Transitioning to Recovery Based Treatment Mark M. Lowis, LMSW Member: International Motivational Interviewing Network of Trainers Ray Rais, LMSW Quality Improvement Coordinator – Macomb County Community Mental Health
Tolstoy: “I know that most men, including those at ease with problems of the greatest complexity, can seldom accept even the simplest and most obvious truth if it be such as would oblige them to admit the falsity of conclusions which they have delighted in explaining to colleagues, which they have proudly taught to others and which they have woven, thread by thread, into the fabrics of their lives.”
Give me 5 Minutes to learn Names
Transition? From What? To What? Institutional Memory Goal is to Maintain Stability in within the System What the Agency Offers Prescribing/telling Compliance Based Monitoring compliance Mandating Behavior Deficit Based Targeted Treatment Goal is to Exit the System through Amelioration Individualized Issues Assistive Interventions Collaborative Guiding Incremental change Manageable Recovery based
Exercise • Work in groups at table • Select a scribe for your table • Select a speaker to represent you table • Together brainstorm a list of deficit based terms • Start by saying; “I see you as….” and finish with the deficit based term/label. (IE: I see you as lazy.) • Facilitator gathers list from speaker
Exercise • Work in groups at table • Select a scribe for your table • Select a speaker to represent you table • Together brainstorm a list of strength based terms • Start by saying; “I see you as….” and finish with the deficit based term/label. (IE: I see you as protecting yourself.) • Facilitator gathers list from speaker
“Strength Based” means “Making Sense” out of Resistance!
Some Kinds of Plans Behavioral – Uses Behavioral Modification Awards Points Privileges Incentives Consequences
Some Kinds of Plans • Institutional – • Uses levels of functioning to determine privileges within the institution • Deficit based – • Professional determines a person’s needs based on inability • takes over decisions • struggles to control or manage • contest between system and free will of client.
Some Kinds of Plans • Agency – • Converts a person’s desire (what they want from treatment) to what the agency offers • says what the client can and can’t have • Staged – • Work is collaborative and assistive • Step-by-step process toward recovery • Steps are manageable for the person being served • The pace of recovery is determined by readiness • Throughout the process the focus is on transition
Institutional Memory • Historical Approach to Treatment in which the need is to protect the public • Identify Persons with Mental Illness based upon dangerous, aberrant or abhorrent behavior • Remove from Mainstream • Place in institution • Stabilize Symptoms • Maintained forever • State Facility • Forensic Center • Jail
Institutional Take Possession Remove Place Depersonalize Stabilize Maintain Ineffective Costly
DeinstitutionalizeHome SettingSmaller InstitutionsLess ConfiningMore personalPlacementStabilizeMaintain Costly Seeking full citizenship Community Based Group Homes Same Approach Smaller Institutions Resistance from Community
Person Centered Planning Goals and Objectives are still Maintenance and Institutional Institutional Assess Diagnose Prescribe Person Centered Facilitate Collaborate Assist
Strength BasedIts not looking for their strengths. Its knowing that they are there Honors autonomy Emphasizes choice and control What assistance are they seeking What do they already understand How do they see us working with them
Strength Based The individual has the right to dignity and respect from the practitioner(s) and every person whom they encounter at the agency (Mutuality)
Push BackExamples • A job is not a service • We aren’t an employment agency • We don’t do housing • We don’t do that • The CMH has cut our funding so we can’t • They don’t know what they want • Some of them just want us to tell them • The just want medication • They’re just trying to get…
MaintenanceApproach (Institutional Memory) • Prescribed Goals and Objectives • Encounters are cumulative and general • Time frames are subjective • Consumer must accept expert advise • Consumer must match expectations of system • Confront Resistance • Guardianship • Consequences • More Restrictive • Seclusion and Restraint • Behavior Management Committee
Recovery Approach • Good agreement on Goals, Objectives and Interventions • Consumer has total choice and control • Professional is assistive and collaborative partner • Encounters are specific • Resistance is understood from consumer perspective • Professional has interventions for any level of readiness • Goal is to achieve amelioration and discharge • Consumer is welcome back if necessary • Time frames are realistic
Maintenance Plan • Problem #2 – The consumer lacks coping skills • Goal #2 – The consumer will Develop Coping Skills • Objective #1 – The consumer will attend all therapy sessions AEB therapist documentation • Intervention #1 – Therapy 1x/week • Objective #2 – The Consumer will make 3 positive self-statements per week AEB therapist documentation • Intervention #2 – Therapy 1x/week • Objective #3 – The consumer will identify 3 coping skills AEB therapist documentation • Intervention #3 – Therapy 1x/week
Now What? What would the Problem Statement Become? What would an Objective Look Like? What would an Intervention look like?
Recovery Plan • Targeted issue – Symptoms interfere with keeping job • Goal – Stop symptoms from interfering with ability to keep job • Objective 1 – Meet with psychiatrist to discuss and describe symptoms and the way in which they interfere with ability to keep a job • Objective 2 – Be able describe medication including dosage, how taken, possible side effects, how it will help with Goal • Objective 3 – Develop agreement with psychiatrist on medication
Recovery Interventions (Us) • Intervention – Psychiatric Evaluation to determine medication to support goal for sustaining employment • Intervention – Demonstrate way in which medication will assist with goal • Intervention – Periodic medication review to determine how used, effects/side effects, reaffirm usefulness toward goal and adjust if necessary. • Intervention - Assist with any concerns or barriers
Intervention What we do that is assistive and collaborative in helping the person with objectives for achieving the goal
Dean Fixen The Therapist Is The Intervention!
Sufficiency Standards and Authorization • Amount – number of units needed to provide the service • Scope - How the service will meet the need addressed (Think of Medical Necessity) • Duration – How long the service will be provided based on attaining the objective • Service – Psychiatric Evaluation, Medication Review, Group/Individual/Family Therapy, Case Management, etc.
Deficit Based Transition Goals • Maintain reduction in symptoms for 12/months • Maintain medication compliance for 12/months • Comply with treatment • Stay at Par for 12/months!! • Intervention – Monitor for compliance
Transition GoalsRecovery • Find a home that provides more independence. • Person’s description of the goal: “I want my own place” • Assist Primary Health Care Provider in transfer of medication • Person’s description of the goal: “I don’t need help to take my medication” • Intervention – Assist in connecting, scheduling, attending and adjusting to a resource (Warm Transfer)
Recovery Based Supports and Services EXAMPLES: • Psycho-Education • Health Education • Individual, Family, Group Treatment • Pharmacological • Case Management • Primary Health Care Physician-Community Clinic • Community Resources • Referral to Human Service Agencies • Community Living Supports • Discharge by Warm Transfer • Collaborative • Welcome back
Recovery Based Discharge Queues • “Person's” treatment goals are attained “to their satisfaction” • On-going care is achievable through Primary Health Care Physician-Community Clinic • On-going issues are able to be provided through other human service agencies (MRS, Work First, DHS, etc) or support network • Consumer is not attending “for a reason” • Consumer attends only to protect SSI/D • Consumer cannot be contacted • Leaves area • Refuses services • Receiving services elsewhere
Planning Process 1st Identify the “Person’s” Targeted Issues • Symptoms of Mental Illness (specific) Impact on… • Co-occurring Substance Use (specific) Interferes with… • Co-occurring Health Issues (specific) affect… • Safe and Affordable Housing impacted by one or more life conditions (specific). • Employment-Income-Resources impacted by one or more life conditions (specific). • Social (specific) and Community Participation (specific) affected by… • Self Care (specific) interrupted by… • Issues compounded by 2 or more conditions
Planning Process 2nd Identify Goals for Amelioration of each of the Person's Targeted Issues 3rd Identify the Person's Stage of Readiness for working on each Goal 4th Design Objectives based on the Person's Readiness 5th Design interventions in collaboration with the client to achieve Objectives 6th Establish accurate, sensible time frames for achieving Objectives 7th Be willing to adjust Plan when necessary 8th Discharge Goal is always part of plan
Staging – Block II Refer to “Stage to Intervention” Power Point