Transcript Building recovery-based systems and programs

Building Recovery Based Systems and Programs
Mark Ragins, MD
Medical Director
MHA Village Integrated Service Agency
Mental Health America
of
Greater Los Angeles
www.mhavillage.org
[email protected]
The Recovery Revolution
True revolutions in social services are rare. They involve changes
in our values, practices, relationships, cultures, systems, and
communities.
The main revolutions in our era have been:
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12 step recovery
Deinstitutionalization
Hospice
Mainstreaming special education kids
…and now Recovery with serious mental illnesses
Top 10 Reasons to Use Recovery Based Practice
1. When people don’t believe they have a mental
illness and you want to help anyway
2. When people don’t do what you tell them to do
3. When people can’t be cured and have to live with
significant symptoms
4. When the illness has swallowed them up and
become their identity and their whole life
5. When substance abuse is a major issue and you
want to integrate substance abuse and mental
health services
Top 10 Reasons to Use Recovery Based
Practice
6. When their culture leads to a different understanding of
mental illness and their use of services than you have
7. When trauma is a major issue and you want to help
without retraumatizing them
8. When hopelessness and passivity have taken over
9. When people have significant strengths and want to take
on more self responsibility
10. When people want to go on with their life in the “real
world”
DOMAINS OF TRANSFORMATION
INSIDE
OUTSIDE
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VALUES
EMOTIONS
BEHAVIORS
PRACTICE
WE
CULTURE
MISSION
SYSTEM
PROGRAMS
DOMAINS OF RECOVERY PROGRAMS
I
WE
INSIDE
OUTSIDE
HOPE,
GROWTH, and
RESPECT
ENGAGEMENT,
EMPOWERMENT,
REHABILITATION,
SHARED RESPONSIBILITY,
and TEACHING
WELCOMING,
HEALING,
RECOVERY, and
COMMUNITY
INTEGRATION
INDIVIDUALIZATION,
INTEGRATED SERVICES,
FLOW PROMOTION, and
RELATIONSHIP BASED
SERVICES
Fundamental Recovery Concepts
• Recovery is not the same as cure
• Recovery is person centered, not illness
centered
• Recovery is from the crippling not the illness
• Recovery is goal directed
• Recovery is strengths based building resiliency
Treating Acute Illnesses
• Professionals as experts diagnosing illnesses
and ordering treatment
• Patient provides history and complies with
treatment
• Life is put on hold while in treatment
• Short term professional-patient relationships
We treat almost only chronic mental illnesses
• Mission of public mental health to focus on chronic
illnesses
• Because of stigma people don’t come into treatment
until waiting has been ineffective
• Mental illnesses are particularly disabling, difficult to
rehabilitate and adapt to
• Mental illnesses are often associated with
hopelessness
• Mental illnesses impact self image rapidly and
powerfully
Treatment Implications
• Emphasize patient education, collaboration, and selfhelp
• Focus on hope
• Try to keep people in their lives
• Incorporate rehabilitation and adaptation
• Focus on impact on self image
• Promote long term, more personal doctor-patient
relationships
Mental illness creates special challenges in all these
areas
Recovery Implications
• For acute illnesses recovery results from symptom
elimination and cure
• For chronic illnesses recovery results from:
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Achieving self-management of the illness
Maintaining hope and self-image
Carrying on with life through rehabilitation and adaptation
Replacing professional supports with natural supports
For acute illnesses recovery is illness-based
For chronic illnesses recovery is person-based
ILLNESS CENTERED
friends (social support network)
housing (treatment setting)
illness
vocational class
(therapeutic activity)
family
PERSON CENTERED
employment
housing (home)
illness
(a part of me)
person
friends
family
PERSON CENTERED
ILLNESS CENTERED
The relationship is the foundation
The diagnosis is the foundation
Begin with welcoming – outreach and
engagement
Begin with illness assessment
Services are based on personal suffering and
help needed
Services are based on diagnosis and treatment
needed
Services work towards quality of life goals
Services work towards illness reduction goals
Treatment and rehabilitation are goal driven
Treatment is symptom driven and rehabilitation is
disability driven
Personal recovery is central from beginning to
end
Recovery from the illness sometimes results after
the illness and then the disability are taken care of
Track personal progress towards recovery
Track illness progress towards symptom reduction
and cure
Use techniques that promote personal growth
and self responsibility
Use techniques that promote illness control and
reduction of risk of damage from the illness
Services end when the person manages their
own life and attains meaningful roles
Services end when the illness is cured
The relationship may change and grow
throughout and continue even after services end
The relationship only exists to treat the illness and
must be carefully restricted throughout keeping it
professional
Person Centered Recovery
• Recovery with Chronic Illnesses must be
person centered not illness centered.
• Illnesses don’t recover, people do.
Recovery is from the crippling, not the injury.
Recovery is from the destruction, not the illness
Person Centered 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
Recovery is the approach that can make the dream of
deinstitutionalization a successful reality.
• Focus on building lives, not just treating
illnesses
• Emphasize opportunities for growth and
recovery
• Integrate substance abuse
• Focus on Transitional Age Youth
• Focus on highly problematic people
• Hire large numbers of people with experiences
with mental illnesses
MEDICAL MODEL
symptoms
illness
decrease symptoms
return to life
REHABILITATION MODEL
illness
functional impairment
improved function
return to life
RECOVERY MODEL
worker
illness
father
church
goer
husband
illness
person
Lakers
fan
1.
2.
3.
4.
HOPE
EMPOWERMENT
SELF-RESPONSIBILITY
MEANINGFUL ROLES
RECOVERY
1. Hope – believing the future can be better
2. Empowerment – believing you can make
the future better
3. Self-Responsibility – taking actions to make
the future better
4. Achieving Meaningful Roles – building a life
in the community of your choice
Hospice is the most successful person centered service
system we have
Hospice lessons:
• People recover not from their illnesses, but from the
destruction, the “crippling,” caused by their illnesses
• The patients with the most destruction need
recovery the most
• “Caring not curing”
• The recovery model is less frustrating and more
inclusive than the medical model because it’s goals
are more obtainable
• “Live with dignity”
RECOVERY-BASED SERVICES:
Welcoming / Engagement
Charity
Treatment
Rehabilitation
Advocacy / Community Development
Graduation
Three Types of
Services and Supports
1. Direct mental illness treatments
2. Coping with mental illnesses and destructive
emotions
3. Rebuilding lives.
In the last twenty years we’ve made far more
progress in the last two types than in the
first type of service.
RECOVERY-BASED SYSTEM DESIGN
Stages
1. “unengaged”
2. “engaged but not self-coordinating”
3. “self responsibility”
0. “unidentified”
D. “discharged”
RECOVERY-BASED TREATMENT PLANNING
Stages
1. “unengaged” – needs engagement
2. “engaged but poorly self-coordinating” – needs to build
skills and supports
3. “self responsibility” – needs to build self sufficiency
and community supports
Stage of Recovery
Unengaged
Engaged, but poorly
self-coordinating
Self responsible
Care taking services
Growth oriented services
• Forced treatment
• Protection
• Benefits
establishment
• Acute stabilization
• Outreach and engagement
• Peer bridging
• Concrete quality of life
goals
• Relationship building
• Structure
• Making decisions for
people
• Case management
• Chronic stabilization
• Supportive services
• Skill building
• Personal service
coordination
• Collaboration building
• Benefits retention
• Maintenance therapy
and medication
• Community integration
• Self-help
• Peer support
• Wellness activities
• Growth promoting therapy
Unengaged – Tasks
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Help them connect with staff
Help them connect with program and peers
Get them IDs and documentation
Get them money to live on
Try to begin a psychiatric and medical assessment and
treatment
Help secure safe and stable housing
Get to know their families
Try to keep the community from kicking them out – usually to
jail and/or psychiatric hospitals
Try to keep them from badly harming themselves and others
Unengaged – Time to move on
• Engaged with the community
• Engaged with us, or someone else, to get help
• Engagement with their goals consistent with
our mission and values
Engaged, but poorly self-coordinating – Get
a Life
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Money
Home
Education
Employment
Managing Mental Illnesses
Emotional growth and relationships
Physical health
Managing alcohol and drugs
Sex and intimacy
Pregnancy and parenting
Family relationships
Law abiding
Engaged, but poorly self- coordinating –
Skill Building Focus
The point isn’t to get things for them, but to teach them how to
get the next one themselves.
Don’t do it for them. Have them do it while you sit next to them
guiding them.
They have to learn things the hard way, by making mistakes, but
don’t waste their suffering. Help them learn the life lesson.
Help them expand their world. Expose them to new possibilities.
Help them discover their own abilities.
Engaged, but poorly self- coordinating –
Time to move on
Some people continue to need this level of services and support
and remain at the Village or other FSP.
Some people have built enough skills and supports to graduate
to a lower level of care – standard outpatient or wellness
center.
Some people will be ready to move towards self-sufficiency and
community integration to leave the public mental health
system (even if they still need meds or treatment).
Self Responsible - Tasks
• Develop self-sufficiency: economic, housing,
personal empowerment and self-responsibility,
wellness, coping skills
• Develop community identity, roles, and supports to
achieve community integration
• Develop self paid professional treatment, if needed
Community development and advocacy are key staff
tools
Self Responsible – Time to move on
Graduation is crucial. Many members have never successfully
completed anything before. The high profile presence of
graduation decreases “drop outs”.
Gradually relationships change – not really “termination” – may
remain “friends” or “extended family” or “mentors”
May give back to program inspiring other members. Some chose
to work in mental health.
Need to celebrate and continue to follow their success stories for
both remaining members and staff
Employment Services
• Unengaged: day labor, “work for a day – house for a
day”
• Engaged, but poorly self-coordinating: agency
businesses, supported employment including job
development and coaching, group placements,
supported mental health employment
• Self responsible: non-disclosure competitive
employment job development, employment with
accommodations, competitive mental health
employment
Medication Services
• Unengaged: accessibility, build relationship,
“try it” samples, build “usefulness”
• Engaged, but poorly self-coordinating: learn about
medications together, education and choices,
medication management, “patient driven”
• Self responsible: self-management with
“consultation,” finding community resources,
becoming “ex-doctor”
Incorporating Recovery Values
It’s not just what you do that changes as people
progress, or even why you do it. It’s also
important how you do it.
You shouldn’t be doing things the same way
throughout someone’s course of recovery.
The relationship changes as you move along.
Extreme Risk - Values
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Harm reduction and protection
“Trauma sensitive” services
Use coercion reluctantly
Don’t waste their suffering
Welcome them back
Unengaged - Values
• There’s “no wrong door”
• Everyone is welcoming
• A good treatment is built on a good
relationship
Engaged, but poorly self-coordinating Values
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Support, don’t care-take
Services are mobile
Services are accessible
Integrate services into a “one-stop shop”
Be a “no fail” program
Self Responsible - Values
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Create natural, community supports and roles
Encourage people to “give back”
Encourage mental health advocacy
Create “graduation” rituals and services
Why Should We Integrate Services?
It’s much easier to do one kind of service very well than lots of
services, but almost everyone needs lots of services, and if
they’re not in one place, they won’t use them.
“Do whatever it takes” doesn’t just mean to go beyond normal
service limits, being dedicated, accessible, flexible, and
creative. It also means “Do whatever service it takes.”
“Meet them where they’re at” doesn’t just mean be good at
welcoming, charity, housing first, and harm reduction. It also
means being able to support an array of goals for people at a
range of places in their recovery.
Integrated Service Agencies
• Unengaged: Outreach and engagement,
drop-in centers
• Engaged, but poorly self-coordinating: ACT
teams, case management, club house
• Self Responsible: Appointment based clinic,
wellness center, private care
Person-Centered Levels of Service
(Recovery Based Spectrum of Care)
Extreme risk
Locked setting
1:1 supervision
Legal interventions
Community
protection
Acute treatment
Engagement
Unengaged
Engaged, but not self
coordinating
Outreach Drop- Intensive
and
in
case
engagement center management
(ACT)
Welcoming
Charity
Evaluation and
triage
Documentation
Benefits assistance
Accessible
medications
Drop-in services
Case
management
Team
and
Clubhouse
Case management
Integrated services
Accessible
medications
Supportive services
Direct subsidies
Rehabilitation
Self responsible
Appointment
based clinic
Wellness
center
Appointment based
therapy
“Medications only”
Wellness activities
(WRAP)
Self-help
Peer support
Community integration
Where’s therapy?
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“Corrective emotional experience”
Engagement – relationship building
Adapted into “therapist – case manager role”
“In vivo” skill building
Creating healing environment – “therapeutic milieu”
Group therapy without walls
Carl Rogers – empathy, authenticity, caring
“1 step Recovery”
Step 1: Take your meds and do what you’re told.
Being “compliant” and leaving it to your doctor
to prescribe meds to cure you hardly ever
works.
What else are you going to do?…and how are
you going to get help to do it?
“12 roads to recovery”
1. Talk to other people instead of isolating
2. Actually feel feelings and emotions instead of
deadening them, medicating them, avoiding
them, or getting high.
3. Learn some emotional coping skills
4. Learn to “use” medications instead of just
“taking” medications
5. Take responsibility for your own life and make
some changes in yourself
6. Go to work even when you’re not feeling well.
Program Adaptations
Form an integrated services program by providing a variety of
services (established and created individually) to help people
recover
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What stage is this service best suited to?
How does it promote quality of life goals?
How does it promote progress in recovery?
How can it be connected to self-help and peer support?
How can it be connected to the community?
How will you handle its relationships with other services in
the program?
“12 roads to recovery”
7. Get roles outside of mental illness and the
mental health system
8. Improve physical health and wellness
9. Love other people – family, partners, kids
10. Work on acceptance and forgiveness instead of
blaming and vengeance
11. Give back by helping others
12. Find meaning and blessings in suffering and
reconnect with God and spirituality.
Recovery Based Services
1. Engagement and welcoming
2. Shared decision making and building selfresponsibility
3. Rehabilitation – building skills and supports
4. Integration of services – including consumer
provided services
5. Recovery based medication services
6. Integrating therapy and healing throughout services
7. Community integration and advocacy
8. Graduation and self-reliance
9. Providers living recovery values
Recovery Oriented Administration
Staff should be treated by administration the
way we want them to treat their clients.
Staff routinely complain that administrators
don’t “practice what they preach”. Some of
this is feeling administrators are too distant
from daily work with clients and some is
feeling that administration isn’t done with the
same values as expected from line staff.
CREATING RECOVERY-BASED CULTURES:
RECOVERY-ORIENTED LEADERSHIP
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Hope
Authority
Healing
Community Integration
What is recovery-oriented supervision?
Culture is Subjective
The culture of a program may be very different
from the program leaders’, the line staff’s and
the consumers’ perspectives.
Recovery is the consumers subjective experience
of the process of rebuilding including their
treatment and rehabilitation.
Sources of Program Culture
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Mission / Vision
Administrative “metaculture”
Leader
Habits / Traditions
Consumers
Degenerative
Culture and Paperwork
• Strong culture is said to exist where staff
respond to stimulus because of their
alignment to organizational values.
• Conversely, there is weak culture where there
is little alignment with organizational values
and control must be exercised through
extensive procedures and bureaucracy.
My Seven Key Dimensions of a
Recovery Based Culture
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4.
Welcoming and Accessibility
Growth orientation
Consumer inclusion
Emotionally healing relationships and
environments
5. Quality of life focus
6. Community integration
7. Staff recovery
Tracking Building Recovery Culture
Exploring
Welcoming and
Accessibility
Growth
Orientation
Consumer
Inclusion
Emotional
Healing
Quality of Life
Focus
Community
Integration
Staff Morale
and Recovery
Emerging
Maturing
Excelling
Building and Sustaining Cultures
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Artifacts and symbols
Stories, histories, heroes, legends, jokes
Rituals, rites, ceremonies, celebrations
Beliefs, assumptions and mental models
Rules, norms, ethical codes, values
Learning Cultures:
Expectations of Line Staff
• Understand the “big picture” top-down vision and
purpose and incorporate “administrative concerns”
• Generate bottom-up concrete plans
• Support bottom-up leaders
• Generate time and motivation to implement plans
• Spend time in groups evaluating impact and making
changes in plans
• Sustain process beyond leaders’ initial enthusiasm
Program recovery based culture and
psychiatrists
The stronger the program’s recovery based culture the
easier it will be to for the psychiatrists to become
recovery based.
Psychiatrists can be leaders in their program’s overall
transformation.
Overall, its best to include psychiatrists in overall
transformation efforts, learning and growing, making
changes and taking risks together with everyone else.
Choices of Psychiatrists’ Roles in Recovery
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Ignore it
Refer when “indicated”
Actively collaborate with recovery providers
Integrate into a recovery based program
Stages of Recovery Based Careers
• Student / Intern: Relationship skills, Understanding
impact of illnesses, Usefulness in goals, Poverty services
• Early Career: Collaborative medication, Trauma effects,
Strengths based, Team work, Shared responsibility with
clients
• Mid Career: Collect stories from “practice”, Develop “art”
of treatment, Emotional engagement with stability
• Late Career: Numerous long term relationships / stories,
Experience / patience, Mentoring
Common challenges
1. Changing hiring patterns and roles – including
consumer volunteers and staff
2. Increased attention to ethics and safety with
lower walls and barriers
3. Avoiding permanent crisis mode
4. Billing for recovery services
5. Creating team work
6. Integrating services
Common benefits
1. Decreased drop-outs even with challenging subpopulations
2. Integration of services
3. Enhanced dual diagnosis services
4. Enhanced quality of life outcomes
5. Decreased power struggles with clients
6. Decreased staff burnout
7. Increased flow through and graduation from
services
8. Increased community involvement