Preparing the Adult Mental Health Workforce to Succeed in a Transformed System of Care

1. Preparing the Adult Mental Health Workforce to Succeed in a Transformed System of Care An Introduction to Recovery, Hope and Resiliency Module III NASMHPD/OTA Workforce Curriculum Module developed by Huckshorn, LeBel, Putnam and Jorgenson 2009 1 The President�s New Freedom Commission � does not attribute the shortcomings and failings of the contemporary system to a lack of professionalism or compassion of mental health care workers. Rather, problems derive principally from the manner in which the Nation�s community-based mental health system has evolved over the last 4-5 decades. Care must focus on increasing consumers� ability to successfully cope with life�s challenges, on facilitating recovery, and on building resilience, not just on managing symptoms.� This module will define and make real some of the language that we now use in our transforming system of care to better enable you to provide care that is grounded in an appreciation of possibilities and hopefulness. Dr. Pat Deegan, self-identified consumer and mental health advocate says it best� �Professionals who learn to collaborate with the active, resilient, adaptive self of the client will find themselves collaborating in new and rewarding ways with people who have been viewed as hopeless by others.� The President�s New Freedom Commission � does not attribute the shortcomings and failings of the contemporary system to a lack of professionalism or compassion of mental health care workers. Rather, problems derive principally from the manner in which the Nation�s community-based mental health system has evolved over the last 4-5 decades. Care must focus on increasing consumers� ability to successfully cope with life�s challenges, on facilitating recovery, and on building resilience, not just on managing symptoms.� This module will define and make real some of the language that we now use in our transforming system of care to better enable you to provide care that is grounded in an appreciation of possibilities and hopefulness. Dr. Pat Deegan, self-identified consumer and mental health advocate says it best� �Professionals who learn to collaborate with the active, resilient, adaptive self of the client will find themselves collaborating in new and rewarding ways with people who have been viewed as hopeless by others.�

2. Learning Objectives (handout) Upon completion of this module the participant will be able to: Describe the concept of Recovery Define the concept of Resiliency Identify some of the key components of Recovery Understand the importance of supporting Hope in Recovery 2 And above all hope�For ourselves and the people we serve� a new or renewed sense of competence in ourselves and our competencies so that we can meet and cope with whatever our life�s journey brings. And above all hope�For ourselves and the people we serve� a new or renewed sense of competence in ourselves and our competencies so that we can meet and cope with whatever our life�s journey brings.

3. Hope, Recovery, and Resiliency In order to work together to reach our destination-a recovery focused mental health system�we need a common ground�a language that makes it possible for everyone involved to communicate effectively, and to interpret, embrace, and apply these concepts with a shared understanding Kathryn Power, 2004 3 Read slide first Linguistic philosophy teaches us that how we speak about something indicates how we value and treat it. How many people here remember the days when we used to refer to people as the chronics�? Show of hands� How about using the term �The mentally ill?... How many of you, in this audience, would like to be known as �cases�? How about �cases to be managed?� How about �the diabetic� the hypertensive� the erectile dysfunctional� the bone cancer?� The use of language shapes how we treat people. Language is powerful�and impacts clearly on how we shape our environments. Our last few decades have indeed supported an environment of deficit or chronicity-based programs for the people we serve. This odd allegiance to a �deficit-based, medical model of diagnoses and our focus on problems� has caused our entire field to get stuck in a non-recovery model of care that does not provide hope, choice or even recognize strengths. This needs to change. In partnership with the people we serve , �we need a common ground�a language that makes it possible for everyone to communicate effectively�and the ability to apply recovery focused concepts and competencies with a shared understanding� Read slide first Linguistic philosophy teaches us that how we speak about something indicates how we value and treat it. How many people here remember the days when we used to refer to people as the chronics�? Show of hands� How about using the term �The mentally ill?... How many of you, in this audience, would like to be known as �cases�? How about �cases to be managed?� How about �the diabetic� the hypertensive� the erectile dysfunctional� the bone cancer?� The use of language shapes how we treat people. Language is powerful�and impacts clearly on how we shape our environments. Our last few decades have indeed supported an environment of deficit or chronicity-based programs for the people we serve. This odd allegiance to a �deficit-based, medical model of diagnoses and our focus on problems� has caused our entire field to get stuck in a non-recovery model of care that does not provide hope, choice or even recognize strengths. This needs to change. In partnership with the people we serve , �we need a common ground�a language that makes it possible for everyone to communicate effectively�and the ability to apply recovery focused concepts and competencies with a shared understanding�

4. ...Finally I went into the office (reluctantly and at the insistence of my husband and daughter) and said that I was there under duress and did not believe there was any help for me�. ...He listened and talked to me as if I were a real person and his equal. He told me he had treated several hundred people like me, but I was the only expert on my situation.� My healing began then, at that moment... Mary Ann Beall

5. Recovery and Resiliency In 2003, The President's New Freedom Commission on Mental Health recommended the identification of recovery as its legitimate goal.�(The President�s New Freedom Commission on Mental Health, 2003) 5 On April 29, 2002, the President identified three obstacles preventing Americans with mental illnesses from getting the excellent care they deserve: Stigma that surrounds mental illnesses; (2) unfair treatment limitations and financial requirements placed on mental health benefits in private health insurance; and (3) the fragmented mental health service delivery system. He then authorized the formation of what is now called The President's New Freedom Commission. In the final report of 2003, amongst other things, the Commission recommended the identification of recovery as its legitimate goal and articulated this Vision Statement (next slide) On April 29, 2002, the President identified three obstacles preventing Americans with mental illnesses from getting the excellent care they deserve: Stigma that surrounds mental illnesses; (2) unfair treatment limitations and financial requirements placed on mental health benefits in private health insurance; and (3) the fragmented mental health service delivery system. He then authorized the formation of what is now called The President's New Freedom Commission. In the final report of 2003, amongst other things, the Commission recommended the identification of recovery as its legitimate goal and articulated this Vision Statement (next slide)

6. New Freedom Commission Vision Statement We envision a future where everyone with a mental illness will recover, a future when mental illnesses can be prevented or cured, a future when mental illnesses are detected early, and a future when everyone with a mental illness at any stage of life has access to effective treatment and supports - essentials for living, working, learning, and participating fully in the community (New Freedom Commission, 2003) 6 �.A future we all want for ourselves and our loved ones. A future that will also see our workforce issues potentially solved by being able to hire �people in recovery� to serve our clients and provide compassionate and recovery focused services and help us understand what it means to be diagnosed with these issues. �.A future we all want for ourselves and our loved ones. A future that will also see our workforce issues potentially solved by being able to hire �people in recovery� to serve our clients and provide compassionate and recovery focused services and help us understand what it means to be diagnosed with these issues.

7. Definitions of Recovery �the process in which people are able to live, work, learn, and participate fully in their communities. For some, recovery is the ability to live a fulfilling and productive life despite a disability. For others, it implies the reduction or complete remission of symptoms (New Freedom Commission, 2003) 7 The New Freedom Commission defined recovery, after requesting input from over two thousand providers, family members, service users, researchers, officials, providers and others. The New Freedom Commission defined recovery, after requesting input from over two thousand providers, family members, service users, researchers, officials, providers and others.

8. Definitions of Recovery Mental health recovery is 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 striving to achieve his or her full potential (USDHHS, 2005) 8 The journey of recovery is very individualized as you can imagine. And there are many definition of recovery. We offer several for your consideration. What is most important however, is how you as practitioners incorporate recovery-oriented practices into the fabric of the support you offer. This will be discussed at length in the next module. The journey of recovery is very individualized as you can imagine. And there are many definition of recovery. We offer several for your consideration. What is most important however, is how you as practitioners incorporate recovery-oriented practices into the fabric of the support you offer. This will be discussed at length in the next module.

9. Definitions of Recovery �Recovery is a deeply personal, unique process of changing ones values, feelings, goals, skills, and roles. It is a way of living a satisfying, hopeful, and contributing life, with or without limitations caused by the illness� (Anthony et al, 2002, p. 31) 9 According to Bill Anthony, (Executive Director of the Center for Psychiatric Rehabilitation at Boston University) �as the recovery concept becomes better understood it could have major implications for how future mental health systems are designed.� He developed a set of Recovery Assumptions, based on the writing of consumers. We will review several of them as we explore our understanding of recovery. Recovery can occur without professional intervention�Recovery changes the frequency and direction of symptoms�Recovery does not feel like a linear process�Recovery from the consequences of the illness is sometimes more difficult than recovering from the illness itself�Recovery from a mental illness does not mean that one was �not really mentally ill�� A common denominator of recovery is the presence of people who believe in and stand by the person in need of recovery� A recovery vision is not a function of one�s theory about the causes of mental illness�Recovery can occur even though symptoms reoccur. According to Bill Anthony, (Executive Director of the Center for Psychiatric Rehabilitation at Boston University) �as the recovery concept becomes better understood it could have major implications for how future mental health systems are designed.� He developed a set of Recovery Assumptions, based on the writing of consumers. We will review several of them as we explore our understanding of recovery. Recovery can occur without professional intervention�Recovery changes the frequency and direction of symptoms�Recovery does not feel like a linear process�Recovery from the consequences of the illness is sometimes more difficult than recovering from the illness itself�Recovery from a mental illness does not mean that one was �not really mentally ill�� A common denominator of recovery is the presence of people who believe in and stand by the person in need of recovery� A recovery vision is not a function of one�s theory about the causes of mental illness�Recovery can occur even though symptoms reoccur.

10. The Arts in Recovery From nine years old until recently I have been hospitalized many times.� The thing that I have found to be most helpful is the use of the arts and being able to go out and share face to face my�experiences with other peers, particularly at drop-in centers.� There I can share that recovery is possible Sharon Wise 10

11. Resiliency Resilience is the personal and community quality that enables us to rebound from adversity, trauma, tragedy, threats, or other stresses--to go on with life with a sense of mastery, competence, and hope. (New Freedom Commission, 2003) 11 The concept of Resiliency is most often heard and described within the research and literature for children�s mental health, but really it has applicability across the lifespan. There are many definitions of resiliency. This slide shows the way in which resiliency is presented within the New Freedom Commission Report. The common element of most definitions of resilience is the adaptive ability to do well in the face of adversity. The concept of Resiliency is most often heard and described within the research and literature for children�s mental health, but really it has applicability across the lifespan. There are many definitions of resiliency. This slide shows the way in which resiliency is presented within the New Freedom Commission Report. The common element of most definitions of resilience is the adaptive ability to do well in the face of adversity.

12. Promoting Resiliency Take a strength-based approach to promoting well-being Identify known risk and protective factors, and focus on those that are malleable Keep in mind that the most effective approaches to enhancing resilience are those that take an ecological approach to reduce risks and enhance protection at the individual, family, and community levels (SAMHSA, 2007) 12 In 2007, the Federal Center for Mental Health Services submitted a report to congress on mental health promotion that discussed the public health approach to fostering resilience. Key points within this report included: The importance of creating programs and services that emphasize the STRENGTHS of individuals, families, and communities, rather than their weaknesses; Understanding known risk and protective factors. Put simply, a risk factor is something that will increase the likelihood of a negative event or outcome (such as exposure to chronic violence), and a protective factor is something that will decrease the likelihood of a negative outcome (such as having a strong and reliable support system). Resilience should NOT be viewed as an exclusively �innate characteristic;� rather, for the purposes of developing services and programs that can improve functioning, the key is to focus on those elements that are subject to positive change (i.e. areas in which you can reduce risk factors and enhance protective factors). In this context, resilience should not be viewed as a static trait, and it is important to bear in mind and that "individuals do not develop resilience by 'pulling themselves up by the bootstraps' when faced with life's challenges. Resilient adaptation to adversity comes about as a result of characteristics of an individual interacting with resources in the environment.� Finally, programming which is most effective at promoting well-being is holistically oriented to focus on the individual within the context of a personal, familial, social, and community context.In 2007, the Federal Center for Mental Health Services submitted a report to congress on mental health promotion that discussed the public health approach to fostering resilience. Key points within this report included: The importance of creating programs and services that emphasize the STRENGTHS of individuals, families, and communities, rather than their weaknesses; Understanding known risk and protective factors. Put simply, a risk factor is something that will increase the likelihood of a negative event or outcome (such as exposure to chronic violence), and a protective factor is something that will decrease the likelihood of a negative outcome (such as having a strong and reliable support system). Resilience should NOT be viewed as an exclusively �innate characteristic;� rather, for the purposes of developing services and programs that can improve functioning, the key is to focus on those elements that are subject to positive change (i.e. areas in which you can reduce risk factors and enhance protective factors). In this context, resilience should not be viewed as a static trait, and it is important to bear in mind and that "individuals do not develop resilience by 'pulling themselves up by the bootstraps' when faced with life's challenges. Resilient adaptation to adversity comes about as a result of characteristics of an individual interacting with resources in the environment.� Finally, programming which is most effective at promoting well-being is holistically oriented to focus on the individual within the context of a personal, familial, social, and community context.

13. � What I recovered is what I lost and what I lost was myself.� Being believed about my trauma issues� is what has been helpful in my recovery; also support from my peers when I needed it Pat Risser 13 The process of growth is something that we all experience. But�.. Please take a few minutes and write down your answers to these questions. (3 minute exercise) What are the unwritten and or unspoken rules or beliefs that you or you workplace have about the people you serve being able to make decisions about their own care? Do you agree or disagree with these rules or beliefs? How do these beliefs get perpetuated, and what would it take to change them? (self-reflection exercise)� No need to share responses. The process of growth is something that we all experience. But�.. Please take a few minutes and write down your answers to these questions. (3 minute exercise) What are the unwritten and or unspoken rules or beliefs that you or you workplace have about the people you serve being able to make decisions about their own care? Do you agree or disagree with these rules or beliefs? How do these beliefs get perpetuated, and what would it take to change them? (self-reflection exercise)� No need to share responses.

14. Transformation, Recovery and Resiliency Recovery: Journey of healing and transformation enabling a person with a mental illness to live a meaningful life in the community of his or her choice while striving to achieve his or her potential (National Consensus Statement on Recovery, 2005) 14 A comprehensive and widely divergent group of experts met in Washington, DC to review technical papers and reports; they then convened and crafted the following principles and ten components known as the National Consensus Statement on Recovery (USDHHS, 2005) A comprehensive and widely divergent group of experts met in Washington, DC to review technical papers and reports; they then convened and crafted the following principles and ten components known as the National Consensus Statement on Recovery (USDHHS, 2005)

15. The National Consensus Statement on Recovery: Fundamental Components Self Direction Empowerment Individualized Holistic Non-Linear 15 (Self-Direction) Consumers must be supported to lead, control, choose, and determine their own path to a self-determined life. (Holistic) It is about an individual�s whole life� housing, employment, education, mental and physical healthcare, natural services, addictions treatment, creativity, social supports (family and friends), and their roles and experiences in their community. (Empowerment) Service users must be given the authority to choose from a range of options and to participate in decisions that affect them. There are multiple paths to recovery based on the person�s strengths, needs, preferences, experiences and culture. (Individualized) (Non-Linear) Recovery is not a step-wise process that proceeds in a Step 1, 2, 3 manner. It recognizes that setbacks happen and that learning happens from life experiences. (Self-Direction) Consumers must be supported to lead, control, choose, and determine their own path to a self-determined life. (Holistic) It is about an individual�s whole life� housing, employment, education, mental and physical healthcare, natural services, addictions treatment, creativity, social supports (family and friends), and their roles and experiences in their community. (Empowerment) Service users must be given the authority to choose from a range of options and to participate in decisions that affect them. There are multiple paths to recovery based on the person�s strengths, needs, preferences, experiences and culture. (Individualized) (Non-Linear) Recovery is not a step-wise process that proceeds in a Step 1, 2, 3 manner. It recognizes that setbacks happen and that learning happens from life experiences.

16. The National Consensus Statement on Recovery: Fundamental Components Strengths-Based Respect Peer Support Responsibility Hope 16 (Strength- based) Instead of focusing on �problems and deficits,� this approach values and builds on a person�s strengths, capacities, life experiences, coping abilities, and (Respect) honors the inherent worth of the person, him/herself, thereby ending the obvious, and more insidious types of discrimination against people with mental illness (Peer Support) Mutual support from others who have experienced, learned and are in recovery from the same kinds of illnesses is invaluable for service users in our system.. Peers in recovery encourage and engage others and provide a sense of belonging and of �future� that goes beyond being a �patient�. (Responsibility) Consumers, service users, or patients have a personal responsibility for their own self care and own recovery. (Hope) Taking these steps often requires much courage.(Strength- based) Instead of focusing on �problems and deficits,� this approach values and builds on a person�s strengths, capacities, life experiences, coping abilities, and (Respect) honors the inherent worth of the person, him/herself, thereby ending the obvious, and more insidious types of discrimination against people with mental illness (Peer Support) Mutual support from others who have experienced, learned and are in recovery from the same kinds of illnesses is invaluable for service users in our system.. Peers in recovery encourage and engage others and provide a sense of belonging and of �future� that goes beyond being a �patient�. (Responsibility) Consumers, service users, or patients have a personal responsibility for their own self care and own recovery. (Hope) Taking these steps often requires much courage.

17. Recovery and Hope The role of the staff is central. It means that we constantly act in ways that communicate the potential every person has for a better life, even when that person cannot believe in themselves (Davidson et al, 2005) 17 As such, sometimes the first important step that any direct care staff can take is just to treat every person in care with dignity. Providing Hope may be the most important thing that any of us can ever do. Your role is key in enhancing your work environment in implementing these fundamental components. As such, sometimes the first important step that any direct care staff can take is just to treat every person in care with dignity. Providing Hope may be the most important thing that any of us can ever do. Your role is key in enhancing your work environment in implementing these fundamental components.

18. After numerous hospitalizations and medication regimes for a period of more than 30 years, I have recovered. Following a lengthy period in the hospital, I was drawn to the PEER Center in Fort Lauderdale, Florida�..I was able to offer them assistance as a volunteer. I found that it was exactly what I needed in my life�becoming a productive person. I needed to be needed and to feel that I was capable of accomplishing something useful. It was the beginning of my recovery Ed Pazicky, Altered States of the Arts

19. Exercise 19 Leader will make sure participants have paper and pens and ask them to�make a list in answer to�the following question: � What do you have in your Recovery Toolbox that helps you to take care of yourself when something is troubling you?�Or What helps you to maintain balance in your every day life in�order�to avoid stress or prevent�crises from erupting?�� � Answers should be as concrete as possible; supportive people, �activities, resources, artistic endeavors, hobbies, etc. � A discussion�follows with participants to talk about their unique and�individualized��tools. � A Second Part of the exercise (or for another time): � Lead a discussion on how�to assist service recipients in developing their own toolbox utilizing their strengths and types of activities they find helpful.�Leader will make sure participants have paper and pens and ask them to�make a list in answer to�the following question: � What do you have in your Recovery Toolbox that helps you to take care of yourself when something is troubling you?�Or What helps you to maintain balance in your every day life in�order�to avoid stress or prevent�crises from erupting?�� � Answers should be as concrete as possible; supportive people, �activities, resources, artistic endeavors, hobbies, etc. � A discussion�follows with participants to talk about their unique and�individualized��tools. � A Second Part of the exercise (or for another time): � Lead a discussion on how�to assist service recipients in developing their own toolbox utilizing their strengths and types of activities they find helpful.�

20. Recovery and Hope Hope can and will come from the least suspected quarters, whether in the secret corner of our own hearts or of others L. Stuhl Mueller C.P. 20 The primary vehicle for the delivery of most mental health interventions is the relationship that exists between us as direct care staff and the people we serve. You have a pivotal role in providing hope through helping people in redefining their lives, in becoming involved in meaningful activities, in respecting their choices, and building a network of supports. The following poem should be printed and handed out to participants as a closing for this module. It is a great inspirational poem that exemplifies one person�s perspective and strengths in their journey of recovery. Anthem: Hope of Recovery This I know: Through the travails Of unending sorrow, Through physical And mental suffering, I t is possible to return, To turn one�s life Back towards peace, An earned acceptance Of what can be, That the possibilities for joy Are endless, Uncovering each day Like a golden nugget, Like a present for a holiday, Will come to the front If we have hope, No matter what happens, Families feeling so far away, Pain tearing and reopening wounds, We must have hope, That its magic elixir will send Us into brighter futures, Knowing it will not be easy, That there will be many relapses, Temptations at every turn, And with all the difficulties Of our daily activities, Still l we must hold fear at bay, And looking back Into a vast mirror That is our years, We will behold, Illuminated by hope�s Brightest burning fires, A great forest of weathered But spirited trees strongly rooted And forever standing tall. James D. Eret, Writing Director Creative Arts Consortium San Diego, CaliforniaThe primary vehicle for the delivery of most mental health interventions is the relationship that exists between us as direct care staff and the people we serve. You have a pivotal role in providing hope through helping people in redefining their lives, in becoming involved in meaningful activities, in respecting their choices, and building a network of supports. The following poem should be printed and handed out to participants as a closing for this module. It is a great inspirational poem that exemplifies one person�s perspective and strengths in their journey of recovery. Anthem: Hope of Recovery This I know: Through the travails Of unending sorrow, Through physical And mental suffering, I t is possible to return, To turn one�s life Back towards peace, An earned acceptance Of what can be, That the possibilities for joy Are endless, Uncovering each day Like a golden nugget, Like a present for a holiday, Will come to the front If we have hope, No matter what happens, Families feeling so far away, Pain tearing and reopening wounds, We must have hope, That its magic elixir will send Us into brighter futures, Knowing it will not be easy, That there will be many relapses, Temptations at every turn, And with all the difficulties Of our daily activities, Still l we must hold fear at bay, And looking back Into a vast mirror That is our years, We will behold, Illuminated by hope�s Brightest burning fires, A great forest of weathered But spirited trees strongly rooted And forever standing tall. James D. Eret, Writing Director Creative Arts Consortium San Diego, California

21. Optional Video:Recovery as a Journey of the Heart Pat Deegan, PhD Boston University Center for Psychiatric Rehabilitation Note to Instructor: This optional video is not available for free download, however, it is available for purchase through the National Empowerment Center: http://www.power2u.org/mm5/merchant.mvc?Screen=PROD&Store_Code=NEC&Product_Code=Video-RecoveryJourneyHeart&Category_Code=dvd-video Questions to consider as you listen to this video or DVD� How do the concepts of Recovery relate to you personally? What are the words or phrases you use that might be helpful or hurtful to the people you serve? How could your daily workplace change if the mental health system wholeheartedly adopted the underpinnings or enhancing recovery and building resiliency? Note to Instructor: This optional video is not available for free download, however, it is available for purchase through the National Empowerment Center: http://www.power2u.org/mm5/merchant.mvc?Screen=PROD&Store_Code=NEC&Product_Code=Video-RecoveryJourneyHeart&Category_Code=dvd-video Questions to consider as you listen to this video or DVD� How do the concepts of Recovery relate to you personally? What are the words or phrases you use that might be helpful or hurtful to the people you serve? How could your daily workplace change if the mental health system wholeheartedly adopted the underpinnings or enhancing recovery and building resiliency?