Recovery-oriented Approaches to Treatment and Service Engagement

April 4, 2018

Recovery to Practice

Spring 2018 Webinar Series

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Therapeutic Alliance and Its Impact on Engagement

Recovery to Practice

April 4, 2018

Forrest “Rusty” FosterSenior Implementation Specialist

Center for Practice Innovations

Regina “Gina” ShoenAdvocacy Specialist, Office of Consumer Affairs

New York Office of Mental Health

Through this webinar, participants will be able to:

• Describe the engagement process

• Define recovery-oriented care

• Understand the importance of stage of change inengaging clients

• Understand motivational interviewing in building thetherapeutic relationship

• Identify the steps in shared decision making

• Describe the important role peers play in engagementprocess

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Learning Objectives

Engagement

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Is the process of establishing a mutually collaborative, trusting, and respectful helping relationship.

Miller & Rollnick (2013)

Why Engagement is Important?

•Half of all people with a serious mental health problem had not received mental health treatment in the prior year.

•Low engagement may lead to exacerbation of symptoms, rehospitalization, and not fully realizing the potential benefits of treatment. (Dixon, et al, 2016)

•Most individuals who do engage in treatment and stay in treatment have improved outcomes.

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So, what works?

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What Individuals Being Served Say Works

• Relationship is key - warm respect, friendliness, interest, patience, and sincerity.

• Providers showed acceptance and support.

• Individualized care.

• A focus on meaningful life goals.

• Goals that are identified by the individual.

(Lucksted, A. et al.2014)

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Recovery-oriented Care

“Recovery-oriented care identifies and builds upon each individual’s assets, strengths, and areas of health and competence to support the individual in achieving a sense of mastery over mental illness and/or addiction while regaining his or her life and a meaningful, constructive sense of membership in the broader community.”

(Tondora & Davidson, 2006)

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“Engagement involves making contact with the person rather than with the diagnosis or disability, building trust over time, attending to the individual’s stated needs and, directly or indirectly, providing a range of services in addition to clinical care.”

Connecticut Department Mental Health and Addiction Services (DMHAS). Practice Guidelines for Recovery Oriented Behavioral Health Care (2006)

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Recovery-oriented Care

• Enhances the relationship between the individual and the provider.

• Aids in the development of mutual understanding, hope, empathy, trust, safety.

• Promotes advancing personal and treatment goals.

• Supports staying involved in treatment

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Stages of Readiness for

Change

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• Practitioners often want individuals to change.

• Individuals not always ready to make a change even when they voluntarily choose to enroll in services.

• Mismatch which can lead to

• Individuals not feeling understood.

• Practitioners feeling frustrated

• Individuals disengaging from treatment.

Prochaska & Diclemente’s

Stages of Change (cont.)

• Ambivalence is normal.

• It’s Important to identify where the person is in their readiness for change

• Match treatment to individual’s readiness

• Guide but do not direct

• Provide information, give advice (with permission)

• Honor autonomy (choice)

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A brief overview of

Motivational Interviewing

• How we view an individual is one of the keys to the engagement process.

• Openness to a way of thinking and working that is collaborative rather than prescriptive.

• Honors the individual’s autonomy and self-direction, and is more about evoking than installing.

• Involves at least a willingness to suspend an authoritarian role

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The Spirit of Motivational InterviewingMiller and Rollnick (2013)

Acceptance: empathy, affirmation, autonomy, absolute worth

Collaboration: partnership

Compassion: caring what happens to the individual

Evocation: eliciting a individual’s own reasons for change

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Active Listening People will more likely develop

a trusting, working relationship

with you if…

• You listen to them.

• Don’t criticize or judge them.

• Let go of your agenda (at least

in the beginning).

• Allow them to tell their story.

• Be interested and curious.

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Roadblocks to Listening

• Confronting

• Ordering, directing, or commanding

• Warning or threatening

• Lecturing or preaching

• Judging or criticizing

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Core Skills -Tools for Engagement

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Open Questions: questions that can’t be answered with a “yes/no” or otherwise limited response and that invites elaboration and deeper thinking

Reflective Listening: A guess at what individual means by what they just said (not an interpretation) that is always in the form of a statement never a question

Affirmations: statements that recognize strengths and positive personal characteristics

Summaries: reflections that pull together several things a person has said

Shared Decision Making (SDM)

• The practitioner and the individual work collaboratively.

• Both take steps in sharing treatment decisions.

• The practitioner brings educational information related to illness, treatment options, risks/benefits, evidence base.

• The individual brings information based on personal experience.

• Practitioners actively solicit individuals’ perspective's on problems, preferences, values, and potential solutions.

Emphasizes choice, self-determination, and empowerment.

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Shared Decision Making (Cont.)

The individual is:

• Involved in all treatment decisions.

• Is part of the treatment team.

• Is an expert in his or her own values, treatment preferences, and treatment goals.

The team – and the individual –arrive at consensus regarding the preferred treatment options.

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Shared Decision Making &

Motivational Interviewing

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Motivational Interviewing• Helps engage individuals and build

the therapeutic relationship.

• Works well with people who are ambivalent about change.

Shared Decision Making• Assumes there is already a

constructive relationship.

• Individual is ready to decide.

• Focused on understanding the best options for treatment and then selecting which to select based on individual’s preferences and values.

What Peers Bring

To Service Delivery

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• Dedication and commitment to work

• Ability to create an immediate connection with the people they serve

• Ability to use their stories and lived experiences to inspire hope

• Ability to build bridges that engage other providers on the treatment team

… And More!

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Peer Staff/Peer Specialists have the ability to:

• Guide people in accessing community resources and services.

• Support people in the development of intentional relationships and meaningful roles in their community.

• Demonstrate to the team, family members, and others that people do recover.

The Presence of Peers Can…

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• Bring a different perspective to other treatment team members during team meetings.

• Support the use of recovery language by reminding organizations to minimize the use of labels that are demeaning to those seeking help.

• Provide living proof that people recover to other members of the treatment teams.

Evidence for Peer Supports

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• Peer support has an established history and demonstrated

role in the spectrum of mental health services. (Grant, 2009)

• Peer support occurs when people share common concerns or problems and provide emotional support and coping strategies to manage problems and promote individual

growth. (Davidson, et. al, 1999)

• In addition to mental health, peer support has demonstrated productive outcomes in the areas of substance abuse, parenting, loss and bereavement, cancer, and chronic illnesses. Kyrouz, Humpherys & Loomis, 2002; White 2000)

Pillars of Peer Support

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• The role of Certified Peer Specialists (CPS) is to work with individuals to engage in treatment, regain balance and control of their lives, and support recovery. (Chinman, Young, Hassel &

Davidson, 2006; Sabin & Daniels, 2003; Orwin, Briscoe, Ashton & Burdett, 2003)

• These positions are important parts of mental health treatment teams in a variety of mental health settings including: inpatient outpatient, emergency rooms, and crisis centers (Fricks, 2005)

Pillars of Peer Support (Cont.)

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• A key differentiating factor in the CPS role from other mental health positions is that in addition to traditional knowledge and competencies in providing support, the CPS operates out of their lived experience and experiential knowledge. (Mead, Hilton & Curtis, 2001)

• The Peer Specialist works from the context of recovery, frequently utilizing language based upon common experience rather than clinical terminology, and individual-centered relationships to foster strength based recovery. (Davidson, et. al, 1999)

• Peer specialists are uniquely qualified to assist individuals in engaging in treatment and in identifying goals and objectives that form the context of the peer support relationship. (Chinman, 2006)

Evidence for Peer Support

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• When peers are part of hospital-based care, the results indicate shortened lengths of stays, decreased frequency of admissions, and a subsequent reduction in overall treatment costs. (Chinman, Weingarten, Stayner&

Davidson, 2001)

• Other studies also suggest that the use of peer support can help reduce the overall need and use for mental health services over time. (Chinman, et. al, 2001; Klein,

Cnaan, & Whitecraft, 1998; Simpson & House, 2002).

Evidence for Peer Support (Cont.)

• The Consumer Operated Service Programs (COSP) multi-site randomized controlled trial (RCT) examined the effects of a number of different peer-provided models including drop-in centers, mutual support programs, education curricula, and advocacy programs.

• They found that subjects who received COSP plus traditional mental health services reported higher levels of individual empowerment than those in the control condition who received only traditional services.

(Campbell et al., 2004 and Rogers et al., 2007)

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Peer Support

• Whether part of the formal process or simply as a matter of people building relationships in peer support groups, the notion of one to one peer support is central.

• Some peer support groups contract to provide peer bridger services which help those individuals who are in psychiatric hospitals make the transition to community life

• This is an especially valuable service assisting long term residents of psychiatric hospitals in overcoming the fears related to leaving a facility.

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Summary

• Keep the focus on the individual and their identified goals.

• Engagement hinges on receiving what could be considered non-clinical services, such housing, and supported education and employment.

• Reach out to individuals and provide services in natural living environments.

• Be consistent and persistent in your effort to actively engage reluctant individuals.

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And lastly…• Many people may fear or initially

not want to change.

• Respect an individual’s autonomy.

• The individual’s perspective and wishes matter more than our sense of what might be best.

• Set aside our own fears, values, and choices in order to join with an individual in making his/her own choices.

• Change takes time. It doesn’t happens over night.

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Presenters’ References

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• Dixon LB, Holoshitz Y., Nossel I. Treatment engagement of individuals experiencing mental illness: review and update World Psychiatry 15:1 -February 2016 13

• Elwyn G., Dehlendorf C, Epstein RM, Marrin K, White J, Frosch DL. Shared Decision Making and Motivational Interviewing: Achieving Patient-Centered Care Across the Spectrum of Health Care Problems. Annals Of Family Medicine 12, 2014.

• Motivational Interviewing: Helping People Change Third Edition. (2013) Miller, W.R. & Rollnick, S. Guilford Press: New York

• Motivational Interviewing with Adolescents and Young Adults. (2011) Naar-King, S. & Suarez, M. Guilford Press: New York

• Stinson, J.D. & Clark, M.D. (2017). Motivational Interviewing with Offenders Engagement, Rehabilitation, and Reentry. New York: Guilford.

Questions DiscussionComments

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Thank you to our presenters

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Rusty FosterRegina Shoen

SAMHSA’s

10 Principlesand

4 Dimensionsof Recovery in

Behavioral Health

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HomeHealth

CommunityPurpose

Recovery to Practice

Through education, training,

and resources SAMHSA’s

Recovery to Practice (RTP)

program supports the

expansion and integration of

recovery-oriented behavioral

health care delivered in

multiple service settings

between multiple disciplines.

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Want to continue your learning?

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1Allen, M.L., Cook, B.L., Carson, N. et al. Patient-Provider Therapeutic Alliance Contributes to Patient

Activation in Community Mental Health Clinics. Adm Policy Ment Health (2017) 44: 431.

https://doi.org/10.1007/s10488-015-0655-8

2Denneson, L. M., Cromer, R., Williams, H. B., Pisciotta, M., & Dobscha, S. K. (2017). A Qualitative Analysis of

How Online Access to Mental Health Notes Is Changing Clinician Perceptions of Power and the Therapeutic

Relationship. Journal of Medical Internet Research, 19(6), e208. http://doi.org/10.2196/jmir.6915

3Dixon, L. B., Holoshitz, Y. and Nossel, I. (2016), Treatment engagement of individuals experiencing mental

illness: review and update. World Psychiatry, 15: 13–20. doi:10.1002/wps.20306

http://onlinelibrary.wiley.com/doi/10.1002/wps.20306/full

4Frank AF, Gunderson JG. The Role of the Therapeutic Alliance in the Treatment of Schizophrenia Relationship

to Course and Outcome. Arch Gen Psychiatry. 1990;47(3):228–236.

doi:10.1001/archpsyc.1990.01810150028006 https://jamanetwork.com/journals/jamapsychiatry/article-

abstract/494915?redirect=true

5Sowers, W. E. (2012). Recovery and Person-Centered Care: Empowerment, Collaboration, and Integration (pp.

79–89). Springer, New York, NY. https://doi.org/10.1007/978-1-4614-3149-7_7

RTP Companion

Newsletter on

Family

Engagement

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Sign up to receive the RTP quarterly newsletter by visiting our webpage:https://www.samhsa.gov/recovery-to-practice

The next RTP webinars in the series:

Engagement and Recovery

Oriented PracticesMay 2nd – Engagement and WRAP

May 23rd – Engagement and Technology

Registration is open now!

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Coming soon:• Integrated Behavioral Health• Peer Support for People

Experiencing Homelessness

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Engagement

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