Implementing Recovery Oriented Interventions

with Diverse PopulationsPiper S. Meyer, Ph.D.

University of North Carolina at Chapel HillUSA

Special Thanks:

Susan Gingerich, MSW

Kim Mueser, Ph.D.

Kerry Arnold

Overview Focus on challenging populations

• Cognitive impairments and developmental disability

• Persons on an inpatient unit

Defining Recovery

Strategies to implement recovery and adaptations for challenging populations• Recovery goals

• Motivational Strategies

Integrating recovery in treatment• IMR as an example

IMR and Diverse Populations

Inpatient units

• Long and short-term

• Forensic

Persons with Developmental Disabilities

Outpatient settings

• Persons with cognitive impairments

Recovery Challenges-Inpatient units

Too sick to understand or believe in recovery.

Too symptomatic to pay attention.

Not enough time to make any progress while they are here.

• Just focus on getting them out of the hospital.

They will just come back here in a week.

Once they go back to the community no one to follow-up with recovery

Just another phase like many of the other treatments that have been implemented.

This conflicts with current treatment protocols.

Recovery Challenges-Developmental

Disabilities Too difficult a concept to understand.

Difficult to remember and track progress.

Some problems with attendance

Difficulty understanding even basic concepts

Problems staying on topic

Giving very brief answers

Directing most comments to class leader

Limited interaction among class members

Challenges to the Recovery Model in Diverse Populations

Helping persons understand recovery• Taking ownership for their recovery

Finding a role in personal recovery

Integrating recovery in treatment and life

Educating practitioners about recovery • Helping practitioners identify a role in the

recovery process

Working within a symptom-focused climate

Recovery can be a SUCCESS

Despite these common challenges we have been able to implement recovery:

• Short-term inpatient unit with and without successful IMR implementation

• 2 different facilities with persons with developmental disabilities

• Helped re-write simplified handouts

• Long-term inpatient units with the most difficult clients

Defining Recovery

What is Recovery?

Do you believe in Recovery?

Even for the most ill, symptom impaired, high needs, filled with pain and anguish person you work with?

What is Recovery?

Outcome?

Process?

Both?

One definition of Recovery

“Recovery is a process, a way of life, an attitude, and a way of approaching the day’s challenges. It is not a perfectly linear process. At times our course is erratic and we falter, slide back, regroup, and start again. . .

Patricia Deegan (1988)

…The need is to reestablish a new and valued sense of integrity and purpose within and beyond the limits of the disability; the inspiration is to live, work, and love in a community in which one makes a significant contribution.”

Marie

What roles are important to me to think of myself in recovery

Marie

illness

Family

Friends

Values&Beliefs

Spirituality

SchoolP

olitics

Wo

rk

Cul

ture

SexualityHopes&Dreams

Goal of IMR:

Putting the Person in the Center

IMRIM

R Supporters

Recovery in Diverse Populations

Important to consider all possible roles in person’s life

Consider how person can take ownership over recovery What are the areas that are most important?

Strongly emphasize there is more to a person than his/her illness

Keep coming back If person unable to discuss it the first attempt,

wait a few days and try again

Challenge-staying on topic

As much as possible, stay with content of the handout

Write topic on flip chart or whiteboard

Validate clients’ responses, but bring back to the topic of the day

Direct clients to main points (or pictures) on flip chart or white board

Use consistent format for structure and timing of each class

Recovery & Hope

“If people are treated as capable, they often surprise

everyone and live up to expectations.”

• Ken Steele “The Day the Voices Stopped.”

In IMR

People define what recovery means to them, as individuals.

People set their own personal recovery goals.

Strategies to Implement Recovery

Benefits of pursuing long-term meaningful goals

What happens if a person has no goal?

Goals can: Provide a sense of purpose and feeling of control

Improve self-esteem and confidence

Add structure and meaning to daily lives

Help learn to better use time

Help cope better with problems

Involve engaging with other people

(Lyubomirsky, 2008)

Goals and Challenging Populations

Don’t need to be complicated

• Begin with 1 short-term goal with 2-3 simple steps

• Think about something they can feel good doing immediately

• Add structure/purpose to the day

Share these with everyone involved in treatment

• Celebrate successes

• Build on motivation

Challenge-improving attention and

comprehension Help clients understand how topic relates to them

Keep our speech simple and brief

Check in every 3 to 5 sentences to make sure clients are understanding

Use examples and “illustrations” or “demonstrations”

Stay focused on one topic at a time

Ask clients to repeat what they heard in their own words

Recovery Goals Individualized

Personally meaningful

Range from the modest to the ambitious

Exploration of personally meaningful goals often needed to engage consumer before introducing IMR program

IF the person has participated in treatment

a long time: Help clients to understand:

• Setting a recovery goal is not treatment as usual.

• Setting a a recovery goal has nothing to do with what they think you the practitioner want them to say.

• Instead, it has everything to do with what is important to them in their life.

Educating Practitioners and Clients about Recovery

How to discuss recovery?

• Definitions

• Individual recovery goal

Taking ownership

Making goal achievable

Commitment to goals begins with goal setting

• Follow-up in every session

Challenges

People are too “sick”

• Set goals on short-term inpatient unit for 80% clients within 24-48 hours of admission

People don’t understand recovery

• Developed concrete goals for persons with developmental disabilities and cognitive impairments

Goals will be outrageous or unreachable

• Goal can be individualized to be both achievable and reasonable given current situation

Recovery Goals Determine if the person is ready to

work on the goal.

Insure that the goal is important to the person

• Freely chosen

Determine if the person is confident they can achieve their goal.

Enlist support in achieving their goal

Used to explain conditions that foster intrinsic motivation

Why is that important in recovery?

Intrinsic motivation/optimal functioning occurs when psychological needs of autonomy, competence, and relatedness are met.

• Self-motivation less likely when needs are thwarted

People who are intrinsically motivated show better

• Performance, creativity, self-esteem, vitality, and general well-being

Self-Determination Theory

Strategies to increase motivation

Encourage ways to make goals more interesting

Remind client how much goal is valued

Help client identify with the goal

Help client find meaning in the goal

Find ways to make the steps toward achieving the goal more rewarding

Increase commitment toward goals Make a public commitment

Encourage follow through(Lyubomirsky, 2008)

Strategies to increase motivation cont’d

Create confidence for change Encourage person to just try it out

Be flexible Modify as needed

Normalize the goal process

Break down into even smaller steps Help to create a plan with concrete steps

(Lyubomirsky, 2008)

Implementing Recovery in

Diverse Populations

Recovery Strategies Helping individual define what recovery

means to him or her

Identifying areas of his or life that are satisfying, and areas that are not satisfying

Choosing an area of life that is not satisfying and identifying a meaningful goal in that area

Breaking down that goal into manageable steps

Example-Modification of

Recovery Strategies for Inpatient Unit

Tips for Introducing Recovery

Define recovery

• Or what is a “big deal”

• Living a happy, healthy life, what would that look like?

Review the different areas of satisfaction and identify discrepancies

• Identify area that are most important

How could this look different

working with a challenging population?

IMR Personal Goal Tracking Sheet

Name:___Jacob____________ Date Personal Goal Set:___7/29/09_________ Personal Goal: To have a conversation with my brother First Short-term Goal related to achieving your Personal Goal:

1._Have at least 1 conversation per day _________________

Steps: 1. _Make a list of coping skills for when I feel stressed Completed ____

2._Practice using a coping skill when I am around others Completed ____

3._Review steps of skill for starting a conversation__ Completed ____

4._Practice starting a conversation at least once a day_ Completed ____

Goal Follow-up: It’s important to track how your goals are going. Please check off the steps you have completed on your first short-term goal. Then write down your new steps below. Next or New Steps:

Steps: 1. ____________________________________ Completed ____

2.____________________________________ Completed ____

3._____________________________________ Completed ____

4._____________________________________ Completed ____

And if goals had been followed up

on?

IMR Personal Goal Tracking Sheet

Name:___Jacob____________ Date Personal Goal Set:___7/29/09_________ Personal Goal: To have a conversation with my brother First Short-term Goal related to achieving your Personal Goal:

1._Have at least 1 conversation per day _________________

Steps: 1. _Make a list of coping skills for when I feel stressed Completed _X_

2._Practice using a coping skill when I am around others Completed ____

3._Review steps of skill for starting a conversation__ Completed ____

4._Practice starting a conversation at least once a day_ Completed ____

Goal Follow-up: It’s important to track how your goals are going. Please check off the steps you have completed on your first short-term goal. Then write down your new steps below. Next or New Steps:

Steps: 1. _Practice deep breathing when I am around others Completed ____

2._Say Hello to 3 people on the unit each day_____ Completed ____

3._Make a list of topics to talk about with brother Completed ____ with a staff member 4._Review steps of starting a conversation with brother Completed ____ with a staff member

Example of poster for Inpatient unit

describing treatment

Illness Management and Recovery: Coping With Stress

How can coping with stress help you?

Monday Class-What is Stress

• Goal-To identify at least one situation that you find stressful

Agenda

1. What is Stress?

2. What kinds of situations make you feel under stress?

3. How do you feel when you are under stress?

Ideas for Skills Practice

1. Describe a stressful situation that occurred over the past couple of days.

2. Make a chart to track stressful events over the next 2-3 days. Include information about the

situation and how you felt before and after the event.

Tuesday Class-Signs that You are Under Stress• Goal-Identify at least 1 sign you are under stress

Agenda

1. Different signs of stress-physical and emotional

2. Stress can also affect thinking, mood, and behavior

3. Become aware of your own signs of stress.

4. Did you have any signs of stress in the last few days? If yes, what were they?

Ideas for Skills Practice

1. Briefly describe a sign of stress that you experienced recently.

2. Fill out the Signs of Stress Checklist.

Wednesday Class-Preventing Stress

● Goal-Identify at least 1 strategy you can use to prevent stress

Agenda

1. Figure out at least one situation that is stressful to you or has caused you stress in the past.

2. What is a strategy for handling the situation so that it won’t be as stressful in the future?

3. Develop a routine of doing activities that you enjoy.

4. What activities do you enjoy doing or find relaxing?

5. How can you participate in this activity more often?

6. Who would you feel comfortable talking to if you feel you are under stress?

Ideas for Skills Practice

1. Choose a strategy for preventing stress. Write down the strategy and note when and where

you plan to use this strategy over the next few days.

2. Try out a a new strategy for preventing stress. How did it go?

Stress is the feeling of pressure or tension that comes from dealing with challenging

situations

Being aware of signs of stress can help you take steps to prevent it from getting worse.

Thursday Class-Strategies for Coping With Stress

● Goal-Identify at least one strategy you can use to cope with stress.

Agenda

Strategies for coping with stress:

1. Talk to someone about the stress that you have been feeling.

2. Use positive self talk, for example, “This is hard, but if I take this one step I can do it.”

3. Do meaningful activities.

Ideas for Skills Practice

1. Choose a strategy for preventing stress. Write down the strategy and note when and where

the you plan to use this strategy over the next few days.

2. Try out a a new strategy for preventing stress. How did it go?

Friday Class-Relaxation Strategies

● Goal-Use at least one relaxation strategy in session (relaxed breathing, muscle relaxation, or

imagining a peaceful scene) and identify a situation where using the coping strategy may help you

cope with stress

Agenda

1. Go through the steps of at least one relaxation strategy (relaxed breathing, muscle relaxation, or

imaging a peaceful scene)

2. What is an example of a common situation in your life when you could use relaxed breathing,

muscle relaxation or imagining a peaceful scene to help with tension in your body?

Ideas for Skills Practice

1. Practice the relaxation strategy (relaxed breathing, muscle relaxation, or imaging a peaceful

scene) with a staff member.

2. Make a plan to practice muscle relaxation on your own. Write down and note when and where

you plan to use this strategy in the coming week..

Additional Class-Making a Plan for Coping with Stress

● Goals-Identify what strategies are helpful to you to cope with stress and develop an individual plan

for coping with stress.

Agenda

1. What strategies are helpful to you when you are feeling stressed?

2. Fill out the Plan for Coping with Stress including the sections: stressful situations I am aware of,

signs that I am under stress, my strategies for preventing stress, and my strategies for coping with

stress once it happens.

3. Role play how you will use your plan.

Ideas for Skills Practice

1. Make a plan to do something from your “Coping with Stress Plan.”

2. Role play how to use a strategy in your plan.

What approaches are effective?

Small groups (or one-to-one)

Opportunities for repetition of main points and skill building• Increased session frequency

Assistance with generalization

Multiple sources of reinforcement

Effective Interventions, cont’d

Hands-on assistance with practice in both session and home settings

Calling on concrete versus abstract thinking

Focusing on functional skills application

Modifications to IMR

Agency treating individuals with developmental disabilities

• Developed easier to read handouts and clinical guidelines

• Developed homework sheets to guide the supporter

• Supporters for each individual in group

• Attended every group and took notes

• Practiced skills with individual and helped with homework

Modifications to IMR

Short-term inpatient settings

• Goals set within 24-48 hours admission

• Goals set individually using simplified method

• Goal-follow-up daily

• Steps can be completed on the unit

• Handouts for persons cognitive impairments

• Focus on key modules/information

• Integration with all disciplines

Recovery not limited to group sessions

Look for opportunities to incorporate into:

Assessments Rounding and check ins Treatment groups One-to-one meetings Family meetings Evening and weekends Responding to challenging situations Discharge planning

Recovery-What have we learned?

Defining recovery is possible given the right tools and being persistent

Develop goals that are achievable

• Steps that are successful while in treatment

• Given the situation and resources

• Build on success

Always follow-up on goals

Incorporate goals in all areas of treatment when possible

Recovery-Next Steps

How can recovery become self-sustaining?

Peer led movements

Working with forensic populations

• Implementing within restrictive environment

Concluding Remarks

Recovery is individualized

Implementing treatment using a recovery orientation takes practice

Recovery can be integrated at all levels of treatment