APNA 30th Annual Conference Session 4015: October 22, 2016 Responding to the IOM Report on Psychosocial Interventions: Application of the Perspectives of Psychiatry Karan Kverno, PhD, PMHNP-BC and Tamar Rodney, MSN, PMHNP-BC The speakers have no conflicts of interest to disclose. Learning Objectives • Upon completion of this presentation, participants will be able to: – Describe key explanatory concepts from each of the four Perspectives of Psychiatry . – Utilize the Perspectives of Psychiatry conceptual framework to match elements of evidence-based psychotherapeutic interventions to the needs of individual patients. – Take part in the recommendations of the IOM (2015) report on psychosocial interventions for mental and substance use disorders. The Need for an Elements Approach to Evidence-based Psychosocial Interventions • Psychopharmacology alone is often insufficient for complete recovery. • Psychosocial interventions are effective, yet there has been a decline in their use. • Evidence based, psychosocial interventions are made up of multiple elements. • We don’t know what elements are effective at improving specific symptoms, functioning or well- being. (Delaney & Handrup, 2011; Institute of Medicine, 2015; Janicak, Marder & • Pavuluri, 2011) Kverno 1
APNA 30th Annual Conference Session 4015: October 22, 2016 Psychosocial Intervention Concepts • Elements: activities, techniques or strategies – Non-specific elements – Specific elements • How change is affected: – Mechanisms: Biological, behavioral, cognitive, emotional, interpersonal – Moderators: Person-specific factors such as sex, race, class • Outcomes: – Symptoms, functioning and well-being (IOM, 2015) IOM Framework for Developing Standards for Psychosocial Interventions Strengthen the Strengthen the evidence ‐ base evidence ‐ base Implement Identify elements of interventions and Engage interventions improve outcomes Consumers Conduct systematic Develop quality reviews to inform measures clinical guidelines (IOM, 2015) Application • The application of effective interventions involves assembling combinations of elements that, based on evidence, are targeted to particular disorders and other patient characteristics. (IOM, 2015, p. 10) • Case formulation is key in matching elements to patient characteristics. Kverno 2
APNA 30th Annual Conference Session 4015: October 22, 2016 Case Formulation and Treatment Implications DSM- 5 Approach • Considers whether symptoms fit into a recognizable disorder or syndrome - or not. Perspectives of Psychiatry • Considers the presentation from each of four perspectives. Bird Life: A Guide to Study of Our Common Birds (1897). (APA, 2013; Chisolm & Lyketsos, 2012; McHugh & Slavney, 1998) HIDE • Diseases—what a patient . . . Has • Dimensions—what a patient . . . Is • Behaviors—what a patient . . . Does • Stories—what a patient . . . Encountered (McHugh & Slavney, 1998) Disease Perspective Example: Schizophrenia Treatment: Medication (McHugh & Slavney, 1998) Kverno 3
APNA 30th Annual Conference Session 4015: October 22, 2016 Dimensional Perspective Example: Wild Boy of Aveyron (circa 1798) Treatment: Guidance (McHugh & Slavney, 1998) Behavior Perspective • Example: Anorexia • Treatment: Interruption (McHugh & Slavney, 1998) Life Story Perspective Example: Bandura’s Bobo Doll Experiment (1961) Treatment: Rescripting (Bandura, Ross & Ross, 1961; McHugh & Slavney, 1998) Kverno 4
APNA 30th Annual Conference Session 4015: October 22, 2016 Examples of Disorders and Syndromes Across the Perspectives Diseases Behaviors Dimensions Life Stories Delirium Alcohol Subnormal IQ Demoralization dependency Dementia Drug dependency Personality Grief disorders Schizophrenia Paraphilias Excessive emotional Adjustment responses disorder (“neurosis”) Bipolar disorder Anorexia / bulimia PTSD Panic disorder Sleep disorders False memory syndrome (McHugh & Slavney, 1998) Case Example: Personalizing Treatment • Disease • Dimensional • Bipolar • Unstable extroversion Medicate Medicate Guide Guide Interrupt Interrupt Rescript Rescript • Behavioral • Life Story • Risky alcohol • Demoralization use Case Example: Evidence-based Psychosocial Elements Behavior: Dimensional: Life Story: Risky alcohol use Unstable extroversion Demoralization Nonspecific ‐ Therapeutic alliance ‐ Therapeutic alliance ‐ Therapeutic alliance (Examples) ‐ Engagement ‐ Engagement ‐ Engagement ‐ Health literacy ‐ Health literacy ‐ Health literacy Specific ‐ Brief intervention ‐ Problem solving for ‐ Use of thought (Examples) (SBIRT) conflict resolution records to identify and reframe distorted cognitions Psychosocial elements (IOM, 2015) Kverno 5
APNA 30th Annual Conference Session 4015: October 22, 2016 LEADERSHIP Do not wait to ‘be invited to have a seat at the table,’ find ways to be an active participant and take full advantage of the opportunities to establish psychiatric mental health nursing’s expertise in psychosocial interventions. (Susie Adams, PhD, PMHNP/CNS-BC, FAANP, 2015, p. 347) Take Part in Building an Elements Based Framework • Consider the nonspecific and specific interventions that you provide for patient-specific problems. • Do a systematic review of the literature to strengthen the evidence base. • Conduct clinical studies to identify and validate elements of psychosocial interventions. Use quality measures to track effectiveness. • Participate in developing an elements framework, with a common language, whereby strategies and techniques can be applied across target problems, disorders, or contexts. Future: Implications for Teaching and Practice • An elements framework will: – advance training in and implementation of evidence-based psychosocial interventions. – provide guidance as to what models of training are most effective – determine how the acquisition of core competencies should be assessed. (IOM, 2015) Kverno 6
APNA 30th Annual Conference Session 4015: October 22, 2016 Conclusions • The IOM committee recommends that psychosocial interventions be elevated to a position of equal regard as physical health care. • Nurses have an important role in identifying key elements and examining the evidence to build a framework to improve the outcomes of psychosocial interventions. • The Perspectives of Psychiatry provide an approach for matching elements of evidence-based psychosocial interventions to the needs of individual patients. Participant Discussion What is your system of case formulation? • • How do you determine the appropriate elements of psychosocial care? • How can we work together to contribute to an elements based framework to improve the outcomes of psychosocial interventions? • How will this framework inform nursing practice? Nonspecific Specific Generalist APRN References Adams, S. (2015). The IOM report on psychosocial interventions for mental and substance use disorders. Opportunities for • psychiatric-mental health nurses. Journal of the American Psychiatric Nurses Association, 21 (5), 343-347. doi: 10.1177/1078390315606107 • American Psychiatric Association (2013). Diagnostic and statistical manual of mental disorders (5th ed.) . Arlington, VA: Author. ISBN: 978-0-89042-555-8 Bandura, A., Ross, D., & Ross, S. A. (1961). Transmission of aggression through imitation of aggressive models. Journal of • Abnormal and Social Psychology, 63 , 575-582. • Chisolm, M. S., & Lyketsos, C. G. (2012). Systematic psychiatric evaluation. A step-by-step guide to applying the Perspectives of Psychiatry . Baltimore: The Johns Hopkins University Press. ISBN: 978-1-4214-0702-9 Delaney, K. R., & Handrup, C. T. (2011). Psychiatric mental health nursing's psychotherapy role: Are we letting it slip away? • Archives of Psychiaric Nursing, 25 (4), 303-305. Doi:10.1016/j.apnu.2011.04.005 • Institute of Medicine. (2015). Psychosocial interventions for mental and substance use disorders: A framework for establishing evidence-based standards. Retrieved from http://iom.nationalacademies.org/Reports/2015/Psychosocial- Interventions-Mental-Substance-Abuse-Disorders.aspx Janicak, P. G., Marder, S. R., Pavuluri, M. N. (2011). Principles and practice of psychopharmacotherapy (5 th ed.). Riverwoods, • IL: Wolters Kluwer Health. ISBN 978-1-60547-565-3 McHugh, P. R., & Slavney, P. R. (1998). T he perspectives of psychiatry (2 nd ed.). Baltimore, MD: The Johns Hopkins University • Press. ISBN: 0-8018-6046-6 Substance Abuse and Mental Health Services Administration , & U.S. Department of Health and Human Services (SAMHSA- • HRSA). (n.d.). SBIRT: Screening, brief intervention, and referral to treatment. Available online: http://www.integration.samhsa.gov/clinical-practice/sbirt Kverno 7
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