Recovery: Are we there yet? A process of learning to approach each - - PDF document

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Recovery: Are we there yet?

Patricia B Nemec PsyD CRC CPRP Patricia B. Nemec, PsyD, CRC, CPRP

USPRA-GEORGIA

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October 2010 Please do not photocopy without permission Separate handouts with references are available Contact: patnemec@patnemec.com

Recovery

A process of learning to approach each day’s challenges, overcome our disabilities, learn skills, live independently, and contribute to society contribute to society. This process is supported by those who believe in us and give us hope.

http://www.transformation-center.org

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An Experiential Shift

Despair to Hope Alienation to Purpose Isolation to Relationship Withdrawal to Involvement Passive adjustment to Active coping

• Priscilla Ridgway

(2001)

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Research on Recovery

• Outcome

– Research evidence – Longitudinal studies over 20-37 years 46 84% recovered or significantly improved

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– 46-84% recovered or significantly improved

• Deegan’s historical research

– Worcester State Hospital 1840-1893: 58% – “The treatment has changed dramatically and recovery rates are about the same”

http://www.nasmhpd.org/spec_e-report_fall04panel.cfm

Recovery is Real

“I had spent over 20 years believing that I had a mental illness, that something was wrong with my brain. I was told it was incurable and I would spend the rest of my incurable and I would spend the rest of my life on psychiatric medication. Now I’ve come to believe that what I was told was not

• true. The experts were wrong.”
• Loren’s Story

Firewalkers: Madness, Beauty, & Mystery

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Changes in Perspective

Containment Segregation Treatment Survive Rehabilitation Recovery Wellness

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Thrive

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Recovery-Oriented Services

• Person-centered
• Strengths focus
• Support development
• Skill development
• The rehabilitation formula:

Success = Skills + Supports

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Person Centered Services

• User-friendly, accessible, welcoming
• Service user is source of control
• Coordinated, seamless
• No wrong door; service users respected
• Whole person view, strengths-based
• Accepting, commitment to engaging

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Person-Centered Assessment

• Based on interests, preferences, wishes,

hopes, dreams, goals

– Motivation is discovered, not created

• Focuses on functional needs to achieve
• Focuses on functional needs to achieve

personal goals

• Identifies and evaluates skills

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Person Centered Planning

• Not just producing a signed service plan!
• A person-centered process

– Assessment of goals, needs is the foundation Pl i id ifi i hi l – Planning identifies strategies to achieve goals – Intervention creates progress towards goals

• Shared Decision Making

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Person-Centered Intervention

• Fits the person’s view of the need/problem
• Evidence of effectiveness
• Chosen from among options
• Delivered by provider of choice

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Motivation

• Motivation is discovered, not created
• A person who is motivated shows it by….?
• In contrast, a person who is unmotivated…?

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What is motivation?

• Invisible—like an “energy force”
• Motivation to do (or to avoid)
• Can only be inferred from actions
• Intrinsic vs. extrinsic motivation

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Facilitators of motivation

• Choice (internal motivation, no coercion)
• Expectations (Positive outcome, Self-efficacy)
• Experience
• Interest
• Maturity
• Physical capacity to make change
• Relationship(s)
• Risk tolerance (see also expectations, maturity)

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Self-determination theory

Motivation Motivation

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Autonomy Autonomy Competence Competence Relatedness Relatedness

It’s my choice I can do it I care about you… …and you care if I do it

Deci & Ryan

The Ike Powell Formula

M = FN x PV x FS x PR

• Motivation

– Felt Need If there's a 0 anywhere, – Practical Vision – First Step – Positive Results

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If there s a 0 anywhere, your end result is 0!

Motivation vs. Engagement

• Motivation refers to drivers of action

– Drivers toward achieving something – Drivers toward avoiding something

E t f t ti

• Engagement refers to connection

– Consensus regarding purpose of relationship – Trust, based on respect, dignity, mutuality – Recognition of the value of collaboration

• Disengaged: drops out, not nec unmotivated

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Who drops out?

• Younger, male, ethnic minority
• Low social functioning and social isolation

– Not married; out of contact with family

• Low SES, education level, unemployment
• Co-occurring SMI and substance use
• Not accepting, or identified with, diagnosis
• Poor alliance with service provider(s)

– Initial period of tx most likely time for dropout

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Kreyenbuhl, Nossel, Dixon (2009)

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What do the “dropouts” say?

• Desire to solve problem on one’s own

– Feeling a loss of control (meds / effects)

• Already improved, no treatment needed
• Treatment unlikely to help
• Practical constraints

– Forgot, moved, lacked transport

• Fear of the mental health system
• Dissatisfaction with treatment/services

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Kreyenbuhl, Nossel, Dixon (2009)

Why are they dissatisfied?

• Treatment/services are not helpful
• Unsympathetic providers

– Who don’t listen Wh d ’ i – Who don’t encourage or expect active participation in decision making

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Engagement

• Engagement ≠ Compliance

– More accepting than rejecting of services

• Voluntary cooperation
• Accepting of staff presence even when

there is a disagreement

• Actively setting and pursuing goals/roles

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Milestones of Recovery Scale

Why have goals?

• Goals result from commitment
• Goals contribute to motivation
• “Be” goals: Who/Where
• “Do” goals: Actions to get to the “be”

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Readiness

• Assessing and Developing Readiness
• Readiness for…

– Engaging in the rehabilitation process E l i i (d i ) – Exploring current environments (domains) – Considering other possible environments – Choosing to stay/go from current place

NOT readiness for achieving a goal (e.g., work)

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Readiness Factors

• Need
• Commitment
• Awareness

– Self – Options (environments) – Illness/Wellness?

• Relationship

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Factor 1: Need for change

• A “push” to change

– Need to get out of the current situation

• Motivation: Desire for change
• Urgency: Pressure to change

– External pressure = currently unsuccessful – How quickly is change needed or desired?

• Satisfaction

– Internal experience of pressure = dissatisfied

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Factor 2: Commitment to change

• A “pull” to a new situation
• Commitment can occur w/any level of need
• Change is:

– Possible – Positive – Likely

• Awareness of process of change
• Perceived support to make the change

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Factor 3: Awareness

Informed decision making involves

• Personal criteria for decision-making:

– Interests V l Self-awareness – Values – Preferences

• Knowledge of options (Environments)

– Physical characteristics of a setting – Requirements and expectations Self-awareness

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Factor 4: Relationship

• Does the person value your help?
• Is the person sufficiently connected to you,

the helper, to weather the ups and downs

• f change?
• f change?

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Exploring Readiness

• Develop a partnership
• Observe and listen
• Focus on:

– Indicators of stage of change – Readiness factors

• Use effective engagement skills
• Use Motivational Interviewing strategies

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Stages of Change

Contemplation

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Preparation Action Maintenance (relapse)

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Motivational Interviewing

• Motivational interviewing is a directive,

person-centered counseling style for eliciting behavior change by helping people to explore and resolve ambivalence explore and resolve ambivalence. Miller & Rollnick http://motivationalinterview.org/

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MI Spirit

• Motivation is discovered, not created

– Effective helping is generally quiet / eliciting.

• A person must articulate and resolve his or

her own ambivalence her own ambivalence.

– Direct persuasion is not helpful

• Readiness to change fluctuates
• Therapeutic relationship is a partnership

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MI Principles

• People always use their best strategies to

get needs met, even if dysfunctional

• People not likely to change if they think

their strategies are working for them their strategies are working for them

• People rarely change for someone else
• People are most likely to change when their

behaviors conflict with their values/beliefs

• Change requires both desire and ability

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Effective helper behaviors

• Reflective listening

– Aim to understand person's frame of reference

• Expressing acceptance and affirmation
• Selective reinforcement of the person’s own

self-motivational statements

• Monitoring the person’s readiness
• Affirming the person’s freedom of choice

and right to self-direction

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Partnership/Engaging Skills

• Orienting
• Open-ended questions
• Affirmations
• Reflective listening
• Summarizing

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Engaging Skills: Orienting

• To the Activity

– Overall description – Tasks and steps

T th P f th ti it

• To the Purpose of the activity

– What is the benefit for the person participating

• Roles

– Of the person providing services – Of the person using services – Of any other people involved

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Engaging Skills: Open Ended Q

• Definition?
• Purpose?
• Not as easy as you might think!

– Open, but not too open – Not too many (try orienting instead) – Try indirect leads (sentences that work like Qs) – Avoid imposter questions

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More Engaging Skills

• Attending: SOLER*

– Squared – Open – Leaning

• Active Listening

– Reflection – Clarification – Empathy – Eye contact – Relaxed

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*Egan

Exploring

• Create a safe place
• Get on the same track
• Start the conversation
• Check your understanding
• Drill down
• Get specific
• Monitor your biases

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Readiness Development

• Examine need

– Explore satisfaction, Roll with resistance – Consider harm reduction, crisis planning

St th it t

• Strengthen commitment

– Explore ambivalence, Evoke change talk – Future vision, Self-efficacy, Support

• Build awareness (of self and of options)
• Establish and nurture relationship

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Recovery

• 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 community of his or her choice while striving to achieve his or her full potential.

• How do your organization and services

embody the 10 components?

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Barriers to Recovery

• Negative attitudes (pathologizing)
• Unskilled staff, low retention rates
• Services keep people out of ordinary

i lif h h li ki i community life, rather than linking to it

• More emphasis on safety than success

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Person Centered Services

• Skilled service providers
• Facilitative system
• A person-centered service planning process

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Integrated services

• A best practice
• Mental health treatment
• Psychiatric rehabilitation
• Addictions
• Physical health / wellness

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Integration Models

• Service coordinator
• Multidisciplinary team
• Medical home

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Integration by “phase”

Early signs Increased t Stabilization Resolved Early intervention Self-monitoring Medication Medication Family support ACT Psychoeducation Skill development Therapy Skill development Voc, Cogn Rehab WRAP

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signs symptoms

RELAPSE

Adapted from Lenroot et al. (2003)

Medical Necessity

• A person needs a service or intervention

because a health condition (indicated by a diagnosis) creates a barrier to the person’s ability to manage some aspect of his/her ability to manage some aspect of his/her daily living.

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Medicaid: Medical Necessity

• Essential “for the maximum reduction of

physical or mental disability and restoration

• f the individual to the best possible

functional level” functional level

• 1. Essential
• 2. Disability
• 3. Functioning

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Service Planning

Getting from here… Assessed Needs

Goal

Objective Wishes …to there Objective Objective INTERVENTION

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Goals and Objectives

• Positive outcome
• What the person will do
• Reflects individual’s chosen path
• Time limited
• Attainable
• Measurable

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Stay tuned for interventions……..

“SMART”

• Specific
• Measurable
• Achievable
• Realistic
• Time limited

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To Whom?

Procedural Justice

• Can refer to

– Institutional procedures/policies – Individual actions (“interactional justice)

C l t l ti hi b t

• Can apply to relationships between

– System – Agency relationships – Management – Staff – Service provider – Service User

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Applying Fairness

• Full orientation and informed consent
• Policies/procedures: accessible/transparent
• Responsiveness
• Ethical responsibility to

– Treat people fairly – Advocate – Promote self-advocacy

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Service Planning

• The plan links assessment to intervention
• Sets the overall goal
• Selects the objectives leading to the goal
• Details actions

– Interventions

• Tasks

– Steps

– Person responsible – Target dates for starting/achieving objective

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“Good” goals are…

• Measurable
• Person-centered
• Time-limited

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SMART Specific Measurable Achievable Realistic Time-limited

Specifying objectives

• What is your goal?
• What steps are needed to get to your goal?
• What would I see if you were making progress?

– What would you have? (resources supports) What would you have? (resources, supports) – What would you do more often? (skills, behaviors) – What would you do better? (skills, behaviors)

• What’s getting in the way of achieving the goal?

– What do you need to do or have that would help you overcome that obstacle?

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Actions for goal achievement

• Interventions / services to meet objective

– Tasks to be completed – Responsible person(s) Due date for completion or review of progress – Due date for completion or review of progress

• Psych rehab interventions include:

– Skill development – Resource (or support) development

More on this later…

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Documentation

• Progress notes:

– Records delivery of intervention – “If it’s not written down, it didn’t happen” Describes effects – Describes effects – Demonstrates individual outcomes, especially progress towards goals

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Psychiatric Rehabilitation (PsyR)

Definition: Psychiatric rehabilitation promotes recovery, full community integration, and improved quality of life for persons who

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improved quality of life for persons who have been diagnosed with any mental health condition that seriously impairs their ability to lead meaningful lives. USPRA, 2007

Mission of PsyR

To increase the functioning functioning of persons with psychiatric disabilities, so they can be successful and satisfied successful and satisfied in their environments of choice choice with the least least environments of choice choice with the least least amount of professional intervention.

From: Anthony, Cohen, Farkas, Gagne (2002) Psychiatric rehabilitation Available from http://www.bu.edu/cpr

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Skills + Success + Supports Satisfaction

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Psych Rehab Principles

• Recovery (Hope)
• Choice and Voice
• Respect
• Individualization
• Individualization
• Quality services

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Psych Rehab Technology

• Process flows from the mission:

– increase functioning (skills + supports) – to be successful / satisfied in environment of choice (ORG)

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– in environment of choice (ORG)

• A “toolbox” not a manual or model
• Individualized and personally meaningful

The PsyR Process

Diagnosis Setting an Overall Rehabilitation Goal Assessment of Assessment of

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Assessment of Skills Assessment of Supports Planning Intervention Develop Skills Develop Supports

BU CPR

Psych Rehab Diagnosis

• Setting an Overall Rehabilitation Goal
• Functional Assessment

– Skills needed for success (ORG environment) Skill d d f l i f i – Skills needed for personal satisfaction – Are the person’s skills at the needed level?

• Resource Assessment

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Psych Rehab Diagnosis

• Overall Rehabilitation Goal (ORG)
• Functional Assessment

– What are the skills needed to be successful in the ORG environment? (required)

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the ORG environment? (required) – What are the skills needed to be satisfied in the ORG environment? (personally important) – Are the person’s skills at the needed level?

• Resource Assessment

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Diagnosis: ORG

• Overall Rehabilitation Goal (one domain)

– Intention: Stay or Go – Timeline: typically 6 to 24 months Setting: where I want to live learn work

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– Setting: where I want to live, learn, work – Role within the environment

• Example:

By Jan. 2007, I want to be a cook in a hotel restaurant kitchen.

Setting the Goal

• Structured decision-making process
• Personal criteria = How will I choose?

(requires self-awareness)

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• Alternatives = What are my options?

(requires environmental awareness)

• Decision-making matrix

Overall Rehab Goal (ORG)

• Identifying Personal Criteria

– What criteria will I use to make my choice? – Name each criterion, define it, measure it

R hi Alt ti E i t

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• Researching Alternative Environments

– Identifying potential settings – What do I want to learn about these options?

• Setting the Goal

– Intention, role, setting, timeline

Decision Making Matrix

• Options are evaluated using preferences
• Specific preferences work best
• Options are identified by:

– Narrowing the search by using the person’s “make it or break it” preferences – List obvious options (including current situation) – Gather information on options about preference areas (and other interesting facts)

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Using the Decision Matrix

• Preferences come from

– Exploring current and past experiences – Defining specific future preferences Researching options (discover new preferences) – Researching options (discover new preferences)

• Options come from

– Personal knowledge (past experiences) – Suggestions from others – Research possibilities

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Researching Options

• Narrow the search using the person’s “make

it or break it” preferences

• List obvious options, including current

G h i f i h i

• Gather information on each option

(preferences and interesting info)

• Double-check final preferences
• Rate each option (+ or – or 0)
• Total +s to find the best option

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Rating Options

• The Decision Matrix rates options

+ means the person’s preference is fully met 0 means the person’s preference is partially met,

• r there are some positive and some negative
• r there are some positive and some negative

aspects about that option

• means the person’s specific preference is

definitely not met by that option

MET NOT MET

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Example: Decision Matrix

ORG: cook in a hotel restaurant

Rating scale 1-5

Suites Hilton Inn

Dinner shift

Yes (5) Yes (5) No (1)

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Dinner shift

Yes (5) Yes (5) No (1)

Laundry service

$$ (3) No (1) No (1)

Vacation benefits

Yes (5) Yes (5) Yes (5)

Total

13 11 7

Skill Interventions

• Direct skills teaching

– Used when P=0 (and no knowledge) – Structured lesson, detailed break-down

Skill i

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• Skills programming

– Used when P<N (person can do skill) – Systematic sequence of steps – Designed to overcome performance barriers

Resource Interventions

• Resource coordination

– Links person to existing resource/service (resource use is a skill issue)

R difi ti

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• Resource modification

– Adapts an existing resource – May need negotiation with ORG environment

• Resource creation

– May require system change, advocacy

Summary: PsyR Techology

• D-P-I process
• Multi-step systematic structure
• Not necessarily all steps done in order

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• Can be cyclical, for example

– Readiness assessment re-done frequently – PsyR process can serve to develop readiness – FA may result in changing ORG – FA repeated after skill intervention (pre/post)

Interventions

• Reflects preferences of person served
• Will clearly achieve objective / goal
• Something service provider does
• Described in detail

– Duration, intensity, frequency

• Documented in progress notes

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The PsyR Process

Diagnosis Setting an Overall Rehabilitation Goal Assessment of Assessment of

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Assessment of Skills Assessment of Supports Planning Intervention Develop Skills Develop Supports

BU CPR

Mission of Psych Rehab

To increase the functioning of persons with psychiatric disabilities, so they can be successful and satisfied in their environments of choice with the least

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environments of choice with the least amount of professional intervention.

From: Anthony, Cohen, Farkas, Gagne (2002) Psychiatric rehabilitation Available from http://www.bu.edu/cpr

Practice vs. Process

• Model

– Defines program structure – Fidelity to original design

A h

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• Approach

– Describes interactions – Recommends “tools”

• “Technology”

– Methods, materials, tools, techniques

Psych Rehab Diagnosis

• Overall Rehabilitation Goal (ORG)
• Functional Assessment

– What are the skills needed to be successful in the ORG environment? (required by envir)

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the ORG environment? (required by envir) – What are the skills needed to be satisfied in the ORG environment? (personally important) – Are the person’s skills at the needed level?

• Resource Assessment

Diagnosis: Functional Assessmt

• Listing critical skills

– Environmental requirements – Personally important behaviors Most critical skills

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– Most critical skills

• Describing skill use

– Behavior, circumstances, frequency measure

• Evaluating skill performance

– Present vs. needed level

Example: Skill from F.A.

Critical skill name: Responding to feedback Description: % of times/week I will paraphrase key points f j b f h Ch f ll

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• f my job performance when Chef tells me

about an area needing improvement. Needed level: 75% Present level: 25%

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What is a skill?

• A complex action, something a person does
• Performed competently, in a way that will

achieve the desired purpose of skill use Skill d l i

• Skills, once mastered, are lasting
• Bigger than a behavior
• Smaller than an activity

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Example: Functional Assessment

• Lists skills needed to be successful and

satisfied in ORG (environment of choice)

• Based on requirements of environment

E li it Cl l t t d – Explicit: Clearly stated – Implicit: Important, but must be discovered

• Based on personal standards for success
• Described: measure, behavior, circumstance
• Evaluated (if possible) in the real setting

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Assessment → Intervention

• Direct Skills Teaching

– If present use of skill is 0 – If person lacks knowledge of skill Sometimes if performance is inconsistent – Sometimes if performance is inconsistent

• Programming for Skill Use

– If present level is less than needed – The person can do the skill but doesn’t

• But what about motivation?

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Developing Skills

• When?

– Skills are deficits (from Functional Assessment)

• How?

– Direct Skills Teaching Direct Skills Teaching

• For skills that the person does not know how to do,

has never done, cannot describe how to do it

– Skills Programming Skills Programming

• For skills that the person knows how to use…
• …but does not use in the goal environment exactly

as needed or as often as needed

Direct Skills Teaching

• Structured lesson plan
• Breaks skill into component behaviors
• Teach each behavior: Tell, Show, Do
• Include real-world practice

– Homework – Feedback – Accurate self-assessment

111 MacDonald-Wilson & Nemec

Direct Skills Teaching

• Definition

Definition

– Leading the person through a systematic series of instructional activities resulting in competent use of new behaviors

• Benefit

Benefit

– Prepares practitioner to develop new skills with the person

• Skills

Skills

– Outlining Content; Planning the Lesson; and Programming

• Condition

Condition

– When person cannot perform skill needed for ORG

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Direct Skills Teaching

• Planned, systematic instruction
• Based on breakdown of knowledge,

behavior

C t t tli – Content outline

• Uses a prepared lesson plan

– Tell, Show, Do – “ROPES”

A Content Outline contains:

• Skill Name (action verb + object)
• Skill Description (what it is)
• Benefit (why learn how to do it)
• Behaviors (key components of how to)
• Condition (when to do the skill)

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Sample Content Outline

• Skill name: Conversing about Impersonal Topics
• Definition:

– …means Melanie talks to others for at leave five minutes about subjects other than herself

• Benefit

Benefit

– …shows Melanie’s interest in subjects other than herself

• Behaviors:

– Starting the conversation – Communicating interest in what others are saying – Closing the conversation

• Condition

– When Melanie is talking to others for a long time

BU-CPR

DST: Planning the Lesson

• Definition

– Designing a series of instructional activities to teach the person how to perform the skill.

• Benefit

– Prepares the practitioner to teach a new skill Prepares the practitioner to teach a new skill

• Skill Behaviors

– Elaborating the content Tell Tell – Creating examples Show Show – Arranging practice opportunities Do Do

• Condition

– When getting ready to teach a new skill

“Elaboration” or Explain content, Define terms, Give helpful hints “Examples” or Demonstrations of the whole skill or a key behavior

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“Examples” or Demonstrations of the whole skill or a key behavior “Practice Opportunities” or Role plays and homework assignments

Lesson Plan “ROPES”

• Review
• Overview

– Explaining the skill (content outline)

• Presentation

– Tell, Show, Do for each critical behavior

• Exercise

– Practicing the whole skill (the “Big Do”)

• Summary

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Programming Skill Use

• Transfer of skill to real life

(generalization)

• Follows direct skills teaching

O h d kill b t d ’t

• Or when person can do skill, but doesn’t
• Identifies barriers
• Builds a program

– Steps designed to overcome barriers – Supports to help person do steps

Programming Skill Use

• Definition

– Prescribing a step-by-step procedure to prepare the person to use the skill as needed

• Benefit

– Eliminates obstacles to using the skill as needed

• Skills

– Identifying barriers – Developing the program – Supporting action

• Condition

– When the person needs assistance in using the skill

Skills Programming

• Barriers to skill use include

– Lack of: knowledge, planning, resource – Lack of confidence (self-efficacy)

St t b i i l d

• Steps to overcome barriers include

– Research, planning, resource acquisition – Rehearsal, successive approximation

• Supporting action includes

– Target dates, monitoring, reward / celebration

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Barriers

Explore with person what is getting in the way

• Lack of Confidence

– Person does not feel able to use the skill

• “I just can’t” or “It’s too much” or “I feel overwhelmed”

L k f K l d

• Lack of Knowledge

– Person does not have information needed to use skill

• “I don’t know…” BUT “I don’t know how to” = a skill deficit
• Lack of Forethought (lack of planning)

– Person does not take time to get ready to use the skill

• “I just never thought about it” or “I wasn’t thinking…”
• Lack of Resources
• “I don’t have…”

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Develop the Program

• Identify most critical barriers

One problem using a skill might be due to several

different types of barriers

S l t t f t t t h h b i

• Select type of step to match each barrier

– Each barrier might need to be resolved with more than one step

• Use several sub-steps, if necessary, to

accomplish a major step

Successive Approximation

• Getting slowly closer to performing the skill

exactly as needed

– Approximate circumstances A i t f – Approximate frequency

• For example:

– Try doing in a role play, then in a “safe” environment, then the real environment – Try doing it once in the real environment; don’t worry about doing it as often as needed

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Supporting Action

• Schedule Timelines

– Organize steps sequentially – Set target dates

d d f d d d

• Expect to review and modify dates as needed
• Choose Rewards

– Celebrate accomplishing steps – Involve the person in selecting things that would reinforce new behaviors

• Set method for monitoring completion

Rewards are

• Acknowledgements of success
• Within the person’s control

– Not externally provided reinforcers

• Not all steps require rewards
• Not all steps require rewards

– The person decides what and when – Encourage choosing things that are

» Reasonable (about the same “size” as the step) » Available and affordable » Motivating to the person » Contingent on completing the step

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Strategic Interventions

• Strategy

– General direction for accomplishing goal – Guides selection of actions at any point

T ti

• Tactic

– Defines isolated action to be taken – Selected for a specific purpose – Tactic’s success can be evaluated

129

Strategic Engagement

• Relationship Building
• Motivational Enhancement
• Readiness Development
• Negotiation / Procedural Justice
• Empowerment

131