MAKING MENTAL HEALTH RECOVERY WORK

PRESENTATION AT FMHAC CONFERENCE, SEASIDE, CA

MARCH 16, 2006MUNIR A SEWANI, PHD

AND CORALYN MCCABE, MSW

DISCALIMER

• OPINIONS AND COMMENTS EXPRESSED IN THIS PRESENTATION ARE THOSE OF

THE PRESENTERS AND DO NOT REPRESENT THE POLICIES OF SAN

BERNARDINO COUNTY DEPARTMENT OF BEHAVIORAL HEALTH AND STATE DEPARTMENT OF MENTL HEALTH, CONDITIONAL RELEASE PROGRAM.

PRESENTATION GOALS

• RECOVERY MODEL • DEVLOPMENTAL STAGES, ERICKSON

AND KHOLBERG• FORENSIC OUTPATIENT MODEL• INTEGRATION OF THESE MODELS IN

DELIVERY OF MENTL HEALTH SERVICES IN THE COMMUNITY

• ROLE OF THE PROVIDER

RECOVERY MODEL

• MANY DIFFERENT MODELS HAVE BEEN PRESENTED SINCE THE 1990 THAT ADDRESS MENTAL HEALTH RECOVERY.

• SEVERAL OF THESE MODELS WERE DEVELOPED BY GROUPS AND MENTAL HEALTH AGENCIES ADDRESSING DEVELOPING TRENDS IN MENTAL HEALTH DELIVERY SYSTEM.

• WE WILL LOOK AT SOME OF THESE MODELS.

• RECOVERY ADVISORY GROUPRECOVERY MODEL A WORK IN PROCESS, MAY, 1999 (RALPH, R O, RISMAN, J AND KIDDER, K,) MAIN AUTHORS.

• THE ACHIEVEMENT OF WELL-BEING OR WHOLENESS IS NOT LINEAR.

• THIS GROUP PRESENTS THREE STAGES WHICH, ONE GOES THROUGH TOWRDS RECOVERY.

• THE THREE STAGES INCLUDE:• ANGUISH• AWAKENING• INSIGHT• FOLLOWED BY: ACTION PLAN,

DETERMINED COMMITMENT TO BEOME WELL AND WELL-BEING/EMPOWERMENT.

• THIS MODEL FURTHER STATES THAT RECOVERY MUST BE BOTH INTERNAL AND EXTERNAL.

• INTERNAL RECOVERY INCLUDES TRNASFORMATION IN COGNITIVE, EMOTIONAL, SPRITUAL AND PHYSICAL DIMENSIONS.

• EXTERNAL DIMENSIONS INCLUDES INDIVIDUALS ACTIONS AND REACTIONS TO EXTERNAL INFLUNCES.

• INDIVIDUALS’ ACTIVITY, SELF-CARE, SOCIAL RELATIONS AND SOCIAL SUPPORTS.

• EXTERNAL INFLUNCES, AT TIMES ARE NOT WHITIN AN INDIVIUAL’S CONTROL.

• THESE EXTERNAL INFLUNCES INCLUDE, MENTAL HEALTH DELIVERY SYSTEM IN ONES COMMUNITY, FINANCIAL SUPPORT, HOUSING, EMPLOYMENT, PEER SUPPORT, FAMILY AND BOTH ORGANIZED AND INFORMAL COMMUNITY SUPPORT.

• WE WILL LOOK AT THIS MODEL IN OUR COMPARISON.

The Community Support SystemCSS

• The CSS vision is of hope and assumption that people can live successfully in the community when given adequate support.

CSS Philosophy: Key principles of service delivery:

• Consumer-centered• Empower clients• Racially and culturally appropriate• Flexible • Focus on strengths

CSS philosophy continue:

• Normalize and incorporate natural support

• Meet special needs• Be accountable• Be coordinated

CSS Recovery treatment system must include the following assumptions:

• Recovery can occur without professional intervention;

• People who recover have people who stand by and believe in them;

• Recovery can occur whether one sees mental illness as biological or environmental;

Continuing:

• Recovery can occur even though symptoms may reoccur;

• Recovery often changes the frequency and duration of symptoms;

• Recovery is not linear process• Recovering from the consequences of

being ill is often more difficult than recovering from the illness itself;

Continued:

• Recovery does not mean that one did not have a mental illness.

Similar views about Recovery are presented in the following: • Recovery is a deeply personal

unique process of changing one’s attitudes, values, feelings, goals, skills, and/or roles (Anthony, 1994)

• Willingness to try and the discovery that you can that you can do and be again (Deegan, 1994)

The Empowerment Model of Recovery (Daniel B. Fisher, MD, PhD, 2005)HopeFreedom from labels, financial restraints of SSI, connectedness to the community, reestablishment of personal connections, peer guided, collaboration with the provider.

Wellness Recovery Action Plan5 Foundations of Recovery(WRAP)• Hope• Personal responsibility• Education• Self-Advocacy• Developing and maintaining a

support system.

WRAP, Includes wellness tools

• Activities• Routines• Thoughts and Behaviors which maximize

wellness and minimize symptoms.• Reaching for support, peer counseling, ongoing and

open relationship with care professionals, day planning, stress reduction, focusing exercises, diversionary fun activities, journaling, and exercise, diet, sleep, exposure to light, monitoring stimulation, cognitive deliberation for action and decision making.

RECOVERY ADVISORY GROUPRECOVERY MODEL A WORK IN PROCESS, MAY, 1999(RALPH, R O, RISMAN, J AND KIDDER, K,)

• Stages of Recovery• ANGUISH: Despair, Bottoming out, Fear,

Confusion, Panic, Hopelessness, Negative thoughts, Loss of competence, Loss of freedom

• AWAKENING: Things can change: Recognition of Anguish. Asking for assistance, Accepting encouragement, recognizing that the pain of where you are is greater than changing.

Continued:

• INSIGHT: Insight that there is something better: Seeking help, Beginning of hope, Experimenting, taking small steps, Positive self-talk, learning about what social supports can help me.

Continued:

• ACTION PLAN: I must do something to make things better. Searching for more meaningful activities and social interactions, Learning to cope with difficult feelings.

• DETERMINED COMITTMENT TO GET WELL: I will recover. I can make my own decisions. I am hopeful about my future. My life has meaning and value, Establishing meaningful contacts, Self-knowledge, self-efficacy, self-worth, self-determination.

Continued:

• WELL BEING EMPOWERMENT: • I have a meaningful life, Sense

of well-being, Compassion for myself and others, Acceptance of ups and downs, Meaningful work, volunteer, hobbies, Integrated in everyday activities

What's next in the presentation?

• Move from recovery model to the role of therapist in forensic outpatient program.

• Therapist/Service provider wears many hats, among which include authority and therapist at the same time.

• How did we resolve this role for us.• We see ourselves as parenting to

address the role of authority, teacher, role model, nurturing, compassionate and therapist.

• Furthermore, we look at treatment progress in the outpatient forensic program with perspective of developmental stages, specifically, Erickson and Kohlberg.

Erickson’s Stages of psychosocial Development:

• TRUST VS. MISTRUST: A sense of basic trust should develop. Provide predictable structure. Cause and effect should be regular so it can be learned from.

• AUTONOMY VS. SHAME AND DOUBT: The time to learn self-reliance and self-esteem. Autonomy is the ability to make decisions.

• INITIATIVE VS. GULIT: Building on the confidence to control one’s self, the individual will now attempt more goal oriented influence over the environment. The individual will require enough liberty to select meaningful activities, as well as some challenging tasks.

• COMPETENCE VS. INFERIORITY: The individual is mastering the elements of culture. They initiate and complete their own tasks and learn from their own errors.

• IDENTITY VS. ROLE CONFUSION: Identity is the general picture a person has of the self. It is the cultivation of one’s character that is occurring here.

• INTIMACY VS. ISOLATION: Relationships in general are the point in this stage. The ability to communicate easily is the lesson of this crisis. The validity of ourselves comes from others.

• GENERATIVITY VS. STAGNATION: It is at this time that the individual becomes a responsible, contributing member of society. Productivity and creativity are the means to that end.

• INTEGRITY VS. DESPAIR: This is a time of introspection and reflection. The culmination is a sense of oneself as one is and of feeling fulfilled.

• LEVEL 1: Preconventional Morality• Stage 1: Individual obeys rules in order

to avoid punishment. • Stage 2: Individual conforms to society’s

rules in order to receive rewards.• LEVEL 2: Conventional Morality• Stage 3: Individual behaves morally in

order to gain approval from other people.• Stage 4: Conformity to authority to avoid

censure and guilt.

• LEVEL 3: Postconventional Morality:

• Stage 5: Individual is concerned with individual rights and democratically decided laws.

• Stage 6: Individual is entirely guided by his or her own conscience.

Stages in outpatient treatment.

• Intensive• Intermediate• Supportive• Transitional • Aftercare

Case presentation