Building Recovery Based Systems and Programs

Mark Ragins, MDMedical Director

MHA Village Integrated Service Agency

Mental Health America of

Greater Los Angeles

www.mhavillage.orgmragins@mhala.org

The Recovery RevolutionTrue 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:

• 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 do3. 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 life5. 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 over9. When people have significant strengths and want to take

on more self responsibility10. When people want to go on with their life in the “real

world”

DOMAINS OF TRANSFORMATION

INSIDE OUTSIDE

I

VALUESEMOTIONS

BEHAVIORSPRACTICE

WECULTUREMISSION

SYSTEMPROGRAMS

DOMAINS OF RECOVERY PROGRAMS

INSIDE OUTSIDE

I

HOPE, GROWTH, and RESPECT

ENGAGEMENT,EMPOWERMENT, REHABILITATION, SHARED RESPONSIBILITY, and TEACHING

WE WELCOMING, HEALING, RECOVERY, andCOMMUNITY 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 self-

help• 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:– 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

housing (treatment setting)

friends (social support network)

vocational class (therapeutic

activity)

family

ILLNESS CENTERED

person

housing (home)

illness(a part of me)

employment

friends

family

PERSON CENTERED

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

return to life

symptoms

illness

decrease symptoms

REHABILITATION MODEL

return to life

illness

functional impairment

improved function

RECOVERY MODEL

illness

person

worker

father

husband

Lakers fan

church goer

illness

1. HOPE2. EMPOWERMENT3. SELF-RESPONSIBILITY4. 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 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”

Hospice is the most successful person centered service system we have

RECOVERY-BASED SERVICES:

Welcoming / Engagement

Charity

Treatment

Rehabilitation

Advocacy / Community Development

Graduation

Three Types of Services and Supports

1. Direct mental illness treatments2. Coping with mental illnesses and destructive

emotions3. 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 Care taking services Growth oriented services

Unengaged

• Forced treatment• Protection• Benefits establishment• Acute stabilization

• Outreach and engagement• Peer bridging • Concrete quality of life goals• Relationship building

Engaged, but poorly self-coordinating

• Structure• Making decisions for people• Case management• Chronic stabilization

• Supportive services• Skill building• Personal service coordination• Collaboration building

Self responsible

• Benefits retention• Maintenance therapy and medication

• Community integration• Self-help• Peer support• Wellness activities• Growth promoting therapy

Unengaged – Tasks• 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

• 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

• 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

• 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

• 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 Unengaged Engaged, but not self coordinating

Self responsible

Locked setting Outreach and

engagement

Drop-in

center

Intensive case

manage-ment

(ACT)

Case manage-

mentTeam

andClubhouse

Appointment based clinic

Wellness center

1:1 supervisionLegal interventions

Community protection

Acute treatmentEngagement

WelcomingCharity

Evaluation and triage

DocumentationBenefits assistance

Accessible medications

Drop-in services

Case managementIntegrated services

Accessible medications

Supportive servicesDirect subsidiesRehabilitation

Appointment based therapy

“Medications only”Wellness activities

(WRAP)Self-help

Peer supportCommunity integration

Where’s therapy?

• “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 isolating2. Actually feel feelings and emotions instead of

deadening them, medicating them, avoiding them, or getting high.

3. Learn some emotional coping skills4. Learn to “use” medications instead of just

“taking” medications5. Take responsibility for your own life and make

some changes in yourself6. Go to work even when you’re not feeling well.

Program AdaptationsForm an integrated services program by providing a variety of

services (established and created individually) to help people recover

1. What stage is this service best suited to?2. How does it promote quality of life goals?3. How does it promote progress in recovery?4. How can it be connected to self-help and peer support?5. How can it be connected to the community?6. 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 wellness9. Love other people – family, partners, kids10. Work on acceptance and forgiveness instead of

blaming and vengeance 11. Give back by helping others12. Find meaning and blessings in suffering and

reconnect with God and spirituality.

Recovery Based Services1. Engagement and welcoming2. Shared decision making and building self-

responsibility3. Rehabilitation – building skills and supports4. Integration of services – including consumer

provided services5. Recovery based medication services6. Integrating therapy and healing throughout services7. Community integration and advocacy8. Graduation and self-reliance9. 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

1. Hope2. Authority3. Healing4. 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

• 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

1. Welcoming and Accessibility2. Growth orientation 3. Consumer inclusion4. Emotionally healing relationships and

environments5. Quality of life focus6. Community integration7. Staff recovery

Tracking Building Recovery Culture Exploring Emerging Maturing Excelling

Welcoming and

Accessibility

Growth Orientation

Consumer Inclusion

Emotional

Healing

Quality of Life Focus

Community Integration

Staff Morale and Recovery

Building and Sustaining Cultures

• 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

• 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 challenges1. Changing hiring patterns and roles – including

consumer volunteers and staff2. Increased attention to ethics and safety with

lower walls and barriers3. Avoiding permanent crisis mode4. Billing for recovery services5. Creating team work6. Integrating services

Common benefits

1. Decreased drop-outs even with challenging sub-populations

2. Integration of services3. Enhanced dual diagnosis services4. Enhanced quality of life outcomes5. Decreased power struggles with clients6. Decreased staff burnout7. Increased flow through and graduation from

services8. Increased community involvement