An understanding of the recovery "model" in contrast to the traditionalmodel of mental health services

1. Moving From Pathology to Person Chris Summerville, D.Min., CPRP Chris@mss.mb.ca 7th Annual Pacific Forensic Psychiatry Conference March 30 - April 1, 2011 Vancouver, BC 1

2. Disclosures 2 *No declarations.

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4. A. It is not easy going crazy or losing your mind. Mental illness is an experience! 4

6. Loss of Choice Making Skills

7. Increased harm & Risk

9. Fear

11. Belief in self

14. Life Roles

15. Choice Making Skills Mental Illness 5

16. B. Traditional models of care have focused on illness and symptom reduction. 6

17. Contrast Person Centred with an Illness Centred System PC: The relationship is the foundation. IC: The diagnosis is foundational. PC: Begin with welcoming – outreach and engagement. IC: Begin with illness assessment. PC: Services are based on personal suffering and help needed. IC: Services are based on diagnosis and treatment needed. PC: Services work towards quality of life goals. IC: Services work towards illness reduction goals. PC: Treatment and rehabilitation are goal driven. IC: Treatment is symptom driven and rehabilitation is disability driven. 7

18. PC: Personal recovery is central from beginning to end. IC: Recovery from the illness sometimes results after the illness and then the disability are taken care of. PC: Track personal progress towards recovery . IC: Track illness progress towards symptom reduction and cure. PC: Use techniques that promote personal growth and self responsibility. IC: Use techniques that promote illness control and reduction of risk of damage from the illness. PC: Services end when the person manages their own life and attains meaningful roles. IC: Services end when the illness is cured. PC: The relationship may change and grow throughout and continue even after services end. IC: The relationship only exists to treat the illness and must be carefully restricted throughout keeping it professional. (Ragins, 2008) 8

19. Two Types of Power Vs. 9

20. Two Types of Programs 10

21. Treatment approaches that focus on symptom remission/reduction: Being in control; Offering professional support; Managing symptoms; and Being paternalistic. Dr. Jacqueline M. Feldman, MD, Professor and Behavioural Neurobiology at the University of Alabama 11

22. Person Centred Treatment The foundation of a good treatment is a good relationship, not a good diagnosis. The purpose of mental health treatment, including medication, is not just to treat mental illnesses. It’s to help people with mental illnesses have better lives. Medications should be quality of life goal directed instead of symptom relief directed 12

23. C. People using mental health services lie on a spectrum. 13

24. D. How did this pathologizing of person come about? 14

25. Why has mainstream psychiatry been slow to embrace the recovery model? Part of this had to do with some of the ways psychiatrists had been trained in psychiatric diagnoses. For example, in the text of the Diagnostic and Statistical Manual of Mental Disorders, ed. 3 (DSM-III) was a statement implying that a diagnosis of schizophrenia was not compatible with any kind of recovering of social or vocational functioning: "A complete return to premorbid levels of functioning in individuals diagnosed with schizophrenia is so rare as to cast doubt upon the accuracy of the [schizophrenia] diagnosis.” 15

26. This approach was taken, in part, to guide clinicians away from diagnosing patients with transient symptoms as having schizophrenia. An unintended and unfortunate consequence of DSM-III criteria for schizophrenia was to reinforce an atmosphere of therapeutic nihilism. The net effect was the widespread acceptance of a model of treatment that emphasized relapse prevention and stability as being the primary goals of treatment. 16

27. The underlying belief for most clinicians was that while psychotic symptoms are treatable and relapse prevention possible, once stable, patients were unlikely to improve beyond the current level of symptomatic and functional improvements. The focus on stability with the assumption that further improvement is not possible can be considered to be a "maintenance model" of treatment. (Weiden, 2010) 17

28. E. A New Paradigm: The primary aim of mental health services is to promote personal recovery and social inclusion. 18

29. The goals, our goals should be: Help people achieve personal recovery. Gain a quality of life. Create environments in which recovery can take place and flourish. 19

30. F. What is Recovery? 20

31. Minimizing the impact of mental illness Maximizing well being Therefore...... 21

32. Recovery as wellness involves: Social Environmental Intellectual Occupational Physical Emotional Spiritual Financial 22

33. “Recovery is being able to live a meaningful and satisfying life, as defined by each person, in the presence or absence of symptoms. It is about having control over and input into your own life. Each individual’s recovery, like his or her experience of the mental health problems or illness, is a unique and deeply personal process.” 23

34. The most widely used definition ofpersonal recovery is from Anthony (1993) “…a deeply personal, unique process of Changing one’s attitudes, values, feelings, goals, skills, and/or roles. It is a way of living a satisfying, hopeful, and contributing life even within the limitations caused by illness. Recovery involves the development of new meaning and purpose in one’s life as one grows beyond the catastrophic effects of mental illness.” 24

35. Recovery themes Identity formation: mental illness is one facet of a more differentiated self Autonomy/self-agency: greater capacity for self-initiated action Hope: renewed sense of possibility Supportive, healing relationships: professional and personal Enhanced role functioning: employment, parenthood, etc. (Mancini, 2008) 25

36. The Five Stages of Recovery Moratorium – A time of withdrawal characterised by a profound sense of loss and hopelessness; Awareness – Realisation that all is not lost and that a fulfilling life is possible; Preparation – Taking stock of strengths and weaknesses regarding recovery and starting to work on developing recovery skills; Rebuilding – Actively working towards a positive identity, setting meaningful goals and taking control of one’s life; Growth – Living a meaningful life, characterised by self-management of the illness, resilience and a positive sense of self. (Andresen, Caputi & Oades, 2006) 26

37. Five Stages in the Recovery ProcessLarry Fricks, 2007 There are times when a person... Impact of Diagnosis Life is Limited ...is overwhelmed ...has given in to ...the Disabling Power of a Psychiatric Diagnosis Symptoms Stigma Self Image ...is moving beyond ...is questioning ...is challenging Actions for Change Change is Possible Commitment to Change 27

38. Components of the recovery process. Finding and maintaining hope – believing in oneself; having a sense of personal agency; optimistic about the future; Re-establishment of a positive identity – finding a new identity which incorporates illness, but retains a core, positive sense of self; Building a meaningful life – making sense of illness; finding a meaning in life, despite illness; engaged in life; Taking responsibility and control- feeling in control of illness and in control of life. (Andresen, Oades & Caputi, 2003) 28

39. G. What are the working implications and working practices? (How do you do know that you are a recovery-oriented practitioner?) 29

40. Key characteristics at a practitioner level Openness Collaboration as equals A focus on individual’s inner strengths Having hopeful expectations (Hopefulness like hopelessness is contagious.) Reciprocity A willingness “to go the extra mile.” Relationship skills of empathy, caring, acceptance, mutual affirmation, encouragement of responsible risk-taking, and a positive expectation for the future. (Borg & Kristiansen, 2004) 30

41. 12 Aspects of Staff Transformation Looking Inward and Rebuilding the Passion. Building Inspiration and Belief in Recovery. Changing from Treating Illnesses to Helping People with Illnesses Have better lives. Moving from Caretaking to Empowering, Sharing Power and Control. Gaining Comfort with Mentally Ill Co-Staff and Multiple Roles. Valuing the Subjective Experience. Creating Therapeutic Relationships. Lowering Emotional Walls and Becoming a Guiding Partner. Understanding the Process of Recovery . Becoming Involved in the Community . Reaching Out to the Rejected. Living Recovery Values. (Ragins, 2009) 31

42. Top Ten Tips for Recovery Oriented Practice. Actively listen to help the person to make sense of their mental health problems? Help the person identify and prioritise their personal goals for recovery – not professional goals? Demonstrate a belief in the person’s existing strengths and resources in relation to the pursuit of these goals? Identify examples from my own ‘lived experience’, or that of other service users, which inspires and validates their hopes? Pay particular attention to the importance of goals which take the person out of the ‘sick role’ and enable them actively to contribute to the lives of others? 32

43. Identify non-mental health resources – friends, contacts, organisations – relevant to the achievement of their goals? Encourage self-management of mental health problems (by providing information, reinforcing existing coping strategies, etc.)? Discuss what the person wants in terms of therapeutic interventions, e.g. psychological treatments, alternative therapies, joint crisis planning, etc., respecting their wishes wherever possible? Behave at all times so as to convey an attitude of respect for the person and a desire for an equal partnership in working together, indicating a willingness to ‘go the extra mile’? While accepting that the future is uncertain and setbacks will happen, continue to express support for the possibility of achieving these self defined goals – maintaining hope and positive expectations? (Shepherd, 2007) 33

44. Ranking of Professional Competencies by Consumers, Consumer Providers and Providers 1. Having genuine respect for clients. 2. Having clients develop skills to cope and manage psychiatric conditions. 3. Seeing clients as persons apart from diagnosis and symptoms. 4. Helping clients to accept and value themselves. 5. Listening to clients without judgement. 34

45. 6. Believing in clients’ potential to recover. 7. Trusting the authenticity of client’s experiences and accounts. 8. Being accessible to clients when they need help. 9. Caring about clients. 10. Understanding clients. (Russinova, Rogers, Ellison & Lyass, 2011) 35

46. “The most mental health care practitioners can do is offer recovery-oriented care in support of the person’s efforts toward his or her recovery while enhancing the person’s access to opportunities to learn how to manage his or her condition and pursue his or her own hopes, dreams, and aspirations.” -Dr. Larry Davidson, Ph.D. 36

47. See “100 Ways to Support Recovery: A guide for mental health professionals” by Mike Slade, 2009 found http://www.mentalhealthshop.org/products/ rethink_publications/100_ways_to_support.html?shortcut=100ways# See “How to Recognize a Recovery-Oriented Practice by Davidson, Tondora & O’Connell, 2010 at http://www.wapr.info/Bulletins/WAPR_bull_26-27_apr2010.pdf 37

48. H. Measuring Recovery in Mental Health Services 38

49. The Recovery Promoting Relationship Scale (RPRS) http://www.nasmhpd.org/general_files/publications/Hospital%20CEO%20Toolkit/Updated%20PDF%20Toolkit/1.3%20Recovery%20Promoting%20Relationships%20Scale%20RPRS%20Manual3.pdf Developing Recovery Enhancing Environments Measure (DREEM) Article: http://pb.rcpsych.org/cgi/content/full/31/4/124#REF2 Information available from: Hugh.Middleton@eastmidlands.csip.nhs.uk 39

50. Recovery Star http://www.mhpf.org.uk/recoveryStarApproach.asp The Illness Management and Recovery Available at: http://store.samhsa.gov/product/SMA09-4463 40

51. Personal Recovery and Mental Illness: A Guide for Mental Health Professionals. Mike Slade. Cambridge University Press. 2009. 41

52. Living Outside Mental Illness: Qualitative Studies of Recovery in Schizophrenia. Larry Davidson. New York University Press, 2003. 42

53. THANK YOU 43