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HEALTHY PLEASURE (Help people making healthy choices)

Presented by Kevin J. Edwards, Ph.D., L.P. &

Robert B. Jones, M.D. Northern Pines Mental Health Center

Brainerd, MN

Todays Goals

•  Describe relationships between physical health and mental health

•  Know 4 concept areas of healthy living to be addressed

•  List three ways to increase access to healthy living choices for consumers in your organization

•  Gain ideas to help your consumers to implement healthy choices

Part 1

Need for risk reduction

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People with Severe and Persistent Mental Illness have

25 years shorter Life Span •  MN 10x10 project •  Mental illness is linked to Cardio-Metabolic risk •  Principles of risk reduction

–  Treatment of diagnosed medical conditions –  Prevention of risk factors though lifestyle change =

healthy choices

Barriers to implementation and maintenance of meaningful lifestyle

choices

• Access to primary care • Lack of resources (Low income) • Transportation (rural settings) • Not knowing options • Humans often take path of least resistance

when experiencing conflict

Our goals

•  Identify and Overcome Barriers • Maintain person centered values • Create multiple pathways for access • Build in natural rewards and reinforcement

for implementation and maintenance •  Implement within the framework of ACT

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Part 2

Our context

Our framework comes from ACT consumers

What is ACT?

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ACT Defined • Evidence based approach originally

developed in the 1970s • Assertive community treatment is a team

based consumer centered treatment process

• Fosters community integration and improvement in functional capacity

• Services meet the consumer

ACT Practice Principles

– ACT is a service delivery model, with integrated case management

– ACT’s primary goal is recovery through community treatment and rehabilitation

ACT Defined • 27 teams in Minnesota who work with

people:

– Severe and persistent mental illness – Significant difficulty doing the everyday things

needed to live independently in the community, or have

– Continuously high-service need (frequent psychiatric hospitalizations, ER visits, other services lack of progress)

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Close Attention to Consumers’ Needs

– ACT team members work closely with consumers to develop plans to help them reach their goals—consumer goals are key

– ACT teams review each consumer’s progress frequently in reaching those goals. If consumers’ needs change or a plan isn’t working, the team responds immediately

ACT Provides Assistance with… –  Activities of daily living

–  Housing

–  Family life

–  Employment

–  Benefits Managing finances

–  Health care

–  Medications

–  Co-Occurring disorders integrated treatment (substance use)

–  Counseling

Part 3 Integrating healthy living and life style change into the ACT service delivery

model

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Healthy Living not only good for ACT consumers but for you too! • Lifestyle change requires choice,

implementation, and maintenance for successful habituation

•  Increasing access means identification and removal of barriers

• Create balance between “important to” and “important for”

Importance of addressing Metabolic syndrome for Healthy

Living

•  Grouping of 6 metabolic abnormalities

•  Result of specific lifestyle patterns interacting with genetic and epigenetic susceptibility (largely preventable)

•  Major cause of morbidity and mortality – Prevalence

of 24% of Americans over age 20

Metabolic Syndrome Is:

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Obesity

Hypertension

Pro-thrombotic State

Pro-Inflammatory

State

Atherogenic Dyslipidemia Glucose

Intolerance

Smoking

Sleep Disorders

Cardio-Metabolic Risk

•  Overweight-Obesity (Abdominal)

•  Glucose Intolerance •  High Blood Pressure •  Dyslipidemia •  Pro-thrombotic state •  Pro-inflammatory state •  Smoking •  Iatrogenic Intervention*

•  Type 2 Diabetes •  Coronary Artery Disease •  Cerebrovascular Disease •  Organ Failure

–  Renal Failure –  Congestive Heart Failure –  Encephalopathy –

(Premature Cognitive Impairment)

–  Connective tissue and mobility

Risk Factors vs. Disease States

Principles of Care Prevention Treatment

Lifestyle Change

Lifestyle Change

Lifestyle Change

Lifestyle Change

Lifestyle Change

Lifestyle Change

Lifestyle Change

Lifestyle Change

Lifestyle Change

Lifestyle Change +

Medical treatment of individual cardio-metabolic risk factors and disorders

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•  Increased Prevalence •  Reduced activity level •  Negative symptoms/Mood dysregulation

reducing motivation •  Increased SPMI genetic risk •  Increased familial genetic risk •  Psychotropic Medication associated risk

Obesity vs. SPMI

Minnesota’s 10x10 Public Health Goals •  A Minnesota Public Health Goal/The Pledge for

Wellness •  We envision

–  A future in which pursue optimal health, happiness, recover, and a full and satisfying life in the community via access to a range of effective services, supports, and resources.

•  We pledge –  To promote wellness for people with mental illnesses by

taking action to prevent and

Ø Smoking Ø Obesity/poor nutrition Ø Lack of exercise Ø Medications – 2nd generation atypical antipsychotics Ø “Unsafe” sex Ø IV drug use Ø Healthcare Access Ø Living situations (homeless shelters, group homes,

jails)

Modifiable Risk Factors Impacting Cardiovascular, Pulmonary, Infectious Disease Mortality:

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Focus: PCP – Creating Balance (Adapted from Essential Lifestyle Planning – M. Smull 3/28 – 3/29/2011)

Important To Important For

•  Includes what matters most to the person – their own definition of quality of life

•  Includes issues of health and safety –  Health and Wellness –  Emotional health and

safety –  Support and Self Efficacy

Creating Balance: Lifestyle and Choice Important To Important For

Ø Includes those things in life which help them to be satisfied, content, comforted and happy. It includes: –  People to be with /

relationships –  Things to do –  Places to go –  Rituals or routines –  Rhythm or pace of life –  Things to have

Ø Includes only those things that we need to keep in mind including– –  Physical and emotional

health and safety, –  Wellness and prevention –  supports needed –  What others see as

important to help the person be a valued member of their community

Important TO

Important FOR

When there is all choice with no responsibility:

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Important TO

Important FOR

When health & safety dictate lifestyle:

When there is balance:

Important TO

Important FOR

•  Learning about what matters the most to the person first

•  It is not either/or: Paying attention to health,

safety and valued social roles is critical, but alone it is insufficient

•  Risk management techniques often focus on

assuring safety or health at the cost of what creates satisfaction for the person.

• We need to change our frame of reference to believe that both can co-exist.

Balancing important To and For

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•  Self monitoring, including record keeping; •  Nutrition and food behavior education •  Goal setting •  Stimulus control •  Behavioral Substitution •  Problem Solving •  Cognitive Restructuring •  Relapse Management and •  Other behavior change such as slowing eating,

portion control, and lifestyle activity.

Behavioral Strategies for Lifestyle Change (NASMHPD)

Reward Pathway

•  Affective neuroscience: Understanding how brains generate pleasure and other psychological components of reward important in daily life

•  Pathological losses of pleasure may be a devastating part of many neuropsychiatric disorders

•  Some medication treatments may contribute to loss of capacity in susceptible people

Multiple components

• Reward is an active metabolic brain process that reacts to a stimulus set – Liking: conscious and unconscious – Wanting: motivation for reward – Learning: associations and predictions about

future rewards based on past experience

• Some stimulus sets are more likely to elicit pleasure than others: – Food intake and sexual pleasure

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Pleasure Generators

• Subcortical hedonic hotspots • Cortical integration of pleasure, motivation

and emotion • Role of dopamine • Necessary vs. sufficient • Context and meaning

Choice can trump the midbrain

DorsolateralDorsolateral--Prefrontal CortexPrefrontal Cortex

ww Developed later in evolution & Developed later in evolution & develops later in the individualdevelops later in the individual

ww Projections to / from sensory Projections to / from sensory association cortexassociation cortex

ww Mediates crossMediates cross--temporal temporal contingenciescontingencies

ww Integrates sensory informationIntegrates sensory information

ww Damage leads to a Damage leads to a dysexecutive dysexecutive syndrome: poor planning & syndrome: poor planning & organizing skill, loss of set, lack organizing skill, loss of set, lack of persistence, poor judgment, of persistence, poor judgment, etc.etc.

Common frontal lobe/executive dysfunctions

Occur in Prefrontal and Frontal Cortex

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Orbitofrontal CortexOrbitofrontal Cortex

ww Developed earlier in evolution & Developed earlier in evolution & develops earlier in the individualdevelops earlier in the individual

ww Projections to / from limbic Projections to / from limbic systemsystem

ww Important in emotional regulation Important in emotional regulation & behavioral inhibition& behavioral inhibition

ww Involved in olfactory functionInvolved in olfactory function

ww Damage leads to a Damage leads to a disinhibited disinhibited syndrome: hyperactivity, syndrome: hyperactivity, impulsivity, aggression, poor impulsivity, aggression, poor social functioning, etc.social functioning, etc.

Common frontal lobe/executive dysfunctions

Occur in Prefrontal and Frontal Cortex

Recovery from addiction: A Comparison with CVD Risk Reduction (adapted from Scott McNairy MD VAMC and D. Sellman, Addiction, 2009)

Ø “Not so much a matter of changing one’s mind but changing one’s brain”

Ø Involves a person making substantial changes in their “whole pattern of living”.

Ø Think of recovery then as “a life-style change” in phases from clinical to self managment.

Ø Valuing small improvements, patience and persistence, and expecting inevitable disappointments.

A few important things known about addiction: A comparison

Ø (Addiction) is fundamentally about compulsive behavior

Ø Compulsive (drug) seeking is initiated outside of consciousness (a mid-brain disease)

Ø (Addiction) is about 50% heritable and very complex (+ environment: access and stress)

Ø Most people with (addictions) have other psychiatric problems as well

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Important things, continued

Ø  (Addiction) is a chronic and relapsing disorder in the majority of people seeking help. (relapse is part of the disease)

Ø  Different psychotherapies appear to produce similar treatment outcomes

Ø  “Come back when you’re motivated” is no longer an acceptable theraputic response (the sooner in treatment the better).

Ø  The more individualized and broad-based the treatment a person with (addiction) receives, the better the outcome.

Part 4

The Program

Healthy Living for

Real People (an approach to healthy pleasure)

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General Principles • No failure • Model action • Provide variety of entry points and choices • Freedom to move among choices quickly • Personalized fit “just for me” • Seek inherent reward

Four Engagements

• Healthy pleasures • Fuel for life • Mind body connections • Big T

Healthy Pleasure (engagement-reward-resiliency)

• Byline: “it’s good for you” • Goal to create diversity in pleasurable

experiences • Teaching points

– Biology of pleasure—”reward pathway” – Diversity of pleasure – Financing your joy –  Including social supports

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Fuel for Life (food intimacy-it’s personal)

• Byline: “You are what you eat!” • Goal: creating healthy food behavior and

relationships • Teaching points:

– Food Inc. – The psychology of food choice – Self sufficiency

Food Inc.

• Food labels • Food groups • Smart shopping • Nutrition • Processed verse whole foods • Managing salt

The Psychology of Food Choice

• Marketing • Gratification • Community • Family • Culture • Convenience

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Self Sufficiency

• Growing – Outdoors – hydroponics

• Harvesting • Preparation • Preservation

Mind Body Connections (body awareness and

conditioning) • Byline: “It’s not all in your mind!”

• Goal: creating connections • Teaching points:

– Cardio/Pulmonary health – Adaptive strategies – Mindfulness

Cardio Pulmonary

• Muscle mass • Aerobic movement • Conditioning • All about lungs—link to smoking reduction

lessons

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Adaptive Strategies

• Managing pain • Low impact (biking, swimming) • Biometric feedback • Community resources

Mindfulness

• Yoga •  Isometrics • Meditation • Balance • Flexibility • Tai Chi • Brain work

Big T (smoking cessation)

• Byline: Winning your battle against “Big T”

• Goal: creating the experience of being a non- smoker

• Teaching points: – Creating confidence – Diversity of pathways – Peer support – Return to recovery

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Your Turn----Group Activity

• Take 10 minutes: 1. With the people around you, please

discuss how you can bring additional health living choices to your consumers or for yourself

2. Prepare to share your ideas with the whole group

THE END