LEAP® Course & Train-the-Trainer Course
The science is clear and unequivocal, the number one reason that people with severe mental illness (SMI) do not accept help or treatment is due to a “lack of insight” into being ill, otherwise known as anosognosia—a neurological symptom that leaves a person unable to understand that s/he is ill, consequently becoming non-compliant, treatment resistant, and isolated. Anosognosia causes refusal of, or inconsistent, treatment, worsening of symptoms over time, deterioration in long-term prognosis and other devastating outcomes: i.e., repeated cycle of involuntary hospitalizations followed by noncompliance then relapse, criminalization, poorer psycho-social functioning, increased aggression, homelessness, and suicide (DSM IV-TR, American Psychiatric Association Press, 2000; DSM-V, American Psychiatric Association Press, 2013).
Despite the nearly three decades of anosognosia research and evidence, there continues to be a gap of education available to help professionals and family caregivers to address this pervasive symptom and the obstacles it creates. To worsen the problem, the “usual psycho-education approach” continues to drive people suffering from these neurological illnesses away from family and professional help. However, a new hands-on approach has been pioneered by Dr. Xavier Amador, internationally renowned clinical psychologist, published clinical researcher, forensic expert, best-selling author of I AM NOT SICK, I Don’t Need Help and family caregiver of relatives with schizophrenia and bipolar disorders.
LEAP (Listen-Empathize-Agree-Partner)® is a set of evidence-based practices that create therapeutic alliances and trusting relationships with people suffering from severe mental illness. Designed to build and strengthen mutual respect, it helps people who are non-adherent, or partially adherent, to become more cooperative and engaged in treatment and services, including medication, psychotherapy, psychosocial programs, club houses, peer-support, and supervised housing. The mission of The LEAP Institute is to transform the healthcare, educational and government systems by providing evidence-based education, training and ongoing support to individuals and organizations involved in the care and safety of people suffering from severe mental illness, including:
- Mental Healthcare Professionals
- Criminal Justice Professionals
- Peer Support Specialists
- Family Caregivers
The LEAP Program educates about much more than the LEAP® communication technique.
THIS PROGRAM EMPHASIZES SCIENCE-BASED EDUCATION ABOUT:
- How to offer long acting treatments
- Signs and symptoms of SMI and what they predict
- Suicide prevalence and prevention
- Risk of violence in SMI
- The problem of noncompliance with treatment(s)
- The use of long-acting injectable antipsychotic medications
- Criminalization of persons with mental illness
- Research on the therapeutic alliance in SMI
- Resources for families, healthcare and criminal justice professionals
- Research on how to help someone with SMI accept treatment and services
To date, tens of thousands of individuals worldwide have attended facilitator-led courses and been trained on the LEAP® approach in a one-day LEAP® Course or certified as LEAP® Trainers in a two-day Train-the-Trainer Course, to teach within their organizations and communities.
Once trainees learn the truth about what causes “denial” they stop trying to convince the person of something that is impossible for them to see and focus on using communication tools to develop a collaborative relationship that leads to treatment and recovery.
Scope of the Problem
Poor and partial-adherence to treatment presents staggering obstacles to recovery. It is associated with a poorer course of illness, increased involuntary hospitalizations, suicide, poorer subsequent response to treatment, estrangement and discord with caregivers and providers, criminal behavior, and failure to reach optimal levels of recovery. In light of the tremendous advances made in the treatment of schizophrenia and bipolar disorder, the tragedy of both untreated, and inadequately treated, mental illness is compounded. The urgency to implement strategies that optimize adherence and recovery has never been greater.
Non-adherence rates in schizophrenia and bipolar disorder continue to hover around 50% while partial adherence rates are even higher (75%). Considering that millions of people either flat out refuse to participate in treatment, or if they do, practice only partial-adherence, the “real-world” effectiveness of both the older, and more promising newer treatments, is abysmal.
The symptom of lack of awareness of illness (a.k.a. “anosognosia” see DSM IV-TR and DSM-V, APA Press, 2000, page 304, and APA Press, 2013, page 101) is very common and among the top predictors of poor adherence to treatment. After all, who would want to take medication for an illness they did not believe they had? Research shows that poor insight is among the top predictors of poor adherence, far more predictive than the person’s experience of side effects. Although recent innovations in drugs used to treat these disorders have addressed many of the limitations of traditional antipsychotic medications (e.g., severity of side effects, aspects of cognitive dysfunction), they still do not deal with the problem of poor adherence to treatment.
Improving Insight and Adherence
Unfortunately, medications do not appear to improve the level of insight, on the other hand, LEAP® has been found to predict improved adherence, more positive attitudes about treatment and satisfaction with treatment (Paillot, et. al., 2009). More recently, studies testing the efficacy of such interventions using psychiatric nurses and family members in patents with schizophrenia suggest that extensive professional background is not needed to be effective. For example, training caregivers in the LEAP® approach is especially effective as there are many more opportunities for interaction than is afforded providers. Furthermore, maladaptive communication patterns in the family are usually improved reducing expressed emotion, discord, and estrangement. This, in turn, is associated with reduced risk for relapse.
Because of poor insight into the illness and poor adherence to treatment many persons with schizophrenia and bipolar disorder exist at the margins of society and are unable, or oftentimes unwilling, to utilize available drug therapies and services. A set of communication and problem-solving skills that can be used by mental health providers, care-givers and other stakeholders can be readily learned by participating in the LEAP® training program.
LEAP® Course | OUTLINE
The LEAP® Course is a one-day facilitator-led training workshop designed to provide participants the (A) critical research and (B) skillset required to create a therapeutic alliance and build a collaborative relationship with persons who have severe mental illness, that lead to the acceptance of treatment and services.
The success of the LEAP® approach rests on three pillars:
1. Person-Centered Focus: Developing a new relationship with the person that focuses exclusively on problems that the “patient” perceives.
2. Treatment Team: Breaking down the barriers that keep the healthcare provider, family caregivers, other stakeholders (law enforcement, judges, probation, attorneys), and consumer from functioning as an effective team.
3. Common Goals: Finding common ground between team members and the consumer, that can be shaped into goals that will be worked on together.
Research on Poor Insight and Engagement in Treatment
Participants will be introduced to the empirical research on the prevalence, etiology and treatment of both poor insight and poor adherence. Although largely didactic, the workshop is interactive in that participants are repeatedly queried to assess and highlight misconceptions they hold about the causes and treatment of poor insight and poor adherence.
SKILLSET AND TOOL OVERVIEW
Participants will learn the following skillset and evidence-based “7 LEAP® Tools of Communication”
• Listen reflectively to delusions, anosognosia, and desires without any judgement and instead communicate genuine respect.
• Strategically express empathy without reality-testing and actively normalize the person’s experience.
• Identify areas of agreement; agree to disagree.
• Quickly form partnerships and move forward to achieve common goals (ultimately linked to acceptance of treatment and services).
• Respectfully delay giving contrary opinions and redirect conversation.
• Give recommendations and non-judgmental opinions in a manner that communicates respect and results in trust.
• Apologize for words and actions that harmed the relationship.
Participants will learn to:
- Distinguish between anosognosia vs “denial” of mental illness (i.e. schizophrenia, bipolar disorders)—a debilitating symptom prevalent in 50% of individuals with these disorders.
- Utilize evidence-based approaches, set aside psycho education and logical arguments, and instead focus entirely on developing a relationship with the mentally ill person so s/he feels respected, not judged and trusts the other person’s opinion that treatment would be beneficial to reaching personal goals.
- Name the most effective forms of frontline treatments and pharmacotherapy on improving insight for person with anosognosia.
- Preserve and build on relationship/ alliance when disrupted by disagreements, paranoia,involuntary treatment, etc.
- Reduce anger, paranoia, and quickly gain cooperation and compliance.
- Collaborate with the mentally ill person to work towards common goals.
- Identify the “Top Two Predictors” of treatment adherence.
- Participant Course Manual
- The 7 LEAP® Tools Card
- Didactic and Experiential Roleplays
- Certificate of Completion
- Mental Healthcare Professionals/Prescribers, Psychologists, Social Workers, Counselors, Family Services Staff,Therapists, Nurses, Nurse Aids, Psychiatric Technicians, Clerical Staff, Peer Support Specialists, Crisis Response Workers, School-based Psychologists, and Caseworkers.
- Criminal Justice Professionals/Police/ Corrections/ Probation Officers, Crisis Intervention Team Members, Attorneys,and Judges.
- Family Caregivers and others involved in the care and safety of people suffering from severe mental illness.
The LEAP® Course has been certified as eligible for CEs, CMEs and other professional continuing education credits by a wide range of national and international credentialing bodies.
In 2018, the LEAP® Program was included in the Family Toolkit by
Substance Abuse and Mental Health Services Association (SAMHSA)
Train-the-Trainer (TTT) Course | OUTLINE
This interactive one-day facilitator-led workshop is designed to certify individuals to teach the LEAP® Course [see course outline] within their communities and organizations—providing families and professionals the knowledge and skillset to create collaborative relationships with persons who have severe mental illness, so they engage in treatment and services.
Pre-requisite: The LEAP® Course (one-day)
Participants will learn to:
- Teach the LEAP® Course, including the evidence-based “7 LEAP® Tools of Communication”.
- Present the course following its fidelity to the core program.
- Properly utilize the LEAP Course® Trainer Slides and Notes.
- Facilitate essential roleplays designed to (A) increase empathy for individuals with severemental illness, and (B) improve communication skillset.
- Debrief roleplays, identify best practices and reinforce learned skillsets.
- Field difficult and derailing questions and clinical scenarios.
COURSE SKILLS APPLICATION
- Roleplay Practice—Participants will apply their course skills through practicing, observingand interacting in didactics and experiential real-life roleplay simulations, designed to buildfirst-person experience of individuals suffering from severe mental illness.
- Feedback—Instructor immediately debriefs roleplays, provides feedback and identifies bestpractices with participants.
- TTT Application
Learn & Implement
- TTT Work Session
- Roleplay Simulations
- Review Training Video & Online Tools
- Conduct Practice Training (60 days)
- Receive Ongoing Support & Coaching
- Trainer Manual
- Study Resources & Online Tools
- Learn to LEAP® Training Video (4 Hour) provided on USB drive
- Didactic and Experiential Roleplays
- Certificate of Completion
- Trainer Certification Action Plan
Amador, X, Arango C, “Lack of Insight, Searching the Core of Psychoses.” (Guest Editors).Schizophrenia Bulletin, 37(1), 2011.
Amador, X, et al., “Awareness of illness in schizophrenia.” Schizophrenia Bulletin, 17(1): 113-132, 1991.
Amador X, Andreasen NC, “Awareness of illness in schizophrenia, schizoaffective and mood disorders.” Archives of General Psychiatry, 51(10):826-836, 1994.
Amador, X, I Am Not Sick, I Don’t Need Help! New York: Vida Press; 2000.
Amador, X, I Am Not Sick, I Don’t Need Help! How To Help Someone With Mental Illness Accept Treatment. New York: Vida Press; 2012.
Amador, X, I Am Not Sick, I Don’t Need Help! How To Help Someone Accept Treatment. New York: Vida Press; 2020.
Amador, X, & David, A. S. (Eds.). Insight and Psychosis: Awareness of Illness In Schizophrenia and Related Disorders (2nd ed.). New York, US: Oxford University Press; 2004.
Lasser, R.A., et al. A New Psychosocial Tool [LEAP] for Gaining Patient Understanding and Acceptance of Long-acting Injectable Antipsychotic Therapy, Psychiatry (Edgemont) 2009;6(4)
Amador X, Reshmi P, Defending the Unabomber: Anosognosia and Schizophrenia. PsychiatricQuarterly, 71(4): 363-370, 2000.
Arango, C, et al., Relationship of Awareness of Dyskinesia in Schizophrenia to Insight Into Mental Illness The American Journal of Psychiatry, 156:1097-1099, 1999.
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Diagnostic and Statistical Manual of Mental Disorders. 5th ed. Washington DC, American Psychiatric Association Press, 2013. Pg. 101.
Ihm, M, A Fidelity Study of Listen-Empathize-Agree-Partner (LEAP) with Assertive Community Treatment (ACT) Mental Health Clinicians, Columbia University, Dissertation Abstracts International, 2012.
Paillot, C. et al., Double Blind, Randomized, Controlled Study of [LEAP] A Psychotherapy Designed To Improve Motivation for Change, Insight into Schizophrenia and Adherence to Medication.Schizophrenia Bulletin, 35 (suppl 1): 343, 2009.
Tremeau, F, et al., “Insight and anosognosia of tardive dyskinesia in schizophrenia.”Schizophrenia Research, 24(1):273, 1997.
Young DA, et al., Unawareness of illness and neuropsychological performance in chronicschizophrenia. Schizophrenia Research, 10(2): 117-124, 1999.
Zygmunt, A, et al., Interventions to Improve Medication Adherence in Schizophrenia AmericanJournal of Psychiatry, 159:1653-1664, 2002.