RecoveryIt’s not a modelIt’s a process

Presented by

Chad Costello, MSW

Director of Public Policy

Mental Health America of Los Angeles,

and Heather Martin

History Recovery from mental illness is nothing

new – has been around along as mental illness, which has been around as long as we’ve been around.

Even in places where the concept of mental illness is absent, the concept of recovery is present.

Recovery is not unique to mental illness – humans recover from all kinds of things all the time.

History of Mental Health Treatment – United States Pre-colonial – at home, family Urbanization – state governments

began attempts to address problem Asylums/Mental Hospital

Pennsylvania and Virginia – mid 1700’sEssentially locked up

Those not cared for by family or in asylums wound up in jail, almshouses, work houses or other institutions NOT MUCH HAS CHANGED

The Rise of Moral Treatmentearly 1800 - 1850 the return of the individual to reason by the

application of psychologically oriented therapy (Grob, 1994).

Philippe Pinel – 1793 – La Bicetre – Paris Unchained patients and let them move about the

grounds William Tuke – 1796 – The York Retreat – England

Minimizing restraints – treating people with respect Dorothea Dix & Horace Mann Benjamin Rush – early 1800’s – Pennsylvania

Believed that insanity was a disease of the mind Had the cause wrong though

Also believed in forced treatment

Money, Medicine and Mental Hospitals

1850 - 1890

Years and years of moral treatment at nice large institutions was very expensive Population continued to grow So did costs Underfunding and overcrowding led

to a need to figure a way to get people out faster

Mental Hygiene – 1890 - 1920

Mental hygiene = public health + scientific medicine, + social progressivism.

Believed in the principles of early treatment Wanted to move mental health care into the

mainstream Through the use of medicine and public health

strategies, mental illness could be all but eradicated

Funding responsibility shifted from local gov’t. to state gov’t.

Communities starting sending even more people to state hospitals

Mental Hygiene The new treatments

proved largely ineffective Patients continued to stay

for years, filling hospitals.

But the Contemporary, Long-term Studies of Schizophrenia have Found...

o 46-68 % of each cohort significantly improved and/or recovered.

o Recovered means: no symptoms, no meds, no odd behaviors, working, relating well living in the community.

o Improved: In all areas but one.

Vermont/Maine Comparison• Wide heterogeneity• Better community

function p< 0.001• More work

p<0.0009• Less S/S p< 0.002• Rehabilitation-

oriented system: comprehensive and coordinated

• Mission clear

• Modest heterogeneity

• Less community function

• Less work• More symptoms • No rehab system:

unconnected & Sparse

• Mission confusing

In Sum People do in fact recover You have no ability to predict

success or failure so stop trying to do so.

“The concept of recovery is rooted in the simple, yet profound,

realization that people who have been diagnosed with mental

illness are human beings.”

Pat Deegan, Ph.D.

“I have a condition that is neither positive or negative –not an illness to be “cured”, but a

condition that can be accommodated

in order to enable me to live the way I choose.”

Howie the Harp, 1991

Recovery Four primary stages:

Hope Empowerment Self-responsibility A meaningful role in life

Hope Recovery begins with a positive vision of

the future. To be motivating, hope must be a real,

reasonable image of what life can look like.

Individuals need to see possibilities – getting a job, earning a diploma, having an apartment – before they can make changes and take steps forward.

Empowerment To move ahead, individuals need a

sense of their capabilities. Hope needs to be focused on what

they can do for themselves. Individuals need access to

information and the opportunity to make their own choices, preferably from a “menu”.

Self-responsibility As individuals move toward recovery,

they realize they need to be responsible for their own lives.

This comes with trying new things, learning from mistakes and trying again.

Individuals must be encouraged to take risks, such as living independently, applying for a job, enrolling in college or asking someone on a date.

A Meaningful Role in Life To recover, individuals must have a

purpose in their lives separate from their illness.

They need to acquire newly-acquired traits such as hopefulness, confidence, and self-responsibility to “normal” roles such as employee, neighbor, graduate and volunteer.

Meaningful roles help people to “get a life.”

Break – 15 minutes

Philosophy and Principles The overarching goal of mental health

recovery is full integration of clients into all aspects of community life.

Principle guided practice is the cornerstone of helping people achieve full integration – this allows you to work “without a net” –aka a P&P manual.

Philosophy and Principles Primary Principles

Client choice Quality of life Community focus Whatever it takes

Client Choice Utilizing a “menu approach”, services are

provided based on individual’s own goals. Clients choose what services they want and the

staff members with whom they would like to work.

De-emphasizing traditional “professional” to “patient” relationships and respecting individuals as equal partners in their recovery.

Actually have to have choices – one size fits all only winds up fitting everyone poorly – smock vs. a tailored suit.

Professional Role(s) All about relationships dammit! To be a good diagnostician, you need quality

information, to get quality information you need a good relationship

To be a good facilitator of recovery, you need quality information, to get quality information you need a good relationship.

Is what you’re doing helping or hurting the relationship?

If you can’t facilitate recovery – get out of the way.

Quality of Life Helping clients to regain their role as

a member of the community of their choosing by focusing on key life areas such as: Housing Work Education Finances Social goals

Community Focus Living, learning and working should be

done through integration rather than segregation.

Staff need to spend most of their time out of the office, supporting individuals as they pursue their quality of life goals.

How many hours are you open? 40 vs. 168

“Whatever it Takes” Services must be made available on a

continuous basis and offered on a “no-fail” approach.

Avoiding or transferring individuals because of the challenges they pose is prohibited.

Demonstration of high level of commitment, leads to a higher level of commitment from clients to the program and their own goals.

LUNCH – 45 minutes

Recovery Services Teaming between mental health professionals,

paraprofessionals, clients and family members is a powerful tool.

Utilization of specialists – employment, financial planning, community involvement, substance use, etc.

Promote idea that all staff – management, treatment, case management, etc., are recovery workers – representing an impressive breadth of professional and personal experience from which to draw to support individuals in recovery.

Recovery Services Welcoming and Engaging Service Planning Psychiatric Care Employment Substance Abuse Recovery Housing Assistance Financial Services Community Involvement

Welcoming and Engaging This is an essential “service” on its own. Characteristics of a welcoming

environment Security guards? Door buzzers? Bulletproof glass? Name badges? Separate bathrooms?

We blow this all the time as a system!

Service Planning Must move away from compliance and/or

diagnosis based goals – recovery is seldom convenient and goals belong to an individual, not an illness.

The concept of “goal setting” is foreign to many individuals. This is not a sign of pathology – it is a natural response to living situations.

Service planning is done with, not on behalf of, an individual, and it defines the relationship between provider and client.

Psychiatric Care “Collaborative psychiatry” emphasizes

client choice through the use of education around medication and symptoms.

This puts clients in control of their illnesses, makes them partners in their treatment, and lets them pursue their work, living, education, and social goals.

Medication as a tool to help clients manage things that get in the way of doing what they want – Betty Dahlquist, CASRA.

Employment Choose, Get, Keep with a rich range of

options. Real work for real pay in the

community. Not “cute” or “little”. Job development, help in getting

hired, coaching on and off work site. People want jobs not vocations. Working does not lead to symptom

exacerbation – a crappy life does.

Substance Abuse Recovery Axis 1 + substance use ≠ addict. For those for whom substance abuse is a problem,

coordinated care simultaneously addressing both issues is THE ONLY route to success.

The days of “we don’t do that here” are over. You need to “do that” and do it well.

Using harm reduction allows you to work with individuals as you are helping them move towards goals of sobriety and recovery.

You need to know where you stand on this – either help or get out.

Motivational interviewing is amazing Traditional sobriety based interventions still have an

important role.

Housing Assistance Poverty sucks! Housing is a treatment Once again, a range of

options is important. Positive relationships with

property owners are a must.

Financial Services Where the money meets the road. Do not leave it to third parties – they don’t

care and the incentives run the wrong way. Done well, it is no more risky than anything

else – the pros far outweigh the cons. Practical application through budget

development, opening a bank account, balancing a checkbook, and supported shopping.

Community Involvement Helping individuals become active in their

community of choice by taking part in a wide range of activities. A client dance at the day program doesn’t cut it.

Assisting in learning about and using local resources.

Coaching in the details of effective interaction.

Staff will have to operate out of normal business hours.

A Meaningful Role in Life To recover, individuals must have a

purpose in their lives separate from their illness.

“GETTING A LIFE”

BREAK – 15 minutes

Making field “work” This one is on you. Find the recovery

“champion” Making recovery

“champions” Suggestions??