Hello and welcome. I'm Dr. John Torres, the Director of Digital Psychiatry at Beth Israel Deaconess Medical Center and a member of the SMI Advisor Clinical Expert Team. I'll be acting as a moderator and I'm pleased that you're joining us for today's SMI Advisor webinar, WAM, a Peer-Delivered Wellness Self-Management Program. SMI Advisor, also known as the Clinical Support System for Serious Mental Illness, is an APA and SAMHSA initiative devoted to helping clinicians implement evidence-based care for those living with serious mental illness. Working with experts from across the SMI clinician community, our interdisciplinary effort has been designed to help you get the answers you need to care for your patients. Now, I'd like to introduce you to the faculty for today's webinar, Dr. Judith Cook. Dr. Cook is an internationally recognized authority on mental health service research, specifically the study of clinical and rehabilitation outcomes for children and adults receiving community-based care. She directs a federally funded research center, along with numerous grants focused on intervention science and psychiatric epidemiology. She designs and implements innovative programs to enhance health and behavioral health of vulnerable populations. Dr. Cook works with federal, state, and local authorities on behavioral health service system redesign and alternative financing strategies. Her recent work focuses on randomized controlled trials of evidence-based practices, evidence-based treatments for serious mental illness and outcomes for individuals with co-occurring mental illness and chronic medical conditions. Dr. Cook, thank you so much for leading today's webinar. Thank you, John. I'm very pleased to join you today to describe Whole Health Action Management, or WHAM, and tell you about a study done at the UIC Center on Mental Health Services Research and Policy. Before I begin, I'd like to acknowledge study funding from the National Institute on Disability, Independent Living, and Rehabilitation Research of the Administration for Community Living at HHS and from the Substance Abuse and Mental Health Services Administration's Center for Mental Health Services. What I'll be presenting today does not reflect the opinions or endorsement of any federal agency. Also, I have no conflicts of interest to disclose regarding today's presentation. I'd like to acknowledge the organizations involved in developing and studying WHAM. One is the Georgia Mental Health Consumer Network with Sherry Jenkins Tucker, Jackie Wolfgang, and their colleagues. Another is the Appalachian Consulting Group with Ike Powell and Larry Fricks. And a third is the Georgia Department of Behavioral Health and Developmental Disabilities with Wendy Tigreen. The three community mental health agencies where we taught WHAM were also critical. They are Community Friendship in Atlanta, Thresholds in Chicago, and Trilogy Behavioral Health Care, also in Chicago. Today's learning objectives include, first, becoming familiar with WHAM's purpose, content, and organization. Second is developing an understanding of how WHAM teaches people to enhance their health and well-being through goal-setting, weekly action planning, peer support, and science-based principles of resilience and whole health. And third, you'll discover how you can access more information about WHAM and how to become trained and certified to deliver it. WHAM is designed to help people with mental health and substance use challenges enhance their physical health and wellness. It was developed by people in behavioral health recovery and is designed to be co-taught by two trained peer specialists. It uses a peer support, recovery-oriented approach to help people create new health habits based on their interests, strengths, and abilities. This last point is very important. A central feature of WHAM is that it doesn't focus on eliminating bad habits, but instead it shows people how to build new healthy habits of their own choosing. WHAM has five essential components. The first is a person-centered health goal that people create after receiving education about whole health and resiliency. Second is a weekly action plan of small steps that lead toward goal achievement. A daily personal log helps people keep track of and document these steps. At weekly WHAM support groups, people discuss their progress toward goal achievement and receive support for healthy lifestyle changes. This also occurs during one-on-one meetings with a peer specialist. Here are the topics people learn about as they are choosing their goal. These include restful sleep, healthy eating, physical activity, managing stress, service to others, the value of a support network, the role of optimism in health, how to avoid negative thinking, spirituality, and having meaning and purpose in one's life. One key learning in WHAM is the relaxation response studied by Herbert Benson and colleagues at Harvard's Benson-Henry Institute. The relaxation response is an essential resiliency tool that engages the parasympathetic nervous system in order to relieve stress. Participants learn how stress affects the body, increasing blood pressure, heart rate, breathing speed, and blood vessel constriction, and the negative effects on the body of these responses over time. They learn to use relaxation techniques that counter these effects through combining meditation, controlled breathing, and muscle tightening and release. They also learn about research showing that the relaxation response improves health conditions caused by or exacerbated by chronic stress, such as fibromyalgia, insomnia, hypertension, and others. Another key learning in WHAM is dealing with negative self-talk to create a sense of optimism flowing from positive expectations. Participants first learn about the well-documented link between a positive frame of mind and good physical and emotional health. They also learn how negative thinking is enhanced and perpetuated in a spiral that leads to self-reproach and inertia. Then participants learn a strategy from cognitive behavioral therapy called catch it, check it, change it to reframe negative self-appraisals by comparing them with factual reality. So instead of my skirt is too tight, a fact, leading to a negative self-appraisal, I am fat and ugly, people learn how to replace the appraisal with a reality statement, such as I have other skirts that fit well, or if I move the button, the skirt will look much better. This reliance on fact interrupts the negative thinking spiral and replaces it with a sense of gradually increasing optimism based on positive expectations. In this case about becoming healthy. Yet another key component of WHAM is the impact goal setting process. I'm sure many of you are familiar with the concept of structured goal setting from positive psychology as a strategy for health behavior change. WHAM participants are helped to identify a goal that improves their health, is measurable, is positively stated, is achievable given their current life circumstances, calls forth behaviors, and can be completed within the class time period. Once people have chosen their health goal, they create a weekly action plan consisting of small steps toward that goal that can be accomplished in the next seven days. They also rate their level of confidence in being able to carry out their plan on a scale from 0 to 10. They share their plan and confidence rating and get supportive feedback. Then the following week they report back to the group or in their individual meeting on the success of their action plan. They get support regardless of their level of success or failure and then decide whether to continue their plan for the next week or revise it. Use of this motivational interviewing strategy is designed to create small successes, help people be realistic about their potential for behavior change, and provide the structure for forward movement toward goal attainment. Let's take a look at a sample health goal and action plan to illustrate this process. This individual ate junk food at pretty much every meal. Pop tarts for breakfast, frozen burritos from the dollar store for lunch, and fast food hamburgers or fried chicken for dinner. He had the goal of adding two nutritious foods to his diet three times a week that he wanted to accomplish by the end of WAM classes. Notice that this goal met the requirement of being positively stated. He didn't say, I'm going to stop eating junk food, for example. It was also measurable, involved actions, would improve health quality, and met other impact criteria that I just described. There were a number of action steps needed and the first was to get ideas about what would be nutritious but also something he really wanted to eat. So he was going to check out a book from the library about low-fat, low-salt diets. He needed to be able to afford these new foods so he had to find a reasonably priced local grocery store. His plan was to buy ingredients that enabled him to add one nutritious food to one of his meals during the coming week. He also had some affirmations about healthy eating that he found online and was going to repeat these to himself once a day. They included, I am worth the time and money I invest in my health, I'm learning new things that heal my body one step at a time, and healthy food tastes great and nourishes my body. Another participant was a woman who was obese and very sedentary. Her goal was adding a 30-minute walk to her daily routine every other day by the end of WAM classes. Her action plan showed what a great planner she was. She really got the concept of action steps down to deciding what shoes and clothes she could wear to be comfortable and getting these ready each day. She lived in a She wanted to find a friend willing to walk with her and wanted to invite that person to take two 15-minute walks in the coming week. She also wanted to practice the relaxation response whenever she felt anxious about leaving the house. She also wanted to practice the relaxation She also wanted to practice the relaxation response whenever she felt anxious about leaving the house. Completion of WAM's daily log reminds people to think about their goal and action plan every day. They're asked to record anything they did that day to further their goal, as well as the amount of effort it took and any obstacles or facilitators they encountered. This serves as a record that the person can look back at to see exactly what they did or didn't do to accomplish the steps in their weekly action plan. It also helps them identify what might be getting in the way of these steps and figure out how to address these hurdles with the help of the group or in individual sessions. When people report on their progress each week, they refer to both their daily logs and their action plan to describe what they achieved. Now that you've learned about the content of WAM and some of its active ingredients for health behavior change, I'll describe the format of WAM that we tested in our research. It involved weekly group and weekly individual sessions that ran for three months. Starting with the group meetings, these were led by peers trained to deliver WAM by trainers from Appalachian Consulting Group. The first three group sessions lasted two and a half hours. This allowed time to educate participants about what whole health is, how to develop whole health goals and action plans, and how to give and receive peer support. Sessions 4 through 12 lasted for 90 minutes and included special health and recovery topics such as the power of peer support, how to talk to your doctor, and how to recognize recovery. At the end of session 12, a graduation ceremony was held at which participants received a certificate and enjoyed a healthy dessert to celebrate. They were encouraged to invite friends and family members to graduation and given an opportunity to address the group, reflecting on what they had learned from WAM and any changes they had made in their health and wellness. The individual sessions occurred with one of the two teachers on a day following each week's group meeting. The first three one-on-one sessions lasted about 45 minutes. This allowed time for the participant and teacher to build a supportive trusting relationship and also provided an opportunity to take the information learned in group sessions and personalize it for the participant. It also helped clarify any information from group sessions that participants found confusing or had questions about. For those who wanted it, this also was a time for additional peer support around issues related to mental health, physical health, and other life areas. The remaining individual sessions lasted for 15 to 20 minutes and in addition to the other activities described, these sessions helped promote continued engagement in WAM. Another part of the individual meetings were weekly health check-ins. These were used to see if there were upcoming medical appointments and discuss how to prepare for them. It created opportunities to help people plan what they wanted to say to their doctor and make a list of any questions or concerns they wanted to raise. Also discussed was whether the person might need to see a primary care doctor or other health specialist and how to make that happen. Next, I'd like to tell you about our randomized controlled trial study of WAM and what we found. We recruited 137 research participants from the Atlanta and Chicago programs and we randomly assigned 68 of them to WAM and 71 to Services as Usual. The Services as Usual participants also received a gift card and a health manual for men's or women's health. Then we conducted three months of WAM group and individual meetings. Everyone in the study completed paid interviews when they entered the research and then again at three and six months later. We also collected attendance data and assessed fidelity, which I'll describe in a minute. We measured four participant outcomes. The primary outcome was improved patient activation for health care. This refers to people's knowledge of health management skills and their belief that they are responsible for their health. It also includes proactively monitoring how they feel and taking action to stay healthy even during times of stress. Level of activation has been shown to predict better medical outcomes, lower use of emergency and inpatient services, and better treatment adherence. We also measured three secondary outcomes. One was people's rating of their general physical health. This has been shown to predict mortality and other objective health indicators. Another secondary outcome was how hopeful they felt about their future and their ability to influence that future. Prior research has shown that higher scores on measures of hope are associated with better physical health and psychological adjustment. Finally, since research shows that health has a strong positive influence on the likelihood of employment, we measured whether people were engaged in any paid work. We also measured how satisfied WAM participants were with the intervention overall and with specific features that it contained. Fidelity refers to making sure WAM is being taught the way people have been trained to deliver it. It measures delivery of the intervention content using the prescribed teaching activities and instructors adherence to the interventions principles, like adding a new health habit rather than stopping a bad one. This is important whether or not you're doing a research study. We measured fidelity in two ways. One was the use of checklists for each session that were completed with teachers within 48 hours after the session ended. The checklist measured whether each session's topics, teaching methods, and time frames were used. The checklist score was the percentage of required features that were present for each session. So, a score of a hundred percent meant that all of the topics, teaching methods, and time frames were followed. Fifty percent meant that half of them were, and so forth. The second way we measured fidelity was through session recordings. With participants permission, reviewers listened to audio tapes of randomly selected group and individual sessions to judge whether the principles of WAM were being followed. They also completed the checklists to see whether the checklist ratings done by the teachers were accurate. Our fidelity results showed that teachers delivered WAM with a high degree of fidelity, averaging 97 to 100 percent. This was true across the three community agencies where it was taught, across the seven separate sets of WAM classes that were held, and across the different session numbers of WAM. Fidelity scores were shared with the teachers at our weekly supervision meetings, and we conducted refresher training if we noticed any problems with fidelity. These supervision meetings also gave us a chance to review attendance and study retention numbers with the teachers. It gave the teachers a chance to discuss any logistical challenges and participant issues they were encountering, and to receive support for these challenges. Here's a look at our study participants characteristics. Around half were female and half male. Two-thirds were African-American, and around a third were white. Most had completed high school or a GED. Most were not married or in a relationship. Very few were working, and most lived alone. Half had annual incomes that were less than $10,000 per year. Their average age was 51 years, and this ranged from our youngest participant, who was 24 years old, to our oldest participant, who was age 73. Close to half had diagnoses on the schizophrenia spectrum. Around a third had a bipolar disorder. 17% had major depressive disorder, and the rest had a variety of disorders. All had a health problem they wanted to work on. That was an inclusion criterion for the study. 93% reported a specific physical condition, illness, or disease. Over a third, 37%, had received treatment for a substance use disorder. In our multivariable analysis of outcomes over time, we found that WAM participants showed significantly greater improvement than the control group in each of our outcome areas. They improved more in patient activation, meaning that they were better able to proactively monitor and manage their health. They also rated their physical health significantly better than those in the control group. They were significantly more hopeful about their ability to influence their futures, and this is interesting because of WAM's desire to enhance optimism and hopefulness. They were also more likely to be gainfully employed. While this was a significant increase, it wasn't a huge proportion who were employed at the end of the study, and this leads us to believe that WAM, combined with evidence-based practice-supported employment, might be mutually reinforcing. Finally, the research was recently published in the journal Psychiatric Services. They were also very satisfied with their WAM experience. Overall, 97% said that they were very or somewhat satisfied with WAM. 97% said that they liked learning new things about whole health. 93% said that they liked receiving peer support. 97% said they liked setting manageable health goals. 98% liked the support group meetings. And a somewhat smaller percentage, but still overwhelmingly positive, 83% liked the individual meetings. When we asked participants to compare their health before and after WAM, almost two-thirds rated their health as better. A third said it was around the same, and 4% felt their health was worse. One of the major challenges of offering WAM is recruitment. Recruitment into any health intervention can be challenging, and this is especially true for people who have multiple co-occurring health conditions and don't feel in control of their lives. Many have had bad experiences in the past with trying to change their health lifestyles and are reluctant to try again. This can make recruitment a formidable challenge, and I'd like to share some strategies that we found to be effective. We held meetings to introduce WAM where we emphasized that people wouldn't be asked to change their personal habits. Instead, they'd be choosing new things that they enjoyed and really wanted to do. We also stressed that people wouldn't be pressured to do things they didn't feel capable of doing. And we talked about how WAM's approach to reaching health goals is different because it uses science based on whole health and resiliency factors. We also emphasized that people wouldn't be judged and could change their goals if they weren't working out. Another effective recruitment strategy is using your existing relationships with potential participants to personalize specifically what they can get out of WAM. For example, one man wanted to be able to dance at his granddaughter's wedding. When he realized that he could select dancing as his health goal, he signed up for WAM immediately. Another woman wanted to look better in the dress she was wearing to her 20th high school reunion, but she adamantly did not want to diet. She was told that she could work instead on adding more nutritious meals to what she ate, which she found appealing, and she decided to join WAM. The idea here is to find out what people really want to do to enhance their whole health and explain how WAM can help them to do it. Another successful strategy is to use testimonials from WAM graduates who share their success stories and act as role models. You might consider recruiting from an integrated health program or clinic. This lets you connect how WAM can help people with the health issues they're already addressing. If you can get the nurses and other medical staff on board by explaining what WAM has to offer, you can have them encourage participation in their patients. Once people join, the next challenge is keeping them involved in WAM. In our research, people attended an average of 10 out of the 12 weekly group sessions, but we had to work very hard to make that happen. We offered make-ups for missed groups by covering the information during individual sessions. We found that if people fell too far behind, they fell out of step with their classmates and quit. We also used the individual sessions to encourage people who were having a great deal of difficulty adhering to their weekly action plan. One of the major problems that people have with their health goal setting is being too ambitious in deciding what they want to do. So it was important to help people that set a weekly action plan that they weren't able to achieve, not become discouraged, not think that they couldn't improve their health, but encourage them to see that they needed to change that weekly plan in order to accommodate what they were really able to do and capable of accomplishing. Helping people look back at the daily log was one way that we could make that happen. So for example, if a person had a weekly action plan that they really felt that they could do, and yet we look back at the log and saw that they didn't think about that plan each day, that the amount of effort that they devoted to the plan, and we asked people to measure that effort in terms of number of minutes they might have spent or number of times they might have done something. Having people concretize and count things was a way to show them that while they thought they might have wanted to do something, in actuality they didn't seem to be spending much time on accomplishing the action steps each week. Another thing the daily log was helpful for was taking a look at barriers as well as facilitators. Many people didn't realize that one of their major facilitators was getting social support. People tend to focus more on what barriers are going to be. Things like the cost of buying healthy food, or the cost of acquiring a swimsuit so someone can swim, or gym shoes that are appropriate for walking. They don't often connect that on days when they might have gotten social support for a goal that they were able to actually accomplish whatever was in their action steps. This was the case, for example, with the gentleman who was going to say healthy affirmations. He found that this was a part of his action plan that he tended to skip, but he also noticed that on times when he had good social interactions with other people, met with his family, attended another support group, he did say those daily affirmations. These individual meetings are a really important part of helping people delve into what might be facilitating as well as hindering the action steps in their weekly action plan. Some people were shy about sharing personal health information in a group, so we encouraged them to buddy up for extra peer support during and between sessions. We also used the one-on-one time to see what might be preventing attendance. We saw something that you're probably all familiar with, which was that transportation was a major hurdle. We encouraged attendance by arranging for people who were willing to give each other reminder calls or text the night before. We also encouraged carpooling and traveling together on public transportation. For those of you who are interested in training your staff or workforce to deliver WAM, the National Council for Behavioral Health offers training and certification by Appalachian Consulting Group trainers. Appalachian Consulting Group, run by Ike Powell and Larry Fricks, who are people in recovery, created WAM, wrote the manuals, and provide the training through the National Council. For those of you who are interested, I've provided a web link for further information about this training. It does cost, but the cost is negotiable, and I encourage you to click on this link to learn a little bit more about how to get the official training and certification in order to be able to teach WAM. You can also access the research version of WAM that we tested at my center. The instructor and participant manuals are included in my center's solution suite. This is a set of integrated health and self-direction interventions. There are 18 products available for free download, and each product includes an overview of the intervention, a podcast on how it's been used, a how-to training webinar with slides that you can view, and you can click on a button to request technical assistance in using it or teaching it to others. I've included the link to the WAM page on this slide. I do want to remind you, however, that anyone teaching WAM should be trained and certified by Appalachian Consulting Group or someone trained by them if you want to be able to achieve the kinds of outcomes that we achieved in our study and offer the evidence-based version of WAM. Next is my contact information, and I'd like to encourage you to visit the website of the Center on Integrated Healthcare and Self-Directed Recovery for this and other resources. Also, to check out the 18 free products with free podcasts and training webinars in the Center's Health and Recovery Solutions Suite. And again, that Solutions Suite includes the research version of WAM. Please consider following the Center on Twitter to receive announcements about WAM, WAM research, and other recovery topics. I want to thank you for listening today. Now, I'll turn it back over to John for questions and discussion.

Whole Health Action Management

peer-delivered wellness self-management program

mental health

substance use challenges

physical health

goal-setting

peer support