Service and Treatment Planning in the Recovery Paradigm with Consumers Coping with Serious Mental Illness

1. Service and Treatment Planning in the Recovery Paradigm with Consumers Coping with Serious Mental Illness Jack R. Friedman, Ph.D. Center for Applied Social Research University of Oklahoma, Norman

2. What is the Recovery Movement? • Partially, a response to NAMI, et al., to reframe consumer’s rights and consumer self-determination as civil rights • Nothing about us without us! • Partially, a response to what is perceived to be an unsustainable dependency/disabling relationship that has emerged in public mental health care • Belief that current mental health care practices contribute to passivity, hopelessness, and chronicity • Partially, a response to fiscal problems associated with federal disability programs • Demotivational quality of current disability/federal insurance system • President’s New Freedom Commission (2003)

3. What does “Recovery” mean? • “Recovery from” vs. “in Recovery” • “Recovery from” is a state • “In Recovery” is a process • “Recovery is what the person with the mental illness does” • “Recovery-oriented care [is] what practitioners provide in support of the person’s recovery” (Davidson, Rakfeldt, and Strauss 2009:7) • How is it different from the AA-style, substance abuse orientation toward Recovery? • AA-style: identity as a “type” and fixed part of one’s identity – “a schizophrenic” • Recovery Model: the idea that a mental illness is not central to who one is – “a person recovering with/from schizophrenia”

4. What is REALLY going on with the Recovery Movement? • Challenges how one should think about what it means to “get better” • What IS a “normal” life? • Challenges the “medical model” of mental health care • What is the GOAL of mental health care? • “Medical Model” goal is SYMPTOM REDUCTION • “Recovery Model” goal is HELPING A PERSON TO BECOME A PRODUCTIVE CITIZEN AND ACHIEVE THE BEST POSSIBLE LIFE

5. What is different about Recovery Services? • Wrap-around in its focus (similar, on the surface, to Assertive Community Treatment (ACT)) • Strengths-oriented (“capabilities approach”) • Role of Consumer/Peer Advocates in treatment settings • Hope-oriented • Challenges the primacy of the “Medical Model” of Care

6. What would be different about what YOU do? • Don’t ask “what can I do for you,” but, rather, “what can I do to help YOU achieve YOUR goals” • Focus on assessing a client’s strengths • Focus on “engagement” in one’s Recovery • Recognizing that the client needs to have “the dignity of risk” and “the right to fail” (Deegan 1992) • Move beyond the “Maslow Defense”! • Learning from your clients about those aspects of their lives that are not usually explored in order to help them articulate their goals

7. Recovery-Oriented Practice:An Example through “Assessment”

8. Milestones of Recovery Scale (MORS)David Pilon, Ph.D. and Mark Ragins, M.D. • Comes out of research conducted at “The Village,” an innovative outpatient system in Southern California • Focused on designing an assessment tool for Recovery-Oriented care that “should measure the objective and easily observable behavioral correlates (‘milestones’) of recovery rather than the subjective internal experience of individuals experiencing recovery.” • In many ways, MORS is both in contrast to and a complement to GAF assessments

9. Global Assessment of Functioning (GAF) Scale • Axis V • 0-100 scale of functional impairment • 1-10 Persistent danger to self and/or others • 21-30 Behavior significantly influenced by delusions/hallucinations/serious impairment to communication or judgment, etc. • 51-60 Moderate symptoms or moderate difficulty in social, occupational, or school functioning • 61-70 Mild symptoms […] but generally functioning pretty well, has some meaningful interpersonal relationships • 91-100 Superior functioning in a wide ranger of activities, life’s problems never seem to get out of hand, is sought out by others because of his or her many positive qualities. No symptoms

10. 3 Factors in the MORS • Level of Risk • Level of Engagement • Level of Skills and Supports

11. Level of Risk • The consumer’s LEVEL OF RISK is comprised of three primary factors: 1) the consumer’s likelihood of causing physical harm to self or others, 2) the consumer’s level of participation in risky or unsafe behaviors, and 3) the consumer’s level of co-occurring disorders.

12. Level of Engagement • the degree of “connection” between the consumer and the mental health service system. • Note that level of engagement does not mean amount of service. A consumer who willingly makes appointments once per month and works on improving his life should be considered more engaged and connected than a consumer who passively attends groups on a daily basis.

13. Level of Skills and Supports • the combination of the consumer’s abilities and support network(s) and the level to which the consumer needs staff support to meet his/her needs. • It should include an assessment of their skills in • independent living (e.g., grooming, hygiene, etc.), • cognitive impairments, • whether or not they are engaged in meaningful roles in their life (e.g., school, work), • whether they have a support network of family and friends • their ability to manage their physical and mental health, finances, and substance use, etc. • their ability to meet their needs for intimacy and sexual expression.

16. Exercise • Look at these examples and assign them a MORS score: • Don’t Call Me Elvis (page 5) • Secret Agent Man (page 7) • From Riches to Rags (page 8) • The Delusional Cashier (page 9)

17. DON’T CALL ME ELVIS M.J. is a 21-year-old male who lives in an apartment with his father, mother and older brother. He was diagnosed with schizoaffective disorder, depressive type at the age of 16. His current treatment consists of Risperdal, Paxil and day treatment. He is medically compliant and takes his medication without complaints, but freely admits that he does not think the medication helps him. Furthermore, M.J.’s mother picks up and administers his medication. M.J. does not know the name of his medications. He identifies one as treatment for depression, but he doesn’t know what Risperdal is for. When asked about the side effects of the medication, M.J. replied that he is experiencing minor side effects, mainly blurred vision. Despite his taking the medication, he still continues to suffer from daily depression, feelings of hopelessness, and grandiose delusions. M.J. continues to believe he has the power to control other’s minds and make them do things, but he does not know how. He also has recurring suicidal ideations without intent, mostly regarding hanging himself. His last attempted suicide and hospitalization was six months ago. M.J. hopes to move to an apartment in London in the coming year. He believes that would be a great place to live. He thinks about getting a job and has even filled out applications at Target, Big Lots and Home Depot. None of these employers found M.J. fit to hire. He does not attend school, nor does he have any plans to in the future. M.J. is on conservatorship. His mother gives M.J. money occasionally, which he secretly spends on alcohol and drugs. He calls the “party line” on a weekly basis and meets strangers, often returning the following day. In a recent nighttime altercation, a stranger at a gas station insulted M.J. by calling him an “Elvis look-a-like.” He responded violently by cutting the man’s face with his knife. M.J. does not buy groceries or cook for himself. Although he claims to have many friends to support him, his mother believes his friends are a bad influence and encourage him to use drugs. YOUR RATING _______

18. DON’T CALL ME ELVIS MORS Rating: 3 (High Risk / Engaged) Question #1: Is the consumer being rated below the line (doing poorly/badly) or above the line (doing okay/well)? Answer #1: This consumer is below the line (doing poorly/badly) and should be rated between 1 and 5. Explanation: This consumer appears to have very little life outside of the treatment for his mental illness. Question #2: Is the consumer currently at extreme risk of harm to self or others (Milestone 1)? Answer #2: No. Although the consumer states that he recently engaged in assaultive behavior, he does not currently appear to be an immediate danger to self or others. Therefore, his rating will be in the range from 2 – 5. Question #3: What is the consumer’s level of risk? Answer #3: This consumer should be considered high risk and a rating of Milestone 2 or 3 should be given. Explanation: Given the high levels of symptoms, risky behaviors like substance abuse, being on conservatorship and potential for violence, this consumer should be considered high risk (Milestone 2 or 3) rather than poorly coping (Milestone 4 or 5). He is not rated at extreme risk because he is not currently an immediate a danger to self or others. Question #4: Is the consumer engaged or not engaged? Answer #4: This consumer is very engaged (participating) in treatment and therefore should be rated at Milestone 3 (High Risk/Engaged). Explanation: Although this consumer has little insight into his illness, he participates in his treatment and seems quite cooperative and tolerant of mental health staff.

19. SECRET AGENT MAN Joe is a 35-year-old male who lives in a rented basement with his mother. He was diagnosed with schizophrenia, paranoid type, at the age of 25. His current treatment plan consists of bimonthly shots of RisperdalConsta for his psychosis, Lexapro for his anxiety, and a day treatment program five times a week. For the past three months Joe has take his medication; although he admits he does not think medication is an important part of his treatment. He has met all scheduled appointments to receive his Consta injections and has not refused the Lexapro administered by his mother. In addition, Joe has been attending the day treatment program on a daily basis. He stated that he enjoys the day treatment program because he is able to exercise and go places, like the beach. Although Joe is compliant with his treatment, he does not take an active role in obtaining his medication. Joe’s mother picks up his medication for him and administers it to him. In addition, Joe does not make his own appointments with his doctor or case manager and always needs to be reminded the day before. Joe cannot identify the names of his medications, but states that the medication “corrects the chemical imbalance in my mind caused by my illness.” He also reports suffering many side effects from the medication, including blurred vision, dizziness, and impotence. Furthermore, Joe stated that he still experiences delusions, hallucinations, anxiety, and has some suicidal thoughts. Joe often hears voices calling for help, which upsets him and makes him feel useless because he cannot help them. This makes it difficult for Joe to manage his symptoms. For example, Joe will stop whatever he is doing to try to find out where the voice is coming from. He will leave the basement in search for the person calling for help. Joe’s symptoms also include feelings of depression. He stated that he often feels disappointed with the quality of his life and his inability to function normally. These feelings cause him occasional suicidal ideations, but all without intent. Joe stated, “I have never and will never try to kill myself.” Joe has a few goals that he wants to reach. His three main goals are to get a classic car to fix up, obtain a job as a secret agent of the FBI, and find a girlfriend, and in that order. Joe believes that a classic car would make him eligible to be an FBI Agent. As an agent, it would be easy for him to “track down” a girlfriend that would want to be with him. Joe receives SSI checks directly, but he does not manage his money. His mother pays for rent, food and Joe’s essentials. She gives Joe a weekly allowance for his own personal use, which he spends on snacks. Joe does not have a driver’s license and can only travel short distances on the bus because he fears having a panic attack. YOUR RATING _______

20. SECRET AGENT MAN MORS Rating: 5 (Poorly coping / Engaged) Question #1: Is the consumer being rated below the line (doing poorly/badly) or above the line (doing okay/well)? Answer #1: This consumer is below the line (doing poorly/badly) and should be rated between 1 and 5. Explanation: This consumer appears to have very little life outside of the treatment for his mental illness. He is also fairly symptomatic. Question #2: Is the consumer currently at extreme risk of harm to self or others (Milestone 1)? Answer #2: No. Although the consumer states that he recently engaged in assaultive behavior, he does not currently appear to be an immediate danger to self or others. Therefore, his rating will be in the range from 2 – 5. Question #3: What is the consumer’s level of risk? Answer #3: This consumer should be considered poorly coping and a rating of Milestone 4 or 5 should be given. Explanation: Although this consumer is extremely dependent and unable to care for himself, he appears to be at little risk because of his family support (mother). Question #4: Is the consumer engaged or not engaged? Answer #4: This consumer is very engaged (participating) in treatment and therefore should be rated at Milestone 5 (Poorly Coping/Engaged). Explanation: This consumer is actively participating in his treatment and appears to have good relationships with his treatment staff.

21. FROM RICHES TO RAGS Sam is a 54-year-old male who has been living at a homeless shelter for the last seven months. Sam was diagnosed with major depression after losing his once highly successful business and is going bankrupt. Sam comments, “I went from eating at Spagos to eating at homeless shelters.” Sam lost his business, friends and most importantly his family. His current treatment consists of Paxil and day treatment. Sam’s beliefs and attitudes toward treatment are positive. For instance, he comes to the clinic daily and administers his medication as prescribed because he strongly believes that the treatment is reducing his depression. Although Sam experiences many side effects from the medication, such as thirst, nervousness, tremors and dizziness, these side effects do not change the way he feels about the medication. For the past two weeks, Sam has been experiencing anxiety, depression and slight hallucinations. Sam is mildly bothered by these symptoms and says they are bearable with the medication. He still experiences feelings of worthlessness, but has not had any attempts of suicide for the past year. Sam has not been pursuing or setting goals. Although Sam would like to return to school to learn computer skills, he thinks that he is too old to start all over. Staff requested that Sam start a sheltered workshop job at the clinic’s snack store. Sam agreed to the duty, but has no desire to apply for a part-time job. Sam has a valid driver’s license, but independently uses public transportation. Sam does not have friends outside the day clinic, but is friendly and has interactions with staff. He has good personal hygiene and takes care of his possession and living space. YOUR RATING ________

22. FROM RICHES TO RAGS MORS Rating: 5 (Poorly coping / Engaged) Question #1: Is the consumer being rated below the line (doing poorly/badly) or above the line (doing okay/well)? Answer #1: This consumer is below the line (doing poorly/badly) and should be rated between 1 and 5. Explanation: This vignette typically is very difficult for many staff, who often want to rate this consumer above the line, specifically coping/rehabilitating. They tend to focus on the fact that he is doing well with his treatment and ignore the fact stated in the very first sentence: “Sam is a 54-year-old male who has been living at a homeless shelter for the last seven months.” While the consumer appears to be making the best of his situation, in our view it is not possible to be homeless and be considered “doing okay/well.” The objective circumstances of this consumer require that he be rated no higher than a 5. Question #2: Is the consumer currently at extreme risk of harm to self or others (Milestone 1)? Answer #2: No. There is no evidence that he is currently an immediate danger to self or others. Therefore, his rating will be in the range from 2 – 5. Question #3: What is the consumer’s level of risk? Answer #3: This consumer should be considered poorly coping and a rating of Milestone 4 or 5 should be given. Explanation: Although this consumer is homeless, there appear to be few if any risk factors in his life, probably because he is in a shelter. If he were homeless and on the street, our assessment of his level of risk might change to “high risk.” Question #4: Is the consumer engaged or not engaged? Answer #4: This consumer is very engaged (participating) in treatment and therefore should be rated at Milestone 5 (Poorly Coping/Engaged). Explanation: This consumer is actively participating in his treatment and appears to have good relationships with his treatment staff

23. THE DELUSIONAL CASHIER Bob is a 23-year-old male who lives at home with his mother, stepfather, brother and stepbrother. He has been living with schizophrenia for the past six years. During his senior year of high school, he began experiencing delusions of persecution from his teachers and classmates. Bob also started to hear evil voices that disparaged him. After seeing a school counselor, he was referred to the local mental health clinic. His treatment consists of Zoloft, Risperdal, monthly follow-ups with his psychiatrist and weekly group therapy meetings. Although Bob frequently misses his meetings, his is compliant with his medication. Bob is content with his medication and feels that any changes in his medication are at the discretion of his doctor. He does experience side effects such as constipation, tremors/shaking, and nausea/vomiting, but these side effects do not inhibit his compliance. In addition, Bob is still suffering from delusions and hallucinations. For example, he hears voices that tell him that people hate him. He also hears people talking in his house when he is alone. Bob also reports anxiety, depression, fearfulness and nervousness on a daily basis. When Bob experiences these symptoms at work, he either isolates himself or attempts to continue working normally. Overall, Bob’s symptoms do not impair his ability to work. In the past two weeks, Bob has not used drugs or alcohol. He commented that he has been clean for over six months. Bob is not a danger to himself or others. He has no history of suicide attempts or any suicidal ideations. He hopes that in the coming year he will be able to move into his own apartment, however he is currently not making any efforts to live independently. Bob’s future goal is to eventually go to college and have a career in which he can help people, possibly as a counselor. To attain this goal, Bob attends adult school four times a week, where he is facilitated in attaining his GED. In addition, Bob independently located and applied for a job. As a result, Bob has been working as a cashier for six hours a day on the weekends at Walgreens for the past six months. Bob is very independent. He has good personal hygiene and takes care of his personal possession and living space. He receives SSI checks directly and manages his money well. Although he does not always plan healthy meals, Bob prepares simple meals for himself. He has a valid driver’s license and drives his mother’s car or uses public transportation to go places. Bob has friends that he talks to and spends time with on a daily basis. He spends the majority of his leisure time with his girlfriend of three months. He is generally happy with their relationship, but often feels like ending it when he becomes symptomatic. Bob commented that she has been very supportive of him. YOUR RATING _______

24. THE DELUSIONAL CASHIER MORS Rating: 7 (Early recovery) Question #1: Is the consumer being rated below the line (doing poorly/badly) or above the line (doing okay/well)? Answer #1: This consumer is above the line (doing okay/well) and should be rated between 6 and 8. Explanation: This consumer appears to have many important roles outside of the treatment for his mental illness, including going to school and very substantial work. Question #2: Is the consumer totally self-supporting and therefore in advanced recovery? Answer #2: No. The consumer is receiving SSI and therefore would fall in the range of 6 – 7. Question #3: What is the consumer’s primary source of role identity and current level of skills and supports? Answer #3: This consumer should be considered in early recovery and a rating of Milestone 7 should be given. Explanation: He should not be considered in advanced recovery because he receives SSI. Although he lives with his parents, he also has a significant other and is quite independent. This vignette is a good example of how a consumer can be considered in early recovery even though he is quite symptomatic.

25. What is one up against in implementing Recovery-Oriented care? • Provider preconceptions and experiences • Consumer preconceptions and experiences • System structures