Alex Mabe, Ph.D. Gareth Fenley, M.S.W.

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  • This slide provides a clinical vignette that illustrates that recovery can refer to both symptom reduction/remission/cure as conceptualized in the traditional model of mental health care as well as recovery in the sense of the opportunity to be self-determined and able to seek goals and outcomes that are meaningful to the individual. It is intended to be a prompt for discussion and guided, if need be, with Socratic questions to examine various ways that “recovery” can be conceptualized.
    Recovery From: Recovery may pertain to reducing feelings of anxiety and paranoia beliefs (if that is the true nature of the situation).
    Recovery In: Recovery may involve the opportunity to have and manage his own bank account.
    Point of Emphasis: Both perspectives could have merit and could be worthy of pursuit in providing good mental health care. This slide provides an opportunity to build a bridge between the contrasting models of mental health care – both have perspectives that can contribute to the well being of individuals with mental illness.
  • For many years now, the prevailing view of serious mental illness is that the course of the illness is such that there is often a downward spiral of escalating symptoms and declining ability to have a productive and meaningful life. Many a provider has conveyed to the individual with mental illness a bleak picture of the future… Yet, research has demonstrated that… Longitudinal studies of serious mental illness outcome: Partial to full recovery (in symptom-reduction terms) has been possible for 25 – 65% of sample. Of course, treatment did provide benefits and was related to improved outcome.
    (See Carpenter & Kirkpatrick, 1998; Davidson & McGlashan, 1997)
    Point of Emphasis: Even within the traditional model of mental health care, the assumption that serious mental illness invariably leads to deteriorating functioning has been proved to be incorrect. And in this sense “recovery from” may be more possible than we have realized in the past.
  • This is a famous painting of the Lunatic Asylum in Bedford England. As portrayed in the painting, people with mental illness are viewed as “insane”, incompetent, devious, and dangerous and thus subject to the scorn and curiosity of others.
    Unfortunately, many of these same stigmatizing views are held today and beg the question, is it possible that “lunatics can run the asylum?”
    Point of Emphasis: Individuals with mental illness are traditionally seen as unable to collaborate/contribute in their own care. In fact, many family members have been encouraged to surrender care decisions entirely to professionals and even to consider some loved ones “dead.”
  • A different use of the term recovery has been introduced by the mental health consumer/survivor movement. This sense of recovery does not require remission of symptoms or other deficits, nor does it constitute a return to normal functioning. Rather, it views mental illness as only one aspect of an otherwise whole person. Unlike in most physical illnesses, people may consider themselves to be in this form of recovery while continuing to have, and be affected by, mental illness. Recovery in this sense refers instead to overcoming the effects of being “a mental patient”— including poverty, substandard housing, isolation, unemployment, loss of valued social roles and identity, loss of sense of self and purpose in life, and iatrogenic effects of involuntary treatment and hospitalization—in order to retain or resume some degree of control over their own lives. Given the traumatic nature of being treated as a mental patient, advocates consider a return to a pre-illness state impossible, emphasizing instead the gains the person has had to make to manage and overcome the disorder.
    Point of Emphasis: Recovery does not have to refer only to a reduction or remission of psychiatric symptoms. It can also refer to efforts to reclaim a life of purpose and meaning despite the ongoing presence of psychiatric symptoms.
    (See Davidson, O’Connell, Tondora, Lawless, & Evans, 2005).
  • Recovery from serious mental illness has alternately been defined as a measurable end state (symptoms remit and disabilities are overcome) or an ongoing process (despite continuing symptoms and/or disabilities, people have hope that life goals can be attained (Corrigan & Ralph, 2004; Davidson & Roe, 2007).
    The traditional model of mental health care has focused on recovery from mental illness and thus has pursued and incorporated empirically derived practices of diagnosis and treatment. This emphasis on clinical diagnosis and treatment has resulted in advances in the field in regard to how to better understand and treat mental illness. Therefore, this aspect of traditional care has merit and should be a continued aspect of effective mental health care. The recovery movement has legitimately pointed out the narrowness of this traditional perspective on mental illness and captured another important prospect of the human experience that elevates and empowers individuals to pursue a life of purpose and meaning that can be defined and achieved even while experiencing the adverse effects of a mental illness. The recovery perspective offers new hope in its definition of recovery.
    Point of Emphasis: “Recovery” can be legitimately construed and pursued as: (1) Recovery from mental illness in which the goals focus on the reduction or elimination of symptoms and the amelioration of the deficits caused by mental illness; and (2) Recovery in mental illness in which the goals focus on learning how to live a safe, dignified, full, and self-determined life in the face of the enduring disability which may, at times, be associated with mental illnesses.
  • There are several definitions of recovery and this slide provides one that has been created by the National Consensus Conference on Mental Health Recovery and Mental Health Systems Transformation on December 16-17, 2004. – sponsored by Substance Abuse and Mental Health Services Administration and the Interagency Committee on Disability Research in partnership with six other Federal agencies (Substance Abuse and Mental Health Services Administration ,2006).
    In summary, recovery is a concept introduced in the lay writings of consumers beginning in the 1980s. It was inspired by consumers who had themselves recovered to the extent that they were able to write about their experiences of coping with symptoms, getting better, and gaining an identity. Recovery also was fueled by longitudinal research uncovering a more positive course for a significant number of patients with severe mental illness.
    Recovery is variously called a process, an outlook, a vision, a guiding principle. There is neither a single agreed-upon definition of recovery nor a single way to measure it. But the overarching message is that hope and restoration of a meaningful life are possible, despite serious mental illness (U.S. Department of Health and Human Services, Substance Abuse and Mental Health Services Administration, Center for Mental Health Services, National Institutes of Health, National Institute of Mental Health, 1999).
    Point of Emphasis: Recovery at its core is about finding purpose, meaning, and hope in the face of adversity… finding one’s way in dealing with the challenges of mental illness.
  • For example, an individual seeking services may list as a primary goal, “I wish to return to work full-time.” For this person, Recovery means that she is working toward re-engagement in a life activity that she found meaningful and purposeful. Perhaps she could function well enough to return to work despite ongoing psychiatric symptoms (and this occurs in many cases). In fact, the provision of certain medications (given side effects) and engagement in psychotherapy may (in some cases) actually hinder a person’s opportunities to live a life with purpose.
    This consumer role is a much more active, collaborative, and responsibility-assuming one than the traditional “mental patient” role. No longer are those obtaining mental health services supposed to act as “good patients.” Instead, these individuals are encouraged to educate themselves regarding treatment, assume control and responsibility for their own lives, and collaborate with practitioners to achieve the best care possible. In addition, consumers of services are no longer on the outside looking in at the treatment team. Consumers, other individuals with mental illness (not necessarily active in treatment), and groups that advocate for individuals with mental illness are now integral members of the treatment team (see Frese, Stanley, Kress, & Vogel-Scibilia, 2001). Furthermore, the emergence of Certified Peer Specialists as providers of mental health services represents a further innovation in the identity of the consumer of services as integral members of a treatment team. For the provider, the role shift entails a willingness to truly collaborate with consumers of care in regard to treatment planning, assessment of consumer strengths, and exploration of community agencies or natural supports that could assist the individual/family.
    Stigma is a major barrier to the adoption of the new role that individuals with mental illness possess while in Recovery. Many in society (despite evidence to the contrary) believe that those diagnosed with persistent forms of mental illness are poor, dependent on others, unintelligent, physically unhealthy, dangerous, and unclean. These beliefs lead to discriminative acts (which are often justified as being well-intentioned and protective toward the person) that reinforce these very stereotypes. Individuals with mental illness then “buy into” these stereotypes themselves and handicap their own progress.
  • General Comment: The practitioner possesses valuable specialized knowledge and skills. The individual in Recovery possesses personal strengths, abilities, and knowledge that have allowed him/her to survive thus far. The combined knowledge, effort, and skill of both is required for the most effective care. Ultimate responsibility and control for the Recovery process lies with the individual seeking treatment. Thus, the input regarding what individuals and families want and need in their efforts is crucial to development and provision of excellent care.
  • Point of Emphasis:
    Bullet 1: highlighted a national agenda to transform the mental health system to a consumer friendly and Recovery oriented model of care.
    Bullet 2: to discuss his commitment to the recovery model as the primary framework for both federal and local substance abuse and mental health service provision.
    Bullet 3: sent a Draft Resolution on APA Endorsement of the Concept of Recovery for Serious Mental Illness to APA boards, committees, divisions, and affiliated SPTAs this spring.
  • Our current approach to mental health care is working just fine.
    Or
    Consumers with mental illness are just too impaired to actively partner in their own care.
    Or
    Recovery is just for consumers with serious and chronic mental illness.
  • Stigma, loss of judgment due to illness, or other barriers make some people with mental illness unwilling or reluctant to acknowledge need and to seek treatment and to maintain their treatment.
    The Surgeon General’s Report on mental health in America suggested that many people receiving mental health services do not believe that the services that they received were relevant or helpful.
  • From 1987 to 1997: Percent of patients receiving medications doubled.
    Average number of visits declined from 12.6 to 8.7. Olfson et al., 2002
    While acute benefits of medications have been consistently observed across mood disorders, psychotic disorders, and Attention Deficit Disorder, these benefits have often entailed modest treatment effect sizes ranging from .3 to .8.
    As reported in the Surgeon General’s report on Mental Illness, since the 1950’s we have made very little progress in attenuating the problem of stigma toward those with mental illness.
    People with mental illness often internalize negative attitudes toward those with mental illness result in reluctance to seek and/or maintain adequate mental health care. Studies have indicated more positive attitudes toward treatment = less stigmatization.
  • We agree with most recent reports which recommend that . . .
    Mental health services need to be re-oriented to promoting resilience and recovery
    Mental health services need to be person- and family-driven
    Hope, valued social roles, and a life in the community are to be desired
    Despair, discrimination, and a life in institutional settings are not desired
    Above used with permission of Larry Davidson, Ph.D. Davidson, L. (2007, January). Recovery and serious mental illness: What it is and how to promote it. Presentation at the Medical College of Georgia Psychiatry Grand Rounds (January 11, 2007).
  • singer, daughter of Nat "King" Cole battled clinical depression
  • General Comment: Central to Empowerment is the effort for each individual to assume and maintain control over his/her own life. Consumers are encouraged to participate collaboratively and fully in all treatment decisions made. However, to do so, consumers of care must believe themselves capable of assuming such authority and responsibility. The provider’s role is to provide a treatment environment in which this self-belief may be fostered. Each of these four components of empowerment will now be discussed in turn.
  • These are discussion questions to ask them to consider to what extent their current practice is enhancing a sense of self-determination in mental health and mental health care.
  • YES NO
    People with The mentally ill
    mental illness
    People whoMental patients
    receive mental
    health services;
    Consumers
    A person withA schizophrenic
    schizophrenia
    “He has bipolar disorder.”“He’s bipolar.”
  • Discussion should elicit the picture that we want to be a part of the decision making process…
    What patients say helps build trust in the physician.
    Thom & Cambell, 1997, J. Family Practice.
    Technical Competence
    Thorough evaluation of problems.
    Provision of appropriate and effective treatment.
    Interpersonal
    Communication that the patient is understood.
    Expressions of caring.
    Communications that are clear and complete.
    An emphasis on partnership.
    Demonstrations of honesty and respect.
  • The Certified Peer Specialist (CPS) is a part of the team who can assist with this bridging effort.
    To many traditional providers, the CPS will be entirely new. But staffers who would fit the role of peer specialists have been working in mental health care systems around the United States for many years. The CPS as a formally recognized mental health role has been recognized with Medicaid reimbursement in a growing number of U.S. states since 1999. There are many hundreds of peer specialists working today in this emerging profession.
  • This painting entitled “Hope” by George Frederick Watts at first glance is rather strange given the title that it bears. Yet upon close examination one can see why it is considered one of the great depictions of “hope” in the art world. The work pictures a blind folded woman sitting on what we take to be the world. She embraces a lyre of which every string is broken … but one. The heavens are illuminated by a solitary star and Hope bends her ear to catch the music from the last remaining string of her almost shattered lyre.
    Point of Emphasis: Hope is recognized unanimously by consumers as one of the most important determinants of recovery (Russinova , 1999 ). Lovejoy (1982) emphasized that recovery cannot occur without hope as hope provides the person with all the essential elements of recovery: the courage to change, to try and to trust.
    Based on personal experience, Deegan (1988) described the process of recovery as a transition from despair, anguish, and pessimism to a new hope that life can be different, a hope born out of the presence of another person ready to provide support and care.
  • As reported by Cruz and Pincas (2002) over the course of the past 50 years of research, encounter and treatment outcomes (that is the extent to which patients show up for treatment, adhere to treatment regimens, and receive good outcomes) can be significantly influenced by:
    The degree to which treatments are negotiated and not dictated.
    The degree to which treatment is focused on specific tasks that the patient has helped to identify.
    The degree to which there is attention to the therapeutic alliance.
    And
    The degree to which the provider compassionately communicates and gives support.
    I hope that as you have heard the words of recovery and seen the pictures of just a few of the numerous prominent men and women who have suffered from mental illness but also have accomplished great things… that we begin to share the vision of a new system of mental health care…I hope that you will join us in this new newfound hope in what we and our patients can do together.
  • For Recovery Transformation to take place in an academic psychiatric department we proposed that:
    The virtues of traditional psychiatric care need to be acknowledged and valued – don’t throw the baby out with the bath water.
    While the “Recovery Movement” has been primarily a Consumer movement –to carry forward the transformation of a system, psychiatric providers needs to be included.
    Recovery has been primarily founded on rights and principles – but to move forward there needs to be attention to science and evidence-based practice.
  • Who: Need similar trainers who have the perspective of what it is like to be a provider and/or consumer.
    What: the Complexity requires work on operational definitions and use of building/shaping principles
    Outcome: Need passion and tools. The outcome of the instruction provided on the basis of this manual, however, will rely heavily on the ability of the instructor to gain rapport with the learning participants, to passionately convey the message, and to share inspiring stories that move providers toward knowledge and attitudes that are embedded in the recovery model of mental health care.
  • Who: Need similar trainers who have the perspective of what it is like to be a provider and/or consumer.
    What: the Complexity requires work on operational definitions and use of building/shaping principles
    Outcome: Need passion and tools. The outcome of the instruction provided on the basis of this manual, however, will rely heavily on the ability of the instructor to gain rapport with the learning participants, to passionately convey the message, and to share inspiring stories that move providers toward knowledge and attitudes that are embedded in the recovery model of mental health care.
  • This slide and the next two present a proposed documentation template generated by Project GREAT for the recording of recovery based care in clinical notes. In our mental health care system, all electronic clinical notes have embedded within them this recovery assessment template in order to prompt providers to look for and consider recovery relevant information as part of their diagnostic and treatment conclusions and planning. There are four key components in this template: (1) documentation of life goals and associated provider and consumer tasks/responsibilities intended to facilitate the realization of these goals; (2) documentation of a strengths assessment intended to help providers and consumers identify strengths within the consumer that could be useful in achieving life goals; (3) documentation of systems-based treatment planning in order to prompt providers to consider what additional support/resources might be used to help the consumer achieve life goals- including a specific prompt for consideration of using a CPS as part of the treatment plan; and (4) documentation of hope assessment to help providers and consumers maintain vigilance and respond to issues of consumer hope.
  • This slide and the subsequent slide present the one-page Behavioral Health Planning Form that Project GREAT has generated in order to encourage consumers to communicate to their providers their life goals. In our mental health care system, we provide this for the consumer at the initial diagnostic appointment. Given to consumers when they are processed in for their initial mental health care appointment, the consumers complete the form prior to meeting with the providers on their next appointment and literally hand the form to their providers during the second interview. We have observed that consumers readily can identify at least some relevant life goal, and providers increasingly have been learning to incorporate these life goals in their treatment plans. It should be noted, that this form also includes a prompt regarding interest in working with a CPS. This prompt encourages consumers and providers alike to make use of the CPS’s services.
  • These slides present a proposed one-page Strengths Assessment Form that Project GREAT has generated in order to encourage consumers to evaluate their own strengths as they consider ways they might achieve life goals and foster healing/recovery. This form would be used as part of the initial evaluation but also would be updated on a regular basis. The form was designed to be relatively simple and easy to complete while waiting for the contact with the provider. The components were derived through a review of the strengths assessment literature (See Copeland, 2002; Epstein, Dakan, Oswald, & Yoe, 2001;Epstein & Sharma1998; Kendziora, T., Bruns, Osher, Pacchiano, & Mejia, 2001; Rapp & Goscha, 2006; Resnick & Rosenheck, 2006; Saleeby, 2001).
  • Project GREAT gives this example of a prompt to keep clinicians and consumers alike constantly aware of Recovery principles. The monthly bulletin entitled “Taking Flight” consists of a consumer’s recovery story followed by a summary of learning points based on the story. This one-page bulletin is produced by a CPS and psychologist working together, and distributed electronically and on paper at the Medical College of Georgia.
  • With respect to the Cook and colleagues (1995) Recovery Attitudinal Survey scores, analyses supported the hypothesis that significantly favorable recovery-based attitude shifts would not occur following the initial workshop (targeting recovery knowledge and skills), but would occur following participation in the second workshop (which specifically targeted recovery-aligned attitudes). However, examination of the AQ-27 score differences indicated that no significant change in participant endorsement of stigmatizing attitudes toward consumers of mental health services after participation in either workshop intervention.
    Beliefs in the competence of the consumer improved.
    Stigmatizing attitudes unchanged. Consumers are to be feared, pitied, or avoided.
  • Point of Emphasis: This is a proposed checklist developed by the staff of Project GREAT that could be used for self-assessment and/or clinical care supervision to determine the extent to which the provider is practicing “shared decision making” in the provision of recovery based mental health care. The components were derived through a review of the shared decision making literature that reaches well beyond the practice of mental health care. (See, Adams & Drake, 2006; Charles, Gafnv, & Whelan, 1997; Elwyn, Edwards, Kinnersley, & Grol, 2000; Hamann, Leucht, & Kissling, 2003; Makoul & Clayman, 2006).
  • Alex Mabe, Ph.D. Gareth Fenley, M.S.W.

    1. 1. Alex Mabe, Ph.D. Gareth Fenley, M.S.W. Medical College of Georgia – Charlie Norwood Veterans Affairs Medical Center Psychology Residency
    2. 2.  This presentation is supported in part by an educational grant from U.S. Department of Health Resources and Service Administration (HRSA) Bureau of Health Professions (BHPr) Health Professions
    3. 3. 1) The participants will learn the fundamental principles of the recovery model of mental health care and be able to apply these principles to clinical practice training. 2) The participants will become familiar with the certified peer specialist as a new and valuable trainer for professional psychologists. 3) The participants will learn key components of a recovery training model that employs educational strategies to teach recovery based knowledge, attitudes, and practice skills.
    4. 4.  Jeremy is 40 years of age and has carried the diagnosis of schizophrenia since he was 24 years of age.  Currently, he lives in a group home and works in a rehabilitation center earning minimal wage for basic cleaning services.  In the most recent visit with his psychiatrist, he stated that he wanted to open his own checking account so that the group home supervisors would stop stealing his money.
    5. 5.  Knowledge of Recovery Model Concepts – 93%  Familiar with the literature – 66%  Feel comfortable providing a definition – 55%
    6. 6.  WHO Pilot Study and other Longitudinal Outcome Research on mental illness demonstrated that partial to full recovery (in the traditional sense) is just as common, if not more so, than a chronic, downward, or deteriorating course and enduring disability. Adapted from and used with permission of Larry Davidson, Ph.D. Davidson, L. (2007, January). Recovery and serious mental illness: What it is and how to promote it. Presentation at the Medical College of Georgia Psychiatry Grand Rounds (January 11, 2007).
    7. 7. Experience of Consumers with Psychologists “I found psychologists were no help. They wanted to focus too much on my symptoms. It seemed like they were getting some sort of titillation hearing about my delusions. I don't want to talk about my symptoms particularly my delusions. I am trying to forget my delusions since they were so embarrassing. I want to focus on the future. I must be doing something right since I have a MS, almost a second MS, worked for years, and am presently in a PhD program in computer science. All of this without the help of psychologists. If I had listened to psychologists 20 years ago I would have not accomplished any of this since they told me I was being unrealistic about attending grad school.” FROM: email list for job and school networking for people with psychiatric disabilities, maintained by Boston University
    8. 8.  Mental Health Consumer / Survivor / Ex-Patient / Ex-Inmate Movement  Borrowed idea of being ‘in recovery’ from addiction self-help community, suggesting that even when mental illness is long-term, a person can—and has the right to— reclaim his or her life outside of institutional settings. Adapted from and used with permission of Larry Davidson, Ph.D. Davidson, L. (2007, January). Recovery and serious mental illness: What it is and how to promote it. Presentation at the Medical College of Georgia Psychiatry Grand Rounds (January 11, 2007).
    9. 9.  Recovery from refers to eradicating the symptoms and ameliorating the deficits caused by serious mental illnesses  Recovery in refers to learning how to live a safe, dignified, full, and self-determined life in the face of the enduring disability which may, at times, be associated with serious mental illnesses Adapted from and used with permission of Larry Davidson, Ph.D. Davidson, L. (2007, January). Recovery and serious mental illness: What it is and how to promote it. Presentation at the Medical College of Georgia Psychiatry Grand Rounds (January 11, 2007).
    10. 10. “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.” SAMHSA (2006)
    11. 11. What is ‘revolutionary’ about Recovery?  Minimizing illness is not the same as maximizing the opportunity for a meaningful life  Requires role shifts for both the person with the illness/disability and the provider of services  Must broaden focus of care beyond the illness itself – effects of stigma are equally (if not more) damaging than the illness itself Adapted from and used with permission of Larry Davidson, Ph.D. Davidson, L. (2007, January). Recovery and serious mental illness: What it is and how to promote it. Presentation at the Medical College of Georgia Psychiatry Grand Rounds (January 11, 2007).
    12. 12. Health care as a collaborative enterprise  In recovery-oriented care, it is neither that the doctor is the sole expert nor is it solely self-help.  It is a partnership, more like midwifery than surgery, but perhaps characterized best in the words of The Home Depot: “You can do it. We can help.” Adapted from and used with permission of Larry Davidson, Ph.D. Davidson, L. (2007, January). Recovery and serious mental illness: What it is and how to promote it. Presentation at the Medical College of Georgia Psychiatry Grand Rounds (January 11, 2007).
    13. 13.  New Freedom Commission (2003) and Federal Action Agenda (2005)  June 2007, Psychologist Terry Cline, Ph.D., administrator of the SAMSHA met with APA board of directors  VA Psychology Leadership Conference – April 2008 “VHA mental health services will be recovery oriented…”  Spring 2009 – The Task Force on Serious Mental Illness and Severe Emotional Disturbance
    14. 14. If it ain’t broke, then don’t fix it! Why should we change our clinical practice approach?
    15. 15. Trends in Mental Health Services  60%-80% do not receive needed services  55% of the individuals with serious mental illness stated that they had not received services because they did not need it.  Significant delays in seeking treatment are common.  Dropping out of treatment prematurely is common.
    16. 16. Trends in Mental Health Services- continued  Psychiatric practice appears to be drifting toward primarily psychopharmacological management – consumers have less and less “time with the doctor.”  Treatment effect sizes for medication management and psychotherapy are modest.  Stigma continues to be a serious hindrance for good quality care and positive clinical outcomes.  Self-Stigma leads to treatment avoidance
    17. 17. Our Opinion “It IS broke and it needs fixin’!”
    18. 18. Natalie Cole - Singer Clinical Depression
    19. 19. Key Recovery Concepts As identified by (and adapted from) a SAMHSA panel of providers, consumers, administrators, and researchers: 1. Empowerment 2. Person-Centered Care 3. Whole Person Care (Holistic) 4. Focus on Strengths 5. Support (Systemic Treatment Orientation) 6. Recovery as a Journey (Non-linear Process) 7. Hope Adapted from Substance Abuse and Mental Health Services Administration (2006). National consensus statement on mental health recovery. Rockville, MD: US Department of Health and Human Services. Accessed online 12/20/2006. http://download.ncadi.samhsa.gov/ken/pdf/SMA05/trifold.pdf
    20. 20. Defining Empowerment  A sense of authority in making choices, participating in treatment, and engaging in preferred life activities  Composed of four major components: 1. Self Direction 2. Respect 3. Personal responsibility 4. Advocacy Adapted from Substance Abuse and Mental Health Services Administration (2006). National consensus statement on mental health recovery. Rockville, MD: US Department of Health and Human Services. Accessed online 12/20/2006. http://download.ncadi.samhsa.gov/ken/pdf/SMA05/trifold.pdf
    21. 21. How would you characterize your practice model?  Are you taking care of your patients?  Or are you partnering with consumers to help them take care of themselves?
    22. 22. Person First Language No:No: YESYES The mentally illThe mentally ill People with mentalPeople with mental illnessillness Mental patientsMental patients People who receivePeople who receive mental healthmental health services:services: consumerconsumer A schizophrenicA schizophrenic A person withA person with schizophreniaschizophrenia He’s bipolarHe’s bipolar He has bipolarHe has bipolar disorderdisorder
    23. 23. Earl Campbell – NFL Running Back Panic Disorder
    24. 24. Person-Centered Care
    25. 25. When YOU go to the doctor, how do you want decisions to be made?
    26. 26. Beyond Compliance: Shared Decision Making There are two experts in the room. One knows science and has clinical experience and technical skills The other knows his or her personal preferences and subjective experience Deegan & Drake (2006) Shared Decision Making and Medication Management in the Recovery Process. PSYCHIATRIC SERVICES, 57, 1636-1639.
    27. 27. Tom Harrell - Jazz Musician Schizophrenia
    28. 28. Whole Person Care Holistic Treatment
    29. 29. Collaborative Goal Setting: “Your life to be about something” Question “In a world where you could choose to have your life be about something, what would you have it be about?” Adapted from and used with permission of Kelly Wilson, Ph.D. (2008, May). Using ACT for your most difficult cases.. Presentation at the Medical College of Georgia Psychiatry Workshop (May 2, 2008).
    30. 30. Dr. Kay Redfield Jamison - Psychologist, Scientist, and Author Bipolar Disorder
    31. 31. Focus on Strengths “Let’s talk about what you do well.”
    32. 32. Howie Mandell – Comedian/Actor Obsessive-Compulsive Disorder
    33. 33. Support Systemic Treatment Orientation
    34. 34. A (Not So?) New Part of the Team Certified Peer Specialist
    35. 35. A “Peer Specialist” or “Peer Support Specialist”:  Manages his or her own life with mental illness  Provides mental health services to others with mental illness (peers)
    36. 36. The Peer Specialist’s Role  Part of a multidisciplinary team  Does not treat symptoms  Does provide support, encouragement and wellness planning  Offers role modeling and teaching about Recovery
    37. 37. The Georgia Certified Peer Specialist (CPS) Program  High school diploma or GED required  Competitive admissions process  Two-week training  Certification exam  Continuing education
    38. 38. Monica Seles – Tennis Champion Clinical Depression
    39. 39. Recovery as a Journey Non-Linear Process It [Recovery] is not a perfectly linear process. At times, our course is erratic and we falter, slide back, regroup, and start again.” Dr. Pat Deegan Deegan, P. E. (1988). Recovery: The lived experience of rehabilitation. Psychosocial Rehabilitation Journal, 11, 11-19, p. 15.
    40. 40. Prepare the Consumer  Prepare the consumer for the ups and downs.  Discuss relapses before they happen in terms of learning experiences.  Encourage a balanced outlook on the future.  Work with individuals where they are at.
    41. 41. Jack Dreyfus – Business Leader Clinical Depression
    42. 42. Hope By George Frederick Watts
    43. 43. Hope arises from…  “The Will” - Convey the message that people with mental illness can recover and can have meaningful lives. Finding an obtainable goal when it seemed like none could be found.  “The Way” - A belief that our actions or the actions of others could help to make the desired outcome come about. Finding an unexpected pathway to achieving a goal and the resources to get there. Adapted from: Snyder, C.R., Ilardi S.S., Cheavens J, Michael, S.R., Yamure, L., & Sympson S. (2000). The role of hope in cognitive-behavior therapies. Cognitive Therapy and Research,24, 747-762.
    44. 44. Hope arises from…  “The Relationship” - Affirm personal worth and hope in the relationship. Responding with affirming words.  “The Stories” - Share your stories of hope…and the stories of others who are role models of recovery. Adapted from Snyder, et al. 2000
    45. 45. John Nash - Mathematician/ Nobel Prize Winner Schizophrenia
    46. 46. Project G.R.E.A.T. (Georgia Recovery-Based Educational Approach to Treatment)  System transformation of an academic psychiatric department to a Recovery model of care through teaching and dissemination.  To disseminate the Recovery Model to mental health agencies and medical schools throughout Georgia and beyond.
    47. 47. Recovery-oriented care requires a fundamentally shift- Yet Bridges need to be built Traditional Care Recovery Oriented Care
    48. 48. The Revolution Requires Providers and Consumers Working Together  Providers:  Need to be more collaborative  Need to be more versed on strengths and resilience  Need to broaden definitions of the “treatment team”  Need to be more aware of the critical nature of hope  Consumers:  Need to develop complementary knowledge and skills in order to be able to work collaboratively with their providers
    49. 49. The Revolution Requires Science and the “Consumer’s Voice” Science  Can provide useful tools for refining ways recovery principles can be taught and implemented in clinical practice.  Consumer Voice  Can direct us toward relevant processes and outcomes that are founded on lived experience with mental illness
    50. 50. Curriculum Design  Who: Doctorally trained clinicians and consumers  What: Recovery principles and Practices - Complex material  Outcome: Knowledge, attitudes, skills- practice behavior
    51. 51. Curriculum Design - continued  Trainers: Doctorally trained clinicians and consumers  Key Outcomes:  Key Concepts - Contrasts of traditional and recovery practice, empirical evidence of recovery principles, practice applications  Key attitudes – respect, empowerment  Key behaviors – goal setting, strengths assessment, collaborative decision making, and hope enhancement strategies
    52. 52. Project Great: Defining and Refining as we go Phase I: Bringing in “The Consumer Voice”  Hiring Certified Peer Specialists  Forming a Behavioral Health Advisory Council
    53. 53. Project Great: Defining and Refining as we go Phase II: Developing workshops to immerse psychology and psychiatry faculty and students in the Recovery Model of Mental Health Care.
    54. 54. Workshop Design Connect learning to the participants’ preexisting data bank Allay fears that recovery would supplant their skills/practices Include materials in the form of clinical situations or consumer problems/ treatment stories Provide consumer stories – examples of consumer competence
    55. 55. Workshop Design- continued Introduce person first language Use active learning strategies – Socratic questions, case vignettes with discussion, roleplay Keep science in the forefront Introduce practice prompts (tools) Conduct pre-post measurement of knowledge and attitudes
    56. 56. Project Great: Defining and Refining as we go Phase III: Creating and Disseminating Practice Tools
    57. 57. Documentation Templates Consistent with Recovery Project GREAT Recovery Assessment Form I. Person-Centered Treatment Plan (Life Goals and Objectives) Goal 1: _________________________________________________________________________________ _________________________________________________________________________________ __ New Consumer/Family Tasks _________________________________________________________________________________ _________________________________________________________________________________ __ New Provider Tasks/Responsibility_______________________________________________________________ _________________________________________________________________________________ _________________________________________________________________________________ __ Goal 2: _________________________________________________________________________________ _________________________________________________________________________________ __ New Consumer/Family Tasks _________________________________________________________________________________ _________________________________________________________________________________ __ New Provider Tasks/Responsibility
    58. 58. Project GREAT Recovery Assessment Form - continued II. List Personal Strengths for Consumer related to personal life goals: 1. 2. 3. III. Systems-based Treatment Plan Is this individual/family appropriate for referral for Peer Support Services? (e.g., Peer Support Specialist, Friendship Community Center, AA, NA, NAMI, Parent-to- Parent, Bereaved Parents of America, Health Grandparents Project of Augusta) YES NO Would the consumer like to participate in Peer Support Services here at MCG? YES NO Would any of the following community support areas be appropriate for consideration in your treatment planning (Please circle appropriate services): Activities/Hobbies Child Care Financial support Health Care Housing Physical fitness Occupational/job support School/Educational Support Spiritual/religious support Substance Abuse Program Transportation Other______________________
    59. 59. Project GREAT Recovery Assessment Form - continued IV. Hope Assessment: Person’s beliefs that they are capable of doing things to make things better: High Medium Low Person’s beliefs that there are pathways toward making things better: High Medium Low
    60. 60. Behavioral Health Planning Form Medical College of Georgia “Putting Patient/Family Centered Care and Recovery into Practice” Name: ___________________________ Date: _______________ Welcome to our clinic. This form can help you take an active role in your care with us. Please take a few minutes to fill it out at home, bring it back to the clinic, and give it to your doctor or therapist at your next visit. Tell us what your goals are: Help us make your life goals the focus of your care. Please write down one or two ways that you want your life to be better. Be specific. Think of something that you would enjoy or something that would give you a sense of meaning and purpose. Examples: “I want a job.” “I would like to be able to go out with friends.” “I want to enjoy doing things with my child.” "I want to have more meaningful and fulfilling relationships." Goal 1: __________________________________________________________ __________________________________________________________________ Goal 2: ____________________________________________________________ __________________________________________________________________
    61. 61. Behavioral Health Planning Form Medical College of Georgia “Putting Patient/Family Centered Care and Recovery into Practice” Continued Would you have an interest in also meeting with a Peer Specialist? Yes___ No ____ A peer specialist is a person who has lived with mental health problems and learned skills to live well. The peer specialist can work with you one on one or in a support group.
    62. 62. Strengths Assessment Form Medical College of Georgia “Putting Patient/Family Centered Care and Recovery into Practice” Please Complete This Form While You are Waiting and Give to Your Doctor/Therapist as Part of Your Visit Today Name: ___________________________ Date: _______________ Welcome to our clinic. This form can help you take an active role in your care with us. Please take a few minutes to fill it out and give it to your doctor or therapist as a part of your visit today. Tell us what you believe are your strengths: Because your strengths can play such an important role in your success working with us, we want to know what you do well. Please answer the questions below. 1. What about you makes you strong and has helped you through difficult times? (e.g., positive attitudes, personal traits such as patience/sense of humor/ strong work ethic, or spiritual faith, etc.) ______________________ _____________________________________________________________________ 2. What special skills do you have? ______________________________________ _____________________________________________________________________ 3. What do you do for fun? _____________________________________________ _____________________________________________________________________
    63. 63. Strengths Assessment Form Medical College of Georgia “Putting Patient/Family Centered Care and Recovery into Practice” CONTINUED 4. Which people in your life have been helpful to you?______________ _______________________________________________________________ _ 5. Who helps you keep physically healthy? __________________________ _______________________________________________________________ _ 6. What’s good about the home and neighborhood you live in?_________ _______________________________________________________________ 7. What gives your life purpose and meaning? _____________________ _______________________________________________________________
    64. 64. TAKING FLIGHT: Recurring prompts to “think and do Recovery”
    65. 65. Proposed: Goals Scale Directions: Read each item carefully. Using the scale shown below, please select the number that best describes how you think about yourself right now and put that number in the blank provided. Please take a few moments to focus on yourself and what is going on in your life at t his moment. Once you have this "here and now" set, go ahead and answer each item according to the following scale: 1 = Definitely False;, 2 = Mostly False;, 3 = Somewhat False;, 4 = Slightly False;, 5 = Slightly True;,6 = Somewhat True;, 7 = Mostly True;, and 8 = Definitely True. ___1. If I should find myself in a jam, I could think of many ways to get out of it. ___2. At the present time, I am energetically pursuing my goals. ___3. There are lots of ways around any problem that I am facing now. ___4. Right now I see myself as being pretty successful. ___5. I can think of many ways to reach my current goals. ___6. At this time, I am meeting the goals that I have set for myself.
    66. 66. The State Hope Scale (Goals Scale) Note. When administering the measure, it is labeled the Goals Scale. The even-numbered items are agency, and the odd-numbered items are pathways. Subscale scores for agency or pathways are derived by adding the three even- and odd-numbered items, and the total State Hope Scale score is the sum of all six items. Snyder CR. Sympson SC. Ybasco FC. Borders TF. Babyak MA. Higgins RL. (1996) Development and validation of the State Hope Scale. [Journal Article. Research Support, Non-U.S. Gov't. Research Support, U.S. Gov't, P.H.S.] Journal of Personality & Social Psychology. 70(2):321-35.
    67. 67. Phase IV: Educational Outreach Teams- “See one, Do one.” Engage Residents in Teaching Recovery  9 Presentations since 2007 involving 15 different psychiatry/psychology residents Project Great: Defining and Refining as we go
    68. 68. Phase V: Psychology Residency Curriculum Changes  Increasing exposure to the “Consumer’s Voice” –  CPS in Team meetings  Participation in Behavioral Health Council  Observing peer-to-peer support groups Project Great: Defining and Refining as we go
    69. 69. Phase V: Psychology Residency Curriculum Changes- continued  Demonstration of Recovery Skills –  Rotation and Seminar Evaluations  Evaluations of Faculty  Work Sample Project Great: Defining and Refining as we go
    70. 70. Resident Work Sample “…Ms. B has a number of strengths including her hope and motivation to improve her current difficulties and persistent in achieving her goals. When asked about prominent life goals, Ms. B. identified her desire to participate in more activities that she enjoys including cooking and fishing… to meet this goal [to be a chef] Ms. B. may benefit from a vocational rehabilitation assessment and job skills training… Ms. B may also wish to attend a community college or technical school to pursue a career in the culinary arts.”
    71. 71. Phase VI: Measuring Outcomes Project Great: Defining and Refining as we go 0 10 20 30 40 50 60 70 80 90 100 1980 1990 2000 2006 Line 4 Line 5 Line 6
    72. 72. Recovery Knowledge Change Recovery Knowledge 17.4 20.4 14.9 0 5 10 15 20 25 Pre Post MCG Control
    73. 73. Recovery Attitudes Recovery Attitudes 111.5 137.7 98.9 94.8 117 108.2 0 20 40 60 80 100 120 140 160 Pre Post AQ-27-Pre AQ-27-Post MCG Control
    74. 74. Recovery Documentation Chart Audit: Percent of Charts with Consumers’ Life Goals 28% 64% 0% 10% 20% 30% 40% 50% 60% 70% Jul-08 Feb-09
    75. 75. Recovery Related Consumer Satisfaction Press Gainey- Recovery Related Patient Satisfaction Responses First of Recovery Workshops Completed
    76. 76. Proposed Next Phase: Shared Decision Making Seminar and Supervision Guidelines Project Great: Defining and Refining as we go
    77. 77. Shared Decision Making Checklist Medical College of Georgia “Putting Patient/Family Centered Care and Recovery into Practice” 1. Provided information about the health issue at hand in a manner that was understandable to the patient. strongly disagree disagree undecided agree strongly agree 2. Provided information about treatment options (including options of doing nothing). strongly disagree disagree undecided agree strongly agree 3. Identified values relevant to the decision. a) Described options so that the patient could understand and could imagine what it is like to experience their physical, emotional, social effects. strongly disagree disagree undecided agree strongly agree b) Asked the consumer to consider which positive and negative features matter most. strongly disagree disagree undecided agree strongly agree
    78. 78. Shared Decision Making Checklist Medical College of Georgia “Putting Patient/Family Centered Care and Recovery into Practice” continued 4. Identified mutually endorsed and valued outcomes that are the target of intervention. strongly disagree disagree undecided agree strongly agree 5. Identified tasks that were agreed upon, seen as relevant, and in which there is a responsibility to act. strongly disagree disagree undecided agree strongly agree 6. Have established a relationship built on trust, acceptance, and confidence. a) Technical competence.  Thorough evaluation of the problem.  Provision of effective treatment options strongly disagree disagree undecided agree strongly agree b) Interpersonal Factors  Communication of understanding.  Expressions of caring.  Communications that are clear and complete.  Emphasis on partnership.  Demonstrations of honesty and respect. strongly disagree disagree undecided agree strongly agree
    79. 79. Questions/Discussion For additional information: amabe@mcg.edu

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