Center on Psychiatric Disability and Co-Occurring Medical Conditions

State-of-the-Science Summit on Integrated Health Care

Center on Psychiatric Disability & Co-Occurring Medical Conditions

The Living Well Program - Richard Goldberg

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There is ample evidence indicating that individuals with serious mental illness die earlier, on average, than those in the general population. This is due in large part to higher rates and greater severity of co-occurring chronic medical conditions such as diabetes, respiratory illnesses and cardiovascular disease.

Physical inactivity, poor diet, and smoking, all common among individuals with serious mental illness, may also contribute the elevated rates of chronic medical illness and complicate efforts to manage these medical problems once they have developed.

In recent years, a number of lifestyle interventions have been developed to help mental health consumers engage in physical activity, better manage their weight, eat a more balanced and healthier diet, and engage in a range of health promoting activities.

Evidence is also accumulating on the effectiveness of interventions that help improve self-management of the common symptoms and challenges associated with chronic medical conditions. Such interventions have been shown to improve health-related attitudes and behaviors. They have also been shown to improve health status and help individuals make better use of medical health services.

Many of these interventions are delivered in group format in mental health treatment settings. More recent examples have also involved mental health consumers as leaders or co-leaders of these groups. As with other programs involving peers helps emphasize the principles of recovery and models self-determination.

One such intervention, that I helped develop is called Living Well. Based on a well-known intervention called the Chronic Disease Self-Management Program developed by Kate Lorig and her colleagues at Stamford University, Living well involves mental health consumers as co-leaders and focuses on helping individuals develop confidence and a range of self-management skills needed to live a healthy life.

Participants learn how to make weekly action plans and draw on feedback and support from their peers to make healthy lifestyle changes and play a more active role in managing their chronic medical conditions. Group members also get the chance to apply these skills across a range of topics such as nutrition, exercise, sleep, medication management, making good use of one’s support network, communicating with medical providers and keeping track of medical information.

Let me take a few moments to introduce you to the action planning tool we developed and give some examples of the group content across a few of the topic areas covered in the Living Well program.

Action plans are weekly goals that participants use to make targeted changes in lifestyle behaviors and to practice the self-management skills and strategies covered in the Living Well program. Participants learn to establish action plans that are specific. For example, instead of saying I want to eat better this week, a good action plan might state one’s commitment to eating an apple instead of cookies for dessert after dinner 3 of the 7 nights during the upcoming week. This helps identify exactly what one needs to do be successful. Participants are also encouraged to make plans that reflect a change or behavior they want to do rather than something they feel they have to do. The idea is to help individuals feel more confident to commit to their plans. Over the 12 weeks of the Living Well program, participants use action planning to help put into action what they are learning in group sessions.

Let me also describe some of the skills and strategies that are taught in Living Well. During the session on health eating, for example, participants learn how to use the image of a traffic light to make decisions about the foods and beverages they consume. Red Light foods and beverages are high in calories, have limited or no nutritional value, and are generally unhealthy. Participants are encouraged to Stop (as the red light suggests) and think twice about eating these items. In class, participants identify the Red Light foods and beverages that they would like to eat less of. Yellow Light foods are those that have nutritional value (like cheese for example) but should be eaten in moderation. Participants learn about portion control as a way to think about using caution (as the yellow light suggests) when consuming foods and beverages they have classified as Yellow Light items. Finally, participants are encouraged to identify what foods and beverages they enjoy that are low in calories and healthy to consume. These are classified as Green Light items and participants are encouraged to go forward (as the green light suggests) and eat and drink these healthy options. Participants are also encouraged about using the Traffic Light image at the grocery store so that they can fill their carts with lots of Green Light items, limited amounts of Yellow Light items, and very very very few (if any) Red Light items.

Living Well also includes several sessions on strategies and techniques used to help manage pain, practice good sleep hygiene and deal more effectively with stress. One of my favorite techniques and one I use regularly myself, is called purposeful distraction. This can include engaging in activities such as reading, listening to music or doing crossword puzzles. It can also involve re-focusing your thoughts. For example, if you find your mind is racing with worries or focusing on pain or discomfort you can engage in what we call the alphabet game to help distract yourself. Simply pick a category -- like cars -- and in your mind go through the alphabet and think of a type of car that starts with each letter. For example, Acura, Buick, Cadillac, Dodge etc. You can do this if you are having trouble falling asleep, or sitting on a bus and feeling a lot of pain, or waiting for a doctor’s appointment that you are anxious about. We also learn about deep breathing and other stress reduction techniques like guided imagery and progressive muscle relaxation.

Living Well also includes sessions on how to communicate more effectively with medical providers. Participants learn how to prepare list of questions for appointments, how to describe symptoms and side effects and make specific requests. Participants also learn how to develop and maintain a personal health record that includes information about medications, medical conditions, medical providers, emergency contacts, and receipt of important screening and vaccinations. Living Well also includes a session on medication management that is designed to empower participants to play a more active, knowledgeable and responsible role in managing their medications.

Let me say again that in addition to Living Well there are several other programs now available to help mental health consumers play a more active, meaningful and effective role in coping with chronic medical conditions and living a healthy life. One’s physical wellness is an essential part of one’s recovery and I strongly believe that attending to our medical well-being also supports our mental health wellness. Here’s to living well!

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