Designing the Thinking About Relapse Prevention Program

Theory, Practice, and More Theory

As anyone who has ever experienced an acute psychiatric episode, and everyone who works with mental health consumers knows all too well, the fear (and the incidence) of relapse is a legitimate issue, of paramount concern on both sides. All of the members of the Hedwig House clubhouses, and the staff, are intimately familiar with both the fear, and the experience, of multiple episodes of acute psychiatric illness. Therefore, the goals that I ascribed to this project included helping members to think about and acknowledge their fears, facilitate the sharing of information about their illnesses and experiences with each other; to help them realize how to recognize signs of illness in themselves and others; gain an understanding of wellness levels, and to realize that they (just like Dorothy in the Wizard of Oz) already possess many of the necessary tools to increase wellness. Additionally, both in order to serve as a reminder and to reinforce information and insights gained from the workshop each participant personalizes a program booklet and complete s an advance directive tool (identified as a relapse plan).

Although a program designed by Montgomery County Emergency Services (MCES, the MAP Plan, was available for use at Hedwig House, because it was stipulated that this program must be used without modification, and I felt that parts of it were inapplicable, I decided against its use.

The York Health Services Handbook is a similar publication to the MAP Plan, albeit intended for use as a post-hospitalization tool. It employs some of the same theoretical models and techniques as the MAP workbook. It is based on the work of Professor Max Birchwood’s Back in the Saddle (BITS) model. The BITS model involves therapist/patient monitoring of prodromal symptoms in order to become familiar with individual patterns of impending relapse.

The twenty-three-page health service document, expands upon the BITS model to include a patient’s family and friends, and is given to people leaving the hospital. Designed as a workbook, it can be used at any stage and is available on the Internet. The sections are to be completed by the psychiatric patients incrementally, and at each step shared with others, such as the client’s therapist, caretakers, and support persons. It asks the client to think, critically analyze, and keep track of their attitudes about their illness and recovery, as well as to become cognizant about their fears of relapse. It asks people to consider what precipitated their illnesses, and offers suggestions for conditions that often adversely affect patients, such as divorce, or unemployment. It acknowledges that inherent in the nature of psychiatric illness are feelings of inadequacy, and even worthlessness. It presents all of these concepts without condescension, and does so in ways that are validating. It concludes with concrete steps that patients can take to empower themselves to achieve and maintain wellness, though recognition of warning signs, and the formation of, and means by which to implement, crisis planning. The York Service program is intended to be completed over the course of weeks or months. In thinking about the components of this program, I realized that the Hedwig House members regularly engage in ongoing group activities, which address increasing overall health, and recognizing personally issues. Thus, it became clear that the main thrust of the Thinking About Relapse Prevention program should be on how to help the members think (but not be told) about, to use what they have personally experienced, and what they already know.

The focus of the workshop sharpened tremendously, owing to the conclusions a paper by Hewitt and Birchwood. In Preventing Relapse of Psychotic Illness: Role of Self-Monitoring of Prodromal Symptoms, these researchers report upon their own findings and present a meta-analysis of other studies that focus on prodromal intervention. Prodromal literally means “forerunner,” and in this arena it refers to the recognition of initial psychiatric symptoms. Hewitt and Birchwood’s major conclusion is that when patients are taught, i.e. learn to become cognizant of their prodromal symptoms, the effectiveness of any type of relapse prevention program is dramatically enhanced. Identifying, recognizing and utilizing the prodrome thus became the central focus of the Thinking About Relapse Prevention.

Another important factor that was applied in the Thinking About Relapse Prevention Program was gleaned from a Harvard study by Dr. Jill Hooley, which reports that expressed emotion (EE) may be an indicator of psychiatric relapse. Expressed emotion for the purposes of this study was defined as the articulated negative beliefs and criticisms that emanate from those who form the familial and close personal relationships that surround and influence persons with psychiatric disorders. The study correlated a high incidence of relapse when relatives were highly critical of their affected family member, which indicated that the relatives possessed a high internal locus of control. These relatives believed that that they (not those struggling with psychiatric problems) had the ability to change things, to make things happen, to make things better for their family members. Hooley hypothesized that relatives who level criticisms, and make negative comments, do so in order to assert control over their affected family members, who in their opinions are not (but should be) exhibiting their own internal loci of control. Thus incorporated into the development of this psychoeducational program are exercises designed to help people strengthen (or develop) their own internal locus of control.

A series of audiotapes designed to provide continuing education credits for psychiatric nurses and social workers, also proved to be extremely helpful in designing the Thinking About Relapse Prevention Program. The tape entitled Psychoeducation in the Treatment of Schizophrenia introduced concepts, such as the Health Belief Model, and the Health Promotion Model. The former utilizes some of the positive aspects of internal locus of control when examining patients’ attitudes towards their illnesses, and fostering the belief that there is value in the treatments undertaken. The latter model helps patients create practical and concrete actions to enhance their health and maintain wellness, such as exercise, good nutrition, positive social interactions, and developing stress management techniques. A third model presented therein, the Self Regulation Model, offers methods by which a person can determine the factors that threaten their health, and develop prophylactic techniques against these threats. Each of these models was included (and reinforced) throughout the course of the Thinking About Relapse Prevention program.

Another important model incorporated into development of this psychoeducational program comes from a team of psychiatric rehabilitation nurses, Mary Moller and Millene Murphy. They developed a twelve-session course for consumers and their families that teaches techniques, to recognize and intervene in the prodromal phase, in order to help consumers achieve the highest possible level of wellness. Moller and Murphy identify three levels of wellness, unstable, stable and actualized. These concepts appear in wholesale form in the Thinking About Relapse Prevention program.

Before continuing with theory and literature, further intellectualizing about ways to increase cognition, or even discussing the need to improve overall health and wellness levels, there is another essential factor that must not be ignored. Because psychiatric illnesses are due to disturbances of the functioning of a specific organ—the brain, therefore, (as stressed in the extremely brief chapter on relapse prevention in Best Practices in Psychosocial Rehabilitation) often the most important factor in relapse prevention is medication compliance. This is an area over which mental health consumers have complete control, and depending on how they view the need for medication, can help them to help themselves feel empowered, or could result in feelings of inadequacy due the ongoing need for pharmaceutical assistance.

Control is an essential component of another theory that also plays an integral role inherent in this program. As put forth by Albert Bandura, the central tenet of social learning leaning—the sense of efficacy is both essential for, and often lacking in, psychiatric patients. Clichéd descriptions and the lack of understanding inherent in banalities, such as “feeling blue,” or invalidations such as sufferers can “just snap out of it” are all too common. Families, friends, and even those so afflicted are likely to understand that auditory and visual hallucinations are caused by malfunctions within the brain. However, what all of them are too often unable to grasp is that some of the most depilating symptoms of psychiatric illnesses (because they affect feelings and thoughts and may manifest as severely diminished self-esteem, a sense of worthlessness, a lack of enjoyment, the inability to care about anything) are psychological manifestations of physiological processes. Hence, such inherent threats to self-efficacy are all too often viewed as character flaws. Therefore, cognizance about these effects, and the awareness that such symptoms are just that—symptoms—is strongly emphasized throughout the Thinking about Relapse Prevention Program.

Clearly, psychiatric illnesses do profoundly affect thinking and increasing cognition (which also increases personal agency) is a key component to sustaining wellness and preventing relapse. Therefore, repeatedly emphasized in the program is a belief that one’s own agency is paramount; as evidenced by the results of the expressed emotion study, regarding locus of control. Social learning theory puts forth that a primary source of personal agency is mastery experiences. One way to gain mastery experience is through modeling through vicarious experience. Thus, an important method for developing self-mastery is learning about the successful experiences of others. An equally valid and valuable method by which to gain mastery experience is through vicariously experiencing other peoples’ failures. Failure and setbacks are important step in the attainment of mastery, and are demonstrative of another essential component of mastery—resiliency. Mastery, personal and vicarious experiences, and resilience are the reasons why I chose to emulate many of the techniques employed by Mary Ellen Copeland. .

My introduction to her work came in the form of a little red book (which looks like a grade-school primer), entitled Wellness Recovery Action Plan. However, it turned out to be the most important piece of literature that I reviewed in developing the Thinking About Relapse Prevention Program. In spite of a lack of references in Copeland’s book, just about every concept inherent in the other tools, studies and theories reviewed for this project were evident in her work. It became obvious that there was (please forgive the cliché) absolutely no need to reinvent the wheel; everything that I needed, albeit with a bit of modification, and some metaphoric lubrication was at my ready.

Mary Ellen Copeland offered the clearest, most common sense, and easy to implement steps towards relapse prevention education. But most importantly, she demonstrated a technique that does not tell her readers or workshop participants what she knows, facilitates a process to help them to realize what they know and to the utilize this information. Copland’s technique is graphically illustrated in the video series that accompanies the little red book. She begins with sharing with an audience of mental health consumers about herself. She immediately gains legitimacy with her audience by explaining why she developed her program, wrote her books, and produced her own videotaped workshop series. She explains that after her highly successful life was devastated by manic-depression, major depressive illness and fibromyalgia, and her doctor couldn’t deliver on promised information about getting well and preventing relapse, and even conceded that the information was unavailable or worse yet didn’t exist—thus, she designed, wrote, published, marketed, such sorely needed materials herself, in order to help people help each other. She cannot, nor does she purport to, take all, or even much of the credit for the ideas presented in her books. Copeland’s video taped series of workshops grew out of her travels around the country. Making hundreds of stops, she asked thousands of mental health consumers, what worked, and equally important, what did not work for them. The ideas presented in the books and tapes are distillations of these interviews, in which she also asked consumers who have achieved wellness to offer advice about what types of supports they wished they had gotten, and what they would advise their cohorts to offer each other. This was the technique that I employed in designing and implementing the Thinking About Relapse Prevention Program.

Implementation and Outcome

I conducted a series of six workshops (two in Norristown) in all five of the Hedwig House Clubhouses. Slides developed using power point are included as an addendum to the printed manual and on the CD, as is the advance directive document simply entitled Relapse Plan. Each power point slide contains notes that contain a combination of theoretical references, technique explanations, and/or offers examples of responses that where offered by the program participants.

Having first hand experience with a diverse array of mental health consumers through my experience working in both the Lower Merion and Norristown Clubhouses, I felt comfortable that I could easily adjust this program to all of the clubhouses. And knowing both the population and the procedures in the Clubhouse, I decided that a half-day workshop (that includes a 10-15 minuet break) could accomplish the short-term goals of getting the members to realize that they have a large measure of power and knowledge that can be used to head off or shorten an impending relapse, and to give them an advanced directive document to share with their providers and support people.

I had anticipated that the Monday, Wednesday, Friday group at Norristown would be my most difficult audience. On the whole this group is the most debilitated and most disadvantaged population in the agency, Additionally, mental retardation issues as well as mental illness affect a large percentage of these members. Much to my surprise and pleasure, they were fully engaged and enthusiastic participants in every respect. I will not discount the fact that for the last nine months Norristown has been my home base. Therefore these people know me, like me and to some extent want to be cooperative. However, the degree to which they were interested in the information, and willing to share about themselves was truly gratifying.

As I took this program on the road, I faced what I anticipated might be an immediate hurtle—establishing legitimacy with members who do not know me, and who may be reluctant to share personal information with me, as well as with each other. Therefore, I designed the first two slides in the presentation (although these slides do not appear in the participant booklet) to tell the members who I am, and that I have the scholarship, as well as first hand knowledge to ask them to think about and speak openly on a matters that are deeply private. Although the population in each house is uniquely different, with some requiring a more intellectual approach, some wanting a more personal touch, and others needing information from a distance, the program was universally well received. At the conclusion of each workshop members thanked me, told me about how they have begun to think about things in new ways, and how they will continue to think about, and use, the issues raised. The members in each clubhouse also gave positive feedback to the staff and directors in their respective clubhouses. But perhaps the strongest evidence that members not only found the program useful as they were doing it, and in the immediate post-presentation period, but in the long-term as well came about as one of the Norristown members bid me farewell on the last day of my field placement. S climbed up to my office on the third floor, and before he could fully catch his breath, in a winded voice, he shared an elaborate story illustrating how from now on he would try to stop and think about how and why he is feeling as he does, and furthermore not take action until he has considered causative factors and consequences. S began by reminding me of something he had shared in the workshop—he is prone to violence. With that said, he explained that he wanted to tell me about an incident, which had occurred a week after he attended the Thinking About Relapse Prevention Program workshop. He related how on the particular day in question he had become increasingly irritated by the behavior of another member. But, he related, he stopped to think about how both his irritation and his impulse to react violently were symptomatic of his illness. Therefore, he explained, that owing to what he had learned in the workshop, he stopped to think about (and thus had a greater understanding of) what was underlying his motivations and behaviors, as well as those of the other member who had antagonized him. Thus, he explained, that by having this understanding, and therefore modifying his behaviors and intentions, (owing to his newly learned techniques and tools) he did not end up in the hospital (or jail) as had happened on previous occasions when he lost his temper.

References:

Bandura, Albert. (1995). Exercise of personal and collective efficacy in changing societies. Cambridge: Cambridge University Press.

Copeland, M. (1997). Wellness recovery action plan (WRAP). Peach Press.

Copeland, M. (2001). Wellness recovery action plan (WRAP). [videotape]. Hohokus, NJ Mental Illness Education Project.

Copeland, M. (2001). The Wellness Toolbox. [videotape]. Hohokus, NJ: Mental IllnessEducation Project.

Copeland, M. (2001). Creating Wellness. [videotape]. Hohokus, NJ: Mental Illness Education Project.

Hewitt, L & Birchwood, M. (2002). Preventing relapse of psychotic illness. Practical Disease Management, 10(7), 395-407.

Hughes, R. & Weinstein, D. (2000). Best practices in psychosocial rehabilitation. Columbia, MD: Colburn House Publishing.

Hooley, J. (1998) Expressed emotion and the locus of control. Journal of Nervous and Mental Disease. Volume 186(6). June 1998.374-378.

Moller, M. & Murphy M. (1997) The three R’s rehabilitation program: A prevention approach for the management of relapse symptoms associated with psychiatric diagnoses. Psychiatric Rehabilitation Journal, Volume 20 number 3, winter 1997 42-48.

The Promedica Research Center, (Independent Study Activity) [videotape]. Psychoeducation in the treatment of schizophrenia. The Promedica Research Center: Tucker, GA.