmet) helped me to feel safe ad take care of. Havig supported subsidized housig was what kept me coected ad what took away the worry about havig a decet roof over my head. Takig part i a employmet traiig program was a major turig poit for me i that I was able to lear ew skills, utilize skills I already had ad take the risks eeded to eter back ito the workforce. Aother major turig poit for me was goig ito private, oe-to-oe couselig. I was willig to put forth the effort o matter how much it cost. Throughout my seve years with the public metal health system, I made very miimal progress. I remember beig told that I would be metally ill forever, that I would ever be able to work ad that I would be o medicatio for life. Not so! Throughout my two years of itesive couselig, I progressed i leaps ad bouds. I leared that I had a purpose, that I had eeds like everyoe else ad had the right to meet those eeds, that I could be i cotrol of my life despite

23 experieces ad perspectives 23 havig a metal illess, that I was resposible for my behaviour. I also I leared to empower myself istead of givig my power away. I worked hard at recoverig ad my efforts paid off. Oe caot put a moetary value o that. I had a cousellor who would ot give up o me ad cotiued to believe i me. Later, I wet o to pursue my Reality Therapy Certificatio, because I wated to give to others what was give to me. Two more major leaps occurred i my life. First, I switched from supported subsidized housig to regular subsidized housig through BC Housig, i which oe s ret is based o 30% of their icome. Secod, sice 2001, I have bee workig parttime ad am off of disability beefits. I still struggle with psychiatric symptoms but othig like before. Now I kow what to do to ip thigs i the bud. How do I maitai my recovery? For me, it s all about self-maagemet ad balace. Self-maagemet for me is about beig aware of what I eed to stay metally healthy, such as kowig whe to say o, puttig aside oe day a week as a me day to sped as I wish, kowig whe to ask for help, challegig my mid by learig somethig ew each year, ot takig life so seriously, havig two cats ad doig thigs I love such as travelig. Balace for me is about eatig healthily, exercisig regularly, gettig adequate sleep, decreasig stress, havig positive ad supportive people i my life, cosciously choosig positive thikig, meetig my eeds every day, laughig ad carpe diem (lati for seize the day! ). The mid really is so fragile ad complex. No oe is exempt from a broke mid. It ca happe to ayoe. But there ca be healig ad recovery. It is just so refreshig to remember where I was ad to thik where I am today. OCTOBER 9, HOPE More tha 50 sites will be set up aroud BC to help you lear more about the sigs ad types of depressio, how treatable it is, ad the rage of supports i your commuity that ca help you or a loved oe. You ca also fill out a short quiz o depressio symptoms ad meet with a cliicia to discuss the results. The evet is free, cofidetial ad aoymous. Provicial fudig for this evet provided by the BC Miistry of Health Services Thak you also to our corporate ad media sposors

24 24 ALTERNATIVES AND APPROACHES Helpig Myself to Help Myself Tips for Self-Maagemet of Eatig Disorder Symptoms Tais Hugill MA, RCC, RDT, ADTR Tais is a registered cliical cousellor ad registered dace ad drama therapist, with a private practice i Vacouver. She is also a artist-i-residece for the Vacouver School Board, where she uses dace ad drama to teach healthy body image Iam a therapist who works with people dealig with disordered eatig. A major part of my work with cliets is to help them discover ways to maage what seems like a flood of urges to bige, compulsios to purge ad fears of gettig ucotrollably fat. People sufferig from disordered eatig ofte feel out of cotrol, as if their symptoms have take over their mids, their bodies ad their spirits. Part of the difficulty is that sometimes the symptoms are felt to be a eemy, ad sometimes a fried. There ca be a lot of ambivalece towards givig i to the symptoms, ad this cotributes to the struggle. It is importat to view eatig disorder behaviours, whatever they may be, as simply that: behaviours, or actios that have become a habitual way of dealig with the paiful feeligs ad experieces of life. They are patters that have become copig tools, servig a protective fuctio. They are also actios that create a cycle of destructio ad pai o their ow. Those that seek treatmet discover this ad wish to fid a way ito true health, peace ad lovig selfcare. I some way, eatig disorder symptoms are a effort to do just that, but were developed whe the idividual just did t kow ay better. Viewig symptoms i this way ca lesse the shame ad guilt boud up with the symptoms patters. Istead, they ca be see as sigals, alertig us to a eed that is ot beig met. Umet eeds cause difficult feeligs. Whe these are umbed out by symptoms, the eeds ad feeligs remai ucoscious. Oe feels cotiually usatisfied, empty, hugry without kowig why. Through the stregths of creativity ad body awareess, oe ca gai a friedly relatioship to the experiece of the self i oe s body. This is vital: our bodies are our homes, where all of our memories ad emotios live. They ca be creative resources, through which the world is experieced i pleasure as well as pai. Oe ca practice takig a few deep breaths, ad sca the body for iformatio, oticig areas of comfort ad discomfort, while beig attetive to the feeligs, images, thoughts, memories, ad associatios that are coected with these. Whe there is a thought or impulse to eact a symptom, oe ca take a momet to slow the reactio dow, to discover what is goig o udereath ad get some clues as to what is eeded. Eve if, after a while, the symptom is used, the cycle has our bodies are our homes, where all of our memories ad emotios live. They ca be creative resources, through which the world is experieced i pleasure as well as pai. bee iterrupted. This is a victory that proves other choices ca be made. Ofte, symptoms mask a eed to be soothed, ad to feel safe. Oe ca create lists of activities that are pleasurable, calmig, ad easy to do. For some it may be writig i a joural or talkig to a fried. For others it might be goig for a walk, cleaig the closet, retig a video, pettig the cat, takig a bath or havig a shower. Meditative activities that quiet the body ad the mid, such as a daily sittig or walkig meditatio may be helpful to lower log-felt axiety which makes all other emotios harder to tolerate. Maitaiig a daily joural of symptom triggers ca be useful. List the time, place, activity, people ad feeligs coected with the triggers o oe side ad the chose, helpful activity used o the other. This serves as a record of what works to maage the symptoms ad teaches that the symptoms are ot i cotrol. Recoverig from disordered eatig is a process of learig that takes time. There are may rewards. Through the process, true self-kowledge ca be gaied based o a coectio to oe s deep stregths, ad trust that eatig disorder symptoms are ot ecessary for survival. Whe oe o loger feels impaired by the wouds uderlyig the complex of eatig disorders, life becomes a ufoldig story i which love ad acceptace of self ca be kow, ad shared with freedom at last.

25 alteratives ad approaches Practical Midfuless Tedig the Mid ad Spirit to Med the Mood 25 I m sittig cross-legged o my pale gree comforter, starig at the TV. Someoe, a woma, with too much lipstick ad stark, peciled-i eyebrows squeaks about the greatest buy shoppers could ever hope for o the Shoppig Chael. I otice a familiar feelig sikig ito my chest, dawig ito a heaviess i my arms, trailig ito my legs. What I fear ad respect most begis to show its edges: depressio. I have leared, thak God, that this does t mea I must spiral out of cotrol, ad desced uder its darkess. I have leared if I getly ivite these demos i for tea, the power they threate to hold over me dissolves. I have leared this through the art of midfuless. Midfuless is lovig all the details of our lives. Pema Chodro, author ad teacher, Whe thigs fall apart 1 A ay mids a baby. With tederess ad care, she atteds to the eeds of a wee, bright beig. So, too, does the practice of midfuless. At its most basic, midfuless is observig what is happeig i the preset momet. Practical midfuless, what I use to travel through the emotioal storms of my mood disorder, ivolves somethig more: a purposeful, ucoditioal friedliess ad awareess towards the ier goigs-o of my mid, the subtle shifts i my emotios ad body ideally, just as microscopic chages from ormal mood ito depressio begi. Uder this warm light of watchig, uspoke, almost ubelievable, trasformatios start to take place. Midfuless teaches how to make simple yet radical shift(s) i our relatioship to our thoughts, feeligs ad bodily sesatios that cotribute to depressive relapse. Jo Zabot-Zi Ofte associated with Isight or Vipassaa meditatio, a traditio datig back two ad a half thousad years, this awareess of mood, mid ad matter is easily practiced, with or without the Buddhism that is at its roots. Midfuless [i relatio to prevetig depressio], explais Jo Kabat-Zi, PhD, foudig director of Midfuless Based Cogitive Therapy (MBCT), is based o the meditative view that chage ad health come about through acceptace of whatever is happeig, o matter how paiful, frighteig or udesirable. Acceptace, he otes, does ot mea resigatio, but actively comig to terms with thigs as they are ad learig creative ways of workig with oe s situatio. I am still sittig, kees achig, back sore, o the bed. I have bee slumped here for over three hours. Self-reproach, for reasos ukow, begis to surface. My thoughts slow ad become meacig. I am wary but watchful. I ihale; focus o the rise ad fall of my tummy ad chest, tryig to be aware, without judgemet, of the whir of measpirited feeligs ad thoughts withi. This is ot easy. People, i geeral, ofte fid it difficult to be self-lovig. This is a massive uderstatemet whe fightig depressio. Self-acceptace, at this poit, I ca barely remember, let aloe practice. Gradually, as you remai ope ad midful you begi to feel well i your ow ski. From this comes release ad a profoud ease. Sogyal Ripoche, teacher Maagig a mood disorder requires us to kow what our figerprit of warig sigs looks like. Because midfuless asks us to ote eve the slightest chage i mood, it offers a straightforward tool to do so. I shuffle towards the kitche: dirty plates piled high, coffee stais, bits of dried spiach shellac the tiles. A reletless I m so stupid *#%! I m such a loser I m so stupid *#%! I m such a loser a familiar loop of potetially cripplig remarks. I observe the thoughts ad feeligs ad the throgs that follow them, as they dart ad pich the corers of my mid. I try to do what I ve bee taught; see them just as they are: simply thoughts ad feeligs. Not facts about who I am or edicts of what I m worth. But they seem so real. Feel utterly covicig. I hear myself scream iside. I ihale, slowly, agai. They are simply thoughts ad feeligs passig through me. Nasty, mea, horrible oes, but just thoughts ad feeligs. Not the truth. Not me. I ca make them real by believig the story they tell me or by wrestlig them ito mometary submissio. Either way, I lose my cetre ad therefore lose myself. Ad I become vulerable to the oslaught of a full depressive episode. I practice seeig these demos ad basemet dwellers with child-like curiosity. Look at that, I thik, is t that iterestig: Self-Hate? Hmm. Ad Jealousy, huh? Iterestig. They are characters pitchig camp from time to time iside my head. Victoria Maxwell BFA, BPP* * BFA: Bachelor of Fie Arts BPP: Bi-Polar Pricess Victoria is a metal health educator, cosultat, actor ad writer. Her oewoma show, Crazy for Life, ad her Creatig Optimism: Reducig Depressio i the Workplace program is preseted to audieces ad corporatios across BC ad Caada You ca cotact the author at victoriamaxwell@telus.et

26 26 alteratives ad approaches Bipolar Self-Maagemet Program Review Self-maagemet programs are based o a comprehesive kowledge about oe s coditio, its treatmet ad medicatio, ad based o developig ways to get ad Daa keep well i the log ru i the face of life s everyday challeges. They are a attempt to couter philosophies such as that of Elizabeth Miller s psychiatrist who told her upo discharge from the hospital: You will ot kow whe you are ill; oly I will be able to tell you that. You wo t kow what you are feelig; oly I will kow. This article reviews the work of several authors who realized the value of a cosumer-drive approach to recovery, startig with a approach developed by Miller herself. This approach stems from the premise that people should gai cotrol over their illess by maagig it resposibly. Elizabeth Miller There are four crucial compoets to Miller s approach. First of all, the perso eeds iformatio ad a peer support etwork. Secodly, the idividual eeds to lear to recogize the warig sigs ad triggers of the illess, both geeric ad idividual i character, the eeds to develop a pla for the oset of symptoms i cooperatio with health professioals. Fially, there is the task of maitaiig good metal health overall through moitorig of oe s mood swigs ad symptoms, gettig feedback from frieds ad relatives, havig a healthy diet ad exercise regime, as well as maitaiig proper sleep patters. As Miller says, Not everyoe wats to take resposibility for their illess, but just about everyoe beefits from more iformatio. Willpower ad perseverace help people lear more ad apply the kowledge for their ow beefit. For more, see joural/vol_001 ad2/miller.pdf Maic Depressio Fellowship The Self-Maagemet program of the Maic Depressio Fellowship (i the UK) is a sixweek program of three-hour sessios led by people with bipolar disorder. I the first two weeks, participats lear to recogize the ature of their illess ad what impact it has o their lives. Half way through the course, the sessios cetre o learig about triggers ad warig sigs by keepig a mood diary. Other topics addressed at this stage iclude self-medicatio, buildig support etworks, ad makig actio plas. The last two weeks foototes 1 Chodro, P. (1997). Whe thigs fall apart. Bosto: Shambhala Publicatios. 2 Segal Z., Teasdale J., & Williams M. (2002). Midfuless-based cogitive therapy for depressio. Guilford Press. Practical Midfuless (cot d from prev. page) By fosterig this witess perspective, I start to see a way out. Midfuless has the extraordiary ability to shift distortio ito discermet. Thoughts ad feeligs, which ormally sed me ito tailspis, ow rest i eutrality. I gai objectivity leadig to ew, more adaptive choices ad healthier self-talk. Midfuless offers a precious split secod betwee feeligs ad reactios. I this flash of time, reactios ca be habitual, or ew resposes ca occur. Feeligs of iadequacy ad axiety do ot magically evaporate. But they cease to itesify as quickly ad fade more rapidly. It takes practice to stay awake to these emotios, to refuse to flee, fight or freeze. I have leared this skill over time years to be exact. Midfuless is cultivated, ot iate. Practicig this art daily, eve whe thigs are goig well, icreases clarity ad compassio ad well-beig ufolds. Midfuless is ot a substitute for medicatio ad itelliget cogitive therapy. It is however, oe of my most potet power tools to maitai recovery ad prevet relapse. I repeated studies, MBCT substatially reduce(s) the risk of relapse i those who had three or more previous episodes of depressio (from 66% to 37%). 2 I m at the sik. I step back i my mid, start risig the sticky bowls ad allow thoughts of self-hate ad self-deprecatio float i ad move about as they wish oticig these disorderly characters jostlig for attetio. Literally. I just watch, with as much patiece, as much kidess, as I ca muster which at this poit, is t a lot. I swish the soapy dishcloth over the lip of a travel mug, ad the cruel thoughts ad mea-spirited emotios begi, ever so slightly, to softe. A therapist I worked with taught me to metally catalogue my thikig patters, ad ote the most commo themes. Axiety ad self-loathig? Despair ad disdai? The, like a teacher with a uruly class take role call. Ah yes Despair oh, ad Audacity ad Arrogace. Hmm is t that iterestig. Have t see these scalawags i a while. Ad so the watchig goes. Because practical midfuless at its best is without judgmet ad full of lovig-kidess, it teaches me to embrace my humaess awkwardess ad all to welcome home my quirks, my warts, my diamod-like beauty: the masterful beauty ad warts we all have, ad we all try to hide. This arms-wide-ope positio allows me to hold all my aspects: those I hate, ad those I love. Eve whe I refuse to be kid to myself, ad demad that I berate myself ad whip myself ito perfectio, this too I ca watch. With perhaps less warmth, but still I ca watch. Ad slowly, just as dark turs to daw, more light creeps i, despite myself. related resources Chodro, P. (2002). The places that scare you. Bosto: Shambhala Publicatios. Williams, M. (2002). Midfuless-based cogitive therapy ad the prevetio of relapse i depressio. Olie at

27 alteratives ad approaches 27 address developig a lifestyle that promotes good metal health. This ivolves developig persoal awareess ad maitaiig a daily routie just to ame a few of the topics discussed. Active participatio i the sessios is ecouraged, ad the program is accompaied by exercises that are doe o a idividual or group basis. Positive outcomes achieved with this approach iclude reductio of participats egative attitudes towards the past, as well as reductio of suicidal thoughts ad difficulty with cocetratio. Participats i the program also ted to feel more i cotrol of their illess as well as more ivolved i the treatmet offered to them by their cliicias. For more, see Welless Recovery Actio Pla Mary Copelad s book Livig without depressio ad maic depressio 3 is a practical workbook that shows that it is possible to live with this disorder through iformatio, acceptace ad coscious chage. By gaiig cofidece i oe s kowledge of the disorder, ad about what treatmets ad medicatios work best, the idividual is able to prepare ot oly for a relapse situatio, but also for log-term maagemet of the illess withi the perso s social etworks. The workbook offers practical examples of questios to ask the doctor ad thigs to kow about coditios that might look like bipolar disorder. It also deals with issues such as the value of receivig ad givig peer support, the advatages of developig a lifestyle that ehaces welless, comig to terms with the past, ad gettig the most out of couselig. Numerous charts offer suggestios of how to track oe s moods, how to chage egative thoughts ito positive oes, or what actios to take to avert a relapse. Copelad s cocept of WRAP (Welless Recovery Actio Pla) provides a simple system for moitorig ad maagig emotioal ad psychiatric symptoms, as well as avoidig uhealthy habits or behaviour patters. I order to arrest symptoms ad haste remissio ad recovery, people both lear ad share persoal strategies for dealig with each level of relapse. For more, see All of the programs listed have a commo uderlyig message: that it is possible to break away from the ievitability of the illess, take charge of the course of life, ad to work o gettig oeself out of the treches ad back ito the social etworks that are so valuable for the people who live with this illess. Hearig Voices that are ot Real Advice for Cosumers ad Those who Wat to Help Hearig voices that are ot real ca be a distressig experiece, both for the perso that hears voices ad for those who wat to help. Uderstadig the experiece of hearig voices has bee stifled by the traditioal psychiatric approach, but thakfully there are resources ow available to those who hear voices ad those who wat to help resources that are the result of ew approaches to the task of uderstadig ad maagig voices that are distressig. The covetioal psychiatric respose to voices (otherwise kow as auditory halluciatios) oce sought to dey, suppress ad igore voices. It was believed that oly people with schizophreia heard voices. It was believed that voices made o sese, could ot be uderstood, ad therefore that there was othig that could be doe about them if they did ot respod to medicatio. Furthermore, it was believed that talkig about voices could oly make them worse. Egagemet of the voices was emphatically discouraged, o the theory that to egage the voices was a kid of buyig i to the hearer s delusioal fatasies. The result of this approach was to further isolate the sigificat miority of voice-hearers who do ot respod to medicatio or those who fid medicatio itolerable. For those who hear voices, oe thig is clear: that voices ca have a great deal of cotrol over the perso who hears them. Also, voices do make sese i that they ofte reflect issues that a perso has i their life ad the voices ca have a lot of power. As a result of this icreased awareess, ew approaches to copig with voices help the voice-hearer take cotrol ad gai uderstadig ad power over the voices ad their disruptive effects. Cotrary to the belief that oly people with schizophreia hear voices is the acceptace that hearig voices is a relatively commo experiece, ad uder certai coditios of duress (such as sesory deprivatio, lack of sleep, or with drug use) ayoe ca have the experiece of hearig voices. Have you ever heard your ame spoke, oly to tur your head ad discover that o oe is there? It is a startig poit to uderstadig the experiece of hearig voices ad of beig able to help. Patricia Deega has a PhD i cliical psychology ad has heard voices most of her life. With the Natioal Empowermet Ceter (NEC), a US-based cosumer-ru orgaizatio, she has developed the Hearig voices that are distressig curriculum for metal health professioals, a compoet of which replicates the experiece of hearig voices i a simple but effective way. Participats wear headphoes ad liste to a audiotape that rus as they udertake a series of tasks, icludig social iteractio ad cogitive tests. The result is a dramatic experiece of what it must be like to try to fuctio as the voices are active. Aother resource, Uderstadig voices: A guide for family or frieds, provides writte guidelies for those who wat to help but may be usure of what to do. The full guide, which icludes foototes 1 Miller, E. (1999). Self-maagemet i maic depressio. Joural of Primary Care Metal Health, 2. 2 Harris, A. (2000). Self-maagig maic depressio. Metal Health Care, 31(8), Copelad, M.E. (1994). Livig without depressio ad maic Depressio. Oaklad, CA: New Harbiger Publicatios. Cythia Row Cythia lives i Vacouver ad has a backgroud i freelace writig ad broadcastig. She is also Editorial Assistat for Visios

28 28 alteratives ad approaches I recetly participated i the Hearig voices traiig. I must cofess, I was disturbed by the sudde realizatio that I have bee treatig schizophreia for four years, yet I ve ever kow what it really was. I may have had the kowledge, but ot the wisdom or true empathy util ow. Jim Willow, MD, Psychiatric Residet, PsycHealth Cetre (Wiipeg, Maitoba) a useful guide of dos ad do ts for caregivers ca be foud olie at While Hearig voices traiig ad other resources are useful tools for caregivers, a sigificat amout of progress has bee also bee made i developig copig strategies directly for those who hear voices. Advaces have bee made especially by Europea researchers i the field of cogitive-behavioural therapy, ad by etworks of people who hear voices themselves. This work has resulted i a umber of potetially helpful strategies for people who hear voices that are distressig. I geeral, these approaches to maagig voices ivolve the awareess of, trackig, ad egagemet of the voices i a way that improves oe s cotrol over them. Suggestios that idividuals ca try, with the support of their treatmet team, iclude: Accept that the voices belog to you, ad are ot a exteral force that ca read your mid or steal your thoughts. I the process of developig your ow poit of view ad takig resposibility for yourself, a importat ad difficult first step is to take owership of the voices. Get to kow the voices by keepig a diary, so that you ca kow whe the voices come o ad what might trigger them. Make a cotract with the voices, perhaps allottig a specific time whe you will liste to them. I this approach, the voice-hearer exerts some cotrol over the voices ad lesses their impact. Tell demadig voices that you wat cotrol of your ow life; realize that despite what the voices are sayig, they are a part of you, so you are i charge, ad o harm will come to you whe you do t liste to them. Egage i o-stressful, distractig activity such as gardeig, listeig to music etc., whe the voices come o. Experimet with ways of dimiishig the voices, for example, by shadowig the voices, that is by whisperig the cotet of the voices uder your breath, or by hummig whe the voices come o. Avoid uhelpful strategies, such as passive activities (e.g., watchig TV) arguig with the voices self-medicatio social isolatio Make use of resources that suggest strategies ad etworks that coect voice-hearers. Hopefully, the advice ad resources i this article go some way toward achievig their aim, that is, to make the lives of those who hear voices easier ad better uderstood. related resources Uderstadig voices (fact sheet) This site features a fact sheet developed by UK cogitive psychologist David Kigdo, based o his research i this area. The fact sheet was oe of the sources for the strategies described i this article: Voices/uderstadig_voices.html Hearig voices (fact sheet) A helpful resource o dealig with voices, developed by the UK s Metal Health Foudatio: Hearig voices that are distressig (curriculum program) The curriculum ad tapes ca be ordered through the NEC Store lik o the NEC website at This website is also a excellet source of iformatio for cosumers ad professioals. Acceptig voices (book) Marius Romme ad Sadra Escher have published copig strategies after years of listeig to the experieces of voice-hearers. Their book is called Acceptig Voices (1993) ad ca be ordered from MIND Publicatios, Grata House, Broadway House, Lodo, E5 Eglad (ISBN # ). Olie orderig at www. mid.org.uk/osb/showitem.cfm/category/104 Makig sese of voices (book) Romme ad Escher have also published a recet title (2000) called Makig Sese of Voices: A guide for metal health professioals workig with voice-hearers, which would also be helpful for voice-hearers themselves. Olie orderig at uk/osb/itemdetails.cfm/id/138 or via mail at the MIND address listed above Checkig Thigs Out A Tool for the Cosumer Pukaj Bhusha Pukaj is o the Board of Directors for the BC Schizophreia Society. He has made may presetatios relatig his experieces with schizophreia ad his methods of maagig the illess. He has a wife ad two childre ad lives i Surrey. Medicatios, while extremely valuable i treatig metal illess, ofte still leave a umber of symptoms of psychosis still preset. Medicatios are also i the cotrol of the treatig physicia. But what is i our cotrol as metal health cosumers? People with schizophreia still have problems with their iterpretatios of evets, such as coversatios or aother perso s body laguage. Recet research suggests the frotal lobe fuctios i a perso with schizophreia are impaired. The frotal lobe is ivolved with the complex work of readig ad iterpretig body laguage. I have foud a ivaluable tool to keep my thoughts o a eve keel so that I ca cotiue to work at a job ad to keep my relatioships healthy. I call this process, checkig thigs out. What I do is, whe I come home from work, I relate all my experieces durig the day, to my wife, Aoo, ad she commets o my versio of what happeed: my iterpretatios. This time allows us to share ad have quality time. She also relates her day ad what

29 Evidece-Based Treatmets for Alcohol Problems Brief Itervetios alteratives ad approaches 29 Problems ivolvig alcohol are commo, ad take o a variety of forms. Numerous itervetios for alcohol problems have bee devised over the years, ad the evidece supportig differet treatmets varies. Sice 1980, Miller ad colleagues have published a series of icreasigly rigourous, systematic reviews of the alcohol treatmet literature. I their latest review, 1 a total of 381 studies were idetified, represetig 99 differet treatmet modalities ad ivolvig over 75,000 cliets. A umber of the fidigs are provocative. For example, the majority of treatmets for alcohol problems have little or o evidece of effectiveess. More troublig, the treatmets with the strogest evidece are the oes that are least available i practice, ad the most commoly available forms of treatmet are those with the least scietific support. I the authors words: The egative correlatio betwee scietific evidece ad treatmet-as-usual remais strikig, ad could hardly be larger if oe itetioally costructed treatmet programs from those approaches with the least evidece of efficacy. But there is also good ews. Specifically, a umber of treatmets have repeatedly bee foud effective, presetig a rage of evidece-based optios that beefit cliets. The most effective therapies iclude motivatioal ehacemet, bibliotherapy (readig- or workbook-based itervetios), ad other forms of brief itervetio. I geeral, brief itervetios place cosiderable emphasis o self-directed chage, with miimal iput from professioals. Thus far, the evidece supportig brief itervetios for alcohol problems is cosiderably stroger tha the evidece for all other forms of treatmet to date. Brief itervetios have bee used effectively for several target groups icludig youth, hazardous drikers, depedet problem-drikers, ad cliets who have ot respoded to other forms of treatmet. The effectiveess of brief itervetios is good ews for several reasos. First, there is growig recogitio that may problems with alcohol do ot ivolve severe depedece. May people who would ot be cosidered alcoholics will evertheless experiece adverse impacts due to drikig. Brief itervetios ca be employed effectively with a broad rage of cliets, icludig high-risk drikers. Secod, brief itervetios ca be used i the cotext of a stepped care approach. Rather tha providig itesive treatmet for all cliets, stepped care approaches proceed gradually, begiig with less itesive forms of treatmet, icreasig the itesity oly as eeded. If the cliet respods to the less itesive step, the o additioal resources are required. This ties i with a third beefit of Julia M. Somers MSc, PhD, RPsych Julia is a full-time member i the Departmet of Psychiatry at the Uiversity of British Columbia. His research iterests iclude telehealth ad collaborative care, as well as iovatios i the educatio ad developmet of health professioals. Dr. Somers has also coducted research i the areas of addictios, motivatio for chage, ad child ad adolescet metal health You ca cotact the author at jsomers@iterchage.ubc.ca Checkig thigs out (cot d) happeed, more to share tha aythig else. Ofte times, Aoo will disagree with my versio ad iterpretatio of what happeed ad what the itetios of colleagues at work were. This allows me to put those iterpretatios i a holdig patter, ad I will say, Ok, maybe my beliefs are wrog ad I do ot have to get worked up about so ad so It is ot that I totally dismiss my beliefs, but I place eough of a questio mark behid them to keep my mid i symbiosis ad ot veerig alog the path towards psychosis. This method really works like a charm. I believe without it, I would probably be uable to work or help my wife i raisig our family. It seems to me that most people have varyig success with medicatios: sometimes, they cotrol most of the symptoms of schizophreia ad sometimes they do ot. But for most people, proper medicatios foud through trial ad error lifestyle adjustmets ad the method of checkig thigs out will cotrol the illess. Ufortuately, people ofte do ot wat to relate their iermost thoughts because of shame ad embarrassmet that the thoughts would be uacceptable to aother huma beig. People sometimes do ot eve reveal their thoughts to their doctor or psychiatrist. This keeps people i a patter of distorted thikig ad keeps them out of touch with the reality that is geerally accepted by the rest of the world. Eve whe you religiously take medicatio, you must develop the habit of checkig thigs out so that you cotiue to get better. I strogly feel may people remai closed ad isolated because they do t get it i habit of checkig thigs out. This is a way towards recovery ad stability. Try it out ad develop it ito your ow tool. If you do t have a sigificat other, try it with a family member or good fried.

30 30 alteratives ad approaches Stepped Care Movig Beyod the Visio to the Evidece Joh F. Aderso, MD Joh is a Adjuct Professor (appt. pedig) with the Departmet of Psychiatry, Faculty of Medicie at the Uiversity of British Columbia. Dr. Aderso ca be reached by phoe about this article at (250) or by at Joh.Aderso@ gems3.gov.bc.ca footote 1 Hester, R.K. & Miller, W.R. (2003). Hadbook of alcoholism treatmet approaches: Effective alteratives. 3rd ed. Bosto: Ally & Baco. (p. 41). Backgroud Shared Care ad Stepped Care I 1997, a Caadia Psychiatric Associatio (CPA) ad College of Family Physicias of Caada (CFPC) combied task force released a joit discussio paper etitled Shared metal health care i Caada. 1 The first author is Dr. Nick Kates, a psychiatrist who has pioeered a shared care approach betwee the departmets of psychiatry Evidece-based Treatmets for Alcohol Problems (cot d from prev. page) ad family medicie at McMaster Uiversity. The CPA/CFPC shared care paper emphasizes the importace of collaborative care betwee psychiatrists ad family physicias. The cocept of collaborative or shared care has evolved to iclude the idea of stepped care, i.e., that the level of itesity of care should be matched to the complexity of the coditio. Depedig o complexity, ad o other factors, the brief itervetios: cost-effectiveess. Brief itervetios preset a rare opportuity i the curret cotext of health reform: they are both more effective tha typical treatmet ad they are cosiderably less expesive. A fourth beefit relates to the fact that may people with alcohol problems will drop out of treatmet. Brief itervetios allow providers to make a positive impact i oe or two sessios, stimulatig chages ad icreasig the likelihood that the cliet will retur for additioal treatmet if ecessary. So if brief itervetios are cost-effective, useful with a broad rage of alcohol problems ad have abudat empirical support, the why are t they offered i practice? Ad what types of reforms might help esure that the most effective alcohol treatmets are routiely available to people who eed them? I may areas of health care, coverage by health care plas is reserved for treatmets that reflect evidece-based practice. This is oly ow becomig true with respect to treatmet of alcohol problems. May jurisdictios are curretly workig to better itegrate the treatmet of alcohol problems with other relevat health services, icludig metal health ad primary health care. These reforms have the effect of broadeig the base of practitioers who ecouter alcohol problems ad ca provide care. For may health professioals, brief itervetios will be appealig first because they work, ad secod because they ca be itroduced through a existig treatmet relatioship ad do ot ecessarily require referral to a specialist. Cliets ad family members ca also facilitate chage by iquirig about treatmet alteratives ad the probability of success associated with differet optios. Brief itervetios are ot a cure-all. However, they represet a curretly-eglected compoet of treatmet for alcohol problems, ad warrat much greater attetio by all parties cocered with the welfare of problem drikers. They also deserve cosideratio as the first step i a meu of evidece-based alteratives from which problem drikers may beefit. most appropriate (ad cost-effective) level of care may rage from brief, o-itesive itervetios that ca be iitiated by the family physicia, to itervetios requirig the coordiated, ogoig efforts of a rage of professioals i additio to the family physicia. As will be discussed later, may of these itervetios are cosistet with the priciples of selfmaagemet. The cocepts of shared care ad stepped care are also itegral to the Chroic Disease Prevetio ad Maagemet approach, described elsewhere i this editio of Visios. Stepped Care ad Maagig Metal Health Problems For may persos with metal health problems, the family physicia s office is the first poit of cotact with the metal health system ad, for may of these, the oly cotact. The high rate of cotact betwee family physicias ad people with metal health problems ca be viewed as a widow of opportuity for family physicias to provide itervetios kow to beefit those seekig assistace ad care. I order to meet the eeds of as may people with metal health problems as possible, a stepped care approach to primary metal health care should iclude: etry-level prevetio ad treatmet itervetios, such as brief itervetios (described below) strategies to meet the eeds of those who do t respod to iitial itervetios (ehaced treatmet) aftercare strategies for those patiets who require loger term follow-up ad supervisio Etry-Level Itervetios Etry-level prevetio ad treatmet itervetios share some of the followig characteristics: miimally itrusive easy to implemet relevat to a broad rage of metal health problems likely to be effective for most people likely to geerate a populatio health beefit; that is, it may beefit groups of people, rather tha just idividuals cost-effective There is evidece i the medical literature that suggests that the delivery of these itervetios by family physicias ca be effective. May of these optios, such as those kow as brief itervetios, are cosistet with self-maagemet priciples ad are aimed at helpig people build skills or motivatio to remai healthy or deal with symptoms outside of the office settig. Some of the relevat fidigs iclude studies showig that: the impact of family physicia brief itervetios o both smokig cessatio ad reductios i alcohol cosumptio ca be substatial 2,3 a brief school-based itervetio for childre ca produce durable reductios i axiety problems: a recet Australia study foud evidece of success i a child ad family-focused group

31 alteratives ad approaches 31 itervetio for prevetig axiety problems i at-risk childre through a rage of strategies, for istace, by the youg people developig problem-solvig skills for social situatios. 4 The itervetio could be exteded to other settigs icludig family physicia offices. Curretly, the Cochrae Collaboratio a orgaizatio dedicated to uderstadig which itervetios are evidece-based, or prove effective through rigourous studies is systematically reviewig all studies examiig brief psychological treatmets for depressio. 5 Depedig upo the results of this review, the implemetatio of brief psychotherapeutic itervetios such as maual-based selfmaagemet itervetios based o the priciples of cogitive behavioural therapy (CBT) could have a profoud impact o the large umber of people receivig treatmet for depressio from family physicias. The Depressio Self-Care Guide see page 5 i this issue of Visios is a example of such a maual-based self-maagemet itervetio, also kow as bibliotherapy. Ehaced Treatmet A stepped care approach also icludes a strategy for targetig ehaced treatmet to those patiets who do ot respod to the iitial simpler itervetio(s). These approaches also iclude self-maagemetrelated itervetios, such as psychoeducatio. Some of the relevat fidigs iclude: a recet study that reported o a multifaceted program targetig depressed idividuals whose depressive symptoms persisted six to eight weeks after iitiatio of atidepressat medicatio by their primary care physicias. 6 Patiets i the itervetio group received ehaced educatio as well as icreased visits by a psychiatrist workig i collaboratio with the primary care physicia. The ehaced treatmet improved adherece to atidepressats, patiet satisfactio with care, ad depressive outcomes compared with usual care. a review showig that a sequetial or stepped approach to the treatmet of bulimia may be as effective as stadard cogitive-behavioural treatmet (CBT) ad ca cosiderably reduce the amout of therapist cotact required. I oe study, patiets who received a self-care maual followed, if ecessary, by a brief versio of CBT achieved similar outcomes to those who received stadard CBT. 7 More research is required to uderstad the eeds of those who do t respod to iitial itervetios. I some areas, such as problem drikig, additioal research is eeded to idetify target groups most likely to beefit from brief itervetios 8 as well as to idetify idividuals ot respodig to treatmet. 9 I other areas, such as eatig disorders, more effective treatmets are required for those who fail to respod to self-help ad other brief, costeffective therapies. 10 Follow-up or Aftercare Fially, stepped care defies a role for family physicias i the delivery of aftercare for patiets who require follow-up of a metal health problem, such as for people who have attempted suicide. The authors of a recet review 11 ote the frequecy of suicide attempts see i geeral practice, ad coclude that family physicias have a crucial role i prevetig suicide through aftercare ad ogoig moitorig of patiets who have made attempts. Research cited above 6 also idicates the importace of the family physicia i the ogoig maagemet of depressio, icludig the role of the family physicia i supportig the developmet of self-maagemet skills. Coclusio Attetio to evidece, some of which is outlied above, should assist i removig the obstacles that iterfere with makig evidece-based itervetios icludig those based o selfmaagemet priciples available to people with metal illess. The same evidece should also provide a impetus to the ecessary collaboratio amog health professioals as they help people maage their coditios. foototes Whe you play bigo at Buraby Bigo Coutry, you help support the work of CMHA BC Divisio i our missio to promote the metal health of all British Columbias ad chage the way we view ad treat metal illess i BC. 1 Kates, N., Crave, M., Bishop, J., et al. (1997). Shared metal health care i Caada. Ottawa: Caadia Psychiatric Associatio. 2 Silagy, C. & Ketteridge, S. (1999). Physicia advice for smokig cessatio (Cochrae Review). The Cochrae Library, 4. Oxford: Update Software. 3 Kaha, M., Wilso, L. & Becker L. (1995). Effectiveess of physicia-based itervetios with problem drikers: A review. Caadia Medical Associatio Joural, 152(6), Dadds, M.R., Hollad, D.E., Laures, K.R., et al. (1999). Early itervetio ad prevetio of axiety disorders i childre: Results at 2-year follow-up. Joural of Cosultig ad Cliical Psychology, 67(1), Huot, V., Churchill, R., Corey, R. et al. (1999). Brief psychological treatmets for depressio (Protocol for a Cochrae Review). The Cochrae Library, 4. Oxford: Update Software. 6 Kato, W., Vo Korff, M., Li, E., et al. (1999). Stepped collaborative care for primary care patiets with persistet symptoms of depressio: A radomized trial. Archives of Geeral Psychiatry, 56(12), Treasure, J., Schmidt, U., Troop, N., et al. (1996). Sequetial treatmet for bulimia ervosa icorporatig a self-care maual. British Joural of Psychiatry, 168(1), Drummod, D.C. (1997). Alcohol itervetios: Do the best thigs come i small packages? Addictio, 92(4), Bresli, F.C., Sobell, M.B. & Sobell, L.C. (1998). Problem drikers: Evaluatio of a stepped care approach. Joural of Substace Abuse, 10(3), Wilso, G.T. (1999). Cogitive behaviour therapy for eatig disorders: Progress ad problems. Behaviour Research ad Therapy, 37(Suppl 1), S Liks, P.S., Balchad, K., Dawe I., et al. (1999). Prevetig recurret suicidal behaviour. Caadia Family Physicia, 45, B I N G O Buraby Bigo Coutry Middlegate Mall Kigsway (ear Edmods) Buraby BC Tel: Ope daily 11am to 11pm

32 32 REGIONAL PROGRAMS AND RESOURCES Buildig Metal Health Literacy The Metal Illess First Aid Course Joatha Oldma Joatha Oldma is the Executive Director of CMHA Vacouver/ Buraby brach For more iformatio about the timelies ad details of the proposal, please cotact Joatha at (604) footote 1 Jorm, A.F. (2000). Metal health literacy: Public kowledge ad beliefs about metal disorders. British Joural of Psychiatry, 177, Quoted i Kitcheer, B.A. & Jorm, A.F. (2002). Metal health first aid traiig for the public: Evaluatio of effects o kowledge, attitudes ad helpig behavior. BMC Psychiatry, 2(10). This project proposal is based upo the project Kitcheer ad Jorm evaluated, as well as CMHA s ow experieces i Vacouver. Kitcheer ad Jorm s article is available at X/2/10 People i our commuities who experiece some form of metal illess are ofte misuderstood. For may, a iteractio at the corer store, with a buildig maager or police officer is accompaied by a sese of beig differet, ad with difficulty i beig uderstood. This is ot because people are aturally ukid; it is simply that they have ot kow or loved someoe with a metal illess ad therefore have ever leared how to recogize ad the support someoe who may eed a ufamiliar type of help. Accordig to research, poor metal illess literacy leads to delays i recogitio ad help-seekig, hiders public acceptace of evidece-based metal health care, ad causes people with metal disorders to be deied effective self-help ad appropriate support from others i the commuity. 1 The Vacouver/Buraby brach of CMHA is developig a metal illess first aid course, desiged to address the issue of stigma, commuicatio ad support whe people with a metal illess iteract with other commuity members. By utilizig the skills ad talets of cotracted metal health professioals ad cosumers already ivolved i the metal health commuity, the project seeks to help improve the metal illess literacy of the geeral public, ad particularly key commuity groups, services ad orgaizatios that are idetified as havig a regular ad critical cotact with idividuals with a metal illess. The project is desiged to replace itroductory metal illess commuity workshops that were preseted by the brach oly i respose to proactive requests. Program Goals 1To reduce stigma regardig metal illess 2To promote recogitio of metal illess To improve the commuicatio ad helpig skills of 3people ad istitutios iteractig with idividuals with metal illess 4To icrease awareess ad iformatio regardig metal illess services 5To icrease acceptace of ad support ad participatio i a holistic, recovery-based approach to metal illess Target Groups The focus of the program is to idetify ad directly approach key target groups of workers, professioals ad busiesses that iteract o a regular basis with idividuals with a metal illess. Some key groups that the program could address iclude public service workers (such as parks staff), ad social service persoel (such as icome assistace staff). These groups regularly come ito cotact with people who have metal illess, ad could beefit from traiig about how to recogize metal illess, how to be supportive, or how to coect people with the services they eed. Format ad Cotet The course is desiged to be preseted i a oe-day iteractive workshop format, or i a three-part day format. The workshops will be preseted by a metal health professioal, assisted by a cosumer. The metal health professioal will have a para-medical or cliical desigatio, icludig experiece with those who have a severe or persistet metal illess. The cosumer preseters are to have experiece with the recovery model, to be actively cotributig to their ow welless, have kowledge of commuity resources ad strog presetatios skills. If some of these are lackig, the perso will eed to have aptitude ad willigess to acquire the skills through traiig. The course will be preseted i three mai sectios: a) what is metal illess?, b) commuicatio ad helpig skills, ad c) resources: What is metal illess? We will look at explorig the myths ad realities of metal illess, ad the recogitio ad reductio of stigma. Participats will lear the symptoms of various metal illess diagoses ad groups, icludig dual diagosis, ad also be itroduced to some of the risk factors ad characteristics of metal illess. Commuicatio ad helpig skills will address the commuicatio challeges particular to metal illess, discuss strategies for effective commuicatio with idividuals sufferig from metal illess, ad teach basic helpig skills, icludig givig effective feedback ad support. The differece betwee helpig ad rescuig will be a focus, as well as the issue of how to set ad maitai boudaries. Resources ivolves teachig participats how to idetify ad access the appropriate resources ad teachig commuity mappig, that is, kowig the local resources. A B C We are also workig with a project steerig group to examie ways i which we ca realistically provide follow-up support to workshop participats, whether that be oe-to-oe advice about how to hadle situatios, or orgaizatioal advocacy regardig further traiig or policy developmet. The project is curretly uder developmet ad pilot workshops are expected to take place i early The project is geerously fuded by the Vacouver Coastal Health Authority, the Uited Way of the Lower Mailad, ad Jasse Ortho Pharmaceuticals.

33 Do t Trust Ayoe Over 30 Youth Net Facilitates Metal Health Literacy by Youth for Youth Do t trust ayoe over 30 is a phrase coied log ago by youth who had a hard time believig ayoe over that magical age would uderstad their dreams or fears. It s a matra that Youth Net Vacouver (YNV) has take to heart. The origial Youth Net Ottawa model was created i 1995 after researchers foud youth were experiecig high levels of stress, ad were more likely to tur to their peers tha to access cliicias or specialists. 1 At a time whe suicide is the secod-leadig cause of death amog youg people, Youth Net s model of peer-led discussios focusig o metal health ad metal illess seemed to make a whole lot of sese. Sice its lauch i Jue 2002, YNV has facilitated over 90 discussio groups with youth i Vacouver, goig ito schools, commuity cetres, shelters aywhere there are youth. Our diverse team of traied youth facilitators (aged 18-29) leads discussio groups for youger youth (13-21) ad gets them talkig about what stresses them out, ad the differet ways they cope i their day-to-day lives. Our goal is to work towards de-stigmatizig metal illess, while providig a safe cotext for thikig about differet strategies that will work for them i maitaiig good metal health ad well-beig. I keepig with the peer support model, o oe over 30 is preset durig the discussio groups without coset, ad cofidetiality is assured. 2 To esure that idividuals participatig have support if they are i crisis, YNV has draw together professioals traied i dealig with youg people ito a cliical safety et. They are professioals who are o call durig the discussio groups should a youth idetify him or herself as beig i crisis. I additio to the safety et, our resource maual (give to everyoe i the groups) is a compilatio of resources i Vacouver, evaluated by our facilitators for their suitability for youth. Not oly do we wat to make it easier for youth to talk about what stresses they re dealig with, we also wat to support them i accessig the resources they eed. Kowig that sometimes talkig ca oly go so far, YNV advocates for youth to take actio aroud issues impactig o their metal health. I partership with the Self-Help Resource Associatio s youth iitiative, Kiex, youth are provided with orgaizatioal support ad access to resources (ad some seed moey) to start a group, whether it s to orgaize a queer youth coferece, start a hip hop dace class or a sports group the possibilities are edless but the mai goal is takig actio ad buildig peer support etworks, both of which are importat compoets of metal health. Youth Net has a trasformative effect o the youg people who participate. Whe I thik about trasformatio, I thik of it begiig with the aha! momet of realizatio whe a piece of the puzzle falls ito place that allows chage to happe, or at least helps make more sese of the situatio. I thik about all the seemigly little aha! momets that have take place for youth who have participated i YNV discussio groups, because there regioal programs ad resources was a space to talk opely ad freely about metal health, metal illess ad copig strategies. I thik about the youth who reaches out through his or her depressio, because they fially feel supported ad okay with the idea of askig for help. I thik about a youth livig with a metal illess who hears oe of their peers say for the first time, yeah, I have a metal illess too, breakig their bubble of isolatio. I thik about youth who are challeged to rethik their assumptios ad perceptios of metal illess. Ad I thik about YNV facilitators who are able to coect with youth, trasformig their lived experieces ito teachig tools to help guide ope ad hoest discussios of what good metal health is all about for folks uder 30. To me, the Youth Net discussio groups make a lot of sese... it s ot rocket sciece. It s all based o the simple priciple that youth talkig with their peers i a safe ad supportive eviromet ca truly be a trasformative experiece, oe aha! momet at a time. foototes 1 Research carried out by the Caadia Psychiatric Associatio. 2 Facilitators are aware of their duty to report ay suspected/disclosed abuse, self-ijurious behaviour or itetios of violece agaist others. Amada Walker Amada Walker is Program Coordiator at Youth Net Vacouver 33 bookigs To book a YNV discussio group or to fid out more about becomig ivolved with YNV, call Amada or Sabria at (604) or check out the website at artist: Aie Wilkiso

34 34 regioal programs ad resources Visioig Recovery i a Day Program Schizophreia Rehabilitatio Day Program W Otto Lim, RSW Otto is a cliical social worker with the Early Psychosis Itervetio Program/Schizophreia Rehabilitatio day Program at UBC Hospital, Vacouver Coastal Health Authority For ay questios about the Early Psychosis Itervetio program, please cotact Miriam Cohe RN, BSN, Coordiator, Early Psychosis Itervetio Program, Vacouver Coastal Health Authority; Phoe (604) ; mcohe@vahosp.bc.ca For iformatio ad/or referral to the Schizophreia Rehabilitatio Day Program (SRDP), please cotact Otto Lim, RSW, Schizophreia Rehabilitatio Day Program, Vacouver Coastal Health Authority; Phoe (604) ; olim@vahosp.bc.ca he idividuals ecouter their first episode of psychosis or face a diagosis of schizophreia, they ofte ask, will I ever get better? They will have also experieced difficulties with school or work, coflict ad isolatio from their family ad frieds, disruptio or loss of activities ad iterests, or loss of housig. Despite these difficulties ad losses, they ca begi avigatig their way towards recovery by havig their experieces ackowledged ad their goals ad eeds recogized ad respected. Sice its iceptio i 1987, the Schizophreia Rehabilitatio Day Program (SRDP) at UBC Hospital, has gradually evolved from the origial form of a weekly questio-ad-aswer group, with a physicia ad urse, to the curret model of a full-time five-day-aweek program, complete with a multidiscipliary team of occupatioal therapists, urses, a psychiatrist, ad a social worker. The missio of SRDP is the rehabilitatio of cliets with schizophreia or psychosis. With psychosocial rehabilitatio, the goal is to promote recovery, to empower idividuals with skills to icrease self-worth ad a sese of cotrol over their lives. I more cocrete terms, recovery ultimately meas to move forward with oe s life by maitaiig health ad avoidig hospitalizatio i order to succeed with meaigful activity ad relatioships, to reclaim the self from illess. This ofte meas returig back to school or work, voluteerig or egagig i a social life. Numerous studies have show that psychosocial rehabilitatio, alog with medicatios, ca lead to better outcomes such as improved rate of recovery, decreased severity of symptoms, decreased relapse rates ad fewer hospitalizatios, reduced sufferig of the idividual ad family, ad better quality of life. Recovery from illess, as the sayig goes, is a process rather tha a evet. It requires motivatio ad patiece to accomplish short-term goals that will ultimately lead to larger successes. Psychosocial rehabilitatio is more tha a treatmet model but also a philosophy that is cliet-cetred that is, it focuses o the idividual ad his or her stregths rather tha deficits ad helps the idividual deal with specific eviromets or settigs that may be importat to them like home, family, social etworks ad commuity. The approach also ecompasses the key elemet of maitaiig hope. Psychosocial rehabilitatio withi the SRDP focuses o groupbased skills traiig to eable the idividual to self-maage their illess. I particular, skills traiig focuses o three areas: social/ livig skills, stress maagemet ad relapse prevetio. Social ad livig skills iclude problem solvig, goal-settig, assertiveess ad commuicatio techiques to assist i overcomig social ad daily barriers. Also fallig withi the sphere of social ad livig skills is the eed to develop routie ad structure for the perso. Stress maagemet ivolves the use of simple relaxatio techiques such as breathig exercises, progressive muscle relaxatio, ad visualizatio to maage stress ad axiety. Relapse prevetio icludes educatio about the illess such as medicatio ad side-effect iformatio, symptom recogitio, warig sigs ad crisis plaig. Cogitive-behavioural therapy is used to help people uderstad ad maage the liks betwee their symptoms ad their thoughts, feeligs ad behaviours. Recetly, SRDP has developed two ew modules to address the cocers ad/or goals of cliets: weight maagemet ad datig. The practice of psychosocial skills traiig is achieved through the use of modellig, role-playig, social reiforcemet (e.g. peer, therapist ad video feedback), goal-settig, ad problem-solvig. Homework is assiged to icorporate the skills ad strategies leared from the groups. Vocatioal rehabilitatio is also used to idetify idividual goals ad to assess aptitudes, iterests ad barriers to employmet or school. Drug ad alcohol cousellig ad itervetios may also be offered. I additio, support ad educatio for family members ad sigificat others are also critical elemets of recovery to stregthe the support etwork for the idividual. Iformal feedback give by cliets who have egaged i psychosocial rehabilitatio i the SRDP have idicated that they foud medicatio, goal-settig, social ad physical activities, stress maagemet, ad peer support as useful elemets i attaiig self-maagemet of their illess. Curretly, the SRDP is coductig a ogoig outcome study to review the effects of psychosocial rehabilitatio offered withi the program. The prelimiary results show that after oe year of graduatig from the program, the majority of cliets: are ivolved i productive activity (e.g. work, school, voluteerig, vocatioal traiig) participate i social activity at least oce per week ad maitai regular social cotacts report miimal or o symptoms experiece o hospitalizatios take medicatios ad see their metal health follow-up appoitmets regularly report moderate to very good satisfactio of life I sum, psychosocial rehabilitatio eables the idividual to become the expert i developig skills ad makig the decisios that help them maage their illess, accomplish their goals ad move towards recovery.

35 Early Psychosis Itervetio Group Therapy regioal programs ad resources 35 It s ot what we as professioals brig ito the room that s importat, but what each idividual takes back out with them, havig shared ad gaied from others i the room whose experieces may parallel their ow, said Walter Lidster, a Early Psychosis Itervetio Program Group Therapist Lidster s commet is directed to a group program that is a essetial compoet of the Early Psychosis Itervetio (EPI) program i the Fraser South area. Early psychosis is the early stage of ay psychotic coditio that affects the mid, such as schizophreia or bipolar disorder. About three per cet of all people will experiece a psychotic episode i their life, ad ofte the first episode occurs i youg people betwee the ages of 13 to 30 years old. Despite limited research o early psychosis ad recovery, there is emergig evidece that the opportuity to meet i a group settig with others who have walked i the same shoes supports early recovery ad aids i decreasig the impact of the stigma of metal illess, Lidster says. Recogizig the uique course that each idividual ad their family ecouter whe experiecig the first episode of psychosis, a rage of group programs have bee developed icludig cliet programs, a family support group, psychoeducatioal sessios, ad a siblig group. Oe cliet group targets cliets uder the age of 19, some of whom are i the recovery stage while others are still acute. The sessios begi with a meal prepared with the youth, followed by discussio o stress maagemet, cogitio, relapse prevetio, alcohol ad drug use ad commuicatio. May youth do t have a lot of isight ito their illess ad we help them to recoect, Lidster says, We teach strategies for recovery, for maagig psychosis ad re-learig skills like how to become social ad make frieds agai. Havig a rage of youth, both acute ad i recovery, is a very effective strategy. We stress that you will get better ad seeig is believig, he says, poitig to the tremedous impact those i recovery have o the others. The other cliet group focuses o youg adults from 19 to 30 years old, workig with the may developmetal milestoes ad processes which occur durig this life stage. I a safe, o-judgemetal eviromet utilizig a cogitive therapy approach, cliets develop a persoal uderstadig of psychosis ad their ow copig strategies. At the same time as they eed to provide support, EPI families emotioally impacted by their ow grief ad loss issues may eed a forum themselves. To aswer this eed a mothly support group for families is offered i partership with the Caadia Metal Health Associatio ad the BC Schizophreia Society. Egagig the family as therapeutic parters has emerged as a itegral compoet to the success of the EPI Program, Lidster says. Family ivolvemet appears to reduce the vulerability of the cliet ad aids i maximizig potetial recovery while prevetig relapse. I additio, psychoeducatioal sessios are offered four to five times a year to help parets ad caregivers lear about psychosis ad how best to help their loved oe through recovery. A siblig group has evolved from the family sessios with a apparet eed for a opportuity away from paretal ears for brothers ad sisters to express their fears, their ager at the illess, ad the may times the guilt they feel for what they may have doe to cause their siblig to suffer, Lidster says. Group programs are at the earliest stage of developmet i Fraser North. We have itegrated EPI with the family support groups that already exist here, ad will be tailorig cliet programs to meet the eeds of the cliets i Fraser North. For more iformatio call Walter Lidster: (604) Fraser South, (604) Fraser North. Marie Nightigale Marie is Commuicatios Cosultat with the Fraser Health Authority Reprited from Ifocus, ewsletter of the Fraser Health Authority, December 2002, Volume 1, Number 4 WORLD MENTAL HEALTH DAY TM 2003 OCTOBER 10, Theme: Emotioal ad Behavioural Disorders of Childre ad Adolescets A Global Metal Health Educatio Program of The World Federatio For Metal Health

36 36 regioal programs ad resources Survey of Chroic Disease Maagemet i BC Focus o Self-Maagemet of Metal Illess withi Primary Care T Mykle Ludvigse Mykle is Public Educatio ad Commuicatios Support at CMHA BC Divisio figure 1 expaded chroic care model Iformed, Activated Patiet he classic model of chroic disease maagemet withi primary care was fairly simple, ad is the model of care with which most people are familiar. The job of the doctor was to diagose ad treat, ad the job of the patiet was to follow orders; i theory ayway, the perso would recover ad be o his or her way. For years, this was the model that was used i the treatmet of chroic illesses, whether it be metal illess or diabetes or a heart coditio. Today, however, medical service providers are begiig to uderstad that while this model may still be relatively effective for treatig acute illesses, it is ot terribly effective for chroic illesses. They are also comig to the realizatio that, give the pivotal role of the family physicia i maagig metal illess, a ew way of doig thigs is especially importat i this area. I respose, BC s Miistry of Health Services is implemetig a approach to chroic disease maagemet (CDM), based o a chroic care model developed i the Uited States by the Robert Wood Johso Foudatio, kow as the Expaded Chroic Care Model (see figure 1 below). Prepared, Proactive Practice Team The core compoets of the model iclude: decisio support or cliical guidelies for health professioals reflectig the best available evidece regardig the maagemet of each chroic coditio cliical iformatio systems or databases that allow health professioals ad maagers to track expected performace ad health outcomes delivery system desig the plaig ad implemetatio of a service delivery model that allows for a team approach to providig the cotiuous ad coordiated care that is so ecessary for maagig ogoig health coditios self-maagemet support providig resources ad strategies, such as iformatio ad tools, that allow health professioals to build their cliets ability to maage their ow health care both withi ad outside of the health delivery settig Overall, the model reflects the reality that people with ogoig health coditios eed a rage of evidece-based resources (i.e., itervetios that have bee prove effective), ad that the health care delivery system eeds to be orgaized i a way that allows idividuals to access these easily, iitially ad over time. It also reflects the eed to support idividuals i their ability to play a key role i maagig their ow health, for istace by beig a active parter i makig treatmet decisios, ad by buildig the skills that eable them to maage symptoms ad stay healthy i their day-to-day lives. The ideal sceario evisioed i the model is of a iformed, activated patiet workig productively with a prepared, proactive practice team to produce better health outcomes. It is importat to ote that the Expaded Chroic Care Model beig used i BC differs form the origial Chroic Care Model, most sigificatly i that it icludes prevetio ad health promotio compoets. This reflects the view that the essetial first step i maagemet of chroic disease is to prevet it i the first place or at least delay its oset. While the Chroic Disease Prevetio ad Maagemet iitiative is led by the Miistry of Health Services, implemetatio is takig place withi the health regios. The descriptio below provides a sapshot of the activities takig place withi each health authority, focusig o what each is doig with respect to the model geerally, as well o what each is doig specifically with respect to supportig self-maagemet i the area of metal illesses such as depressio ad axiety, withi primary care settigs. Before focusig o the health authority activities, however, a brief descriptio of other relevat provicial activities is eces-

37 regioal programs ad resources 37 sary cotext for uderstadig what s happeig throughout the provice. Other cetrally coordiated activities that will support the move to chroic disease maagemet of depressio ad axiety i the health authorities iclude developmet of physicia guidelies for maagig depressio, developmet of a busiess case outliig the argumets for adoptig a ew model for maagig both depressio ad axiety, sapshots describig care throughout the provice, ad the developmet of a patiet registry to meet the iformatio eeds required by the CDM approach. Other relevat self-maagemet-specific resources such as the axiety ad depressio self-maagemet toolkits, the metal health toolkit ad addictios tool, all part of the BC Parters for Metal Health ad Addictios Iformatio project are also i the process of beig released, ad will be described elsewhere i this editio of Visios, ad i future issues. Vacouver Coastal Health Authority The Vacouver Coastal Health Authority has focused much effort o itegratig the chroic disease maagemet approach ito their existig primary care delivery system, ad has icluded this as a key factor i their re-orgaizatio. I a March report, the health authority stated that it is ideed a importat strategy i reducig pressure o the acute care system. 1 Vacouver Coastal plas o implemetig a diabetes chroic disease selfmaagemet pla before movig oto other areas icludig cogestive heart failure ad depressio. We do ot wat to take o too much, says Alex Berlad, Primary Care Leader. We wat to take a icremetal approach do a good job with this first wave of projects ad the expad from there. He adds that the authority will be postig a maager positio for the chroic disease maagemet program shortly. While he ackowledges that the health authority is behid where it would like to be ad that there is a defiite lack of resources, Berlad otes that there is cosiderable iterest i the program withi the health authority. There is lots of activity goig o aroud the edges, he says poitig out that if a group of people withi the cliical care commuity came forward to spearhead the program ad stated their desire to move ahead o it, it would help move thigs alog. While the iitial roll-out of the program i the Vacouver Coastal Health Authority does ot evisio depressio or axiety disorders amog the iitial illesses to be maaged by CDM, it will be moitored as a secodary problem with the iitial diabetes ad heart disease programs. Accordig to Berlad, a focus o depressio ad axiety would be the ext logical step. Vacouver Islad Health Authority The Vacouver Islad Health Authority is plaig o havig chroic disease self-maagemet at the foudatio of their delivery system begiig with a group of family physicias workig together o diabetes, cogestive heart failure, ad major depressive disorder, sharig resposibility for chroic care with a larger iterdiscipliary team icludig urses, specialists ad commuity-based services ad resources. We re absolutely coviced that chroic disease maagemet will work well, says Sylvia Robiso, Maager of Chroic Disease Iitiatives. Curretly i the iitial phases of implemetatio, the health authority has recetly siged o 30 family physicias to take part i the program, as well as a few dedicated CDM urses, ad promiet psychiatrist Dr. Rivie Weierma. We have bee thrilled with the respose [from doctors], she says. More people applied tha we were able to accept. The health authority is curretly completig some baselie documetatio of patiets withi the program ad will begi the full roll-out startig September Accordig to Robiso, the aim is to lear as they go alog with the ew system, ad ascertai what works ad what does t. She poits out that it is critical i the curret iitial phase of the project to esure that there is excellet iformatio systems support withi the orgaizatio, for all health care professioals workig o a idividual file. From there, these professioals ca work as a team to provide crucial support to the patiet. For example, physicias may make follow-up calls to patiets to see how they are doig ad to remid them of upcomig appoitmets. Decisio support will also be a key fuctio of these teams, esurig that patiets have access to iformatio from both physicias ad cliicias. For self-maagemet i depressio, there will be key support available for the idividual from the local metal health team, commuity-based peer support ad commuity agecies. Robiso stresses that it is importat to start buildig relatioships ad likages with these critical supports that sometimes are ot always icluded. She poits out the eed to strategize aroud the differet characteristics i each commuity for example laguage or culture that impact o the successful maagemet of depressio or ay other chroic disease. While some of the issues are the same regardless of the disease, Robiso says, some of them are very differet, ad there eeds to be a specific strategy to deal with these differeces. While the fudig for this project (made possible by the Health Trasitio Fud) rus out March 31, 2006, part of the coditios of the iitial grat will help to esure that the program could cotiue after the 2006 cut-off. Robiso is cofidet that it will cotiue post We wat to see what works i Victoria ad how to spread that throughout the islad, ad the throughout BC. Fraser Health Authority The Fraser Health Authority is curretly workig with the Uiversity of Victoria s Chroic Disease Self-Maagemet Program (described i two separate Visios articles o pages 9-10 ad 39-40) to develop a regio-specific, self-maagemet pla. The iitial plas have focused o cogestive heart failure ad diabetes, but the health authority is plaig o developig chroic disease maagemet strategies i other areas icludig depressio. The health authority is usig these test areas of diabetes ad cogestive heart failure to develop best practices models for self-maagemet i other chroic disease areas. A shared care model for depressio is beig explored, with liks to primary care. If there was a critical mass we would do it, says Frak Fug, Health Services Director for the Fraser Health Authority, Fraser East. He poits out that while Fraser Health certaily pays attetio to depressio as a critical secodary issue, major depressive disorder issues are curretly beig hadled i a commuity cotext, withi the metal health cetres. The CDM model that is beig implemeted i the Fraser Health Authority is similar to the oe beig itroduced i the footote 1 (March, 2003). BC chroic disease maagemet update. p. 12. Olie at cdm/research/ updatemar03.pdf

38 38 regioal programs ad resources Vacouver Islad Health Authority. Doctors ad other team members will work together closely to remid people of appoitmets, ad provide some ecouragemet to esure medicatios ad other remedies are beig take, as well as esurig a sigificat level of public educatio i the commuity, workig closely with the provicial govermet ad other agecies to provide that goal. Norther Health Authority The Norther Health Authority has plas to implemet the Uiversity of Victoria s Chroic Disease Self-Maagemet Program i various commuities. Accordig to Elizabeth Tovey, Regioal Director of Metal Health ad Addictios, the Norther Health Authority is iitially workig at buildig skills for the chroic disease maagemet staff to deal with depressio issues whe they arise for people, with chroic disease maagemet programs as secodary issues. Metal health ad addictios services are so eeded i the North, ad [idividuals] requirig medical treatmet [for issues ragig] from diabetes through [to] Hepatitis C, as example[s], [ofte have] risk factors closely associated with metal health ad addictios. The Norther Health Authority is puttig together a commuity respose uit which ca address ay questios from primary care providers. Tovey adds, We still see each service providig a specialty but [they] will also lear to better idetify co-occurrig disorders. Iterior Health Authority While somewhat behid other health authorities i its plas for iitiatig the CDM model, Iterior Health has recetly begu to idetify key strategies for implemetig a CDM model withi the Iterior Health Metal Health Pla. Over the six-moth period betwee October 31, 2003 ad March 31, 2004, Iterior Health will be reviewig where they ca begi developig CDM strategies, ad how to work closely i partership with the Miistry of Health Services. Meetigs were recetly held with seior maagers from throughout the health authority ad with the Miistry of Health Services to get a uderstadig of the program. Accordig to Kim Marshall, Metal Health Maager for Iterior Health, What we would like to see is where the Miistry is goig with this ad how do we implemet this, ad how do we parter with public health ad other agecies. BC Cliical Guidelies for the Diagosis ad Maagemet of Depressio Raymod W. Lam MD, FRCPC Raymod is Professor ad Head, Divisio of Cliical Neurosciece, Departmet of Psychiatry, Uiversity of BC, ad head of the Mood Disorders Cetre at UBC Hospital. Dr. Lam is chairig the Work Group o Depressio Guidelies for BC For more iformatio o the guidelies, visit the BC Miistry of Health Services website at bc.ca/msp/protoguides/ gps/idex.html As a key part of the overall Depressio Strategy for BC, cliical guidelies are beig developed to help physicias maage the treatmet of people with depressio. What are cliical guidelies? They are systematically-developed statemets about specific cliical problems, iteded to assist practitioers ad patiets i makig decisios about appropriate health care. 1 Cliical guidelies are a series of evidece-based recommedatios for good cliical care. They ca help physicias to stadardize their care, provide accessible kowledge about available treatmet optios, facilitate learig of basic priciples, ecourage disease detectio, ad promote quality improvemet ad cliical practice research. Cliical guidelies are ot recipes to be used for every patiet, or are they edless lists of every possible treatmet, or textbooks. They are ot meat to restrict choice of treatmet, ad they should ot be regarded as stadards of care because specific cliical situatios may override the guidelies. Istead, they should be cosidered a framework to eable the physicia to provide the best quality of care for idividuals with depressio. Cliical guidelies are ecessary for depressio because the detectio rate by physicias is still low, outcomes for patiets are ot optimal, there has bee a explosio of ew kowledge about treatmets (both medicatio ad psychotherapy), ad there is still cosiderable variability i the treatmets offered. How are cliical guidelies developed? Cliical guidelies follow the priciples of evidece-based medicie. Evidece-based meas that treatmets are selected based o the scietific weight of evidece to support their use. Prove effective treatmets are recommeded first, before uprove treatmets. The cliical research evidece is rated both o quality ad quatity. The gold stadard of evidece i medicie is the double-blid radomized cotrolled trial, where patiets are radomly assiged to a active treatmet or to a placebo or iactive treatmet. Double-blid meas that either the patiet or the physicia kows which treatmet is used util after the study is completed, i order to avoid bias i assessig the results. Placebo treatmet is ecessary because there is a spotaeous improvemet rate i coditios like depressio for example 40% to 60% of people who take a placebo pill (i.e., like a sugar pill) i a cliical trial feel substatially better i six to eight weeks. That does t mea the depressio is all i their heads; rather, the simple act of participatig i a research study beig diagosed, receivig

39 treatmet, talkig to the doctor, fidig out about the illess, goig regularly to the cliic ca help people with depressio feel better. Radomized cotrolled studies do t tell the whole story, however. Ofte, the studies do ot iclude the typical patiet beig treated with depressio, so the results may ot be applicable to everyoe. That s why cliical guidelies also use expert opiios to evaluate the evidece ad to come up with cliical recommedatios that make sese to physicias. The developmet of BC depressio guidelies is uder the directio of the Guidelies ad Protocols Committee, a joit effort betwee the BC Medical Associatio ad the Miistry of Health/Medical Services Commissio. A work group was appoited, which icludes psychiatrists, family physicias, a psychologist, ad represetatives from cosumer associatios ad the Miistry of Health. The work group started with a detailed map the cliical guidelies developed by the Caadia Psychiatric Associatio ad the Caadia Network for Mood ad Axiety Treatmets i ad adapted them for use by family physicias. A prelimiary summary was published as a theme issue o Depressio i Primary Care [Family Practice] 3 i the BC Medical Joural last year. The draft guidelies are ow beig set out widely for exteral review, with a aticipated release i the autum of However, mailig out writte guidelies to busy physicias is ot likely to chage the way they practice. That s why we eed to pay attetio o how to get physicias to start usig the recommedatios. Educatio is oe way to promote the use of guidelies, but, sadly, educatio aloe has ot bee show to ifluece physicia behaviour. Other methods, which iclude additioal support for physicias such as practice aids, electroic remiders, educatioal materials, small group tutorials, practice maagemet sessios, ad resource directories may have better results. Aother meas for promotig cliical guidelies is to make sure that patiets are also educated about them. I the BC depressio guidelies, selfmaagemet is emphasized, icludig ways that the physicia ca promote ad ecourage self-maagemet. A importat aspect of self-maagemet is learig about the optios available for treatmet. To support this, we pla to develop a Patiet Guide to the Guidelies. This guide will help patiets ad families uderstad what to expect i their treatmet, what kids of iformatio they should expect from their physicia or caregiver, ad what questios they should be askig about their cliical care. Havig patiets as active parters i treatmet will provide aother icetive for physicias to lear ad apply the guidelies. I summary, cliical guidelies are oe tool to help busy physicias orgaize their maagemet of commo cliical problems like depressio. We hope that these depressio guidelies, as part of a overall Depressio Strategy, will help improve recogitio ad treatmet, relieve the burde of sufferig experieced by people with depressio, ad reduce the ecoomic burde that accompaies depressio. People with chroic diseases eed all the support they ca get, ad ow there s a provicial program that s just for them. The Chroic Disease Self-Maagemet program teaches people practical self-mastery skills that eable them to effectively maage their health coditios for a lifetime. First piloted by Staford Uiversity i Califoria, the Chroic Disease Self-Maagemet program (CDSM) is ow taught i several coutries aroud the world. Patrick McGowa, MSW, PhD, ad BC s CDSM program coordiator, first travelled to Staford i 1986 for a closer look ad promptly brought the program home. Deliverig it first through the BC Arthritis Society, McGowa has sice helped trai people to deliver the program i various health orgaizatios all over Caada. I BC, more tha 20 cities, icludig aborigial commuities have beefited. Oe of the most importat aspects of the course is how people iteract with ad lear from each other, says McGowa. The way the course is taught is importat. It brigs about high levels of self-efficacy: a perso s perceptio of how they ca hadle a task i the future. The free CDSM program is held for oe-hour each week over a six-week period, geerally lead by two traiers with chroic diseases. Participats lear to create actio plas (settig reasoable goals for maagig illess), the to report what traspired at the followig meetig. If they had difficulties carryig out their goals, the group will try to help problem-solve. Participats also lear about the symptom cycle, the roudabout circle of symptoms ad associated emotios that ca prevet people from movig forward (see figure 1, right). Caregivers of those with chroic diseases are also ecouraged to take the program ad they participate like everyoe else. Ae Riddick kows too well the challege of dealig with chroic disease. Curretly regioal programs ad resources Kathy Smith Kathy, cosumer ad proprietor of Smith Secretarial ad Desig i Victoria, is a freelace writer who specializes i writig about metal health issues 39 Chroic Disease Self-Maagemet Program Effective Over the Log Haul fatigue disease VICIOUS CYCLE The CDSM headquarters is the Lader office, satellite office for the UVIC Cetre o Agig. For more iformatio, cotact Dr. McGowa at Phoe (604) ; mcgowa@ dccet.com figure 1 the symptom cycle depressio Pstress/axiety ager/frustratio/fear foototes 1 Davis, D.A & Taylor-Vaisey, A. (1997). Traslatig guidelies ito practice: A systematic review of theoretic cocepts, practical experiece ad research evidece i the adoptio of cliical practice guidelies. Caadia Medical Associatio Joural, 157, Caadia Psychiatric Associatio & Caadia Network for Mood ad Axiety Treatmets. (2001). Cliical guidelies for the treatmet of depressive disorders. Caadia Joural of Psychiatry, 46(Suppl 1), S1-S92. Available olie at 3 To, A., Oetter, H. & Lam, R.W. (2002). Treatmet of depressio i primary care: Parts 1 ad 2. BC Medical Joural, 44, Available olie at joural/bcmj/ovember_2002/default.asp tese muscles

40 40 regioal programs ad resources livig i Vacouver, she suffered from a early age with arthritis ad over the years has also had to deal with osteoporosis, Croh s disease, fibromyalgia ad more. But it was t util she was 45 that she first foud the program, ad has champioed its cause ever sice. Whe you re first diagosed with a chroic disease, you go through some grievig for your health. It s like losig your best fried, she says. The each time you re diagosed with aother chroic coditio, you go through the process agai. The program ca help you recogize what s happeig ad help you get through these stages faster. Riddick says learig to maage depressio ad fatigue is very importat. We talk about dealig with depressio, ofte a side-effect of chroic disease, she says. For me, if my symptoms are pai i my body, I ca deal with that quite well, but whe it reaches above a certai level ad I ca t do thigs, I get depressed. Havig leared about the symptom cycle, I ow uderstad feelig depressed is usually trasitory, she says. Ad she s quick to poit out: Sometimes you just have to let yourself feel depressed, but if it lasts for more tha 2 weeks, you should seek professioal help. Riddick, also a program leader, kows that to live successfully with chroic disease, you have to get proactive ad lear all you ca about your coditio. You eed to fid tools ad educatio is the key, she says. Everyoe ca make their lives better; they just eed to kow how. Aother program participat, Joa Jacobso from Vero, is livig a much brighter life ow. A log-time sufferer of depressio, she was t sure if she d ever fid everythig she eeded to cope. Vigilat about maagig her coditio, Jacobso had always adhered to proper diet ad exercise, but eight years ago, she foud that was t eough aymore. I thought I was t tryig hard eough, she says. I thought there was a key somewhere ad that I just eeded to work harder. The after the birth of her secod child, she was prescribed a atidepressat, but was ot told of the side-effects. She struggled for the ext few years to fid the right medicatio ad get o the road to recovery. While lookig to start a support group, she foud the CDSM program. It was ice to meet others who were fuctioig despite their coditios. They were very ispiratioal. Now a program leader, Jacobso says, I foud a lot of thigs that helped me could also help ayoe with a chroic disease. It s clear this program is ideed provig successful for people with chroic health coditios. I April of 2003, it was aouced the govermet would make the program available to every health regio i BC over the ext three years. A iformatio lie is slated to begi operatio this fall. Turig Over a New LEAF A Self-Maagemet Program for Adults with Paic Disorder Sarah Newth, PhD Sarah is the Provicial Liaiso for the Axiety Disorders Associatio of BC (ADABC). She is a cogitive-behavioural therapist, provides cosultatio to other metal health professioals ad has published articles i the area of axiety, stress ad copig I 2002, the Axiety Disorders Associatio of BC (ADABC) lauched the LEAF program (Livig Effectively with Fear ad Axiety). The LEAF program is the first selfmaagemet program of its kid to be offered i British Columbia, ad is aimed at idividuals sufferig from mild to moderate levels of paic disorder. Durig the 14-week program, participats receive traiig i skills that allow them to effectively maage the symptoms of their axiety disorder, regardless of whether or ot they are curretly takig medicatios. The LEAF program is a evidece-based self-maagemet program. People sufferig from metal health problems have a right to access evidecebased programs, i other words, itervetios where evidece from well-coducted research shows that people are helped to lower their level of symptoms ad to live more fulfillig ad healthy lives. Ufortuately, despite the evidece that they work, such programs are ot widely available i BC for people sufferig from axiety disorders. LEAF is curretly available i four pilot commuities: Delta, Surrey, Kamloops ad Kelowa. While this is a begiig, there is sigificat umet eed, cosiderig that over 400,000 people i the provice suffer from a axiety disorder. Axiety disorders are the most commo metal health problem, with approximately with oe i four adults experiecig sigificat problems with axiety at some poit i their lifetime. LEAF is based o a cogitive-behavioural program for paic disorder that has bee show to work for approximately eight out of every te people who complete the program. May people who complete a self-maagemet program such as LEAF are able to use their ew self-maagemet strategies to prevet or miimize paic attacks some eve ed up completely paic free! Ayoe who has bee livig with umaaged paic disorder ca tell you that this is a icredible outcome that ispires hope for the future ad a reewed joy for livig. I the LEAF program, each participat atteds a two-hour sessio oce a week for 14 weeks. The weekly sessios are held i small groups of six to te people who all have mild to moderate levels of paic disorder. A uique ad powerful aspect of the program are the LEAF leaders, who ru each group i pairs. LEAF leaders have persoally overcome their ow problems with paic ad axiety by usig the same cogitive-behavioural skills they teach the participats. Leaders also receive traiig ad weekly supervisio from ADABC experts. As a result, they have strog skills combied with high levels of empathy ad uderstadig. Participats report that they trust their leaders ad feel

41 41 Update: Summer 2003 The Metal Health ad Addictios Iformatio Pla for Metal Health Literacy is a groudbreakig public iformatio iitiative drive by the seve provicial metal health ad addictios agecies listed to the left, workig together i a collective kow as the BC Parters for Metal Health ad Addictios Iformatio. The project is fuded by the Miistry of Health Services, uder the directio of Dr. Gulzar Cheema, Miister of State for Metal Health. Over the ext three years, the project will create a permaet commuicatios ifrastructure, icludig a website ad a series of practical toolkits developed to help idividuals livig with (or at risk for) metal health or substace use problems to maage their health coditios o a day-to-day basis. Combied, the groups have more tha 100 years of service to British Columbias ad regioal brach etworks or likages throughout the provice. The BC Parters project will release four ew tools this fall, desiged to help people with metal health issues, icludig cocurret metal health ad substace use problems. The resources iclude toolkits for depressio, axiety disorders, a geeric metal illess toolkit, as well as a tool for maagig addictios. All of the tools will build o The Primer, a resource that provides basic iformatio fact sheets about a rage of topics havig to do with metal health, metal disorders, substace use problems ad addictios. The Primer was released durig Metal Health Week 2003 ad is available o all the BC Parters member websites. The Metal Illess Toolkit outlies core self-maagemet issues that are geeric to ay diagosis or to cocurret diagoses. The core issues that are addressed iclude: Ÿ learig the basics of the illess ad treatmet alteratives Ÿ how to play a active role i fidig a approach that works Ÿ how to maage oe s health o a day-to-day basis (icludig maagig stress, idetifyig illess triggers, ad developig effective copig strategies to avoid relapse) Ÿ how to access eeded commuity resources I additio to dealig with core self-maagemet issues, the depressio ad axiety disorders tools deal with diagosis-specific issues havig to do with maagig each illess. The Depressio Toolkit focuses o dealig with egative thikig, icreasig activity ad problem solvig. The Axiety Disorders Toolkit deals specifically with maagig bodily symptoms, healthy thikig patters, buildig stregths ad decreasig avoidace. Each of the toolkits also features a self-test ad iformatio about how to access diagosis-specific resources i the commuity. Each of the tools is evidece-based, meaig that it is based o self-maagemet priciples that have bee show to be effective through soud methodological studies coducted over time. For the year ahead, BC Parters activities will focus o dissemiatig the toolkits to the metal health commuity, ad o pilotig ad evaluatig the materials to make sure that the resources meet the eeds of people with metal illess ad/or addictios. Over the ext year, the Parters will also be developig some ew resources, icludig a toolkit for family members ad other caregivers, a metal health promotio toolkit, ad a metal health toolkit for the workplace.

42 42 regioal programs ad resources is the LEAF program for me? For a detailed descriptio of all axiety disorders ad a self-test, please see the ADABC website at Prit out the self-test ad take it to your physicia or metal health professioal. If you have mild to moderate levels of paic disorder, the LEAF program might be suitable for you For more iformatio about the LEAF program cotact ADABC: Phoe (604) ; Web Mail # West 10th Aveue Vacouver, BC V6R 4R8 Fudig for the LEAF program is provided i part by the Miistry of Health Services via the BC Parters for Metal Health ad Addictios Iformatio pla. The LEAF program is led by Dr. Ly Miller, a past presidet of ADABC ad a couselig psychologist who specializes i axiety disorders i childre ad youth ispired by the powerful example of what life ca be like whe paic disorder is better maaged ad uder cotrol. Recet participats stated the leaders did a woderful job of makig us all feel comfortable ad were woderful, compassioate istructors...who could relate to us as they wet through similar experieces. Each LEAF group is held at a coveiet locatio i participats home commuities (e.g., metal health cetres, commuity cetres, schools, etc). The groups are deliberately held i eutral safe locatios that are withi commutig distace ad easily accessible via public trasit. ADABC plas to expad the LEAF program to additioal commuities throughout British Columbia especially the more rural ad remote areas of BC where metal health services are particularly sparse. All LEAF participats are evaluated prior to begiig the program ad after completig the program a importat feature of evidece-based programs. Without these evaluatios, we would ot kow for sure if the program is actually helpig. Pilot data idicates that most LEAF participats experiece sigificat reductios i their symptoms of paic, axiety ad depressio. They also report sigificat drops i their avoidace behaviours ad a icreased ability to do thigs they had t bee able to do before like goig to public places, drivig, takig public trasportatio, doig thigs aloe, or tryig ew thigs. Some participats have eve bee able to retur to work durig the program with the support of the leaders ad other LEAF participats. May LEAF participats also tell us their self-esteem ad cofidece has sigificatly improved. Recet LEAF graduates stated, this program taught me more tha I ever dreamed, I am coquerig my fears, ad I ca ow do thigs I could t do before. It is the cogitive-behavioural skills taught ad practiced i the LEAF program that allow participats to overcome paic disorder ad get their lives back. Participats get the opportuity to review ad practice these skills i sessio with supportive feedback from the LEAF leaders ad the rest of the group. Participats the have the opportuity to practice these skills durig the week. Leaders help pla weekly homework assigmets i a way that sets up participats for success. Developig goals that are realistic ad attaiable icreases motivatio to do eve more. Leaders also give feedback about weekly progress ad help participats troubleshoot ay difficulties that may arise. The cogitive-behavioural skills taught i the LEAF program cover the followig five basic areas: Educatio First, participats are provided with basic educatioal iformatio about the ature of paic disorder, paic attacks ad axiety symptoms. For example, may LEAF participats are surprised to lear that rapid heart beats or difficulty breathig are ormal symptoms of axiety that are ot dagerous. They also lear that most adults experiece symptoms of axiety from time to time. Maagig Symptoms Secod, participats are taught cotrolled breathig ad muscle relaxatio i order to maage the bodily sesatios of axiety ad paic (e.g., rapid heart beats, difficulty breathig, feelig dizzy, feeligs of discoect from reality, muscle tesio, etc). Healthy Thikig Third, participats are taught how to examie their thoughts ad beliefs i order to idetify ay miscoceptios that maitai the cycles of repeated paic attacks. For example, LEAF participats lear that we caot die or go crazy from a paic attack. This is good ews for all of us give that oe i three adults will experiece a paic attack i ay give year, especially durig times of high stress. Overcomig Avoidace Fourth, participats lear to gradually overcome the avoidace behaviours that ca be a sigificat part of livig with a axiety disorder. For example, someoe who ca t ride the bus might start by ridig the bus to the ext stop with a loved oe. Over the course of the LEAF program they might work up to ridig multiple stops with a loved oe ad evetually to ridig aloe. This well-cotrolled gradual exposure to feared experieces is very successful i helpig people get their lives back ad do thigs they had bee uable to do prior to the LEAF program. Maitaiig Gais ad Relapse Prevetio Fifth, ad fially, participats are taught how to maitai their gais ad how to maage or prevet ay relapse of their symptoms. This set of skills icludes settig up ogoig goals for the participats to work o after the program has fiished. Participats also lear that it is ormal to experiece episodes of axiety ad a occasioal paic attack from time to time, especially whe copig with stress. As a result of the program, they ow have the skills to cope with ay future waxig or waig of symptoms. May LEAF participats tell us that they were iitially very ervous ad ucomfortable about attedig a program offered i a group settig. However most LEAF participats feel immese relief after meetig other people who are also sufferig from paic disorder. They realize they are ot aloe ad may look forward to seeig each other each week. By the ed of the program, most LEAF participats tell us the support they receive from others durig the program is ivaluable ad helped them make progress. Oe recet LEAF graduate told us I had a real feelig of belogig to a welcomig group of idividuals. Aother LEAF graduate stated, I met some woderful people...we laughed ad cheered with each success, ad there were may successes... I leave here with ew frieds, ew uderstadig ad a ew future. It s o woder that people are excited about the LEAF program. I the future, ADABC would like to adapt the LEAF program for use with youth who are experiecig similar problems with paic ad axiety. Ideally, additioal LEAF programs would also be made available throughout the provice for other types of axiety disorders. As metioed, there are very few evidece-based resources for axiety disorders i BC other tha medicatios. This is ufair ad must chage give that axiety disorders are the most commo type of metal health problem. If you would like to see evidece-based programs for axiety disorders offered i your home commuity, please express your cocers to the local health authority. For additioal iformatio about how to icrease resources for axiety disorders i BC, please cotact ADABC.

43 regioal programs ad resources 43 profile LEAF Participat Story From all appearaces, Nadia had a ormal life. At 41, she was i a stable career with a Vacouver advertisig agecy, happily married with 2 childre, ad had a house outside of the city, complete with mortgage to pay ad mouths to feed. Like most who are evetually diagosed with a metal disorder, she did ot fit the profile of someoe whom society would ormally perceive as beig i a risk group for a metal illess. While Nadia had a family history of some metal illess her mother lived with depressio prior to her first paic attack i the summer of 2002, she did t otice ay sigs of her illess. There was t ecessarily oe trigger, she explais. I had bee feelig quite axious over the last couple years, ad uder a lot of stress ad the oe morig I was i the office by myself ad I got all worked up about all the stuff goig o. I thought I was goig isae ad thought I was completely breakig dow. Over the ext few moths, Nadia cotiued to have paic attacks, each time hidig them ad ot tellig ayoe i the fear that she was, ideed, goig isae. I would be ruig late for work, she explais, ad I would start to have what I call my catastrophic thoughts ad thik what if I lose my job?, how am I goig to pay my mortgage? My family is goig to be out o the street. These types of thoughts would cotiue, but Nadia cotiued to hide them from her frieds ad family, afraid she was losig it ad was goig to ed up committed a thought which ecouraged more catastrophic thoughts about losig her home ad her job. Evetually Nadia summoed the courage to see her family doctor. After a short 10-miute visit, he prescribed her cloazepam, a bezodiazepie commoly used to treat axiety disorders. Bezodiazapees act as a sedative ad muscle relaxat. They work by slowig dow the cetral ervous system, ad ca be addictive if used over a exteded period of time. They are, however, effective over the short term. But Nadia felt ucomfortable takig a drug. I felt I was just resortig to takig it, she says, addig that she thought it was just maskig what was causig the paic attacks i the first place. She does, however, ackowledge that the drug did ideed help with her symptoms. It was at this poit that she decided to tell her husbad that she was sufferig from a axiety disorder. It was a thorough coversatio, she said, recoutig the discussio. I was very ashamed. I was embarrassed about feelig this way. I did t uderstad what was goig o ad I was t told by my ow GP about the drug that I was takig. My husbad did t wat to hear about [the illess], ad he was very scared. Uder treatmet, but uhappy, she started seeig ads for the LEAF program, both i her commuity paper ad o her commuity televisio statio. Nadia wated to be able to feel cured but also wated to be off the drugs that her doctor had prescribed. Nadia was also, however, extremely axious about callig about the program. But evetually she worked up the courage to pick up the phoe ad erolled i the program. I was very axious to go to my first meetig. My fear was that it would ot work. Nadia wet ito the first meetig expectig somethig far differet tha she eded up participatig i. It souded like work. They had you doig these exercises ad I guess I was lookig for aswers as to what was wrog with me. I thought they were goig to have some magic bullet. After the first meetig, I kew I was goig to have to look iside myself. They had seve or eight other people i the room alog with two leaders who had goe through this themselves. Right away, everyoe uderstood what it meat to have [this illess]. There was this support ad you were able to say I feel this way ad they would t be judgig me for it. I bega to uderstad what was causig the attacks. It was like a light bulb wet off iside i my head as to why thigs were happeig the way that they were. I started to uderstad what was causig the attacks, ad you really start to uderstad the aatomy of it. Nadia leared some basic relaxatio ad copig mechaisms, ad she persoally foud the breathig techiques amog the most useful. Iterestigly, i this type of therapy, participats are slowly exposed to situatios that might trigger a attack ad are forced to cope with it by cotrollig the respose. I Nadia s case, this icluded the all-too-familiar commutig ightmare, which made her fear she d be late, triggerig the catastrophic thoughts that had emotioally paralyzed her earlier. But this time she got through it. I was taught how to be i cotrol of my thoughts ad my body ow I was late ad there were o catastrophic thoughts! she says. A criticism ofte made of these types of programs is that they are ot effective whe push comes to shove ad the real stress is applied. Nadia says that is simply utrue, at least i her case. Prior to startig i the LEAF program, Nadia was terrified of medical procedures i geeral. God, it s goig to happe to me, she recalls thikig to herself wheever someoe had to go i ad have a procedure, ad the the catastrophic thoughts would begi. Shortly after the ed of the LEAF program her stepfather was hospitalized ad her father-i-law died. These were two large, traumatic evets for both her ad her family ad Nadia maaged to cope through uimagiable pressure. I used my strategies to cope ad used my calmig thoughts ad it worked. I was able to get through it. After the program, Nadia was able to almost completely elimiate her use of cloazepam. Prior to the program, I was takig about a ½ pill every day. Sice the program I ve oly had to take the ½ a pill oce o a very stressful day, ad eve the, as I was swallowig it, I was thikig I could have probably doe without it. Nadia says she s leared to recogize the body reactios that tell her a attack could be comig o. Kowig what to look for is crucial. I her case, she says she ofte gets hot ad sweats a lot, ad that s whe she kows that she has to begi usig her strategies to calm dow. These iclude usig her breathig techiques ad her repetitio of various phrases to help prevet the catastrophic thoughts from comig o. Sice leavig the program, Nadia has ot had aother paic attack ad says she feels essetially cured, while uderstadig that this is somethig she will have to live with for the rest of her life. Now that the support group is over, I have revealed what has happeed to me to others. I m ot ashamed about it. Now that I uderstad it, I ca reveal it. I kow that I m ot goig crazy, ad that I m ot goig to be committed. She goes o to say, I feel i cotrol of it, ad I do t wat ayoe to thik that I m ot i cotrol, so I ca tell them. I reveal it to people ad they tell me that their sister had it, or their brother had it or that sometimes they feel that way, too. She says she has o hesitatio i recommedig this program to ayoe havig difficulty with a axiety disorder. She says that sice the program she has bee settig aside more time for herself ad doig thigs for herself that she was ot doig before. She says she is havig people over for dier ad ejoyig her life agai. As she has become more educated about this illess, so has her husbad, so the support that she had i the support group ow exists at home. But she demurs. You kow, I do t really feel a huge eed to talk about it, because I just feel so much better. Callig that umber was probably oe of the hardest thigs I ve ever had to do i my life, she says i retrospect, but it was probably oe of the best thigs I ve ever doe. Mykle Ludvigse

44 44 regioal programs ad resources At this poit, future fudig of cetral coordiatio of the BRIDGES program (icludig facilitator traiig) has ot bee assured. However, the program may still cotiue to be available i your commuity. Cotact the BC Schizophreia Society toll-free at for more iformatio. Gettig From Where We Are to Where We Wat To Be Debbie Sesula BA, RTC Debbie Sesula is the Program Coordiator of the BRIDGES Educatio ad Support Program with BC Schizophreia Society footote 1 I 2001, a survey was coducted of past BRIDGES studets. Out of 235 BRIDGES graduates from that were cotacted, sevety-two idividuals participated i the survey; 72% of the participats were female ad 28% were male BRIDGES stads for Buildig Recovery of Idividual Dreams ad Goals through Educatio ad Support. The missio of BRIDGES is to empower people with metal illess to take a active ad iformed role i their treatmet ad to recover a ew sese of purpose i life. BRIDGES is built o the philosophy of recovery, a philosophy that oe ca live a active ad full life eve while experiecig psychiatric symptoms. BRIDGES cosists of a 15-week educatioal course that is taught by people with a metal illess ad is atteded by people with a metal illess. The curriculum covers key topics such as the basic facts about psychiatric diagosis ad medicatios, idetificatio of eeds, obtaiig metal health resources ad dimesios of recovery from metal illess. Each class is two-ad-a-half hours i legth ad cosists of a classroom format icludig discussios, class activities ad questio ad aswer periods. Learig from each other empowers oe with the tools to build their ow bridge to recovery. I have struggled to build my ow bridge to recovery for seve years, ad becomig ivolved with BRIDGES was the begiig of my climb out of the grasp of metal illess to a whole ew world of recovery ad self-maagemet. Istead of lettig metal illess cotrol me, I leared to cotrol it. I leared to accept my limitatios ad to cope whe the goig got rough, ad that despite my illess, that I have a lot to cotribute ad the skills to match. Ad despite setbacks, I have what it takes to get back up agai. I leared that with BRIDGES, I am ot aloe. I have see first-had the may chaged lives because of BRIDGES. I listeed to the excitemet i the voice of oe getlema, who for the first time i his life, was able to fid employmet ad keep a job. I heard from a youg woma who had bee depressed ad suicidal, ad o loger wats to ed her life. I listeed to the amazemet i profile: bill maycock Bill Maycock had some traumatic blows to his life which left him crippled i a depressed psychotic state. He lived his life i a medicatio haze with o purpose or directio. He heard about BRIDGES ad decided to atted, ot oce, ot twice, but three times. He says, The first time I slept through most of it, the secod time I started to feel hopeful, ad the third time I was begiig to feel worthwhile agai. Previous to BRIDGES, Bill had bee seriously thikig of edig his life. What a trasformatio ot oly did Bill graduate from BRIDGES three times, but he wet o to become a BRIDGES teacher. He surprised himself at what he was capable of doig. He says, The BRIDGES claim is true that it helps oe get from where they are to where they wat to be. oe lady s voice as she shared that she could t eve go out for coffee for may years, but has sice dealt with her fears ad ow goes out for coffee quite regularly. I heard from oe youg getlema who would t go aywhere or do aythig without his mother, ad who ow does thigs for himself ad believes i himself. I listeed to the ispiratio i the voice of oe lady who really wated to go back to school ad has sice foud the courage to do so. I have see people who could hardly say their ow ame make it all the way through the course ad go o to become a BRIDGES teacher. This is what BRIDGES does for me I am so rewarded by observig the may chaged lives. BRIDGES helps idividuals get from where they are to where they wat to be. Sice the itroductio of BRIDGES i BC, resposes from teachers, studets, service providers ad family members has bee very ethusiastic: teachers say the course is fu to teach, studets say they are learig thigs they wated to kow for a log time, service providers ad family members tell of the impact BRIDGES is havig o their cliets ad family members. BRIDGES is ope, free of charge, to ay perso with a metal illess. A referral for BRIDGES is ot required. To lear more about BRIDGES ad to fid out if BRIDGES exists i your commuity, please cotact the BC Schizophreia Society at The Impact of the Program Based o a 2001 survey, 1 the impact of takig the BRIDGES course for participats is as follows: has give me the tools for my recovery (99%) has helped me i my ow persoal recovery (90%) has give me iformatio about resources I did t kow about before (78%) has decreased my eed for hospitalizatio (76%) has decreased my eed for other crisis services (74%) has icreased my socializatio (65%) has helped me to be as idepedet as I ca be (64%) has led to ew friedships with other studets (63%) has decreased my use of metal health services (61%) has icreased my support etwork (57%) has led to my ivolvemet i advocacy (42%) has sice led to my obtaiig a voluteer positio (36%) has sice led to my obtaiig employmet (25%) has led to my becomig a BRIDGES teacher (10%) The most importat curriculum gais for participats icluded: a uderstadig of metal illess (21%) kowledge ad iformatio (19%) isight (16%) kowig others like me (14%) icreased self-esteem (6%) kowledge of resources (6%)

45 profile My BRIDGES Diary regioal programs ad resources 45 Class 1: Itroductio First class is over. It seems like a bit of a blur. So may ew faces, ad a ew experiece. Everyoe seemed perfectly ormal: o obviously disturbed behaviour or visible medicatio side-effects. The istructors are upbeat ad sympathetic but task-orieted so we got through the material withi the allotted time. We did some let s get acquaited stuff. It is ice to kow we ca pass if we are ucomfortable. Talked, too, about the emotioal stages of recovery ad made a commitmet to atted the course. So far, so good. Class 2: Thought disorders: Schizophreia We started the class with a oe-word feeligs check. What is it about oe word that is so hard to uderstad? Today s class dealt with schizophreia ad some of the myths ad realities. Iterestig. Rather glad I deal with mood ad axiety disorders; the medicatios for schizophreia (I gather) are t pleasat. The istructors told their stories today ad it was iterestig, maily because they both seem ormal! Class 3: Mood disorders ad suicide prevetio Today s class was a emotioal oe as it dealt with suicide ad so may of us had attempted it or had seriously cosidered killig ourselves. We worked o a suicide support system ad I realized that although I have may frieds, I have virtually o oe to whom I could tur. I just do ot discuss my coditio. Have to be perfect, have to be ormal. We also discussed mood disorders. It strikes me how people get ito trouble whe they do t get eough sleep. I ve always eeded a lot of sleep ad doe better whe I achieve that. Could it have bee that simple? Class 4: Axiety disorders, persoality disorders I told my story today, as the topic was axiety disorders, ad hey, that s me! I actually was pretty axious doig it, but I felt very accepted ad ot judged at all. The class is startig to bod somewhat, which is ice. People are beig hoest about what they have, do, have doe, ad so o. Some people have really bee through the wriger ad it seems to take a lot of time for people to get help ad the get their lives i order. I feel that I am learig both about my illess ad about myself. Class 5: Recovery from metal illess ad chemical depedecy This is my class. What a package! I feel very, very lucky that my addictio eded whe I got ad used Prozac appropriately. How may druks are really metally ill? How much of metal illess is the result of usig? Which came first, the chicke or the egg? There were four of us i the class who are dual disordered. Four out of 13: almost oe i three. Really, this type of class could be a course i itself. Class 5: Buildig support, crisis plaig It strikes me that I do ot talk much about my illess, except i class. I feel very sad that I have o oe, really, to talk to, to uderstad. Perhaps it is more that I do t reveal myself ad that I m afraid of beig judged. Lots of plaig i this class, forms to fill out. I ca see how this is ecessary but would ayoe i crisis remember to carry it alog? I guess that you have to share your iformatio about your crisis warig sigs with family, doctor etc. Class 7: Biology ad the eviromet This is a little drier tha some classes; I guess that is why we were colourig i areas of the brai. Wow! Iterestig though, the research, theories, statistics. Makes me feel less flawed, less resposible. Class 8: Medicatios ad how to talk to your doctor I am amazed at how may atidepressats I tried before Prozac. Ad oe of them worked. I m thikig that I lea more to the axiety disorder ad the depressio is secodary. The atipsychotics do t soud as uivasive as do the atidepressats. They soud difficult, so may side-effects. I feel lucky to have Prozac, my little fried. Class 9: Metal health services ad psychotherapy What s available? What s ot available? What are the kids of therapy ad how do they work? Not a fa of therapy, at least ot for me. It ever did a thig i terms of stoppig the axiety or depressio. Just Prozac did. However, chatted with the istructor about this ad my experiece is far from uiversal so, I will be tolerat. Ad a lot of people with metal illess have maladaptive behaviour that they eed to chage. I guess that I could stop rescuig people! Am I just beig a perfectioist...o, o, it s ot me, it s a disease. Class 10: Rehabilitatio services I did like the hospital thikig vs. recovery thikig. TAKE RESPONSIBILITY FOR YOURSELF! Some of the fiacial details were very iterestig. So may people with metal illess are so poor. How, the, do you get better with the costat fiacial stress, poor housig, food etc.? Class 11: Tools for recovery: Welless, problem-solvig This stuff is importat especially i the light of the poverty issue. Discussed diet, exercise, sleep, stress reductio ad problem-solvig. Very practical, very logical. This is useful stuff. I really ejoyed the problem-solvig breakig a problem dow ito parts ad the tacklig it, leavig emotio ad feeligs to oe side. I was already doig some of it. Good for me! Class 12: Tools for recovery: Commuicatio skills This was a rather fu class. Role-playig ad practicig assertiveess ad reflective respose. A lot of stuff to use ad it will take practice. Maybe I should make a cheat sheet ad carry it with me! Class 13: Healthy spirituality A thikig/feelig/cosiderig class. What are virtues, what is religio ad so o? Also, idetifyig uhealthy religious practice. I got thikig a lot today ad feel more coected to God. Amazig eough to me, cosiderig that my first obsessio was religio. Hallelujah! Class 14: Advocacy How to chage the system. Not o my ageda right ow. A trifle dull. Class 15: Certificatio ad celebratio Evaluatio forms, certificates ad the a luch with the class, paid for by BRIDGES! Three moths later Whe I look back at the BRIDGES educatio course, I am struck by the followig thigs: that the course was completely free of charge the geuie feelig of we re all i this together, so, let s lear ad help together that it was a safe place to be that the istructors were cosumers, but make o mistake, they were i cotrol that recovery happes. profile: barbara moreau Whe Barbara Moreau first etered the room, she appeared very sulle ad withdraw. After three classes she bega to ope up, sharig with us the ogoig depressio she cotiually struggles with. Fidig others who could relate brought a sparkle of hope to her eyes. She pushed herself 100% throughout the course ad did all the extra readigs. She took pride i what she was learig ad shared her may aha! momets. Barbara o loger appears sulle ad withdraw, but aimated ad approachable. Her ivolvemet with BRIDGES has decreased her eed for crisis services ad has icreased her self-esteem ad cofidece immesely. But Barbara did t stop there: she wet o to become a BRIDGES teacher, determied to be a shiig star to others. Ad a star she has become as her peers see where she was i her life ad where she is ow. She feels good about givig back to her peers the message of hope she was give. She says, I wat to help erase the stigma that exists with metal illess ad teachig BRIDGES is oe way of achievig that. Tracy May

46 46 The Bottom Lie Utreated Depressio ad Axiety Disorders i the Workplace Coferece October 30, 2003 Hyatt Regecy Vacouver Reasos to Atted: 1Because I today s competitive work eviromet, may employees are reluctat to admit to havig difficulty keepig good metal health i the workplace. Sposored By Edorsed By 2 Because compaies are losig their most creative ad productive employees to depressio ad axiety disorders. 3 Because metal illess is the fastest growig cause of workplace disability. 4Because a metally healthy workplace is the best isurace policy agaist log-term disability. 5 Because the CMHA Bottom Lie Coferece is desiged to help small ad large busiesses, orgaizatios, uios, ad beefit providers reduce the impact of depressio ad axiety disorders i the workplace. 6Because the bottom lie costs are staggerig. The Caadia Metal Health Associatio s BC Divisio is proud to host the Bottom Lie Coferece. Workig together closely with idustry ad labour, together we ca lesse the impact of depressio ad axiety disorders o workers ad o the bottom lie.

47 resources 47 Articles The cliical ad cost-effectiveess of self-help treatmets for axiety ad depressive disorders i primary care: A systematic review. Bower, P., Richards, D. & K. Lovell. (2001). British Joural of Geeral Practice. Reclaimig your power durig medicatio appoitmets with your psychiatrist: A guide to becomig a active parter i decisio-makig about treatmets. Deega, P. (1999). Natioal Empowermet Ceter Newsletter. Available at Evidece-based practices for services to families of people with psychiatric disorders. Dixo, L. et al. (2001). Psychiatric Services, 52(7), Also available at Implemetig dual diagosis services for cliets with severe metal illess. Drake, R. et al. (2001). Psychiatric Services, 52(4), metalhealthpractices.org/pdf_files/drake1.pdf How persos recoverig ad cliicias ca promote selfmaaged care. Fisher, D. (1999). Natioal Empowermet Ceter Newsletter. selfmaaged_care.html Psychotherapy for bulimia ervosa ad bigig. Hay, P. & Bacaltchuk, J. (2002). Cochrae Database of Systematic Review. How I perceive ad maage my illess. Leete, E. (1989). Schizophreia Bulleti, 15(2), Self-maagemet educatio: Cotext, defiitio, outcomes ad mechaisms. Lorig, K. & Holma, H. (2000). First Chroic Disease Self-Maagemet Coferece, Australia. gov.au/pdfs/lorig.pdf Behaviour therapy for obsessive-compulsive disorder: A decade of progress. Marks, J. (1997). Caadia Joural of Psychiatry, 52, Illess maagemet ad recovery: A review of the research. Mueser, K. et al. (2002). Psychiatric Services, 54(10), Self-admiistered treatmet i stepped-care models of depressio treatmet. Scoggi, F. et al. (2003). Joural of Cliical Psychology, 59(3), Implemetig evidece-based practices i routie metal health service settigs. Torrey, W. et al. (2001). Psychiatric Services, 52(2), pdf_files/torrey.pdf Stepped care treatmet for eatig disorders. Wilso, G. Vitousek, K. & Loeb, K. (2000). Joural of Cosultig & Cliical Psychology, 68(4), Websites Evidece-Based Practices project, based at Dartmouth Uiversity. Project iformatio o illess maagemet, family educatio ad cocurret disorders approaches. Huma Behaviour ad Health Research Uit, of Fliders Uiversity, Australia. Self-maagemet literature review ad project liks. som.fliders.edu.au/fusa/cctu/ Australia Shared Care Iitiative, icludes self-maagemet guidelies for GPs, urses ad allied professioals. Welless & Recovery Actio Pla model (WRAP), fouded by Mary E. Copelad. The STEADY project, a self-maagemet approach for youg people with bipolar illess. The Improvig Chroic Illess Care iitiative, of the Robert Wood Johso Foudatio. Basis of the BC-based chroic disease maagemet model. Staford Patiet Educatio Research Ceter. Ifo o CDSMP model. patieteducatio.staford.edu/programs/ Comorbidty of Metal Illess ad Substace Abuse Project of the Primary Metal Health Care, Australia Resource Cetre. som.fliders.edu.au/fusa/parc/comorbidhome.html. Chageways, out of Vacouver, BC. Develops evidecebased treatmet protocols ad traiig programs for professioals i the metal health field. Expert Cosesus Guidelies, icludes patiet/family versios of cliical guidelies. Paic Cetre, icludes cogitive-behavioural strategies for paic disorder. Also see Recovery/Self-Maagemet Guides or Books Self-care depressio program: Patiet guide. R. Paterso & D. Bilsker (MHECCU, 2002). Olie at A guide to recovery. Orgaizatio for Bipolar Affective Disorders Society (OBAD, 2002). Olie at Gettig out of it: How to cut dow or quit caabis. H. Metha (Ier East Commuity Health Service [Australia], 2001). Olie at Persoal assistace i commuity existece: Recovery at your ow PACE. L. Aher & D. Fisher (Natioal Empowermet Ceter, 1999). Olie at Storm breakig: A athology of experieces through metal illess ad ito recovery. E. Macaughto (Ed.) (CMHA BC Divisio, 2002) Olie at A map for the jourey: Livig meaigfully with recurrig depressio. N. Dickie (PublishAmerica, 2001) Ridig the roller coaster: Livig with mood disorders. M. Berge (Northstoe, 1999) Feelig good: The ew mood therapy. D. Burs (Avo, 1999) Your depressio map: Fid the source of your depressio ad chart your ow recovery. R. Paterso (New Harbiger, 2002) Gettig better bit(e) by bit(e): A survival kit for sufferers of bulimia ervosa ad bige eatig disorders. U. Schmidt & J. Treasure. (Psychology Press, 1997) More self-maagemet books at awp/swidopsychology/self-help.htm This list is meat as a guide oly ad ot meat to be exhaustive. While we have attempted to iclude helpful refereces, iclusio i this resource list does ot ecessarily reflect complete cotet edorsemet by CMHA BC Divisio

48 48 BC s Oly Olie Searchable Ivetory of Employmet Services services ad growig... Check out a free, comprehesive employmet services database for BC, particularly those specializig i supports for metal illess. This searchable database icludes detailed iformatio about accessig a wide variety of employmetrelated programs. Search by commuity, health regio, cliet base, service type or combiatios thereof. There are curretly 530 agecies listed ad over 90 categories of services such as egotiatig accommodatios, accessig subsidized voluteer opportuities, as well as subsidized educatioal opportuities. Why am I receivig Visios? As part of the ew BC Parters for Metal Health ad Addictios Iformatio (see page 41 of this issue of Visios for more iformatio o this iitiative), members of provicial metal health ad addictios agecies other tha CMHA, whose members already receive Visios, will ow receive a complimetary copy of this quarterly, award-wiig joural. Neither your ame or your mailig iformatio was shared as it was set by the orgaizatio of which you are already a member. If you would NOT like to cotiue receivig your free copy of Visios i the future, please let your member orgaizatio kow. CMHA BC Divisio Melville Street Vacouver, BC V6E 3V6