Introduction to CEP Workshop Workbook

Fraser Todd & Michelle Fowler 2013

This workshop has been organized by the Mental Health Education and Resource Centre (MHERC). The content of the workshop presented in this handbook is drawn from the my teaching delivered through the National Addiction Centre (Aotearoa New Zealand), especially PSMX 404 Coexisting Disorders Assessment, from Te Ariari O Te Oranga and from my own workshops done both independently and with the support of Matua Raki. It remains my intellectual property, but can be used for notfor-profit teaching purposes if appropriately credited. The essence of Te Ariari o te Oranga involves the application of the values of person-focused care, wellbeing orientated treatment and integrated care in a meaningful way, bringing them to life within the relationship between the client and the clinician. The material presented in this workshop is drawn from Te Ariari o te Oranga (Todd 2010), though is updated here in several areas. Copyright is asserted by Fraser Todd over the content. It may be freely used with permission. The name Te Ariari o te Oranga means the dynamics of well-being. The name was coined by that staff ad students of Te Ngaru Learning Systems, was given to a series of bicultural training events on co-exiting and mental health and substance use problems (CEP) over the past decade, and given to the document Te Ariari o te Oranga: The Assessment and Management of Co-existing Mental Health and Substance Use Problems (Todd 2010) by Paraire Huata. As a term, it captures the practice and teaching of CEP in New Zealand where bicultural approaches are honoured.

Fraser Todd

Welcome to this Workshop

This introductory workshop provides an overview of coexisting mental health and substance use problems (CEP). The main focus is on the philosophy of the CEP model currently being promoted nationally by Matua Raki, the National Addiction Treatment Workforce Development Programme, with the support of the other Workforce Development programmes. The essence of this approach involves the application of the values of person-focused care, wellbeing orientated treatment and integrated care in a meaningful way, bringing them to life within the relationship between the client and the clinician. This will be the main focus of the introductory workshop.

Agenda Day 1
Sessions 1 & 2: Introduction & Overview of CEP Lunch Session 3: Session 4: The Aetiological Formulation Continuation of previous sessions, coverage of outstanding issues and wrap-up

Three Dimensions of CEP Practice

The practice of CEP as descried in Te Ariari can be thought of as having three levels of practice of increasing specificity Spirit Principles Techniques The spirit of Te Ariari is a philosophy or set of values that underpin practice. They are not specific to CEP; rather they apply to any person seeking help for health related problems, especially where there is a degree of complexity in their problems. In short, this philosophy is about placing the whole person at the centre of care and recognizing that the outcome they desire is an enhanced quality. Principles are comprised of Seven Key Principles: 1. Cultural considerations 2. Well-being 3. Engagement 4. Motivation 5. Assessment 6. Management 7. Integrated care These principles have been chosen because they are felt to be those most needing highlighting in the current health environment. They differ slightly from those identified in 1998 Guidelines, and are likely to be different from those needing stressing in the future. Techniques include specific clinical skills that put into practice the Spirit and the 7 Key Principles. These include, for example: Strategies to assess values and character strengths Positive interventions Cognitive mapping Motivational interviewing skills Development of autonomy supportive environments Tools for screening Brief assessment and interventions Comprehensive assessment Etiological formulation Structured follow-up and intervention sessions.

These will be the subjects of the more advanced workshops later in the year.

Thinking About CEP

With increasing knowledge and detail, clinicians often find it complicated dealing with the MH and AOD problems and have no cognitive room to deal with further issues. They experience cognitive overload. In other words, the number of things they must think about and manage is too great for their brains to handle. When faced with large amounts of complicated information, clinicians will often forget to do things they know well to do, and focus on the details they are most familiar with. Similarly mental health care becomes more detailed, dividing up into detailed areas of specific focus such as anxiety disorders, eating disorder, alcohol and drug problems and so on. The key to managing complicated problems is to connect the details, to integrate them into a whole. Complex things are multi-dimensional but manageable. While expert practitioners do know more detail, the key difference between them and novice practitioners is the connections they make between their pieces of knowledge. They integrate information by making connections and using frameworks. Similarly, learning about CEP is about using frameworks to integrate knowledge and skills There are a range of frameworks and structures that can organise CEP knowledge and turn if from complicated to complex. The key ones are those that provide the big picture and make up the spirit of Te Ariari

The Spirit of Te Ariari

Person-focused care o Especially personal values, strengths and vision of well-being. Wellbeing orientated care o Using quality of life as the most important outcome and focusing equally on enhancing positive attributes and removing barriers to well-being Integrated care o Driving care from the needs of the person and fitting the system round these rather than vice versa Walking the talk o While we know the above, we are seldom able to put it into practice for a number of reasons. Walking the talk involves using specific techniques to incorporate them into our clinical work.

Exercise 1: Personal and Professional Values

Complete the Values Paper Card Sort Questionnaire (below) In Pairs or threes, share your three most important values

One person leads a discussion with the other around one of their top three values: 1. What is about this value that is important to you? 2. To what extent do you feel you are or are not able to live up to this value? 3. Are there ways you would like to be living up to this value more than you are at the moment? 4. How do you express these values in your work? 5. Are there ways you would like to express this value more in your work?

Personal Values Card Questionnaire

(Adapted from Bill Millers Personal Values Card Sort)

Instructions: 1. Consider each of the values in the list and place a tick in the appropriate box to indicate whether that value is not important, important or very important to you. 2. Aim to have no more than 10-15 ticks in the very important box 3. Look over the values you have rated very important and rate from 1-5 or so the most important to you, in order of importance

Value Acceptance Accuracy Achievement Adventure Attractiveness Authority Autonomy Beauty Caring Challenge Change Comfort

Description To be accepted as I am To be accurate in my opinions and beliefs To have important accomplishments To have new and exciting experiences To be physically attractive To be in charge of and responsible for others To be self-determined and independent To appreciate beauty around me To take care of others To take on difficult challenges To have a life full of challenge and variety To have a pleasant and comfortable life

Not Important

Important

Very Important

Top 5 Rating

Commitment Compassion Contribution Cooperation Courtesy Creativity Dependability Duty Ecology Excitement Faithfulness Fame Family Fitness Flexibility Forgiveness Friendship Fun Generosity Genuineness God's will Growth Health Helpfulness Honesty Hope Humility Humour Independence Industry

To make enduring and meaningful commitments To feel and act on concern for others TO make a lasting contribution in the world To work collaboratively with others To be considerate and polite To have new and original ideas To be reliable and trustworthy To carry out my duty and obligations To live in harmony with the environment To have a life full of thrills and stimulation To be loyal and true in relationships To be known and recognized To have a happy, loving family To be physically fit and strong To adjust to new circumstances easily To be forgiving of others To have close, supportive friends To play and have fun To give what I have to others To act in a manner that is true to who I am To seek and obey the will of God To keep changing and growing To be physically well and healthy To be helpful to others To be honest and truthful To maintain a positive and optimistic outlook To be modest and unassuming To see the humourous side of myself & the world To be free from dependence on others To work hard and well at

Inner Peace Intimacy Justice Knowledge Leisure Loved Loving Mastery Mindfulness

my life tasks To experience personal peace To share my innermost experiences with others To promote fair and equal treatment for all To learn and contribute valuable knowledge To take time to relax and enjoy To be loved by those close to me To give love to others To be competent in my everyday activities To live conscious & mindful of the present moment To avoid excesses and find a middle ground To have one close, loving relationship To question & challenge authority and norms To take care of and nurture others To be open to new experiences, ideas & opinions To have a life that is well ordered and organised To have deep feelings about ideas/activities/ people To feel good To be well liked by many people To have control over others To have meaning and direction in my life To be guided by reason and logic To make and carry out responsible decisions To take risks and chances To have intense, exciting love in my life To be safe and secure To accept myself as I am To be disciplined in my own actions To feel good about

Moderation Monogamy Non-conformity Nurturance Openness

Order Passion

Pleasure Popularity Power Purpose Rationality Responsibility Risk Romance Safety Self-acceptance Self-control Self-esteem

Self-knowledge

Service Sexuality Simplicity Solitude

myself To have a deep and honest understanding of myself To be of service to others To have and active and gratifying sex life To live life simply, with minimal needs To have time space where I can be apart from others To grow and mature spiritually To have a life that stays fairly consistent To accept and respect those who differ from me To follow respected patterns of the past To live a morally pure and excellent life To have plenty of money To work to promote peace in the world

Spirituality Stability Tolerance Tradition

Virtue Wealth World Peace

Choose one of the top 5 most important values.

Discuss What is it about this value that is important to you?

In what ways are you living up to this value in your life?

In what ways are you not living up to this value as you would like to?

How might you live up to this value more?

Part A: An Overview of CEP

This section provides an overview of CEP in New Zealand and a summary of the necessary background knowledge base on CEP. Further information is available in Te Ariari O Te Oranga.

CEP in New Zealand

There has been an interest in CEP in New Zealand since the early 1990s. Double Trouble groups were the initial response in many places. These involved the establishment of group treatments for people with both substance use and mental health problems alongside standard substance use group treatments, mainly within Alcohol and Drug services. Early Psychosis teams were also pioneers by including CEP approaches, especially for young people with psychosis who were using cannabis. The Assessment and Management of People with Co-existing Substance Use and Mental Health Disorders (Todd, Robertson, Sellman 1998) were a set of guidelines with clinical applications to scenarios based on the models used internationally at the time. This was the basis of widespread training over the next decade had a little impact on clinical practice but which failed to generate significant change. Barriers to improving CEP practice included: o The failure of Mental Health systems to support clinical training despite systems issues being highlighted from the outset o DHBs seeing CEP as an add-on to their current services requiring extra resources rather than core business o Negative attitudes and suspicion between AOD and Mental Health services o A view that substance use was not the business of Mental Health Services and vice versa; that MH services treated, for example, depression or psychosis and not substance use problems. As a consequence, most clinical training during the mid-2000s focused on attitude change, especially towards a more person-centred approach in which clinicians were seen as working with people rather than disorders. Relationship building and collaboration between MH and AOD services was also a focus.

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From around 2007, new efforts were made to enhance the CEP capability of services and practitioners. A closer relationship between the service interests of the Ministry of Health and clinical practice led to the release in 2010 of Te Ariari O Te Oranga (a clinical framework) and Integrated Solutions (guidance for mangers and services), which are companions to each other. Subsequently there have been a number of significant developments: o Establishment of a Ministry of Health Advisory Group led by the Director of Mental Health to monitor and promote enhanced CEP capability in the DHBs o CEP incorporated into all relevant MOH strategic plans and documents o CEP prioritized by the workforce development programmes, led by Matua Raki o The development of a number of resources to support practitioners and services enhancing their CEP capability o Training provided to a number of DHBs o The development of local and national CEP practitioner networks.

Enhancing CEP Capability

Enhancing CEP capability involves change on systems, services and practitioner levels. Tools are available to help services assess their current CEP capability. CEP capability is best conceptualized on a continuum as MH or AOD only (the service does not detect the presence of the other), a range of CEP Capabilities (detect through routine screening, detect and assess, detect/assess/plan management) and CEP Enhanced (are able to detect, assess, and treat most relevant cases of CEP within the one service). Most services do not need to be CEP enhanced. The best approach is for a service to identify its level of CEP capability, determine what level of capability it would like to have and plan to develop towards this. The Canterbury District Health Board has an implementation group to oversees developments on system, service and clinical levels. The capability enhancement approach is shown in the diagram below. There are three approaches, each covering similar material but adapted to the specific needs at the time: 1. Generic training for as many staff as possible across services 2. Work with specific services to help plan and implement capability enhancement 3. Learning around specific clinical situations through CADS liaison roles within mental health teams.

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Background Information: The Nature, Extent and Impact of CEP

Definitions
Coexisting substance use and mental health problems (CEP) are known by many different names; Double Trouble, Dual Diagnosis, Mental Illness with Chemical Abuse (MICA), Co -occurring Disorders, or Co-existing Problems. They all mean much the same thing. Co-existing has been the term used in New Zealand for the last decade and problems was chosen to move away from the focus on disorders while still being acceptable to MH services. The usual definition is the co-occurrence of mental health and substance use problems in the same person at the same time. Research definitions often report lifetime rates of CEP; the person has MH and AOD problems at some point in their life, not necessarily at the same time. Current CEP in research usually means that the problems were present during the last month.

The Nature of CEP

CEP is not a single thing. Rather, there are as many different subtypes as there are combinations of drugs and mental health problems. Problems related to CEP range from the simple and straightforward to the multi-dimensional and complicated. The more complicated cases of CEP are among the most difficult to treat and expose the weaknesses in the health system.

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As such, there are general or generic things that need to occur for all people with CEP, as well as specific things for each combination of MH and AOD problems. In almost all cases, when a MH problem is complicated by AOD problems, engagement, treatment outcome, suicide rates and psychosocial functioning are much worse.

The Impact of CEP

The presence of CEP is associated with a range of poorer outcomes including: Poorer compliance with treatment and medication More relapses More readmissions Poorer outcomes Treatment resistance Increased rates of suicide and violence Higher rates of unemployment

Epidemiology
CEP is common. In general terms, the rate of AOD problems in people with specific mental health disorders ranges from 25-30% for most anxiety disorders and major depression, to 50% of those with bipolar disorder and schizophrenia. Rates in those with antisocial personality disorder are up to 80%. In those in treatment for AOD problems, rates of comorbid MH disorders appear to be very high. A New Zealand study of two community AOD services showed that 70% had an axis I non-AOD DSMIV diagnosis in Mood and anxiety disorders were the most common. Of note just under a third had a current diagnosis of PTSD, and 10% had a current diagnosis of bipolar disorder, with less than half of them being in current mental health treatment. Also of note are the very low rates of psychosis in those with AOD problems, and even lower rates of schizophrenia. This is very important given the past emphasis in CEP on chronic psychotic disorders they are very uncommon.

A Brief History of CEP

CEP is an artifact of the way health problems are diagnosed and health systems structured. It emerged as an issue in the 1980s due to a number of developments in treatment, not least the move of clients from hospital to the community. Increased access to alcohol and drugs undoubtedly played a part, as did the advent of DSMIII and its insistence that if criteria for more than one diagnosis was met, all diagnoses should be made. Large population studies such as the ECA and NCS studies also raised awareness of CEP and community mental health clinicians began reporting on the high prevalence CEP and the poor outcomes it was associated with. Most of the treatment models used today were developed during the early 1990s, most prominently those by Osher and Koefed, Drake, Carey and Mueser. At the heart of these models were the principles of comprehensiveness and integration. During the 2000s, the need for widespread screening leading where appropriate to assessment was promoted and several treatment guidelines were published including TIP42 and the UK Dual Diagnosis Toolkit. These guidelines summarise the major standard approaches to CEP that had been developed over the past decade and are considered best practice.

Aetiology (Causes) Traditional Views

The causes of CEP have traditionally been described as: 1. Substance use causes mental health problems 2. Mental heath problems cause substance use problems

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3. Common underlying factors cause both substance use and mental health problems which are themselves not necessarily causally related. Of note common factor models seldom specify what the common factors actually are.

Aetiology (Causes) Common/Trans-diagnostic Factors

In fact, in most cases, all the above models are usually involved in either causing or maintaining problems. For some combinations, the substance use may cause the mental health problems e.g. Alcohol and depression, stimulants and psychosis. For other combinations, the mental health problems appear to be the main driver for the development of substance use problems, especially in the case of bipolar disorder, PTSD and social phobia. Common factors often underpin CEP. Factors which underpin and lead to the development and maintenance of several disorders are also called Trans-diagnostic factors. Different factors may be important in individuals and it is essential to identify if this occurs, given that many of the factors are treatable and that other problems are unlikely to resolve until they themselves are treated effectively. Common Trans-diagnostic factors include: Shared genes Attention control Impulsivity Negative urgency Negative emotionality Cog/Attention bias Emotion regulation Rumination Perfectionism Coping (approach/avoid) Sleep Social context

Limitations of Current Approaches

The best practice guidelines such as TIP 42 have a number of limitations. First, the gold standard integrated dual diagnosis team approach of Drake and colleagues, as well as interventions such as motivation interviewing are very hard to put into practice in clinical settings with fidelity. Pejorative attitudes between MH and AOD clinicians remain significant barriers to implementation. After the release of TIP42, a number of systematic reviews have indicated that the best practice approaches are not effective in changing both MH and AOD problems, and that while these approaches have been shown to improve psychosocial functioning, they do not appear to change symptoms. The strongest evidence is for group approaches, long-term residential treatments and contingency management. While there is some improvement in functioning with the standard CEP approaches, engagement remains highly problematic. Only 30-50% of people with severe CEP engage in treatment. The standard treatments are built around the paradigms for treating chronic illnesses such as schizophrenia, which is uncommon. They may not be applicable to other types of CEP. Most of the strategies for treating CEP involve change at the level of the service and system, such as bringing together AOD and MH treatments. At the clinical level there remains a lack of guidance for how to implement these change. Finally, integration is a key principle, but invariable deals with the

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integration of AOD and MH treatments. For most people with CEP, there is a lot more to integrate than just the AOD and MH problems.

Part B: Te Ariari and the 7 Key Principles

This section looks at the spirit of Te Ariari in more depth and provides an overview of the Te Ariari framework. Two of the 7 Key Principles will be focused on in more depth, as they are integral to the Spirit of Te Ariari

The Spirit of Te Ariari

As mentioned, the Spirit of Te Ariari is a philosophical context for care based on four values: 1. Person-focused care 2. Wellbeing orientated care 3. Integrated care 4. Walking the talk; or expressing these values in our clinical practice.

Person-focused Care

Exercise 2: Person-focused Care

In small groups: 1. Appoint one of your group to note the discussion and give feedback 2. Discuss what the concept of person-focused care means? 3. What strategies do or can you use in your work to make it personfocused
List some of the strategies that you could bring into your practice .

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. . . . . . . . . . . .

There is good evidence that a person-focused approach increases engagement, motivation, treatment compliance and service satisfaction. There is a lot written about person-focused or person-centred care. While we are usually able to describe it, we frequently fail to put it into practice with the people we work with. Reasons for this include cognitive overload, lack of time and therefore a focus on the detail of our work, a lack of simple techniques to implement it and a lack of value placed on by the systems we work in. For person-focused care to be integral to our practice, we need to include it as a central part of our overall framework of care something we consciously think about as a key driver of what we do. We also need specific strategies to implement it. Some strategies include: Referring to the person as a person, preferably by their name rather than their role in our system (patient/client/consumer) Taking time to get to know the person, especially: o Personal values o Strengths (especially character strengths) o Their vision of what wellbeing is for them Empowering the person within the therapeutic relationship Several specific techniques and tools are very useful 1. WHOQOL-100 and WHOQOL-Bref Using quality of life as the key outcome measure, using it at baseline and then at crucial points during follow-up gives a measure of a persons overall quality of life, this, after all is the key thing they and we are seeking. The WHOQOL is a widely used and validated instrument developed by the World Health Organization. The full 100-quesiton version is a very good instrument. However, the Bref is a briefer instrument of 24 questions and seems preferable in clinical practice. 2. Personal Values Card Sort/Paper Questionnaire This is the first exercise you did. The Values Card Sort was developed by Bill Miller of Motivational Interviewing fame. It is a very nice exercise to do, but requires that you have a set of Values Cards on you and it takes 20-30 minutes. I have developed the paper questionnaire based on the Values Cards; it takes less time and can be given as homework tasks, thus being more practical in a busy outpatient setting and it works very well. However, if you have time, I think the Values Card Sort itself is preferable.

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3. Character Strengths measures Character strengths are very useful things to be aware of. Helping a person identify their character strengths (they are not always what people initially think they are), and then putting one or two of the key ones into practice in a new way, each day, for one week has been shown to enhance subjective well-being for at least the next six months. There are a number of ways of identifying a persons core character strengths. The simplest is to ask them which, from a list (see appendix), are their top strengths. A more effective way is to use a rating scale or test such as the VIA-signature strengths test accessed free at the www.authentichappiness.com website. A person needs to register and log on, and take the test online. It takes 20-30 minutes. A paper-based version is in development brief version is in development locally and we will let you know when it is available.

4. Best Possible Selves Exercise This is a positive psychology intervention that aims to improve a persons optimism and hope. Undertaking this exercise has been shown to lead to measurable increases subjective well-being sustained for at least six months. It is also a very useful way to help a person identify their hopes and aspirations for their lives; i.e. what well-being means to them.

Exercise 3: Best Possible Selves

Think about your best possible self at some point in the future say, in 5 years time. Imagine yourself after everything has gone as well as it possibly could. You have worked hard and succeeded at accomplishing all of your life goals. Think of this as the realization of your own best potential. You are realistically identifying the best possible way that things might turn out in your life. Take a few moments to write down what this life would be like.
. . . .

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. . . . . . . . . . . . . . .

Well-being Orientated Care

Wellbeing orientated care relates closely to the second key principle of Te Ariari, Recovery and Well-being. The second value and one that provides the key overarching framework by which to organise care is that of well-being orientated care. This framework is as follows: People desire a state of flourishing; a high degree of wellbeing.

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 They experience distress when they are languishing i.e there is a significant gap between their desired state of wellbeing and their actual state of wellbeing. They try many strategies to improve their wellbeing before they seek help from us specialist services. The traditional role of health services plays a small part in their movement towards increased wellbeing

This framework is obvious; we know it well when it is stated. However, we often fail to put it in to practice in our work. The importance of it is that it reminds use that there is more to wellbeing than simply treating disease or disorder, and more to it than maintaining the health gains made when we are able to treat those disorders. There are active things that can be done to enhance well-being beyond minimizing the barriers. Of note: People who have had complete recovery from major depression have a significantly lower degree of well-being compared to people who have never had major depression. Quality of life can be improved with no improvement in symptoms of disorder Effective positive interventions have an effect size for improving depression around the same as CBT for depression. In particular, forgiveness exercises have a much higher effect size. Positive interventions and CBT are not mutually exclusive. We are well placed to help people take positive steps toward enhanced wellbeing, and even if we choose not to we should see our role as a part of the bigger picture

Therefore, key steps to a well-being orientated approach include: 1. Identifying the persons vision of well-being 2. Enhancing functioning in positive domains 3. Improving functioning in deficit domains 4. Incorporating positive interventions into treatment planning. Therefore, specific evidence-based strategies and techniques to enhance well-being include: 1. Values card sort 2. Character Strengths (VIA-signature strengths above) 3. Gratitude interventions 4. Cultivate optimism (best possible selves) 5. Avoid over-thinking or rumination (mindfulness) and social comparison 6. Nurture social relationships 7. Develop strategies for coping; find meaning, social supports 8. Practice acts of kindness to self (loving kindness medication) and others 9. Learn to forgive 10. Increase flow activities

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Exercise 4: RACHEL Values & Best Possible Selves

Take a few minutes to quietly read through the scenario of Rachel (below). As you read, imagine what Rachels top three values would be and what she would describe as her Best Possible Self in 5 years time. Write them down.

Case Scenario Rachel Rachel is a 30-year-old European mother of a 5 year-old daughter who was referred to your service via the local Emergency Department after having taken an overdose of 15 Paracetamol tablets the previous night. Rachel stated that the overdose had been an impulsive action after drinking a bottle of wine and having an argument with her partner about finances. She stated that she was not trying to kill herself or that she was at risk of future overdose as she was very embarrassed at the outcome. She is reluctant to attend the appointment with your service, but does so under pressure from her partner who threatens to leave her unless she does something about her drinking and her moodiness. History of Presenting Problems Rachel describes depressed mood meeting criteria for moderate Major Depressive Episode since her late teens. Her mood is worse for a few weeks, once every three months on average. At these times she finds life a struggle and has thoughts that she would be better off dead but has never actually developed the intent to kill herself.

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She experienced a sexual assault (rape) at a party while severely intoxicated at the age of 18 years. Since then she has experienced frequent intrusive memories and ruminations related to the rape which has impacted on her intimate relationships, and experiences hyperarousal much of the time though it is worse when socializing in larger groups. She denies any other significant mental health problems. Alcohol and Drug History Rachel did not drink regularly or to intoxication until after the sexual assault at age18 years. She started drinking to intoxication most weekend nights when socialising, and by the age of 20 years was drinking half to three quarters of a bottle of wine most evenings as well. Her alcohol use decreased when, at age 22 years she entered a relationship with the father of her daughter, and over the next few years she would only drink occasionally. Her partner left her when she became pregnant and decided to keep the child. She stopped drinking when she became pregnant at aged 25 years and did not consume alcohol again until her daughter was a year old and she entered a new relationship with her current partner who also drinks heavily. She has used cannabis on a daily basis since her mid teens and experiences craving, irritability and significant generalized anxiety when she goes without it for more than a few days, but find it helps her mood. She currently smokes 50gms of tobacco a week and would like to stop, as it is very expensive. Other Relevant History Youngest of three siblings with an older sister and the eldest a brother. Her father died in a motor vehicle accident when Rachel was 22 years old. Father alcohol dependence. Paternal Grandfather alcohol dependence 21

Brother convictions for assault, cannabis possession, heavy cannabis user Mother social phobia, less problematic the last few years Personal History: She attended six different primary schools due to her fathers frequent change in employment. At primary school she struggled academically with mathematics and reading but was otherwise intelligent. She often got into trouble for disobedience and being easily distracted. She was noted to have a short temper and be intolerant of discipline, talking back to teachers. She was sexually abused on one occasion at the age of 5 by a friend of her fathers. She was frequently truant from secondary school and noted to be irritable and argumentative when she did attend. Upon leaving school she worked in a range of waitressing, bar and sales jobs until becoming pregnant. Over the past two years she has taken several tertiary papers in social work and hopes to get a job in the future in community support. Her current relationship tends to involve frequent arguments though not violence. She has one or two friends whom she has know for ten years. Rachels Three Main Values: 1. 2. 3. Rachels Best Possible Self:

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 . . . . . . . . . . . . . . . . .

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 . . .

Integrated Care
Delivering person-focused wellbeing-oriented integrated care must start with the needs of the client and their family, identify detailed issues within that context, organise services flexibly to support these needs and design systems that support services to do this. Systems integration = brings systems closer together Treatment integration = combines treatments under one service Integrated care = brings all treatments together behind the need of the person Integrated care comes from:

Understanding a persons vision of well-being Starting with the needs of the person Considering both pathways to wellbeing and barriers to well-being (deficits) Aetiological formulation from multi-dimensional/comprehensive assessment Effective collaboration (within and outside multidisciplinary team) Systems orgnised to support integrated care.

Much of what we do as clinicians and practitioners involves integration. There are a number of key points in the clinical process, which we can leverage to enhance integration The tools and strategies we use clinically include: 1. Taking a wellbeing perspective

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2. Screening and assessment processes that integrate a range of sources of information and information across multiple domains 3. Specific processes and structures within the assessment to integrate issues such as MH and AOD problems timelines, ecograms 4. The process of forming an opinion and a multi-dimensional formulation 5. Combining of perspectives within the multi-disciplinary team 6. Collaboration with others outside the MDT

Exercise 5: Self-directed Learning Timelines

In the days after completing this workshop, take a few moments to think about this exercise. Timelines are very useful tools for identifying the relationship between various events, disorders and patterns of substance use over time. The following is a timeline for the scenario of Rachel (above)

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What can you speculate about the relationship between Rachels various problems from this timeline? In particular; 1. How important was the episode of childhood sexual abuse in terms of her subsequent behaviour and substance use problems, compared to, say, the family environment she grew up in? 2. What role did the rape have in terms of causing her alcohol use problems? 3. What effect did her pregnancy have on her substance use and mood symptoms? 4. What two problems do you think are likely to be the most important ones to improve if she is to make progress with her problems?
It is also important to think about integration over time (longitudinally). People deal with a number of different services over time. Often, each service will take a narrow perspective of the persons problems based on what they usually deal with. As a result, problem formulation, diagnosis and treatment approaches may change frequently. This is unhelpful. Integration therefore starts with the big picture the client seeking enhanced wellbeing and our role in this, in particular removing barriers in the context of wellbeing.

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Walking the Talk

As mentioned, there are numerous barriers stopping us putting these values and principles into practice. It is therefore important to have clear, simple and quick strategies we can use in our practice to help us apply them. Below is a table summarising the important values and principles we have mentioned and some useful some techniques and strategies for putting them in to practice.

Person-centred

Values Strengths

Personal Values Questionnaire VIA signature strengths WHOQOL Best Possible Selves Well-being perspective, timelines, Formulation, Collaboration

Wellbeing Integrated Care

Vision of well-being

Culture Engagement Motivation Assessment Management Screening, Brief, Comprehensive Brief Comprehensive Implementation intention, self-efficacy, autonomy, MI WHO-assist Comp Asst + Formulation FRAMES 404 Template

The Te Ariari Framework & The 7 Key Principles

Te Ariari is organized around 7 key principles: 1. Cultural considerations 2. Wellbeing

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3. Engagement 4. Motivation 5. Assessment 6. Management 7. Integrated Care These principles were chosen because they seem to be the ones that require enhancing in the context of our current approaches to treatment. It is likely that in a few years, different principles will need stressing. These principles are applied in each of five phases of treatment. 1. Pre-treatment 2. Early treatment 3. Middle treatment 4. Late treatment 5. Autonomous independence Thus the Te Ariari framework can be expressed as a matrix with related goals at each phase of treatment

Within this framework each phase of treatment can be associate with key goals and specific strategies. These will be discussed in detail in the advanced workshops later this year. For further information, see Te Ariari o te Oranga.

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The 7 Key Principles are discussed in more depth in Te Ariari o te Oranga, will be the focus of specific advanced workshops, and will be outlined in the Self-directed Learning Module Part B which should be available by late April 2013 from FrasersCEPblog. Below are brief comments on each.

Principle 1: Cultural Considerations

Cultural issues are essential to consider in terms of their relevance to values and engagement especially. There is a need for others to step forward and take a lead in developing this area. To allow space for this, cultural issues will not be discussed in this workshop. Further reading is available in Te Ariari o te Oranga. Some questions to ponder: 1. 2. 3. 4. What is the second largest ethnic subgroup in New Zealand? What percentage of people in Christchurch identify as Pakeha? What is the second largest ethnic subgroup in Christchurch Do you have a mihi?

Principle 2: Recovery and Well-being

Wellbeing has been discussed above.

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Recovery expresses central values and processes from a consumer perspective. Essential in this is that consumers should determine their goals, who they work with and what treatments they wish to have. Each persons pathway to recovery is unique and self-determined. Key aspects of recovery include developing of a sense of identity that is not tied to the patient role, allows the consumer to develop a sense of meaning as a valuable member of society, and encourages them to take responsibility for managing their lives. It is useful to think of being a consumer as being a member of a minority, colonized culture. Values that we apply to tangata whaiora and mana whenua could equally be applied to consumers. These include the principles of: Partnership Participation Protection (of resources and taonga)

Principle 3: Engagement
The model described in Te Ariari o te Oranga has been updated. The current model will be available in the SDL Part B (available late April on frasersCEPblog.com) The diagram below mentions key engagement strategies which are described in Te Ariari o te Oranga.

Principle 4: Motivation
The model of motivation in Te Ariari has been updated and will be available in SDL Part B. The current model is outlined in the diagram below uses the stages of change model, collapsed into three main stages and highlights the important transition points between contemplation and preparation, and preparation and action, in which people often get stuck. Techniques to help

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transition from deliberation (pre-contemplation and contemplation) to action include increasing goal commitment, using implementation intentions and dealing with procrastination.

Principle 5: Assessment
Current model focuses more explicitly on a stepped care approach. The screening tools recommended (WHO Assist for AOD and MINI-screen for MH problems) are included in the support material.

Principle 6: Management
See Te Ariari. The advanced workshops on management will include information on managing withdrawal and on incorporating motivational and wellbeing approaches into a standard outpatient follow-up appointment, among other things.

Principle 7: Integrated Care

Discussed above

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APPENDICES AND RESOURCES

Included 1. Personal Values Card Questionnaire 2. Character Strengths Questionnaire (72) 3. Personal Activity Fit Diagnostic 4. Some Positive Interventions

Personal Values Card Questionnaire

(Adapted from Bill Millers Personal Values Card Sort)

Fraser Todd 2013

Instructions: 1. Consider each of the values in the list and place a tick in the appropriate box to indicate whether that value is not important, important or very important to you. 2. Aim to have no more than 10-15 ticks in the very important box 3. Look over the values you have rated very important and rate from 1 -5 or so the most important to you, in order of importance

Value Acceptance Accuracy Achievement Adventure Attractiveness Authority Autonomy Beauty Caring Challenge Change Comfort Commitment Compassion Contribution Cooperation Courtesy Creativity Dependability Duty Ecology Excitement Faithfulness Fame

Description To be accepted as I am To be accurate in my opinions and beliefs To have important accomplishments To have new and exciting experiences To be physically attractive To be in charge of and responsible for others To be self-determined and independent To appreciate beauty around me To take care of others To take on difficult challenges To have a life full of challenge and variety To have a pleasant and comfortable life To make enduring and meaningful commitments To feel and act on concern for others TO make a lasting contribution in the world To work collaboratively with others To be considerate and polite To have new and original ideas To be reliable and trustworthy To carry out my duty and obligations To live in harmony with the environment To have a life full of thrills and stimulation To be loyal and true in relationships To be known and recognized

Not Important

Important

Very Important

Top 5 Rating

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Family Fitness Flexibility Forgiveness Friendship Fun Generosity Genuineness God's will Growth Health Helpfulness Honesty Hope Humility Humour Independence Industry Inner Peace Intimacy Justice Knowledge Leisure Loved Loving Mastery Mindfulness

To have a happy, loving family To be physically fit and strong To adjust to new circumstances easily To be forgiving of others To have close, supportive friends To play and have fun To give what I have to others To act in a manner that is true to who I am To seek and obey the will of God To keep changing and growing To be physically well and healthy To be helpful to others To be honest and truthful To maintain a positive and optimistic outlook To be modest and unassuming To see the humorous side of myself & the world To be free from dependence on others To work hard and well at my life tasks To experience personal peace To share my innermost experiences with others To promote fair and equal treatment for all To learn and contribute valuable knowledge To take time to relax and enjoy To be loved by those close to me To give love to others To be competent in my everyday activities To live conscious & mindful of the present moment To avoid excesses and find a middle ground To have one close, loving relationship

Moderation Monogamy

Fraser Todd 2013

Non-conformity Nurturance Openness

Order Passion

Pleasure Popularity Power Purpose Rationality Responsibility Risk Romance Safety Self-acceptance Self-control Self-esteem Self-knowledge

To question & challenge authority and norms To take care of and nurture others To be open to new experiences, ideas & opinions To have a life that is well ordered and organised To have deep feelings about ideas/activities/ people To feel good To be well liked by many people To have control over others To have meaning and direction in my life To be guided by reason and logic To make and carry out responsible decisions To take risks and chances To have intense, exciting love in my life To be safe and secure To accept myself as I am To be disciplined in my own actions To feel good about myself To have a deep and honest understanding of myself To be of service to others To have and active and gratifying sex life To live life simply, with minimal needs To have time space where I can be apart from others To grow and mature spiritually To have a life that stays fairly consistent To accept and respect those who differ from me To follow respected patterns of the past To live a morally pure and excellent life

Service Sexuality Simplicity Solitude

Spirituality Stability Tolerance Tradition

Virtue

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Wealth World Peace

To have plenty of money To work to promote peace in the world

Choose one of the top 5 most important values.

Discuss What is it about this value that is important to you?

In what ways are you living up to this value in your life?

In what ways are you not living up to this value as you would like to?

How might you live up to this value more?

Fraser Todd 2013

Character Strengths Questionnaire (72)*

(This questionnaire has been developed and made available by Alison Ogier-Price) Read each statement below and circle the number to the right that corresponds most with how well you believe the statement applies to you right now (go with your immediate instinct) from very much unlike me to very much like me (Try not to use 3: neither like nor unlike more than necessary).
This statement is... Very much unlike me 1 1 1 1 1 1 1 1 1 1 1 1 1 1 1 1 1 1 1 1 1 1 1 1 1 1 Unlike me 2 2 2 2 2 2 2 2 2 2 2 2 2 2 2 2 2 2 2 2 2 2 1 2 2 2 Neither like nor unlike me 3 3 3 3 3 3 3 3 3 3 3 3 3 3 3 3 3 3 3 3 3 3 2 3 3 3 Like me Very much like me 5 5 5 5 5 5 5 5 5 5 5

1. 2. 3. 4. 5. 6. 7. 8. 9. 10. 11. 12. 13. 14. 15. 16. 17. 18. 19. 20. 21. 22. 23. 24. 25. 26.

It is important that I live in a world of beauty Pain and disappointment seldom get the better of me I work at my best when I am in a group I like to think of new ways to do things I am curious about the world I believe that everyone should have a say I always let bygones be bygones I often stop and count my blessings I always look on the bright side I often say funny things that make people laugh I keep my promises When the topic calls for it, I can be a highly rational thinker I am as excited about the good fortune of others as I am about my own I can always get people to do things together even if they have their differences I go out of my way to visit museums and other educational sites I easily accept love from others I prefer to let other people talk about themselves Others often come to me for advice I make good choices in friendships and relationships I do not give up I exercise on a regular basis I am very good at sensing what other people are feeling I have a calling in life I throw myself into everything in life I have created something of beauty recently I have taken frequent stands in the face of strong

4 4 4 4 4 4 4 4 4 4 4 4 4 4 4 4 4 4 4 4 4 4 3 4 4 4

5 5 5 5 5 5 5 5 5 5 4 5 5 5

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27. 28. 29. 30. 31. 32. 33. 34. 35. 36. 37. 38. 39. 40 41. 42. 43. 44. 45. 46. 47. 48. 49. 50. 51. 52. 53. 54. 55. 56. 57. 58. 59.

opposition I gladly sacrifice my self-interest for the benefit of groups I am in People consider me to be imaginative I dont get bored I treat all people equally regardless of who they might be I dont try to get event or take revenge I have been richly blessed in my life I am a goal-orientated person It try to have fun in all kinds of situations Others trust me to keep their secrets I dont make snap judgments I am never too busy to help a friend I am good at planning group activities I am thrilled when I learn something new There are people in my life who care as much about my own feelings and well-being as they do about their own I dont often talk about my accomplishments My friends value my objectivity I think through the consequences before I act I finish what I start I control my emotions No matter what the social situation, I am able to fit in My life has a strong purpose I look forward to each new day I experience deep emotions when I see beautiful things I must stand up for what I believe, even if negative results happen It is important to me to respect decisions made by my group Being able to come up with new and different ideas is one of my strong points I am always busy with something interesting If I do not like someone, it is still easy for me to treat the person fairly I try to respond with understanding when someone treats me badly When I look at my life, I find many things to be grateful for Despite challenge, I always remain hopeful about the future I try to add some humour to whatever I do I am true to my own values

1 1 1 1 1 1 1 1 1 1 1 1 1 1 1 1 1 1 1 1 1 1 1 1 1 1 1 1 1 1 1 1 1

2 2 2 2 2 2 2 2 2 2 2 2 2 2 2 2 2 2 2 2 2 2 2 2 2 2 2 2 2 2 2 2 2

3 3 3 3 3 3 3 3 3 3 3 3 3 3 3 3 3 3 3 3 3 3 3 3 3 3 3 3 3 3 3 3 3

4 4 4 4 4 4 4 4 4 4 4 4 4 4 4 4 4 4 4 4 4 4 4 4 4 4 4 4 4 4 4 4 4

5 5 5 5 5 5 5 5 5 5 5 5 5 5 5 5 5 5 5 5 5 5 5 5 5 5 5 5 5 5 5 5 5

Fraser Todd 2013

60. 61. 62. 63. 64. 65. 66. 67. 68. 69. 70. 71. 72.

Thinking things through is part of who I am I voluntarily help others I see in need In a group, I try to make sure everyone feels included I always go out of my way to attend educational events I always feel the presence of love in my life I do not act as if I am a special or important person I am always able to look at things and see the big picture I avoid activities that are physically dangerous I dont get sidetracked when I work I can always say enough is enough I always listen to people talk about their problems I am a spiritual person I have lots of energy

1 1 1 1 1 1 1 1 1 1 1 1 1

2 2 2 2 2 2 2 2 2 2 2 2 2

3 3 3 3 3 3 3 3 3 3 3 3 3

4 4 4 4 4 4 4 4 4 4 4 4 4

5 5 5 5 5 5 5 5 5 5 5 5 5

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Using the numbers that you circled on this questionnaire enter each number next to the corresponding question number below, 1 through 72, down each of the 3 columns. Then add together the 3 numbers on each line and enter the total for that strength. Statements Total Strength 1 ________ 2 ________ 3 ________ 4 ________ 5 ________ 6 ________ 7 ________ 8 ________ 9 ________ 10 ________ 11 ________ 12 ________ 13 ________ 14 ________ 15 ________ 16 ________ 17 ________ 18 ________ 19 ________ 20 ________ 21 ________ 22 ________ 23 ________ 24 ________ 25 ________ 26 _______ 27 ________ 28 ________ 29 ________ 30 ________ 31 ________ 32 ________ 33 ________ 34 ________ 35 ________ 36 ________ 37 ________ 38 ________ 39 ________ 40 ________ 41 ________ 42 ________ 43 ________ 44 ________ 45 ________ 46 ________ 47 ________ 48 ________ 49 ________ 50 ________ 51 ________ 52 ________ 53 ________ 54 ________ 55 ________ 56 ________ 57 ________ 58 ________ 59 ________ 60 ________ 61 ________ 62 ________ 63 ________ 64 ________ 65 ________ 66 ________ 67 ________ 68 ________ 69 ________ 70 ________ 71 ________ 72 ________ ________ ________ ________ _________ ________ ________ ________ ________ ________ ________ ________ ________ ________ ________ ________ ________ ________ ________ ________ ________ ________ ________ ________ ________ Appreciation of Beauty Bravery Citizenship/Teamwork Creativity Curiosity Fairness Forgiveness/Mercy Gratitude Hope Humour/Playfulness Integrity/Honest/Authenticity Judgment/Critical Thinking Kindness Leadership Love of Learning Love/Intimacy Modest/Humility Perspective Prudence/Caution Perseverance/Industry Self-control/Self-regulation Social Intelligence Spirituality Zest/Enthusiasm

Character Strengths Questionnaire (72) Scoring

Fraser Todd 2013

Top Character Strengths

On your scoring sheet (previous page) are listed 24 strengths from Appreciation of Beauty to Zest. 1. Look at that total score next to each of these strengths. Circle the highest number, and all of those with that number. Then circle the next highest number until you have selected 5 or 6 strengths. 2. Write these top 5 or 6 highest scoring strengths in the table below, in no particular order:

Top Character Strengths 1. 2. 3. 4. 5. 6. 7. 8.

3.

Questions 2 3 4 5 6

Total

Some of the top scoring strengths you know you have but you find them exhausting or you dont get enjoyment from them. Cross these off the list. For each strength remaining in the table above, think about the 6 statements below and make a mark or tick in the Questions boxes alongside the strength if the experience described applies to you when you engage that strength 1) A feeling of excitement, joy, zest and enthusiasm while using it (particularly at first) 2) Invigorating rather than exhausting while using it 3) Intrinsically motivated to use the strength 4) A feeling of inevitability in using the strength (try and stop me) 5) Continuous learning of new ways to use the strength or a sense of yearning to find new ways 6) The pursuit of personal projects (activities, hobbies) that revolve around it Add the total number of marks for each strength and enter into the Total column. Write the three highest scoring strengths in the table below. If there are more than 3, pick the 3 you like the most.

4.

5. 6.

Signature Strengths 1. 2. 3.

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Person Activity Fit Diagnostic

(Sonja Lyubomirsky, adapted from Ken Sheldon)
Instructions: Consider each of the following 12 happiness activities. Reflect on what it would be like to do it every week for an extended period of time. Then rate each activity by writing the appropriate number (1 to 7) in the blank space next to the terms NATURAL, ENJOY, VALUE, GUILTY, and SITUATION. People do things or many different reasons. Rate why you might keep doing this activity in terms of the following reasons. Use this scale:

not at all

somewhat

very much

NATURAL: ENJOY: VALUE: GUILTY: SITUATION:

Ill keep doing this activity because it will feel natural to me and Ill be able to stick with it. Ill keep doing this activity because I will enjoy doing it; Ill find it to be interesting and challengi ng. Ill keep doing this activity because I will value and identify with doing it; Ill do it freely even when its not enjoyable. Ill keep doing this activity because I would feel ashamed, guilty, or anxious if I didnt do it; Ill force myself. Ill keep doing this activity because somebody else will want me to or because my situation will force me to.

1. Expressing gratitude: Counting your blessings for what you have (either to a close one or privately, through contemplation or a journal) or conveying your gratitude and appreciation to one of more individuals whom youve never properly thanked. ___ NATURAL ___ ENJOY ___ VALUE ___ GUILTY ___ SITUATION

2. Cultivating optimism: Keeping a journal in which you imagine and write about the best possible future for yourself or practicing to look at the bright side of every situation. ___ NATURAL ___ ENJOY ___ VALUE ___ GUILTY ___ SITUATION

3. Avoiding over thinking and social comparison: Using strategies (such as distraction) to cut down on how often you dwell on your problems and compare yourself with others. ___ NATURAL ___ ENJOY ___ VALUE ___ GUILTY ___ SITUATION

4. Practicing random acts of kindness: Doing good things for others, whether friends or strangers, either directly or anonymously, either spontaneously or planned. ___ NATURAL ___ ENJOY ___ VALUE ___ GUILTY ___ SITUATION

Fraser Todd 2013

5. Nurturing relationships: Picking a relationship in need of strengthening, and investing time and energy in healing, cultivating, affirming, and enjoying it. ___ NATURAL ___ ENJOY ___ VALUE ___ GUILTY ___ SITUATION

6. Developing strategies for coping: Practicing ways to endure or surmount a recent stress, hardship, or trauma. ___ NATURAL ___ ENJOY ___ VALUE ___ GUILTY ___ SITUATION

7. Learning to forgive: Keeping a journal or writing a letter in which you work on letting go of anger and resentment toward one or more individuals who have hurt or wronged you. ___ NATURAL ___ ENJOY ___ VALUE ___ GUILTY ___ SITUATION

8. Doing more activities that truly engage you: Increasing the number of experiences at home and work in which you lose yourself, which re challenging and absorbing (i.e., flow experiences). ___ NATURAL ___ ENJOY ___ VALUE ___ GUILTY ___ SITUATION

9. Savoring lifes joys: Paying close attention, taking delight, and replaying lifes momentary pleasures and wonders, through thinking, writing, drawing, or sharing with one another. ___ NATURAL ___ ENJOY ___ VALUE ___ GUILTY ___ SITUATION

10. Committing to your goals: Picking one, two, or three significant goals that are meaningful to you and devoting time and effort to pursuing them. ___ NATURAL ___ ENJOY ___ VALUE ___ GUILTY ___ SITUATION

11. Practicing religion and spirituality: Becoming more involved in your chu rch, temple, or mosque or reading and pondering spiritually themed books. ___ NATURAL ___ ENJOY ___ VALUE ___ GUILTY ___ SITUATION

12. Taking care of your body: Engaging in physical activity, meditating, and smiling and laughing. ___ NATURAL ___ ENJOY ___ VALUE ___ GUILTY ___ SITUATION

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How to calculate your fit score and determine your self of bestfitting activities:
Step 1: For each of the 12 activities: subtract the average of the GUILTY and SITUATION rating from the average of the NATURAL, ENJOY and VALUE ratings. In other words, for each of the 12 activities:

FIT SCORE = (NATURAL + ENJOY + VALUE)/3 (GUILTY + SITUATION)/2 Step 2: Write down the four activities with the highest FIT SCORES: 1) __________________________ 2) __________________________ 3) __________________________ 4) __________________________

Your name: __________________

The date: ____________________

Fraser Todd 2013

Some Positive Intervention Exercises

Outlined below are the positive exercises mentioned above in the workbook. Values Card Sort Character strengths Best Possible Selves Fast Forward (retirement) Exercise Gratitude Visit Other Gratitude Exercises Count Your Blessings Open Mindset Random Acts of Kindness Positive Communication Savoring Three Good Things Flow activities Loving Kindness Meditation Forgiveness Self-compassion Exercise: Values Paper Card Sort Complete the Values Paper Card Sort In pairs or threes, share your three most important values One person leads a discussion with the other around one of the top 3 values 1. What is it about this value that is important to you? 2. To what extent do you feel you are or are not living up to this value? 3. Are there ways you would like be living up to this value more than you are at the moment?

Exercise: Character Strengths Using the VIA Signature Strengths Inventory (online) or filling out a paper version of a brief character strengths inventory, identify your 3-5 key characters strengths. Pick one of these. Use this strength in a new way each day for a week.

Exercise: Best Possible Selves Think about your best possible self; imagine yourself I the after everything has gone as well as it possibly could. You have worked hard and succeeded at accomplishing all of your life goals. Think of this as the realization of your own best potential. You are realistically identifying the best possible way that things might turn out in your life. Write down what this life would be like.

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Exercise: Fast Forward Fast-forward several years. You are retiring from your job and your workplace is having a celebration for you and have invited your family. Your boss and family members give a speech about your life both in work and as a person. Write down what you would like them to say about your life and your lifes purpose.

Exercise: Gratitude 1 - Gratitude Visit: Think of someone who has been especially kind to you, but who has never heard you express your gratitude. Write and rewrite a Gratitude Letter, describing in concrete terms what they did for you and how it affected your life. Make it soar. Visit them in person, if possible, and read it aloud.

Exercise: Gratitude 2 Think about the many things in your life, both large and small, that you have to be grateful about. These might include particular supportive relationships, sacrifices or contributions that others have made for you, facts about your life such as your advantages and opportunities, or even gratitude for life itself and the world we live in. Identify and think about three underappreciated aspects of your life for which you can be grateful. Exercise: Gratitude 3 Count Your Blessings Every night for the next week, right before you go to bed, write down three things (large of small) that went really well that day. Explain why they happened that way.

Exercise: Gratitude 4 Think about something you have experienced in the last day or two, or something around you that you wouldnt usually notice. This might include particular meetings or classes that you attended, typical interactions with acquaintances, typical thoughts that you have had as you move trough the day, a flower or tree you pass frequently. Spend 10 minutes contemplating that experience, appreciating the beauty in it and expressing gratitude for that experience.

Exercise: Kindness Random Acts of Kindness Each day for a week, perform an act of kindness. The acts do not need to be for the same person and the person may or may not be aware of the act.

Fraser Todd 2013

Exercise: Open Mindset People tend to have either a fixed mindset or an open (growth) mindset. A fixed mindset is an attitude where you believe you, your abilities & circumstances cannot change. A growth mindset is an attitude where you believe that you can change. A growth mindset is associated with significantly higher levels of motivation, goal achievement and resilience in the face of failure. Developing a growth mindset in others: Explain the nature of brain plasticity and growth with acquiring a skill, even in adults. The brain is like a muscle, it develops when used and needs to be exercised Praise effort not ability Do not compare a person to others; rather compare their current performance with their past performances Exercise: Positive Communication There are four main ways of responding to good news in a relationship: 1. Passive Constructive (PC) 2. Passive Destructive (PD) 3. Active Destructive (AD) 4. Active Constructive (AC) Passive responding is responding to the other person in a limp, unenthusiastic way. Active responding is responding to the other person in an energetic and enthusiastic way. Destructive responding is responding in a negative manner, be it passive (turning the conversation back to yourself and your issues) or active (commenting on the negative aspects of the good news. Constructive responding is responding that is encouraging and supportive in nature, be it passive (unenthusiastic e.g. thats nice then not following up on the conversation) or active (strongly enthusiastic support). Our ability to respond with enthusiasm to good news is far more important than how we respond to bad news. Active Constructive responding is associated with greater functioning in relationships Exercise: Pleasure and Savoring Savoring is the process of mindfully engaging in thoughts or activities that encourage positive events to lead to positive feelings. Reminisce about the past Savor the present moment Anticipate the future Exercise: Three Good Things Each night before you go to bed:

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1. Think about anything good that happened to you today. It need not be anything big or important. 2. Write down these three positive things. 3. Reflect on why each good thing happened. Determining the why of the event is the most important thing. Decide on reasons that make sense to you. Exercise: Flow Activities Seligman considers flow activities to be one of the most important pathways to well-being. Flow is a particular way of engaging with the world. A flow activity has the following characteristics: 1. It is an activity that involves a degree of challenge, but a challenge that is achievable 2. The activity has clear goals and feedback on performance is available 3. You feel completely absorbed in the activity, such that your sense of the passing of time is diminished 4. You feel at one with what you are doing, rather than maintaining a perspective of external observer. 5. The activity is intrinsically rewarding in its own right. Flow activities include things like playing a game of squash, a day at work when you are busy, absorbed in your task and the day goes by very quickly, playing a musical instrument, gardening, creative activities. Activities are typically high in challenge and high in skill requirements. Which particular activity leads to flow for a person differs. Exercise: Loving Kindness Meditation (LKM) and Compassion LKM is a meditation or mindfulness technique in which the person focuses on and contemplates with compassion another person in a non-judgmental way and from a perspective of reverence for all living things. To be practiced effectively it requires mindfulness skills. Reflecting on others with compassion is a similar process but does not necessarily require mindfulness skills. Rather, it is simply a matter of thinking about another person, especially someone who has hurt or wronged you, and having compassion for the pain they experience that leads him or her to behave that way. Forgiveness (Enright) Forgiveness is a difficult thing to achieve and often requires a course of treatment. However, it is one of the more potent positive interventions, especially for those who have suffered traumatic experiences in the past. Of note, the key to forgiveness is to free yourself from the pain of the past trauma, rather than to absolve the person you are trying to forgive from responsibility. Enright has identified four phases to forgiveness and describes strategies to help people learn to forgive Enright, R.D. The Forgiving Life. American Psychological Association Washington D.C. 2012. Phase 1 Uncovering Anger Phase 2 Deciding to Forgive

Fraser Todd 2013

Phase 3 Working on Forgiveness Phase 4 Discovery and Release (from the emotional prison) Exercise: Self-compassion Self-compassion is similar to LKM (above) with the focus on yourself. Contemplating yourself and your perceived failings, and looking at these with forgiveness and compassion. Exercise: Mindfulness Mindfulness is a meditative technique that is used to focus the persons attention on the sensations of the present moment. It has a wide range of applications, including helping with specific problems such as rumination, poor attention control and impulsivity. It is also an important way of enhancing your sense of personal well-being. It is strongly recommended that practitioners learn mindfulness techniques and learn how to teach it to tangata whaiora

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