Moving to Recovery

Assumptions…

• This audience – knows something about recovery principles

and person-centered care– is interested in moving from theory/values to

practical implementation strategies– wants to improve their skills

Objectives

• Recovery Principles • Literature Review• System Integration• Practical Tools• Handout-”Packet of Recovery Materials”

Recovery Principles

Recovery

• The 2005 National Consensus Statement on Mental Health Recovery from SAMHSA defines mental health recovery as:– a journey of healing and transformation

enabling a person with a mental health problem to live a meaningful life in a community of his or her choice while striving to achieve his or her full potential

Recovery - Hope

Recovery provides the essential and motivating message of a better future— that people can and do overcome the barriers and obstacles that confront them. Hope is internalized; but can be fostered by peers, families, friends, providers, and others. Hope is the catalyst of the recovery process. Mental health recovery benefits individuals with behavioral health disabilities by focusing on their abilities to live, work, learn, and fully participate in our society, and enriches the texture of community life.

Recovery - Self-DirectionConsumers lead, control, exercise choice over, and determine their own path of recovery by optimizing autonomy, independence, and control of resources to achieve a self-determined life. By definition, the recovery process must be self- directed by the individual, who defines his or her own life goals and designs a unique path towards those goals.

Recovery - Individualized and Person-Centered

There are multiple pathways to recovery based on an individual’s unique strengths and resiliencies as well as his or her needs, preferences, experiences (including past trauma), and cultural background in all of its diverse representations. Individuals also identify recovery as being an ongoing journey and an end result as well as an overall paradigm for achieving wellness and optimal mental health.

Recovery - EmpowermentConsumers have the authority to choose from a range of options and to participate in all decisions—including the allocation of resources— that will affect their lives, and are educated and supported in so doing. They have the ability to join with other consumers to collectively and effectively speak for themselves about their needs, wants, desires, and aspirations. Through empowerment, an individual gains control of his or her own destiny and influences the organizational and societal structures in his or her life.

Recovery - HolisticRecovery encompasses an individual’s whole life, including mind, body, spirit, and community. Recovery embraces all aspects of life, including housing, employment, education, mental health and healthcare treatment and services, complementary and naturalistic services, addictions treatment, spirituality, creativity, social networks, community participation, and family supports as determined by the person. Families, providers, organizations, systems, communities, and society play crucial roles in creating and maintaining meaningful opportunities for consumer access to these supports.

Recovery - Non-Linear

Recovery is not a step-by step process but one based on continual growth, occasional setbacks, and learning from experience. Recovery begins with an initial stage of awareness in which a person recognizes that positive change is possible. This awareness enables the consumer to move on to fully engage in the work of recovery.

Recovery - Strengths-Based

Recovery focuses on valuing and building on the multiple capacities, resiliencies, talents, coping abilities, and inherent worth of individuals. By building on these strengths, consumers leave stymied life roles behind and engage in new life roles (e.g., partner, caregiver, friend, student, employee). The process of recovery moves forward through interaction with others in supportive, trust-based relationships.

Recovery - Respect

Community, systems, and societal acceptance and appreciation of consumers —including protecting their rights and eliminating discrimination and stigma—are crucial in achieving recovery. Self-acceptance and regaining belief in one’s self are particularly vital. Respect ensures the inclusion and full participation of consumers in all aspects of their lives.

Recovery - Responsibility

Consumers have a personal responsibility for their own self-care and journeys of recovery. Taking steps towards their goals may require great courage. Consumers must strive to understand and give meaning to their experiences and identify coping strategies and healing processes to promote their own wellness.

Recovery - Peer Support

Mutual support—including the sharing of experiential knowledge and skills and social learning—plays an invaluable role in recovery. Consumers encourage and engage other consumers in recovery and provide each other with a sense of belonging, supportive relationships, valued roles, and community.

Community Care’s Recovery Goals

• Transforming the attitudes of all those who are directly or indirectly involved with the behavioral health system to believing that recovery is possible for all, empowerment and integration for all behavioral health consumers is essential, and shared decision-making at all levels is key.

Community Care‘s Recovery Goals

• Imparting knowledge to peers and staff regarding innovative and evidence-based practices to promote recovery.

• Building the skills of all stakeholders to promote effective recovery-oriented, consumer-driven services.

Community Care’s Recovery Focus

• A contract with Pat Deegan, Ph.D. & Associates, in partnership with Advocates for Human Potential (AHP).– To provide consultation and training on their

system-wide effort to implement recovery- oriented services at all levels of their behavioral health service system.

• Recovery education and training• RoadMap to Recovery• Steps of Recovery• Conferences

Community Care’s Recovery Philosophy

Community Care’s recovery philosophy is grounded in the belief that recovery from mental illness is not the privilege of a few, but a possibility for everyone.

Recovery Characteristics

Mental health systems that support recovery are characterized by:

• Consumer voice and choice.• Person-centered planning.• Evidence-based practices.• A skilled workforce including peer

specialists.

Recovery Characteristics

• Medical staff who are skilled in shared decision making.

• Community integration outcomes that include a job, home, transportation, and discretionary income.

Recovery Learning Community

• Includes web site (www.recoverylearning.com ), consumer advisory committee, on- and off-site technical assistance, an annual training institute, and special project development.

• Uses a high-tech, high-touch approach, to develop and deliver a shared learning opportunity, on-site technical assistance and mentoring, assistance with implementation efforts, and captures lessons learned.

Substance Abuse Recovery

• People, places, and things

• Shame• Self-medication• Substitute

addictions• Safety and anxiety

• Relevance of family and significant others

• Dual Diagnosis• Co-Dependence• Denial• Spirituality

Substance Abuse Recovery

• Must recognize the inter-relationship of the:– Individual– Environment– Substance

Substance Use Recovery is About:

• Feelings• Acceptance• Growth• Surrender• Trust• Willingness

• Spirituality• Freedom• Love• Life

A Definition of Recovery

• Recovery is a self-determined and holistic journey that people undertake and grow. Recovery is facilitated by relationships and environments that provide hope, empowerment, choices and opportunities that promote people reaching their full potential as individuals and community members.

-from “A Call for Change: Toward a Recovery- Oriented Mental Health Service System for Adults”

Mental Health Recovery

• Must recognize the inter-relationship of the:– Individual– Environment– Diagnosis

Influences on Recovery

• Degree of illness experienced.• +/- impact and/or intervention of others

including the Behavioral Health system.• Interaction with and/or reactions to:

– hospitalizations– medications– incarceration– interpersonal relations

Key Areas of Concern

• Access to good clinical healthcare.• Identifying and developing supportive

relationships.• Determining and accessing meaningful

activity.• Gaining personal power and control over

life.• Overcoming stigma.

Key Points of Recovery

• Developing strong relationships with caring, encouraging, hopeful people.

• Self-determination.• Self-monitoring and self-management.• Vocational activity and schooling.

Key Points (cont’d)

• Developing a sense of meaning and purpose.

• Knowledge and acceptance. • Self-help and peer support.

Partners in Recovery

• Consumer – Depends upon the clinician, family, and

community to provide the best possible services.

• Clinician• Family and community

– Supports in an anti-stigma environment– Housing, employment, peer support– Funding

Role of Clinical Care

• Traditionally focus was on illness and symptoms.

• Recovery embraces the individual’s strengths and focuses on wellness.

• Individual is a partner, another expert.• Clinician works side by side with consumer

to display respect.

Consumer Choice

• Consumers must know and understand that they are entitled to make choices regarding behavioral health services and supports they receive.

The Road to Recovery

• Consumer directed• Strengths based• Culturally competent• Utilizes community/natural supports

Best Practice Principles

• The consumer directs the recovery process and is an essential part of the team.

• Individual differences are considered and valued.

• A holistic approach is utilized:– Medical, Psychological, Social, and Recovery

intervention models are merged.

Best Practice Principles (cont’d)

• Strengths and assets are identified and emphasized.

• A collaborative recovery management plan is developed.

• Families, as defined by the consumer, are involved.

• Services are within the consumer’s community.

Outcomes of Recovery

• Increased Motivation• Increased Self-Esteem• Feeling a part of instead of isolated from• Self respect• Desire to help others• Hope instead of despair

Outcomes of Recovery (cont’d)

• Optimal functioning• To live in the community• To participate in the lifestyle of the

individual’s choice

Literature Review

Literature Review

• Courtney Harding, PhD• Patricia Deegan, PhD• Daniel Fisher, MD, PhD• Mary Ellen Copeland, MS, MA• Priscilla Ridgway, PhD• LeRoy Spaniol, PhD• William White, MA

Courtney Harding, PhD

• Longitudinal research with individuals diagnosed with Schizophrenia.

• People with mental illness can and do recover. – Looked at a period of 20-30 yrs.

Empirical Correction of Seven Myths About Schizophrenia with Implications for Treatment, by Courtenay M. Harding, Ph.D., and James H. Zahniser, ACTA Psyciatrica Scandinava, 1994: 90 (suppl 384): 140-146.

The Vermont Longitudinal Study of Persons With Severe Mental Illness, II: Long- Term Outcomes of Subjects Who Retrospectively Met DSM-III Criteria for Schizophrenia, by Courtenay M. Harding, Ph.D., George W. Brooks, M.D., Takamaru Ashikaga, Ph.D., John S. Strauss, M.D., and Alan Breier, M.D., American Journal of Psychiatry 144:6, June 1987.

Patricia Deegan, PhD

• Multiple publications and research projects• Tools

– Individual– System

• Common Ground• Shared decision making• Decisional uncertainty• Hearing Voices

http://www.patdeegan.com/

Daniel Fisher, MD, PhD

• Psychiatrist diagnosed with Schizophrenia.• Focuses on medication issues.• Established the National Empowerment

Center.http://www.power2u.org/who.html

Mary Ellen Copeland, MS, MA

• Motivational speaker, and recovery educator.

• Emphasizes “wellness”• Has designed WRAP plan

– Utilizes a “train the trainer” model.http://www.mentalhealthrecovery.com/

Priscilla Ridgway, PhD

• Research and materials development– Consumer Workbook-

• Can be used independently of the therapist or as a supplement to treatment.

• Takes a strengths based approach to recovery, using incremental steps.

• Has developed evaluation tools for systems– ROSI, REE, ERFShttp://www.yale.edu/PRCH/people/PriscillaRidgwayPh.D..html

LeRroy Spaniol, PhD

• Created workbooks for recovery.• Designed for therapists to utilize with

consumers. • Culturally competent Spanish version.

http://search.bu.edu/search?q=spaniol&Submit=Search&site=default_collection &output=xml_no_dtd&client=default_frontend&sort=date%3AD%3AL%3Ad1&proxyst ylesheet=default_frontend&oe=UTF-8

William White, MA

• Substance use recovery relationship to behavioral health recovery.

• Extensive writings and material development.

http://www.facesandvoicesofrecovery.org/resources/publications_white.php

IRETA

• Recovery materials– Includes co-occurring information

• Theory and applicationhttp://www.ireta.org/

Systems Materials

• Connecticut www.ct.gov/dmhas/lib/dmhas/publications/practiceguidelines.pdf

• Ohio http://www.mhrecovery.com/best_practices.htm

• Georgia http://www.mentalhealthworld.org/48GCPSP.htm

• Illinoishttp://www.illinoismentalhealthcollaborative.com/consumers/consumer_resources.htm

• Alaska http://akmhcweb.org/

• Pennsylvania http://www.parecovery.org/principles_change.shtml

• New York www.carecoordination.org/video_guide.pdf

System Change

Transformation

• A break with the past• Quantum change• More than just reorganizing

–new mission and vision for the organization• Transformation virtually always refers to a

positive change– a movement to a new venture

• A radical redesign and new strategic intent for the organization

Transformation Principles

• Services and treatments must be consumer and family centered, geared to give individuals real and meaningful choices about treatment options and providers – not oriented to the requirements of bureaucracies

• Care must focus on increasing a person’s ability to successfully cope with life’s challenges, on facilitating recovery, and on building resilience, not just on managing symptoms

President’s New Freedom Commission on Mental Health

Goal of Recovery Transformation

The goal of recovery is:• To move from a state of dependency to interdependency

•To have all aspects of society and organizations utilizing recovery principles

Setting the Compass

Experience of Individuals, Families and Communities

Microsystems of Care

Where care occurs

Health Care Organizations

External Environment of CarePolicy/Financing/Regulation

Competencyknowledge, skills and abilities

Project Management

work / business flow

Change Managementbehavior and attitude

Change Model

Competencies

• Providers should be able to– understand the concepts of recovery,

resilience, wellness, person-centered and culturally competent approaches

– understand and value the centrality of the individual planning process as a roadmap to recovery and wellness

– understand how emerging new frameworks differ from past and current practice

– identify the elements of a plan and the criteria for each element

Competencies• Providers should be able to

– understand the concept of medical necessity and key elements of documentation

– conduct a strengths based person-centered and culturally competent assessment

– create a formulation or integrated summary based upon the assessment

– evaluate the individual’s/families stage of change to inform and guide the planning process

– help individuals/families articulate person- centered goals and discharge/transition needs

Competencies• Providers should be able to

– help individuals/families articulate person-centered goals and discharge/transition needs

– identify barriers and establish priorities to attaining the goal's

– elaborate objectives to resolve barriers in partnership with the person and family served

– build on strengths, choices, preferences and stage of change to recommend interventions, services, supports and other strategies to promote positive change

Competencies

• Providers should be able to– specify a broad range of

culturally-competent stage appropriate supports / services

– accept the individuals’ / families’ dignity, ability to take risk and “right to fail”

– facilitate/monitor/coordinate plan implementation

– provide timely update of assessment and plan– properly document plan elements and services– participate in an ongoing quality management

process with outcome data

12 Aspects of Staff Transformation

1. Looking forward and rebuilding the passion2. Building inspiration and belief in recovery3. Changing from treating illness to helping people

with illnesses have better lives4. Moving from caretaking to empowering, sharing

power and control5. Gaining comfort with mentally ill co-staff and

multiple roles6. Valuing the subjective experience

Mark Ragins, MD

Staff Transformation con’t

7. Creating therapeutic relationships8. Lowering emotional walls and becoming a

guiding partner9. Understanding the process of recovery10.Becoming involved in the community11.Reaching out to the rejected12.Living recovery values

Mark Ragins, MD

Guideline Categories

• Administration• Treatment• Supports

Mission and Vision

• Development of mission and vision statements articulating organizational commitment to recovery and a process for achieving recovery oriented services.

• Organizational review and strategic planning process that incorporates diverse viewpoints from the community of service users.

Organizational Structure

• Annual budget insures adequate resources to support consumer participation in administrative processes.

• Significant representation of persons in recovery on organization’s treatment and support staff.

Training and Continuing Education

• Processes developed for interactions and/or communications between consumer and providers in non-clinical settings.

• Establishment of core competency standards regarding knowledge of recovery principles for all staff.

Continuous Quality Improvement

• Processes in place to ensure that consumers are included in CQI activities as equal partners with professionals.

• Agency budgets will reflect compensation for consumer involvement in CQI activities.

Outcome Assessment

• Outcome indicators will include items related to quality of life, recovery and self fulfilling function.

• Established process for consumer participation in developing outcome indicators for progress in recovery.

Service Arrays

• Integration of consumer, family and peer supports, disease management education and crisis management planning will be reflected in policy and procedure documents.

• Establishment of services supportive of recovery processes and which incorporate self management principles.

Drowning in Help #1

Drowning in Help #2

Drowning in Help #3

The Moral of the Story

• There may be too many reports on drowning and not enough life preservers.

• Help isn’t help if it’s not helpful to the person receiving services. It can be toxic help.

• Help is always co-created between the professional and client.

• Recovery is a self-directed process of healing and transformation that can be supported by the professional, peers, family and the community.

Transformation

T =

V = vision

B = beliefs

A = action

CQI = continuous quality improvement

Resistance to change

(V + B + A) x (CQI)2

Transformation Principles

• Develop relationships with people, not disorders.

• Nothing about us without us!• Practice respect.• Recovery is real!• Recovery is hard work!• Recovery is universal.• Recovery includes the whole community.

Affirmation

Everybody is SomebodyNobody is a Waste of My Time

Access

What’s In A Word?

• Clinical language can be disrespectful– Crazy– Honey– You’re doing well for a schizophrenic– She is such a borderline– He is decompensating– She is low functioning/high functioning– He’s a harmless burnt out schizophrenic

People With Psychiatric Disabilities are Resilient

I Am Not The Problem!

I Am Part of the Solution

Affirmation

Recovery means changing our lives, not our biochemistry

Nuts and Bolts

A Definition of Recovery

• Recovery is a self-determined and holistic journey that people undertake and grow. Recovery is facilitated by relationships and environments that provide hope, empowerment, choices and opportunities that promote people reaching their full potential as individuals and community members.

-from “A Call for Change: Toward a Recovery-Oriented Mental Health Service System for Adults”

Recovery is Being Person-centered in Practice

• The consumer as a whole person• Sharing power and responsibility• Having a therapeutic alliance• The clinician as a person• Language choices

“If you don’t know where you are going, you will probably end up

somewhere else.”

Lawrence J. Peter

Planning Processes

• Development of collaborative process for developing continuous comprehensive service plans between consumers and providers.

• Process in place to inform consumers of treatment/service options and to discuss pros and cons of each prior to service plan development.

A Plan is a Road Map

Provides hope by breaking a seemingly overwhelming journey into manageable steps for

both the provider and the person served.

A E

B C D

“life is a journey…not a destination”

Building a Plan

Request for servicesAssessment

Services

Understanding

Objectives

Goals

Outcomes

Prioritization

Strengths/Barriers

Goals

• Three types– life goals– treatment goals– quality of life / enhancement goals

• Essential features– Attainable, realistic, written in positive terms

• built upon abilities / strengths, preferences and needs

• embody hope• alternative to current circumstances

Barriers

• What keeps a person from their goals?– Intrusive or burdensome

symptoms• Challenges or needs as a result of a co-occurring

disorder– Lack of resources– Need for assistance, supports, skills

development– Housing, employment – Lack of relationships or meaningful activity

Strengths

• Environmental factors that will increase the likelihood of success: – community supports, family/relationship,

support/involvement, work• Competencies/accomplishments• Past successful strategies • Motivation, interests and activities• Services are not an objective

Stages of Change and Recovery

• Prochaska and DiClemente• Ohio Department of MH• The Village—LA County MHA• Stanislaus County• Boston University Center for Psychiatric

Rehabilitation Center• AACP / LOCUS

Stages of Recovery and Treatment

Ohio Village Prochaska & DiClemente

Stage of Treatment Treatment Focus

Dependentunaware

High risk/ Unidentified or Unengaged

Pre- contemplation Engagement

• outreach • practical help• crisis intervention• relationship

building

Dependent aware

Poorly coping/Engaged /not self-directed

Contemplation /preparation Persuasion

• psycho-education• set goals• build awareness

Independent aware

Coping/Self responsible Action Active

Treatment

• counseling• skills training• self-help groups

Inter- dependentaware

Graduated or Discharged Maintenance Relapse

Prevention

• prevention plan• skills training• expand recovery

Dependent Unaware

Dependent Aware

Independent Aware

Interdependent Aware

Meeting client where they’re at…

Each person is able to utilize interventions responsive to their stage of change

ADDICTION RECOVERY

MENTAL HEALTH RECOVERY

Prevention PreContemplation

Contemplation Action RelapsePrevention

Sustained Recovery

EarlyIntervention

Prevention Pre-Contemplation

SelfCareContemplation Engaged in Active

Treatment and RehabEarly Identification

and Intervention

Another view of recovery stages…

Impact of the illness

Life is limited

Change is possible

Commitment to change

Actions for change

OverwhelmedNot ready to

commit to change

Believes there is more to life

Willing to explore

possibilities

Taking responsibility

for a new direction

derived from BU Center for Psych Rehab

moving beyond…

challeng-ing…

question-ing…

giving in to…

over-whelmed

by…

……the the disabling disabling power of power of

the the illnessillness

Th

e p

ers

on

is

Th

e p

ers

on

is ……

as suggested by

Ed Knight

Integration of Addiction and Mental Health Recovery

• Establishment of recovery principles as unifying concepts in provision of holistic mental health, physical health and addiction services.

• The presence of co-occurring substance and mental health disorders is reliably detected through screening processes.

Advance Directives

• Established process for obtaining informed advance directives from consumers during periods of relatively healthy function.

• Established process for review of advance directives during periods of relapse/incapacitation.

Coercive Treatment

• Development of strategies to engage and empower clients on involuntary status that are incorporated into treatment plans and agency programming.

• Demonstration of reduction in the use of coerced treatment options over defined periods.

Advocacy and Mutual Support

• Active facilitation of participation of clients in advocacy organizations is demonstrated.

• An agency liaison with local advocacy and support groups is identified and active.

Access Facilitating Processes

• Completion of access analysis identifying systemic barriers to receiving services.

• Service users report satisfaction with their access to services they have chosen.

Family Services

• Family involvement in agencies will be reflected in educational, social and advocacy programming by the agency.

• Liaison and collaboration with advocacy groups will be reflected in family oriented programming.

Employment and Education

• Development of an array of employment and training opportunities with various levels of support.

• Process for vocational counseling and support is integrated with other aspects of the recovery process.

Housing

• Consumers feel that their housing choices are respected to the greatest extent possible.

• A wide array of housing options and available, including various tolerant housing options.

Medication

• Medication is not just an MD thing.• What is individual’s role?• Decisional uncertainty.• Education.

Principles

• Use in Conjunction with Psycho-social Approaches.

• Simplicity.• Timing.• Target Symptoms/Diagnostic Clarity

(substance induced vs real).• Understand consumer's perspective.• Emotional climate.

Community Care RoadMAP Project

• Medication algorithm specific to schizophrenia, consumer portion applicable to all illnesses.

• Educational support to physicians, consumers, families.

• Four Allegheny County agencies provide at 7 sites.

• RoadMAP facilitators and Community Care meet on a regular basis.

• Facilitator trainings scheduled in October for two agencies in both Berks and Chester Counties.

RoadMAP to Recovery

• A quality improvement initiative designed to involve consumers, practitioners, family members and supporters in a unified effort to practice evidence-based medication prescribing to promote optimal consumer recovery.

SAMHSA Evidence Based Practices

• Illness Management and Recovery.• Assertive Community Treatment.• Family Psychoeducation.• Supported Employment.• Integrated Dual Diagnosis Treatment.

• http://mentalhealth.samhsa.gov/cmhs/communitys upport/toolkits/about.asp

Effective Use of Resources

• Progressive Continuums.• Overlapping and Integrated Levels of

Resource Intensity.• Linking Phases of Treatment.• Quality Processes to Enhance Utilization.

Comprehensiveness

• Includes an array of arrangements sufficient to meet all identified needs.

• Case management, child care, residential support, financial assistance, mutual support, etc.

Coordination and Integration

• Concurrent involvement of agencies on both sides of the transition occurs.

• Information sharing.• System creates rational incentives for

coordination.

Continuity in Planning

• Building on established treatment plans when successful.

• Plan is continuous across entire episode of illness/disability.

• Regional standardization of planning formats.

Support System Involvement

• Family and other significant members of support system, as identified by service user, to be included in planning process.

• Significant efforts to enlist participation are documented .

Cultural Sensitivity

• Recognition of individual’s beliefs, customs, and social context in planning process.

• Transition plan reflects these cultural considerations.

Prevention

• Relapse prevention, using historical context for episodes of illness, incorporated into the plan.

• Appropriate use of community resources.

Resource Access

• Maximize access to available resources.• Encourage autonomy and recovery in

obtaining necessary resources.

Community Care Initiatives

• CTT.• RoadMAP.• Collaboration with ACCR.• Recovery Conferences.• Recovery Institutes.

Collaboration: Allegheny County of Coalition for Recovery

• Group of consumers, families, agency and county representatives, and other stakeholders.

• Resilience and children/youth statements.• Universality statement.• Social Marketing Campaign.• Booklet development.• Dialogues. • Development of community partnerships.

Success is not final, failure is not fatal: it is the courage to continue that counts.

Winston Churchill

Concluding Thoughts

(How Does Each Of Us)Become the change that we want to see in the world.Mohandas Gandi

(Can we become)A small group of thoughtful people can change the world. Indeed, it's the only thing that ever has.Margaret Mead…