Mental Health Recovery

1. Mental Health Recovery • James G. McDonagh, Psy.D., Clinical Psychologist, Local Recovery Coordinator, Ralph H. Johnson Veterans Administration Medical Center james.mcdonagh@va.gov

2. Mental Health Recovery • Topics: • What is Recovery? • What are the origins of Recovery? • How is Recovery different than B.A.U.? • When, where, and how can we change the system? • Why should we try to affect change?

3. Mental Health Recovery • “…is 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.”(emphasis added) • - U.S. Dept. of Health and Human Services

4. Mental Health Recovery • The 10 Essential Premises of Recovery: • An individual with mental illness… • 1. Self-direction: …can lead, control, and exercise choice over his/her future. • 2. Person-Centered: …is considered to be fully ‘human’– the individual isnot primarily defined by his/her mental illness; rather, his/her mental illness is only component of his/her existence.

5. Mental Health Recovery • The 10 Essential Premises of Recovery: • An individual with mental illness… • 3. Empowerment: …has capacity to exercise choice; to consider a range of options • 4. Holistic: …has a life marked by mind, body, spiritual, and community dimensions

6. Mental Health Recovery • The 10 Essential Premises of Recovery: • An individual with mental illness… • 5. Non-linearity: …will have an individualized life course; set-backs and ‘relapses’ are both anticipated and serve as opportunities for future growth • 6. Strengths-based: …will possess strengths; these strengths serve a primary role in self-fulfillment; strengths are the core to effective interventions

7. Mental Health Recovery • The 10 Essential Premises of Recovery: • An individual with mental illness… • 7. Peer-support: …is part of social system; as such, he/she can give support and receive support from others • 8. Respect: …often confronts the debilitating effects of stigma; often internalizes the shame/guilt of mental illness; needs to be treated like everyone else.

8. Mental Health Recovery • The 10 Essential Premises of Recovery: • An individual with mental illness… • 9. Responsibility: …is assumed to be accountable for here-in-now decisions and future decisions; has to make the decision to recover. • 10. Hope: …can (and often will) obtain a meaningful life; will always have the capacity to continue to enhance his/her life.

9. Mental Health Recovery • So, is “Recovery” a … • Process? • Product? • Culture?

10. Mental Health Recovery • Recovery is…a Philosophy. • It informs processes • It yields distinct outcomes • It is reflected in the totality of socially transmitted behaviors patterns, arts, beliefs, and institutions of human work and thought – i.e., culture.

11. Mental Health Recovery • The Origins of Recovery: • 1. World Health Organization (1970s) • Longitudinal Studies of Persons with SMI • Heterogeneous outcomes

12. Mental Health Recovery • Origins of Recovery: • 1. Americans with Disabilities Act (ADA) • 2. Consumer Movement (NAMI, etc.) • 3. Substance use/abuse – AA/NA

13. Mental Health Recovery • Origins of Recovery: • The “President’s New Freedom Commission on Mental Health (July, 03)” • Commitment to evidenced-based practices • Consumer driven • Expand rehabilitative services

14. VA & Recovery • The Uniform Mental Health Services in VA Medical Centers and Clinics (9/11/08) • “Delineates the essential components of the mental health program … to be implemented nationally…(page T-1)”

15. VA & Recovery • “The Uniform Mental Health Services in VA Medical Centers and Clinics (9/11/08)” (43 page document) • “Recovery” mentioned 27 times • “Evidence-Based” mentioned 27 times • “Suicide” mentioned 21 times • Only 2 Positions are directly mentioned/elaborated in the Handbook: Local Recovery Coordinator & Suicide Prevention Coordinator • Reason: Recovery & Suicide Prevention efforts are to cut-across all services

16. Mental Health Recovery • Recovery vs. Business as Usual (BAU) Partnership vs. Provider-driven Strength-based vs. Sympt. Reduction Treats Person vs. Treats Illness Rewards Progress vs. ‘Rewards’ Illness

17. Mental Health Recovery: Changing the System • Psychosocial Rehabilitation and Recovery Center (PRRC) • Provide ambulatory (non-residential) services to veterans with serious mental illness • Designed to maximize functioning in all domains. • Intensity of service utilization is expected to decrease over time as veterans develop skills necessary for community reintegration • Individual therapy, social skills training, psycho-ed. groups, illness management, general wellness programming, family ed programs, peer-support services, CWT, etc.

18. Mental Health Recovery • Measuring Outcomes: • Achieving a meaningful role • Subjective life satisfaction • Perception of control over his/her MI • Number and quality of interpersonal Rel. • Object measures of physical health

19. Landmark Studies that Support Recovery in People with Schizophrenia LRC Work Group, July 2008

20. Definitions of Recovery • Most of the researchers in these studies defined recovery as: • being without symptoms • off psychotropic medications • living independently in community • working • relating well to others with no odd/unusual behaviors LRC Work Group, July 2008

21. SAMHSAEvidenced Based Practices • Assertive Community Treatment • Integrated Dual Disorders Treatment • Wellness Management & Recovery • Supported Employment • Medication Management • Family Psychoeducation LRC Work Group, July 2008

22. Barrowclough C, Haddock G, Tarrier N, Lewis S ,Moring J, O’Brien, R ,Schofield N Mc Govern J:RandomizedControlled Trial of Motivational Interviewing, Cognitive Behavior Therapy, and Family Intervention for Patients with Co Morbid Schizophrenia and Substance Abuse Disorders. Am J Psychiatry 2001; 158:1706-1713 Kern R, Liberman R, Kopelowicz A, Mintz J, Green M Applications of Errorless Learning for Improving Work Performance in Persons with Schizophrenia. Am J Psychiatry 2002; 159: 1921- 1926 Mc Gurk S, Mueser K, Feldman K, Wolfe R, Pascaris A Cognitive Training for Supported Employment:2-3 Year Outcomes of a Randomized Controlled Trial. Am J Psychiatry 2007; 164: 437-441 McHugo G, Drake R, Teague G, Xie H Fidelity to Assertive Community Treatment and Client Outcomes in the New Hampshire Dual Diagnoses Study. Psychiatric Services 1999 Vol 5 No. 6 Mc Hugo G, Bebot R, Harris M, Cleghorn S, Herring G, Xie H, Becker D, Drake R A Randomized Controlled Trial of Integrated Versus Parallel Housing Services for Homeless Adults With Severe Mental Illness. Schizophrenia Bulletin 2004; 30:949-982 Patterson T, Bucardo J, McKibbin C, Mausbach B, Moore D, Barrio C, Goldman S, Jeste D Development and Piolot Testing of a New Psychological Intervention for Older Latinos with Chronic Psychosis. Schizophrenia Bulletin 2005; 31:922-930 Reeder C, Newton E, Frangou S, Wykes T Which Executive Skills Should We Target to Affect Social Functioning and Symptoms Change? A Study of a Cognitive Remediation Therapy Program Schizophrenia Bulletin 2004; 30: 87-100 Wolff N, Helminiak T, Morse G, Calsyn R, Klinkenberg W. D, Trusty M Cost-Effectiveness Evlauation of Three Approaches to Case Management for Homeless Mentally Ill Clients Am J Psychiatry 1997; 154:341-348 Research to support Evidenced Based Practices LRC Work Group, July 2008

24. Mental Health Recovery • Why try… • It works, it saves money • The people we serve (and their elected officials who fund us) want it • Beneficence and avoid harm: Ethical Resp.

25. Mental Health Recovery • The Mantra: • “Nothing about us, without us.”

26. Mental Health Recovery • Change, as is Recovery, is an on-going journey that takes a lifetime. • It takes time.

27. Mental Health Recovery • A debt of gratitude: • Direct Supervisor: Dr. Hugh Myrick • VAMC’s Chief of Staff: Dr. Flo Hutchison • VAMC’s Director: Mr. John Goldman • VISN Director: Mr. Lawrence Biro • Most Importantly: The Veterans we serve