Recovery

1. Recovery It’s not a model It’s a process

2. Presented by • Chad Costello, MSW Director of Public Policy Mental Health America of Los Angeles, and • Heather Martin

3. 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.

4. 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’s Essentially 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

10. 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

12. Money, Medicine and Mental Hospitals1850 - 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

13. 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

16. Mental Hygiene • The new treatments proved largely ineffective • Patients continued to stay for years, filling hospitals.

19. But the Contemporary, Long-term Studies of Schizophrenia have Found... • 46-68 % of each cohort significantly improved and/or recovered. • Recovered means: no symptoms, no meds, no odd behaviors, working, relating well living in the community. • Improved: In all areas but one.

22. 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

23. In Sum • People do in fact recover • You have no ability to predict success or failure so stop trying to do so.

24. “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.

25. “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

26. Recovery • Four primary stages: • Hope • Empowerment • Self-responsibility • A meaningful role in life

27. 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.

28. 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”.

29. 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.

30. 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.”

31. Break – 15 minutes

32. 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.

33. Philosophy and Principles • Primary Principles • Client choice • Quality of life • Community focus • Whatever it takes

34. 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.

35. 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.

36. 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

37. 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

38. “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.

39. LUNCH – 45 minutes

40. 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.

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

42. 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!

43. 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.

44. 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.

45. 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.

46. 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.

47. Housing Assistance • Poverty sucks! • Housing is a treatment • Once again, a range of options is important. • Positive relationships with property owners are a must.

48. 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.

49. 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 businesshours.

50. A Meaningful Role in Life • To recover, individuals must have a purpose in their lives separate from their illness. • “GETTING A LIFE”