Crossing the MindBody Divide Day 2 Morning Our Emotions Part 2 Whole Health for Mood Disorders Our Behaviors and Choices Part 1 Healthy Patterns The Power of Biofeedback and Guided Imagery ID: 933411
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Slide1
Whole Health for Mental HealthCrossing the Mind-Body Divide
Day 2 Morning
Our Emotions, Part 2:
Whole Health for Mood Disorders
Our Behaviors and Choices, Part 1:
Healthy Patterns
The Power of Biofeedback and Guided Imagery
Our Behaviors and Choices, Part 2:
Unhealthy Patterns
Finding Peace and Ease, Part 1:
Working with Stress
Implementation, Part 2:
Your Practice, Your Team
Slide2Whole Health for Mental HealthCrossing the Mind-Body Divide
Welcome Back!
Slide3Pulse Checks
Image: Keepcalm
-o-
matic.co.uk
Slide4Where We’ve Been
Defining Whole Mental HealthMission, Aspiration, PurposeConnections- Self-Care, CIHThinking and CognitionEmotions (Part 1)
Application for Your Own Life
Image:
Breakingthehabit.org
Slide5Where We’re GoingThinking about points of tensionPRACTICE!Emotions II: Tony and Depression
Behaviors and ChoicesPeace and Ease I: Mel and StressImplementation in PracticeLunchPeace and Ease II: Trauma and PTSDVitality and WholenessImplementation at Your Facility and Beyond
Image:
pinterest.com
Slide6Whole Health in Your Practice11. Our Emotions IIWhole Health for Mood Disorders
Slide7Tony and Emotions: I am irritable with my family.
I feel sad a lot of the timeIn 2003, I was told I have depressionThings aren’t fun anymoreNot a danger to himself
Slide8Whole Health and Depression
The PHI can help you get a sense of someone’s emotional well-beingALL of the areas of the circle are relevant
Slide9Depression Facts>1 in 10 US Adults have it10%
are ages 18-257% of American adults have one episode yearly25% prevalence in people with chronic diseaseOnly 60% treated with meds have significant responseOthers have adverse effects or residual symptoms
Schneider &
Wissink
, Depression, in
Rakel
(
ed
) Integrative Medicine, Philadelphia: Sanders, 2018.
Image:
nvf.org
Slide10Depression EtiologyGutGenesNeuroplasticityTrauma and kindlingInflammation
Neurotransmitter imbalanceSchneider & Wissink
, Depression, in
Rakel
(
ed
) Integrative Medicine, Philadelphia: Sanders, 2018.
Image:
deviantart.com
by carts
Slide11Neurotransmitter Control Room
Serotonin
Norepinephrine
Dopamine
GABA
Oxytocin
Cannabinoids
Endorphins
Poor synthesis
Increased breakdown
Increased pump uptake
... and the question becomes,
“Why?”
Slide12Depression and Inflammation
About ½ of depressed people have increased inflammatory markersSlowed tryptophan metabolismMore becomes kynurenine (causes inflammation)
Dysregulates glutamate, lowers neurotrophic factors
HPA axis also
dysregulated
Image:
pngall.com
Schneider &
Wissink
, Depression, in
Rakel
(
ed
) Integrative Medicine, Philadelphia: Sanders, 2018.
Slide13Symptoms for nearly every disease category studied are worse
Diabetes, metabolic syndrome, RA, asthma, MS, chronic pain, psoriasis and many moreConnection to CVD heart risk factors = depression
Obese people have 55% more depression
Depression increases obesity risk 88%
1.15x the risk of cancer
(Jia et al, Pub Health, 2017;149:138-48.)
Comorbidities
Lim et al,
Soc
Psychiatry
Psychiatr
Epidemiol
, 2012;47:1047-53.
Luppino
et al. Arch Gen Psychiatry, 2010;67:220-9.
Image:
caanberry.com
Again, need to think about all aspects of a person - interconnections
Slide14“Me”: Depression is IndividualizedDepression takes many formsArray of DSM diagnoses
Different onset, symptoms, time course, etiologyUnique circumstances may triggerTherapeutic relationship matters tooPeople have strong feelings about different therapies
Whole Health Library, Depression Overview, https://
wholehealth.wisc.edu
/overviews/depression/
Slide15Food & Drink to Prevent Depression2018 systematic review/meta-analysisMost studies clearly found benefit of a healthy diet for prevention2 million people, linear dose response
Odds of depression for any high-quality diet decreased to 64-78% of what they wereMolendijk et al, J Affective Disord, 2018;226:346-54.
47 people need to eat healthy prevent 1 case of depression
Slide16Depression: Food
Image: patch.comMartinez-Gonzalez et al,
Proc
Nutr
Soc
, 2016;75:139-46.
Slide17Food & Drink: What to Eat
2016 review: What dietary elements prevent depression?Fruits and vegetablesOlive oilTree nuts
Fish
Whole grains
Martinez-Gonzalez et al,
Proc
Nutr
Soc
, 2016;75:139-46.
Slide18Food & Drink: What to Cut BackGood to removeMeats (other than seafood)Commercial baked goodsTrans fatsSugar (desserts, beverages)Worth a trial of going off sugar for a week
Also, fast food (Sanchez-Villegas et al, Public Health Nutr, 2012;15(3):424-32.)And alcoholMartinez-Gonzalez et al, Proc
Nutr
Soc
, 2016;75:139-46.
Akbaraly
, et al, Br J Psychiatry, 2009;195:408-13.
Bottom Line: The “Western Diet” increases risk; a whole foods diet decreases it.
Image:
cdc.gov
Removing sugar for a week improves symptoms
Slide19Omega 3’s: In Summary
Essential polyunsaturated fatty acids (body can’t make them)Main types are DHA and EPASources: cold-water fish, other food sourcesThey decrease inflammationOmega-6’s tend to increase itSame pathways as many anti-inflammatory medicationsAlso stabilize cell membranes
Messamore
et al,
Prog
Lipid Res, 2017;66:1-13.
Photo:
sardinecannedfish.com
Workbook page 11
Slide20Omega 6 Pathway
Gamma
Linolenic
Acid (GLA)
Arachidonic
Acid (AA)
Omega 3 Pathway
Eicosapentaenoic
Acid (EPA)
Docosahexaenoic
Acid (DHA)
6-Desaturase
Cycloxygenase
(COX)
Linoleic Acid (LA)
Alpha-
Linolenic
Acid
(ALA)
Stearidonic
Acid
Eicosatetraenoic
Acid
Dihomo
-GLA
Oils
Partially hydrogenated
Vegetable
Sunflower
Safflower
Borage oil
Evening Primrose Oil
5
-Desaturase
Flax, walnuts, hemp, pumpkin seed, green leafy veggies
Animal proteins
Meat
Dairy
Eggs
Seafood
Salmon
Herring
Mackerel
Sardines
Leukotrienes
Series 4
Inflammation
Prostaglandins Series 2
Inflammation
Prostaglandins Series 1
Inflammation
Prostaglandins
Series 3
Inflammation
Leukotrienes
Series 5
Inflammation
Others
–
Thromboxane A2
Inflammation
Mg, B6, Zn,
C, B3
Mg, Biotin, C
B3, Zn
Short Chains
Long Chains
Some omega-6’s can tie in to anti-inflammatory pathways. Both pathways are essential to good health. A healthy ratio is key.
Course Manual, Page 11
Slide21Omega 3’s for Depression
“Emerging...evidence over the past 3 decades suggests that habitual dietary omega-3 PUFA insufficiency, particularly during perinatal development, may represent a modifiable risk factor for mood disorders.”Especially as an adjunctive therapy (not alone)DHA for structure, EPA for function
Messamore
et al,
Prog
Lipid Res, 2017;66:1-13.
Slide22Essential Fatty Acids and Mood: Reviews
Cochrane, 2015: 26 studies; 1,478 peopleSmall to modest benefit for depression symptoms in general. Is it clinically meaningful?2016 review: 13 studies; 1,233 people “...beneficial overall effect” of supplementation in major depressive disorder patients, especially for: Higher EPA doses
People taking anti depressants
Appleton et al, Cochrane, 2015;11:CD004692. Mocking et al,
Transl
Psychiatry, 2016;6:e756.
Image:
cdc.gov
Slide23“The Potential for Nutrition to Reduce Depression, Suicide, and Impulsive Aggression”
“...a rebalancing of the essential fatty acid composition of U.S. military diets, to achieve tissue compositions of PUFAs consistent with traditional Mediterranean diets, may help reduce military psychiatric distress and simultaneously increase force efficacy substantially.”
Hibblen
, Mil Med, 2014;179(11):117.
Image:
Health.Harvard.edu
Slide24What About Specific Nutrients?
B VitaminsDeficiencies can lead to depressionE.g.,
folate
and B12, thiamine, niacin, B6
Multivitamin Supplements
Reduced perceived stress, and improved mood in people without depression
Not helpful with depression
Vitamin D
–
8-14% risk if deficiency
Study that eliminated flawed research showed benefit
Tryptophan intake matters in population studies
Kennedy et al, Nutrients, 2016;8(2):68
. Long et al, Psychosomatic Med, 2013;75(2):144–153.
Image:
Popularscience.com
Slide25Dietary Proteins
Tryptophan
5-HTP
5-Hydroxytryptophan
Serotonin
Melatonin
Tomatoes, olives, barley, rice, walnuts, coffee beans, wine
Methionine
Homocysteine
SAMe
*
S-
adenosylmethionine
Methyl
Groups
B12
Folate
B1, B6, Zinc, Stomach Acid
Fe, C, B12,
Folate
, Mg,
Ca
B6, C, Zn, Mg
Eggs, cheese, tofu, salmon, turkey, nuts
Beans, dairy, eggs, soy, fish/shellfish, cheese, meats, Brazil nuts
Light Level
*The exact mechanism for
SAMe
and depression is unclear. It affects serotonin, dopamine, and norepinephrine levels.
Amino Acids, Serotonin, and
SAMe
Niacin (B3)
Course Manual, Page 9
Slide26Dietary Proteins
Phenylalanine
L-Dopa
Tyrosine
Iron, B3
Chicken, turkey, milk, cheese, yogurt, peanuts, almonds, avocados, bananas, lima beans, pumpkin seeds, sesame seeds
Also increases with music, meditation, achieving goals, creativity, exercise
Amino Acids, Dopamine, and Norepinephrine
B1, B6, Zinc, Stomach Acid
Dopamine
Norepinephrine
Epinephrine
B6
Copper
Vit
C
Mg
SAMe
Iron, B3,
Folate
Course Manual, Page 10
Slide27Depression: Moving the Body
Good research in this area: >1,000 studiesCochrane review, 2013 – > to counseling and/or medsSmall overall effect in the most robust trialsAerobic and
anaerobic both help
Intense is better, and total time is
key, not number of weekly sessions
Cooney et al, Cochrane, 2013(9):CD004366
Schneider &
Wissink
, Depression, in
Rakel
(ed) Integrative Medicine, Philadelphia: Sanders, 2018.
.
Image:
Psychologytoday.com
Yoga=OK, Tai chi = OK!
Cramer et al, J Affect
Disord
, 2017;213:70-7. Wang, Int J
Behav
Med, 2014;21:605-17.
Slide28Image:
Psychologytoday.comMoving the BodyWhy does it help?Adult neurogenesis hypothesis Hippocampus grows 2-6% in elders after 6
mo’s
Exercise increases plasma tryptophan
May also alter inflammatory markers
Farioli
et al,
Curr
Neuropharmacol
, 2018;16(3):308-26.
Slide29Yoga and DepressionModerate benefit in short-term studies2017 review of 7 trials, n=240Comparable to other forms of exercisePositive effects beyond placebo
...But methodology an issueCramer et al, J Affect Disord, 2017;213:70-7.
Image:
retreat.guru
Slide30Tai Chi and Depression2014 review37 RCTs and 5 quasi-experimental trialsBeneficial effects...But methodology an issue
Wang, Int J Behav Med, 2014;21:605-17.
Slide31Power of the Mind: Meditation
2016 summary of 52 trials and reviews:Meditation decreases depression symptom severityReduces relapse, rumination, reactivityCultivates self-compassion
Alters relationship to negative thoughts
Safe, portable, cost-effective
Activates areas of brain linked to feelings of enhanced wellbeing
Khusid
, Mil Med, 2016;181:9:961-8.
Photo:
layoga.com
Slide32Mindfulness Based Cognitive Therapy
MBCT is most commonly studied mindfulness-based group intervention for depressionMeta-analysis: 21% reduction in average risk of new episode by 12 monthsReduced relapse rate more than usual therapy does (66% vs 36%)Reduced relapse even more when added to meds (47% vs 60%)
Comparable to medications in one large trial (2 year follow up) but more studies needed
Comparable to CBT
Telehealth
approaches show promise
Khusid
, Mil Med, 2016;181:9:961-8.
Photo:
veterandiabilityblog.com
Slide33CIH and Depression10-30% of people with depression use complementary approaches20-50% for people with bipolar disorderDietary supplements are most commonly used
People who use CIH are more likely to have depression than general populationMany people take meds and use other approaches at the same timeSolomon et al, J Affect Disord
, 2015;101-113.
Image: “Escaping the Rabbit Hole,”
traceymaxfield.com
Slide34PsychotherapyAlways worth consideration (2/3 of people say it is helpful), and...2018 Cochrane review, 6 trials, n=698Moderately good evidence for treatment
resistant depression along with “usual care”Which one to use?“Cognitive therapy teaches you to step in and use your prefrontal cortex instead of letting your emotions run away with you.”-Anthes
, Nature, 11/13/14
Ijaz
et al, Cochrane, 2018(3):CD010558.
¼ of depressed patients have tried some form of mind-body therapy
Slide35Acupuncture2018 Cochrane review64 trials, 7,104 participantsMay result in moderate improvement
vs usual or no treatmentSmall improvement relative to sham
Smith et al, Cochrane, 2018(3):CD004046.
Slide36Depression: Dietary Supplements
Photo: A Rindfleisch
Slide37Some ExamplesSt. John’s Wort
S-adenosyl methionine (SAMe)5-HTP and L-Tryptophan Inositol (B8, an isomer of glucose) NADH Phenylalanine, tyrosine DHEA
Saffron
Lavender
https://
naturalmedicines.therapeuticresearch.com
/
*It is important to honor scope of practice here. And you need to be up on these supplements before you try them yourself, too.
Photo: A Rindfleisch
Slide38Applying what you have learnedAt your table...
List 2 self-care suggestions you’d use to help Tony with his depressionList 2 professional care approachesDiscuss how each of you would contribute Use pages ## and ## for guidance.Be prepared to share your list!
Slide39Schneider &
Wissink, Depression, in Rakel (ed) Integrative Medicine, Philadelphia: Sanders, 2017.
Healthy spiritual communities can help
Forgiveness therapy may help
Spiritual practices can foster happiness
Warm temperature exposures help depression
Phototherapy helps may forms of depression, not just seasonal affective disorder
Nature time may help
Foster more community, more relationships; less isolation helps
Animal assisted therapy
Sleep deprivation therapy only helps short-term
Poor sleep doubles depression risk
Volunteering
Financial stability
Education
Mindfulness practices specifically geared to depression may be helpful
Whole foods diet (e.g., Mediterranean)
Minimize refined sugar
Diet rich in omega-3’s
Alcohol a depressant
Activity is very beneficial
Do an exercise prescription for both aerobic and anaerobic activities
Depression:
Self-Care Options
p. ##
Slide40Psychotherapy great; recommended in combination with medications
CBT-I helps with depressionInterpersonal therapy helpsMusic therapy shows promise
Acupuncture shows some promise
Supplements (care with side effects)
Augment anti-depressants with L-
methylfolate
5-HTP
St John’s
Wort
likely helps, but watch drug interactions
S-
adenosylmethionine
(
SAMe
) maybe good while waiting for a med to kick in
Fish oil supplements
Saffron
–
pretty good research
Address comorbid health problems:
Thyroid
Sleep apnea
Chronic pain
Substance use
Heart disease risk
Obesity
Biofield
therapies
–
mixed results. Help with emotional coping with various chronic conditions
Psilocybin shows promise
So does
Transcranial
Magnetic Stimulation
Electroconvulsive therapy works very well... At a cost
Not much research favoring biofeedback or hypnosis
Schneider &
Wissink
, Depression, in
Rakel
(ed) Integrative Medicine, Philadelphia: Sanders, 2017.
Remove triggers and exacerbating factors, including medications
Depression:
Professional Care
p. ##
Slide41To Sum UpPersonalized approaches to depression can helpMAP and vitality signs helpfulFigure out what options appeal to each individualDraw in self-care
CIH adds some additional optionsThis approach can be very effective!Solomon et al, J Affect Disord, 2015;101-113.
Slide42Thank You!
Any Questions?
Slide43Whole Health in Your Practice12
. Behaviors and Choices I:Healthy Patterns
Slide44Aspects of Mental HealthThinking and CognitionEmotionsBehaviors and ChoicesPeace and EaseVitality and Wholeness
Fully 95% of our behavior, feeling, and response is habitual. -Maxwell Maltz
Slide45A Spectrum
Engagement
Good Habits:
Adherence/
Compliance
Apathy
Bad Habits
Addiction
Degree of Suffering
Level of Choice
Slide46How do YOU encourage
positive behaviors and choices amongst the Veterans you serve
?
What specific techniques do
you use?
Image:
Aspergillosis.org
Slide47How Do We Support Positive Behaviors and Choices?Discussion of values (MAP)
Individualizing CareMotivational InterviewingRole ModelingOthers?
Photo:
Cleartrip.com
Slide48MAPWe’ll talk about the power of meaning and purpose in life in Module 20Just keep asking “The Big Questions!
Lame attempt at an image: Adam Rindfleisch
Slide49Motivational InterviewingBut does it work? Yes! Some Examples:
Pain: 7 studies, 962 people. Small to moderate effect size for adherence to planPrimary Care: Review of 33 studies; 18 with positive effectsAnxiety: Enhances effects of CBT (12 studies)
Smoking:
Cochrane says it “may assist” (RR of quitting 3.49 with PCP; 1.25 with counselors), and better than usual care
“...a directive, client-centered counseling style for working collaboratively with clients to enact a behavior change.”
Morton et al, Health
Psychol
Rev, 2015;9
(2):205-23.
Alperstein et al, J Pain, 2016;17(4):393-403.
Marker et al,
Clin
Psychol
Rev, 2018;62:1-10.
Lindson
-Hawley et al, Cochrane, 2015;3:CD006936.
Slide50Motivational Interviewing:How Does It Work?Taps into 3 necessary conditions for change (hypotheses)
Technical proficiency of clinicianRelational – good empathy (not as much research)Conflict Resolution – working with ambivalence
Magill et al,
Curr
Opin
Psychol;2019;30:1-5.
Photo:
picpa.org
Slide51Role ModelingClinicians’ behaviors matter in their own right, AND...You preach what you practice
That is, you mention behaviors to your Veterans that you performThey practice what you preachE.g., the ‘apple and helmet’ studyThey follow your leadDiMatteo et al. Health Psychol. 1993;12(2):93-102.
Frank E, et al. CMAJ 2013;185(8):649-53.
Frank E, et al. Arch
Fam
Med 2000;9(3):287-90
.
Photos:
Road.cc
and
techflourish.com
Slide52Impact of Professional FulfillmentHigher professional fulfillment for a clinician is linked to more patient adherence Includes taking medications, exercise, and food choices
Clinicians who have higher job satisfaction receive higher patient satisfaction ratingsDiMatteo et al. Health Psychol. 1993;12(2):93-102. Hass et al. J Gen Intern Med 2000;15(2):122-8.
Photo:
Familycircle.com
Photo:
tobaccofreelife.org
Slide53Motivation is what gets you started. Habit is what keeps you going.
- Jim Ryun
Photo: pixabay.com
Slide54Video - Habitshttps://www.youtube.com/watch?v=wQLHwSphu-M
53
Slide55Work With a NEW PartnerChoose someone to go firstShare a time when you or a patient successfully started a “good” habit or broke a “bad” habit
What cue, routine, and reward made the success possible?After a few minutes, we’ll have you switch.
Slide56A. 21 days B. 66 days
C. Depends on the habit D. Depends on the person
https://www.theatlantic.com/health/archive/2013/10/how-oreos-work-like-cocaine/280578/
Oreos are “...just as addictive as cocaine
–
at least for lab rats. And like most humans, rats go for the middle first.”
Photo:
Theatlantic.com
How Long to Create a New Habit?
Slide57How Long to Create a New Habit? A. 21 days B. 66 days
C. Depends on the habit D. Depends on the person
https://jamesclear.com/new-habit
✓
✓
✓
“21 days to form a habit” is inaccurate
Suggested in 1950s by plastic surgeon, Maxwell
Maltz
,
as a minimum
Based on time to adjust to cosmetic surgery or stop feeling phantom limbs
Photo:
azquotes.com
Slide58How Long to Create a New Habit?
Lally, et al. Eur J Soc Psychol, 2010;40:998-1009.96 undergrads
Followed for 12 weeks
They chose eating, drinking or activity goals
Completed self-report habit index each day
Study tested for and confirmed an asymptotic pattern
Time to habit: 18-254 days
Depended on what habit, frequency of behavior, person
Missing a day
not
a problem
Slide59Habits and the Circle
How can positive habits in each area impact mental health?
Slide60Considering this….
What is one small behavior you might want to build into a habit?
How does that support your MAP?
Math time!
Cue + Routine + Reward = HABIT
Slide61And there’s more...After a little bliss
Slide62Considering this….
What is one small behavior you might want to build into a habit?
How does that support your MAP?
Math time!
Cue + Routine + Reward = HABIT
Slide63Whole Health in Your Practice13. The Power of Biofeedback and Guided Imagery
Slide64Mind-Body: BiofeedbackUsing equipment to track Heart rate (ECG)Heart rate variability
BreathingSkin electricityBrain waves (EEG)Temperature
Photo:
klusster.com
Making unconscious or involuntary physiologic processes perceptible to the senses in order to manipulate them by conscious control
Photo:
eptstrategy.com
Slide65Biofeedback Efficacy
EfficaciousAnxietyADDFemale urinary incontinence
Headache in adults
Hypertension
TMJ
Male urinary incontinence
Probably Efficacious
Substance abuse
Insomnia
Traumatic brain injury
Epilepsy
Arthritis
Chronic pain
Fecal elimination problems
Pediatric migraines
Vulvar
vestibulitis
Passport to Whole Health
, Chapter 12, Section 3.
Image:
kinfolkwellness.com
Slide66Mind-Body: Guided ImageryWhat is it?Focus on images
Use all your sensesYou might follow a path to a “safe place...”Or talk to a wisdom figures (e.g., your subconscious mind)...Or generate images related to your symptoms...The goal is to gain new insightsThe ones with a * will be covered by all VA’s in some form in the near future. Many of these are covered already, but it depends on which VA.
Photo Credit: Adam Rindfleisch
Slide67Relaxation response
Helps with depression, anxiety, coping
Lowers cortisol level (a stress hormone
)
Improves immune system function
Helps cholesterol, blood pressure, heart & breathing rates
Supports digestive function
Guided Imagery: Benefits
Tr
akhtenberg
EC. Int. J.
Neurosci
. Jun 2008;118(6):839-855.
Academy for Guided Imagery website. Available at: http://www.acadgi.com.
Photo:
fhfff.com
Photo:
pexel.com
Photo:
amazon.es
Slide6867
Image: Pembrokeshire, Wales, D. Kopacz (2018)Guided Imagery Experience
Slide69Whole Health in Your Practice14. Behaviors and Choices II:Unh
ealthy Patterns
Slide70Values ConflictsWe all value our health.And, how often do we do something unhealthy because we have a more immediate value?
(E.g., unhealthy eating, not enough sleep, missed exercising, etc.)
Slide71Slide72Behaviors and Mental HealthHow do habits and reward-seeking behaviors arise in different mental health conditions?
Consider:Cue + Routine + Reward = Habitfor various mental health diagnoses…
Slide73Behaviors and Mental HealthExamples:PTSD: Trigger
Traumatic re-experiencing Avoidance Behavior Reward = reduced anxiety and distress. Habit: Isolating and disengaging
OCD: Trigger
Internal anxiety/belief system
behavioral compulsion
Reward = relief of anxiety.
Habitual compulsions
Eating disorder: Trigger
Emotional distress
binge eating
Reward =
dopamine boost & temporary pleasure
Binge eating disorder
Slide74Define “Addiction”
Slide75Rate of Substance Use Disorder in VeteransFrom Substance Abuse and Mental Health Services Administration (SAMHSA.gov
)
Note the trend
1 in 15 Veterans
Slide76Substance Use in VA
25% of Veterans smoke, 74% have ever smoked46% of those with PTSD also have SUD20% with alcohol use disorder have MDD tooVA screens for alcohol and tobacco yearly and at new patient visitsKey is not just identifying the problem. How does it link to all the aspects of a person’s life?
From
https://wholehealth.wisc.edu/overviews/substance-use/
Briere
et al, Comprehensive Psychiatry, 2014;55:526-33.
Image:
Youtube.com
Slide77Addiction: Key PointsAddiction is a chronic diseaseThere are acute episodesThere are exacerbations
Multi-organ system complicationsComorbiditiesAffects all aspects of a person’s lifeScreening is essentialLook for root causesAddiction is multi-dimensional (biological, social, ties to choices and past experience)It is not addressed as well as it could be
Stigma is a significant problem
“We have to hammer on the abusers in every way possible. They are the culprits and the problem. They are reckless criminals.”
-Richard
Sackler
, head of Purdue,
OxyContin
manufacturer
Slide78Addictions & The Brain
Graphics: https://en.wikipedia.org<1% of neurons in the brain are dopaminergic
The “feel-good” neurotransmitter
Tied to rewards
–
anything from foraging to gambling, sex, and social connection
Biases memory toward events that are motivational
Certain substances push it into overdrive
Arias-Carrion, et al.
Int
Arch Med, 2010;3:24-30.
Outcomes in many pathways
Less sensitivity to non-drug rewards
Weakened self-regulation, self-direction
Increased stress sensitivity
Altered executive function and memory
Slide79Addictions: Where Dopamine IsAddictive drugs enhance midbrain dopamine function, esp in the nucleus accumbens
Nicotine affects several areas, including nucleus accumbensAlcohol enhances GABA receptors and slows firing in the Substantia nigra (SNc)Opiates cause a release in the striatumCocaine and amphetamines bind transporters all over, including nucleus
accumbens
Arias-Carrion, et al.
Int
Arch Med, 2010;3:24-30.
Mesencephalic
dopamine system
Image: Arias-Carrion, cited below
Slide80Back to the MicrobiomeReview of 12 studies of eating disorders, alcohol, and substance use
Dysbiosis was “...correlated with alcohol use disorder-related symptoms, i.e. craving, depression and anxiety.”Manipulation may change cocaine-related behaviors in miceEating disorder symptoms are triggered by peptide hormone signals from microbiome
Overall, preliminary but supportive evidence of a role
Temko
et al, Alcohol Alcoholism, 2017;52(4):403-13.
Leclercq
et al,
Proc
National
Acad
Sci
, 2014;111:42:14971.
Image:
npr.org
Another Study: People with alcohol dependence who also had higher depression and anxiety and cravings also had more gut permeability.
Slide81Tony and Behaviors, Habits, Addiction I drink a lot –
it is the only thing that calms me downI buy morphine tablets from a buddy of mineMany family members have substance use problemsI only smoke ½ ppdI smoke pot, but that is no big deal, right?
What else would you like to know?
Shutterstock.com
Slide82Substance Use Disorders and Self-Care
What are your thoughts?
What might be most helpful for Tony?
Slide83Utilizing positive support systems is vital
Tailoring care to each individual is key
Spirituality, as featured in many 12-step programs, can be key. Some of the most effective interventions have a spiritual component
Mind-body approaches, including psychotherapies, help
Exercise doesn’t reduce alcohol consumption, still worth doing
People with substance use problems are often malnourished
Dysbiosis
is linked to alcohol use problems
Caution about malnutrition, low BMI
Substance use disorders and overeating have much in common
Working with triggers of negative habitual behaviors is key
Consider how the recovery model ties in; it has many similarities to Whole Health approach
Goal setting is essential
Utilizing positive support systems is vital
https://
wholehealth.wisc.edu
/professional-care/substance-use/
Substance Use: Self-Care
p. ##
Slide84Around the Circle: Addictions
https://www.pinterest.com/pin/444589794461783350/
Slide85Acupuncture may be of help in opioid use, changes physiology;
NADA ear
protocol not well validated
Supplements
–
Limited Data
Kudzu
Cytisine
Milk thistle
Address comorbidities
Depression
Anxiety
Trauma
Biofeedback has shown
promise in several small studies
Mindfulness approaches have good support in meta-analyses.
Specific techniques:
Mindfulness-based relapse prevention
Mindfulness Oriented Recovery Enhancement
Mindfulness Training for Smokers
Transcranial
magnetic stimulation shows promise
Psychotherapies
Motivational Interviewing techniques can be highly effective, especially with alcohol and tobacco use
Screening and brief intervention
can help
Medical assistance therapy often can be used more effectively
Avoid inciting factors
Be
aware of genetic predisposition
Pay attention to family history, history of past trauma
Hypnotherapy has limited research support, despite marketing hype
https://
wholehealth.wisc.edu
/professional-care/substance-use/
Substance Use: Professional Care
p. ##
Slide86Brief Look at Professional CareToday’s Examples:
Recovery ModelScreening & Brief InterventionMotivational InterviewingMedication Assisted TherapiesMindfulness Based TherapiesClinical Hypnosis
Acupuncture
Dietary Supplements
Slide87The Recovery Model and Ties to Whole Health
Recovery ModelThere are two experts; Veterans are experts on their lives and preferencesVeterans’ valued life goals drive treatment and goals
Focus is on
strengths and resilience
Focuses on positive
identity separate from illness
, normal human needs,
holistic view
Supports
empowerment
and engagement
. Better therapeutic relationships and clinical outcomes
Recovery (with hard work)
to have a good quality of life is probable, even
for the most severe challenges.
Realistic hope
Individualized
Veteran-centered care that meets them where they are
Slide88Screening and Brief Intervention
Screening more accurate than provider judgment alone
Time-limited advice by clinicians are time-efficient and cost-effective
More research for alcohol than illicit drugs
Timko
et al, J
Clin
Nurs
, 2016;25:3131-43.
Photo: physician-employment-
opportunities.com
Slide89Motivational Interviewing and Addiction
2017 review of all articles for past 10 years34/144 articles selected, including 6 Cochrane reviewsTypically more effective than no treatmentComparable to other active treatments
DiClemente
et al,
Psychol
Addict
Behav
, 2017;31(8):862-87.
“This review supports use of motivationally enhancing interventions across addictive behaviors, with strongest evidence supporting use in alcohol and tobacco, with brief interventions showing strong efficacy.”
Strong support for marijuana use, some for gambling
Insufficient data: Methamphetamines and opiates
Slide90Medications and Addiction:
Many Options
Edelman et al, Med
Clin
N Am, 2018;102:635-52.
Slide91Mindfulness-Based Interventions and Addiction
2017 Meta-analysis of 34 RCT’s: Nearly all studies found superior treatment outcomesModerate to large effect sizes for overall substance use, cigarette smoking, cravings and stress. (Pain and emotional states too)2013 review of 24 studies: Reduces use of alcohol, cocaine, amphetamines, marijuana, cigarettes, and opiatesGarland et al, Addict
Sci
Clin
Pract
, 2018;13:14. Li et al, J
Subst
Abuse Treat, 2017;75:62-96.
Chiesa
et al,
Subst
Use Misuse, 2014;49(5):492-512.
“...MBIs reduce substance misuse and craving by modulating cognitive, affective, and psychophysiological process integral to self-regulation and reward processing”
Examples
MBRP: Mindfulness-Based Relapse Prevention
MORE: Mindfulness-Oriented Recovery Enhancement
Mindfulness Training for Smokers
Image: Garland et al.
Slide92Clinical Hypnosis and Addiction
Barnes et al, Cochrane Database
Syst
Rev, 2010;10:CD001008.
2010 Cochrane Review
–
no indication for smoking
Not more effective for smoking than group relaxation
Limited research for other SUDs
Marketing outpaces research...
Slide93Biofeedback and Addiction
Some promising small studies
2018 review: 5 sessions didn’t
help smokers
2018 study: 48 people
Alcohol abstinence higher after 1 year in those who did HRV biofeedback
20 opiate-dependent people: Improvement of somatic
sx
, depression, overall health score, reduction of cravings
Pandria
et al,
Behav
Neurol
, 2018;doi.org.10.1155/2018/2876287
Penzlin
et al, BMC Psychiatry, 2017;17:325.
Deghani-Arani
,
Appl
Psychophysiol
Biofeedback, 2013;38:133-41.
Slide94Acupuncture
National Acupuncture Detox Assn (NADA) protocolCreated 1985, by Dr. M SmithUsed in 250 hospitals Variable results2017 study – combining it with usual treatment improves quality of life, energy, employment likelihood
alcohol at 3, 6 months
smoking at 6 months
2016 review – variable research; use as an adjunct
Carter et al,
Behav
Sci
, 2017;7:37.
Stuyt
et al,
Subst
Abuse
Rehabil
, 2016;7:169-70.
Image:
researchgate.com
Slide95Acupuncture
2016 Systematic Review: Need more researchSome points lead to physiological changes2017 Nellis AFB Retrospective Study:172 people followed for a yearAt least 4 treatmentsDecreased opioid prescription numbersBetter symptom control and functionAlso lowered use of other drugs
Motlagh
et al, Chin Med, 2016;11:16. Crawford, et al, Med
Acupunct
, 2017;29:229-31.
Image:
Zazzlecom
.
Slide96Dietary Supplements - HerbalsKudzu
CytisineSt. John’s WortIboga
Warne, “Substance Abuse” in
Rakel
ed
, Integrative Med 4
th
ed
, 2017; Saunders /
Meletis
et al, Complement
Altern
Ther
, 2008;14(6):275-81.
Image:
nyis.info
Image:
osu.edu
Image:
wikipedia.org
Image:
newscientist.com
Slide97Opioid Abuse: Treat the Suffering
Whole Health for Pain Course Highlights:
Pain Self-Management
Mind-Body Approaches
Spinal Manipulation Therapy
Acupuncture
Dietary Interventions
Physical Activity
...and More
Whole Health Education Library: https://
wholehealth.wisc.edu
/overviews/chronic-pain/
Slide98Community: 12-Step ProgramsAlcoholics AnonymousBased on principles of Christian evangelical Oxford Group
In 1935, they helped Bill W, a NY stockbroker, quitHe helped Dr. Bob quitThey founded AA together in Akron, OhioNo affiliation with or funding from any groupNow over 114,000 groups, 170 countries, 2 million peopleModel for other programs
Looks at whole person
Dermatis
et al, J
Relig
Health, 2016;55:510-21.
Image:
torchlight.care
74% of professional treatment providers include AA as one aspect
Slide9912-Step Programs and Spirit and SoulHalf of people seeking SUD treatment do so at groups like thisAA has 6 of 12 steps that refer to God and Higher Power
– kept very general2016 general (not systematic review) (Dermatis): Long-term sobriety linked to reports of:Feeling God’s presence daily; gratitude may be key
Belief in universality of Higher Power
Connecting to/sponsoring others, perhaps tied to “universal spirit linking all humanity”
Church attendance frequency was not directly correlated
14 studies
(
Tusa
)
–
3 not supportive or relationship of spirituality and abstinence
Dermatis
et al, J
Relig
Health, 2016;55:510-21.
Tusa
et al, J Addictions
Nurs
, 2013;24(4):237-46.
Image:
AALondon.org
Slide10012-Step Programs: Efficacy2006 Cochrane: 8 studies, no clear benefit for AA2018 meta-analytic review, 22 studies, 8000+ dual diagnosis patients:
Significant and positive association with AA exposure and abstinenceSame effect at 6, 12 months follow upNA supports post-residential outcomesAttendance frequency matters to a pointService of others matters (Family, Friends, Coworkers
Tonigan
et al, Addiction, 2018;111(11):1970-81.
Gossop
et al, Addiction, 2008;103(1):119-25.
Image:
Tonigan
et al. (below)
Slide101Tony: What’s the Plan?Gather into small groups
5 minutes to discuss priorities for Tony with his habitsWill ask you to share what you came up with
What do you think?
Shutterstock.com
Slide102Questions?
Slide103Time for a Break
Slide104Whole Health in Your Practice
15. Finding Peach and Ease I:Working With Stress
Slide105Aspects of Mental HealthThinking and CognitionEmotionsBehaviors and ChoicesPeace and EaseVitality and Wholeness
If you want peace of mind, stop fighting with your thoughts. -Anonymous
Slide106Peace
It doesn’t mean to be in a place where
there is no noise, trouble, or hard work.
It means to be in the midst of those things
and still be calm in your heart.
(Author Unknown)
Slide107What do you do to find peace and ease?Discuss with a Partner
Photo: videoblocks.com
Slide108Ease and Dis-ease
Pathos and Pónos -Hippocrates Homeostasis -Bernard; CannonStress!
The definition
:
The state manifested by a specific syndrome which consists of all the nonspecifically-induced changes within a biological system.
-
Selye
Stress is not “Events”
Distress vs. Eustress OR Ease vs. Dis-ease
ipinimg.com
wikipedia.com
Slide109Stress: The General Adaptation Syndrome
Occurs in space (the triad): Adrenal enlargementLymphatic tissue atrophyBleeding, deep ulcers in the stomach and duodenum
Occurs over time
Alarm Reaction
Stage of Resistance
Stage of Exhaustion
Selye
, “A Syndrome Produced by Noxious Agents,”
Nature
, 1936;138:32.
“A Syndrome Produced by Diverse Noxious Agents”
Image:
home.cc.umanitoba.ca
It is not stress that kills us, it is our reaction to it
Slide110The Stress Response
Target Area
AGENT
Nonspecific Action
Specific Action
Pro
Anti
External Conditioning:
Diet, Climate, Other concurrent experiences
Internal Conditioning
: Heredity, Previous Experiences
Tolerable
Stress
Toxic
Stress
End result: Adaptation and learning
End result: Adaptation and learning
End result: Damage and dis-ease
End result: Adaptation and learning
End result: Damage and dis-ease
End result: Damage and dis-ease
Slide111Video – Fight or Flight or Freezehttps://www.youtube.com/watch?v=Ox7Uj2pw-80
110An Impala “Shakes Out” Stress
Slide112Polyvagal Theory
Slide113Polyvagal TheoryModified from an Image by
Porges, The Polyvagal Theory, 1994
Environment:
Internal and External
Nervous System
Danger
Life Threat
Safety
Optimal arousal
Rest and digest
Parasympathetic
ventral
vagal system
Social engagement
Eye contact, expressions, vocalization
Hyperarousal
Sympathetic ventral vagal system
Mobilization – fight/flight
Dissociated rage, panic
Hyperarousal
Decreased heart rate
Parasympathetic
dorsal
vagal system
Immobilization – “freeze”
Dissociated Collapse
Slide114Let’s Do Some Relaxing!When fight/flight/freeze is wrongMost common mental illness in the US19% of Americans had any anxiety disorder in the past year31% have an anxiety disorder sometime in their lives
GAD: 7 millionSocial anxiety: 15 millionPTSD: 8 millionOnly 37% get treatment
Nimh.nih.gov
, Anxiety and Depression Association of America (ADAA),
adaa.org
Image:
healthfreedoms.org
Slide115Anxiety and ComorbiditiesPeople with anxiety are:3-5 times more likely to go to the doctor6 times more likely to have an inpatient psychiatric stay
El-Gabalawy, et al Exp Gerontol, 2014;60:46-56.
Whole Health Library Tool, “Anxiety”
https://wholehealth.wisc.edu/overviews/power-of-the-mind/
Slide116Anxiety PHP’s: You Tell Us!At your table, answer the following:
What is your top Self-Care suggestion for Mel?What is your top Professional care rec, beyond what you would usually do?How could you work with her in your different roles?Take 5-10 minutes to do this. Use the tools in your Workbook
We will discuss your ideas at the end of the exercise.
Melissa’s PHI: Page ##
Don’t start just yet!
Slide117Marital satisfaction and anxiety affect each other
Anxiety can lead to social avoidanceLevel of social support can affect psychotherapy outcomes
All anxiety disorders are linked to poor sleep
Vacations help a little
Taking breaks through the day may help
Whole Health Library Anxiety Overview, https://
wholehealth.wisc.edu
/tools/anxiety/
Anxious people tend to move toward high fat snacks
Limit caffeine
Alcohol can worsen anxiety
Ensure adequate B6 and
folate
Evidence indirect for omega-3’s
Excess processed foods diets
anxiety
Mental imagery can elicit greater calm (as can many mind-body approaches)
Psychodynamic
psycotherapy
helps, as does CBT
Exercise reduces anxiety, especially aerobic (but all do)
Even helpful at 12 minutes minimum
Yoga
–
no clear additional benefits though physiological measures do change
Tai chi
–
variable study findings
Religion and spirituality interventions decrease stress and reduce anxiety symptoms
Consider existential aspect of their lives (e.g., fear of dying)
Consider risk of experiencing violence
Phototherapy helps
Nature time may help
Media fasts help
More education and financial security can help
Anxiety:
Self-Care Options
p. ##
Slide118Supplements
Kava - some good results. Watch liver effectsLimited data:ValerianTheanine
Lysine
Passionflower
Tryptophan
Skullcap
Address other health problems:
Thyroid
Vitamin deficiencies
Chronic pain
Substance use
Pheochromocytoma
Sleep disturbances
Positive psychology can help with emotional resilience
Creative pursuits and music may help
Meditation: could use more research (good for PTSD...)
Research not supportive of homeopathy
Cognitive Behavior Therapy, including CBT for Insomnia, helpful
Interpersonal Therapy and Psychodynamic Psychotherapy also help (esp. when depression also present)
Many other mind-body techniques help, too, for various disorders
Pharmacotherapy is effective
Acupuncture: 2018 review found whole body and ear acupuncture favorable, with few side effects
Cannabinoids
–
poor evidence
Acupressure shows promise
Aromatherapy may help
Biofeedback research generally favorable
Whole Health Library Anxiety Overview, https://
wholehealth.wisc.edu
/tools/anxiety/
Anxiety:
Professional Care
p. ##
Slide119Anxiety PHP’s: You Tell Us!At your table, answer the following:
What is your top Self-Care suggestion for Mel?What is your top Professional care rec, beyond what you would usually do?How could you work with her in your different roles?Take 5-10 minutes to do this. Use the tools in your Workbook
We will discuss your ideas at the end of the exercise.
Melissa’s PHI: Page 19
OK, now start!
Slide120Anxiety: Food & Drink
Caffeine may need to be stopped (sorry!)Long-term use linked to anxiety and depression in some peopleAlcohol can decrease serotonin and catecholaminesEnsure adequate B vitamins B6Folic acid (B9)Omega-3 fatty acids –
indirect evidence
Images:
loveyourliver.com.au
;
meme.net
Lee R, “Anxiety,” in
Rakel
(
ed
) Integrative Med 3
rd
ed
, Saunders, 2017.
Slide121Anxiety and Working Your Body
Reduces anxiety signs and symptomsAerobic has larger effect, but all forms helpful
Effective at 12 minutes minimum most days for 10 weeks
Max benefit 40 minutes/session
Benefits long lasting. Over a year, even with less intense routines by then
Lee R, “Anxiety,” in
Rakel
(
ed
) Integrative Med 3
rd
ed
, Saunders, 2017.
Image:
rivengear.com
Why?
Norepi
, dopamine, serotonin levels
Endorphins
Confidence and independence
Slide122Two 2017 Yoga Meta-Analyses1. Cramer et al, Depress
Anxiety. 2018;35:830–843. 2. Pascoe et al, Psychoneuroendocrinol, 2017;86:152-68.
No effects in those with actual DSM anxiety disorder
Mix of postures and breathing (pranayama)
Small, short-term effects on anxiety ratings
Good safety profile
Yoga poses alter physiological measures of stress
Study 1: 8 RCTs with 319 participants in 2018
Study 2: 42 studies with 2,944 participants
Salivary cortisol
Heart rate
Inflammatory Markers
Blood glucose
Slide123Anxiety and Tai Chi: Verdict still out?Anxiety and Tai Chi2014 review of 37 studies:
Poor methodologyAll showed potential benefitAnother 2014 review12 of 17 articles showed benefitNot great studies (many not RCTs)Wang et al, Int J Behav Med, 2014;21:605–617. / Sharma et al, J
Evid
Based
Complmement
Altern
Med, 2014;20(2):143-53.
Image:
reddit.com
Slide124Anxiety RechargeGAD, PTSD, OCD, panic disorder all have links to poor sleepIn GAD:
time falling asleep time asleep awakenings stage 4Treating sleep with CBT-I = moderate effect on anxiety symptomsMore sleep disorders
Cox et al, J Anxiety
Disord
, 2016;37:104-29.
Photo:
babygaga.com
Slide125Professional Care: Anxiety & Acupuncture2018 review 13 trials8 whole body
4 auricular1 electroacupunctureAll favorableIn those with sham controls, actual points did betterMost just used 2-3 specific points (not personalized)Amorim
et al, Complement
Ther
Clin
Pract
, 2018;31:31-37.
“Overall, there is good scientific evidence encouraging acupuncture therapy to treat anxiety disorders as it yields effective outcomes, with fewer side effects than conventional treatment.”
Slide126Anxiety and Acupressure2015 review of 7 trials, meta-analysis of 5All with positive effect on rating scales–
medium effect sizeVaried results for physiologic indicatorsLow risk of biasMostly emergency and hospital settings, pre-procedureVery safeAu et al, Acupunct Med 2015;33:353–359.
Slide127Dietary Supplements: KavaUsed in FijiConsidered safe in Europe; some liver concerns“Possibly effective” –
favorable results when used >5 weeks vs oxazepam, buspironeKava lactones likely work similar to benzodiazepinesAffect limbic system –
esp
amygdala and hippocampus
Photo:
wikipedia.org
https://
naturalmedicines.therapeuticresearch.com
Slide128Dietary Supplements: ValerianUsed in Europe >1000 yearsMostly used for insomnia. Natural Medicines: Insufficient evidenceOften combined with St. John’s wort
Takes 2 weeks or more to kick in – is NOT an immediate effectAdverse effects are rare – occasional HA and GI issueshttps://naturalmedicines.therapeuticresearch.com
Photo:
wikipedia.org
Slide129Cannabinoids2017 reviewMost studies short termPoor evidenceMany side effects Can cause psychosis in susceptible peopleAnxiogenic
, though does not cause anxiety disorders“...the actual science seems to have been outpaced by the development of applicable legislation and public opinion”
Turna
et al,
Depress
Anxiety
. 2017;34:1006–1017.
Slide130Professional Care: PsychotherapiesCognitive-behavioral therapy is the first-line psychological treatment for anxiety disorders and yields response rates of 46–77% (
Katzman et al., 2014)Psychodymanic psychotherapy also shows benefit, among othersKatzman et al, BMC Psychiatry, 2014;14(1):1-83/ Whole Health Library Anxiety Overview,
https://wholehealth.wisc.edu/tools/anxiety/
Slide131Professional Care:Biofeedback and Meditation2014 review of 63 biofeedback mental health studies43 studied anxiety
Many flaws, generally positive“Accessible and efficient approach”2016 review: Meditation great for PTSD, less data for anxietySchoenberg et al, Appl Psychophysiol
Biofeedback
. 2014;39(2):109-35.
Khusid
et al, Mil Med, 2016;181(9):961-8.
Slide132Jerath
et al., Adv Mind Body Med, 2015;29(4):4-13. How Meditation and Stress Affect Us
Slide133Mindful Awareness:Breathing Practice...Can change heart rate variabilityEnhances body awarenessExpands your “Window of Tolerance”
Decreases mortalityImproves blood pressure Moderate benefit, chronic low back pain Better post-op function and quality of life in lung cancer, possible benefit in asthma
Photo: tgo-4-health.com
Brown et al, Ann NY
Acad
Sci
, 2009;1172:54-62.
Jerath
et al
,
Appl
Psychophysiol
Biofeedback (2015) 40:107–115.
Whole Health Library Overview, “Power of the Mind”
https://wholehealth.wisc.edu/overviews/power-of-the-mind/
Slide134Let’s Do Some Relaxing!Work on slowly dropping breathing rateGoal – 5ish breaths per minute
Image: Vinyasa.com
Slide1351:2 Ratio Breath6 breaths per minute
In3-4
counts
Out
6-8
counts
*If you note any discomfort, try to simply watch it without getting caught up in it.
Can stop any time.
Use caution if you have breathing problems.
Slide136The Power of BreathworkIntentionally changing your breathing pattern can account for 40% or more of the variance in your feelings of fear, anger, sadness, or joy.
Lehrer et al, Psychosom Med, 1999;61:812-21.
Image:
health.harvard.edu
Slide137To Be Continued...
Slide138Whole Health in Your Practice16. Implementation II:Your Practice, Your Team
Image:
dailyrecord.co.uk
Image:
Shutterstock.com
Image:
thesequoiassf.org
Slide139Implementation: Where Are We Headed?
Your Life
Your Practice
Your Team
Your Facility
The
System
Original Graphic:
Vectorstock.com
Slide140Tony is now exploring Whole Health
Invasive ThoughtsADHD
Dementia Risk
PTSD
Alcohol Use
Suicide Risk
Opiates
Smoking
Past Traumas (MST)
How can his
entire
team (including you) support Tony and his family?
A LOT is going on here...
Slide141The Final Element: Integration
IntegrateAll resources support this processTeam members seamlessly integrate all of these steps
Veterans are empowered and equipped to live their lives to the fullest (always in support of their MAP)
Measurement strategies assess impact
Whole Health Clinical Care
EMPOWER
Slide142Whole Health: Building on Current Programs
This isn’t the “flavor of the month”
Many programs already promote elements of WH
HPDP and Healthy Living Messages
MI and Teach
Planetree
Recovery Model
PCMHI
PTSD, Substance Use, and Suicide Initiatives
What else are you doing that aligns?
If I have seen further than others, it is by standing upon the shoulders of giants.
-Isaac Newton
Slide143“Me” is possible because of “We”People don’t exist in a vacuum. Whole Health can only occur in community.Loved ones, social circleWhole Health team
Organizations and groups (VFW, DAV, support groups, etc.)NeighborhoodOnline CommunitiesHospital/facilitiesHealth Care systemNationEcosystem
Slide144Community Passport, p. 311
Small acts, when multiplied by millions of people, can transform the world.
-Howard
Zinn
Slide145Whole Health Takes a Village
No one clinician can be responsible for it all
Whole Health adds support for clinical care
–
peer partners, coaches, CIH providers, and many others.
The PHP will grow and shift over time.
It should not take more time. This should not be another item on the ‘to do’ list.
It won’t always be possible to do this the way you would ideally like to
And...
You keep doing the best you can, and that is a lot.
Slide146“Me” is possible because of “We”People don’t exist in a vacuum. Whole Health can only occur in community.Loved ones, social circleWhole Health team
Organizations and groups (VFW, DAV, support groups, etc.)NeighborhoodOnline CommunitiesHospital/facilitiesHealth Care systemNationEcosystem
Slide147Community Passport, p. 311
Small acts, when multiplied by millions of people, can transform the world.
-Howard
Zinn
Slide148What Makes a Team Successful?
What was the best team you have ever been on? Why?
Photo: virtual-medical-
assistant.com
Photo:
actionforbetterhealthcare.com
Slide149A few tips from the literatureA high-performing team needs 5 things:Shared goals that everyone can articulate
Clear rolesFunction, responsibility, accountabilityMutual trustNo punishmentsSafe to admit errors or ask questions or try new things
Smith et al, Implementing Optimal Team-Based Care, National Academy of Medicine, Sept 2018.
Image:
frepik.com
Slide150A few tips from the literatureA high-performing team needs 5 things:Effective communication
Constantly refining skillsBidirectionalCollaborative leadershipMeasurable processes and outcomesBenchmarks for tracking progressFeedback given frequently
Smith et al, Implementing Optimal Team-Based Care, National Academy of Medicine, Sept 2018.
Image: people-
equation.com
Slide151Thinking About Your Role:Group ExerciseIn a moment you will divide up based on your clinical roles
You will explore the following together:What would you discuss for their PHP based on your expertise?What can you do to support Veteran Whole Health and Whole Health teamwork in your clinical role?Pick a
group representative
to be on a panel discussion about these topics.
Don’t move just yet!
Slide152Go to the part of the room with your #
SCREENNurses
Providers
Admin/ Leadership
Social Work/Chaplains
RT, PT, OT
Peers and Coaches
Psychology
Others?
Front
Back
Middle
Slide153Thinking About Your Role:Group ExerciseWhen everyone is settled, start discussing:
What would you discuss for their PHP based on your expertise?What can you do to support Veteran Whole Health and Whole Health teamwork in your clinical role?Write down you ideas.Pick a group representative to be on a panel discussion about these topics.
Slide154Now, it’s panel time...Seven volunteers with different roles will sit up at the front of the roomEach will take 2-3 minutes to share their perspectives on the demo from the previous module
What would you discuss for their PHP based on your expertise?What can you do to support Veteran Whole Health and Whole Health teamwork in your clinical role?Observers are welcome to ask questions at the end.
Image:
Thehipp.org
Slide155Thinking About Roles:A Small Group ExerciseIn a moment, we will have you move tables and join an interdisciplinary team – we will then give you further instructions!
Slide156Your mission:Your VA has instituted a new Whole Mental Health Clinic! Meet your new team!Introduce yourself and share how your role supports Whole Mental Health Care.Consider Tony’s PHI on workbook page XX. How could your team work together to support Tony’s Personal Health Plan moving forward?
Your Role in a Whole Health Team
Small Group Exercise
Photo: fapop.com
Slide157Your mission:
Your VA has instituted a new Whole Mental Health Clinic! Meet your new team!Introduce yourself and share how your role supports Whole Mental Health Care.Consider Mel’s PHI on workbook page XX. How your team work together to support Mel’s Personal Health Plan moving forward?
Your Role in a Whole Health Team
Small Group Exercise #2
Photo: fapop.com
Slide158Partner DiscussionStarting tomorrow, what is one thing you can do to enhance the function of a team you are on?
Write down your ideas.
Image:
blog.accredited
-online-
colleges.com