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“I am Not Sick, I Don’tNeed Help!”Using LEAP to engage persons with mental illnessand substance abuse into treatment.39th Summer institute on Substance Abuse & Mental HealthNewark, DelawareJuly 26, 2010Xavier Amador, Ph.D.Adjunct ProfessorColumbia UniversityTeachers g

Poor Insight and relationshipsTMwww.LEAPInstitute.org

“Denial” of Illness in the NewsPoor insightintoschizophreniaand bipolardisorder is socommon TMwww.LEAPInstitute.org newsstoriesinvolvingsuch personsappear nearlyeveryday.

The Unabomber: Ted KaczynskiMore “denial” in the headlinesTMwww.LEAPInstitute.org

“Denial” of IllnessImpairs common-sense judgment about theneed for treatment But are we dealing with denial?“Anosognosia”TMwww.LEAPInstitute.org

Unawareness of Mental DisorderXavier Amador, Nancy C. Andreasen, Scott Yale & Jack Gorman,Archives of General Psychiatry, 51(10):826-836, 1994Unaware32.1%Moderately Unaware25.3%Aware40.7%DSM IV Field Trial StudyN 221 patients with schizophreniaTMwww.LEAPInstitute.org

Other problems with “Insight”50% of Patients with Schizophrenia areUnware of having Tardive Dyskinesia (TD)¾ Rosen et. al., 1982, American Journal of Psychiatry¾ Tremeau et al., 1997 Schizophrenia Research¾ Arango; et. al., 1999, Schizophrenia Research¾ Caracci et. al., 1990, American Journal of PsychiatryTMwww.LEAPInstitute.org

The Problem with AntipsychoticMedicationsFrom 50% to 75% exhibit full or partial non-adherence(Rummel-Kluge, 2008).Within 7-10 days of medication initiation (Keith & Kane, 2003): 25% stop taking medication 50% are off medicine after one year, and 75% after two years.Only about 33% reliably take medication as prescribed(Oehl, 2000).TMwww.LEAPInstitute.org

Insight and AdherenceAwareness of being ill (insight) is among the top twopredicators of long-term medication adherence.What is the other top predictor?Relationship with someone who:¾Listens to you without judgment.¾Respects your point of view.¾Believes you would benefit fromtreatment.TMwww.LEAPInstitute.org

What Causes PoorInsight?Psychological defense ?“Culture” and/or Education ?Neuropsychological deficits ?TMwww.LEAPInstitute.org

TMDSM-IV-TRSchizophrenia & other psychotic disordersXavier Amador & Michael Flaum, Co-ChairsPage 304, American Psychiatric Association, 2000TMwww.LEAPInstitute.org

Anosognosia is similar Very severe lack of awareness. The belief persists despite conflictingevidence. Confabulations are common.TMwww.LEAPInstitute.org

When dealing with anosognosia, or poor insight:The “doctor knows best” approach does not work,because collaboration is a goal not a given.DO NOT expect:¾ Gratitude¾ Receptiveness¾ ComplianceDO expect:¾ Frustration and anger¾ Suspiciousness¾ Overt and secretive “non-compliance”TMwww.LEAPInstitute.org

Motivational InterviewingStudied extensively in patients with substance abuse disordersInterventions to Improve Medication Adherence in SchizophreniaZygmunt A, Olfson M, Boyer CA, & Mechanic D, review in: American Journal ofPsychiatry, 2002. (reviewed studies from 1980 through 2000)“Although interventions and family therapy programs relying on psychoeducationwere common in clinical practice, they were typically ineffective ”“Motivational techniques were common features of successful programs.”**Please see LEAPInstitute.org click “Research”for additional evidence.TMwww.LEAPInstitute.org

LEAP The LEAPapproach– Listen– Empathize– Agree– Partner200020072008TMwww.LEAPInstitute.org Based on MAIT, Amador & Beck

Double blind, randomized, controlled study ofthe LEAP Communication ProgramCéline Paillot, Ph.D. Ray Goetz, Ph.D. Xavier Amador, Ph.D.University Paris X, France, New York State Psychiatric Institute,Columbia University Teachers CollegeIn Press Schizophrenia BulletinPresentation at International Congress on Schizophrenia Research,San Diego California, April 2009TMwww.LEAPInstitute.org

Conclusions of LEAP StudyCompared to the control psychotherapy, LEAP: maintained compliance to injectable antipsychotics. improved motivation to take medication. increased insight in specific areas. improved attitudes toward treatment.TMwww.LEAPInstitute.org

ListenReflectively orgListen-Empathize-Agree-Partner

ListenWhy do we resist reflecting back many important thingsour patients tell us?¾We fear we will make “it” worse (i.e., delusions,insight, attitudes about medication, etc.).¾We do not want to be asked to do something wecannot.¾We worry about injuring the therapeutic alliance.¾We fear we have to be gree-Partner

LEAP – ListenWhy do we resist reflecting back manyimportant things our patients tell us? We fear we will make “it” worse (i.e. delusions,insight, attitudes about medication, etc) We do not want to be asked to do somethingwe cannot We worry about injuring the therapeutic allianceTMwww.LEAPInstitute.org

How to delay giving your opinion: “I promise I will answer your question. If it’s alrightwith you, I would like to first hear more about. Okay?” “I will tell you what I think. I would like to keeplistening to your views on this because I am learninga lot I didn’t know. Can I tell you later what I think?” “I will tell you. But, I believe your opinion is moreimportant than mine and I would like to learn morebefore I tell you my opinion. Would that be -Partner

When you finally give your opinion usethe 3 A’sAPOLOGIZE“I want to apologize because my views might feel hurtful ordisappointing.”ACKNOWLEDGE FALLIBILITY“Also, I could be wrong. I don’t know everything.”AGREE”I hope that we can just agree to disagree. I respect yourpoint of view and I hope you can respect ree-Partner

EmpathizeStrategically express empathy for: delusional beliefsdesire to prove “not sick!”wish to avoid treatmentNormalize the Agree-Partner

Agree¾Discuss only perceivedproblems/symptoms¾Review advantages anddisadvantages of treatment &services¾Reflect back and highlight boththe perceived benefits and costs.AGREE TO ree-Partner

PartnerMove forward on goals youboth agree can be workedon gree-Partner

LEAP SituationsRole-plays¾In this scenario ner

Directions for 2010 LEAP Institute goals– Regional trainings and “train the trainers” Amador et al. Am J Psychiatry1– Proposal for anosognosia subtype Schizophrenia Bulletin Special Edition2– Review of efficacy of adherence therapies– Updated review of brain imaging studies– Updated review of frontal lobe findings– DSM V: anosognosia subtype will be proposedTMwww.LEAPInstitute.org

THEURAPEUTIC ALLIANCE PROGRAMME 2010TRAIN THE TRAINERS MEETINGTMwww.LEAPInstitute.org

THERAPEUTIC ALLIANCE PROGRAMME (ADHES)Regional LEAP Trainings (April‐ June 2010)over 200nurses20 psychiatrist trainings29www.LEAPInstitute.orgTM1 psychiatric nurse trainingover350physicians

Regional LEAP TrainingsTMwww.LEAPInstitute.org

Regional LEAP TrainingsTMwww.LEAPInstitute.org

THERAPEUTIC ALLIANCE PROGRAMME‐ first resultsComprehensive surveys are completed by participants after each training. (n 224)32www.LEAPInstitute.orgTM

THERAPEUTIC ALLIANCE PROGRAMME‐ first resultsWould you recommend “LEAP Training” to your colleagues? (n 226)TMwww.LEAPInstitute.org

TMwww.LEAPInstitute.org

Conclusions Poor insight in patients with schizophrenia is common1– 50% of patients with schizophrenia are moderatelyunaware or unaware of mental disorder2 Awareness of being ill (insight) is one of the toppredictors of long-term medication adherence1 Treatment of patients with poor insight:– LAIs3,4– Motivational interviewing and related approaches,such as LEAP5 TMwww.LEAPInstitute.org1. Amador et al. Schizophr Bull 1991;17:113–132; 2. Amador et al. Arch Gen Psychiatry1994;51:826–836;3. Keith & Kane. J Clin Psychiatry 2003;64:1308–1315; 4. Zygmunt et al. Am J Psychiatry2002;159:1653–1664;5. Paillot et al. Schizophr Bull 2009;35(suppl 1):343