Recovery & Motivational Engagement

1. Recovery & Motivational Engagement August 2012

2. Contents • What is Recovery? • Key concepts • The Recovery process • Impact of the therapeutic relationship in Recovery • Understanding stigma • What is Motivational Engagement and Enhancement? • Stages of Change model • Barriers to Engagement • The F.R.A.M.E.S. Approach • Other Key Elements in Motivational approaches • Basic Strategies in Motivational Enhancement • Types of Self-Motivational Statements • Principles of Motivational Interviewing • Responding to Resistance • Relapse

3. The Experience of Recovery Recovery is an individual’s experience of living successfully with a mental illness. “ Recovery occurs when people with mental illness discover, or rediscover, their strengths and abilities for pursuing goals and develop a sense of identify that allows them to grow beyond their mental illness.” Pat Deegan,PhD, consumer leader with Schizophrenia

4. Key concepts about the Recovery Experience Recovery is a personal process of change experienced by each person in a unique way. Recovery is characterized by growth beyond the effects of mental illness. Recovery is a complex and time-consuming process. Recovery is possible when there is hope. Recovery is a universal human experience.

5. What do people Recover from? The effects of mental illness, such as physical symptoms, emotional fears, and feelings of being out of control The trauma associated with a psychotic break and/or hospitalization Negative attitudes from family members, friends, professionals, and towards oneself Loss of a role and positive identity in society Lack of enriching opportunities Stigma and discrimination

6. Traditional versus Recovery Attitude Activity

7. The Recovery Process Phase One: Overwhelmed by the disability and how the person is treated (i.e., initial diagnosis and label of being a person with mental illness) Phase Two: Struggling with the disability and rebuilding connections to the self, others, the environment, and meaning and purpose Phase Three: Living with the disability and new connections to the self, others, the environment, and meaning and purpose Phase Four: Living beyond the disability: Authenticity, Connectedness, and Contribution

8. What Patients say Helps the Recovery Process Internal Conditions Hope – belief that recovery is possible Healing – recovery is not synonymous with cure; active participation in self-help activities; locus of control is with consumer Empowerment – corrects a lack of control, sense of helplessness, and dependency; aim is to have consumer assume increasing responsibility for themselves in making choices and taking risks; full empower requires that consumers live with consequences of their choices Connection – recovery is a social process; a way of being in the company of others; to find a role to play in the world

9. External Conditions Human Rights –reducing and eliminating stigma, discrimination against psychiatric disabilities; equal opportunities in education, employment, housing; access to needed resources Positive Culture of Healing –a culture of inclusion, caring, cooperation, dreaming, humility, empowerment, hope Recovery-oriented services –best practices of clinical care, peer and family support, work, community involvement to be implemented by consumers, clinicians, and community (Jacobson & Greenley, 2001). What Patients say Helps the Recovery Process

10. What are our expectations of the people we serve? - employment - social - educational - housing - self-advocacy Do we, as providers, underestimate persons with mental illness?

11. Renee’s Recovery Story In a 10 year period, Renee Kopache was hospitalized 40 times, was on nearly 40 different medications, survived three suicide attempts, many experiences of self-injury and 23 ECT treatments. Today she has a satisfying personal life and works as Recovery Coordinator of Hamilton County Community Mental Health Board in Cincinnati, Ohio.

12. Renee’s Recovery Story “The discharge summary from my last hospitalization stated that my prognosis is “poor,” and recommended that I not live alone in the community. About two years ago, I purchased my first home. Mental illness is devastating. But, through recovery from the illness, I have a career, social and community life in front of me that only I can limit.” (Kopache, 2011)

13. Resilience According to dictionary.com (n.d.) resilience is defined as; 1. the power or ability to return to the original form, position, etc., after being bent, compressed, or stretched; elasticity. 2. ability to recover readily from illness, adversity, or the like; buoyancy. “The power of the human spirit to sustain grief and loss and to renew itself with hope and courage defies all description.” - Dr. Dan Gottlieb, 1991

14. Providers can Facilitate Recovery Providers are in a key position to make a difference Your (providers’) attitude can either help or hinder the recovery process What are some traits of providers that hinder the process? What about those that help? Your influence directly impacts the way a person conceptualizes their recovery journey Excerpts from Lori Ashcraft’s “Partnering with Providers” presentation 6/20/07

15. The Dilemma Paperwork guides the process toward a focus on deficits Historically, the provider culture had not encouraged partnership What is meant by partnership? What is meant by provider culture? What is the provider culture at your location? Excerpts from Lori Ashcraft’s “Partnering with Providers” presentation 6/20/07

16. Relationship Breakdown What is the most important treatment tool that you have? How does the therapeutic relationship impact treatment? Excerpts from Lori Ashcraft’s “Partnering with Providers” presentation 6/20/07

17. Providers and the Recovery Process Providers may unintentionally interfere with recovery because they are unaware of how to facilitate it Providers may feel obligated to take the lead instead of encouraging the person to do so (enabling behavior) Providers may focus on the patient’s limitations instead of their potential/strengths Excerpts from Lori Ashcraft’s “Partnering with Providers” presentation 6/20/07

18. How it Happens Providers usually see people when they are struggling with problems Hence, they don’t see their successes Therefore, they often don’t see the evidence of recovery They may come to the conclusion that people are helpless and hopeless Excerpts from Lori Ashcraft’s “Partnering with Providers” presentation 6/20/07

19. This Leads to … Not believing that people recover Not believing they can help people recover Discouragement and burnout Poor results and outcomes Counter-stigma: people receiving services begin to see providers as irrelevant to their recovery Excerpts from Lori Ashcraft’s “Partnering with Providers” presentation 6/20/07

20. What can be done about this Provide effective training in recovery facilitation skills Develop an integrated workforce that encourages teamwork Provide training for professionals by peers Measure for recovery success so providers can see how they have helped to promote recovery and eliminate stigma Encourage an environment conducive to recovery Excerpts from Lori Ashcraft’s “Partnering with Providers” presentation 6/20/07

21. What is stigma? 1. mark of disgrace or infamy; a stain or reproach, as on one's reputation. 2. mental or physical mark that is characteristic of a defect or disease. (Dictionary online, n.d.). Stigma is a negative view of a person based on something about them. Many illnesses get stigmatized, not just mental illness.   Stigmatizing attitudes are held by many, including professionals in the MH field.

22. Stigma continued… • One in four people believe people with mood disorders: • are not just like everyone else • should not have children • are easy to identify in the workplace; and they • do not live “normal” lives when treated   • Two-thirds of survey respondents also held the incorrect belief that mood disorder medications are habit forming. "These misconceptions can do irreparable harm to people with legitimate illnesses who should and can be treated." Herbert Pardes, M.D., President of NARSAD’s Scientific Council

23. Our Patients’ Self-stigmatize Self-stigma (the belief that you are weak or damaged because of your own illness) can sometimes be the most difficult kind of stigma to fight. Self-stigma may cause people to stop their treatment, isolate themselves from loved ones, or give up on things they want to do.

24. What can you do to Fight Stigma? You can do a lot! Start with the way you act and how you speak – to everyone. You can contribute to an environment that builds on people’s strengths and promotes good mental health. For example: Avoid labeling people with words like “crazy” or by their diagnosis. Instead of saying someone is a “schizophrenic” say “a person with schizophrenia.” Learn the facts about mental health and share them with others, especially if you hear something that is untrue. Treat people with respect and dignity.

25. Motivational Techniques What is motivational interviewing? Motivational Enhancement Motivational Engagement Facilitative Partnering Collaboration Activity 5 25

26. Motivation Define motivation… A reason or desire to act That which gives purpose and direction to behavior What motivates you? Motivation is dynamic: Purposeful Intentional Positive Changeable

27. So who’s responsible for making the change? The client ultimately is responsible for change, and this responsibility is shared with the clinician through a therapeutic partnership. The CLIENT

28. Motivational Enhancement Goals and Objectives: Demonstrate understanding of change theory Explain the relationship between motivational interventions and stages of change Demonstrate basic skills for enhancing client motivation Identify staff strengths and learning needs Assess clients’ readiness for change In this training we will introduce and review some motivational enhancement terms

29. Stages-of-Change Model Pre-contemplation - person is not considering or does not want to change a particular behavior Contemplation - person is certainly thinking about changing a behavior Preparation - person is seriously considering and planning to change a behavior and has taken steps toward change Action - person is actively doing things to change or modify behavior Maintenance - person continues to maintain behavioral changes until it becomes permanent

30. The Nature of Motivation Motivation has historically been viewed as an “either-or”: Clients were considered motivated if they: Agreed to participate in treatment Were compliant to treatment Accepted the label of their diagnosis Clients were considered unmotivated if they: Resisted a diagnosis Refused to comply with treatment protocol

31. Motivational Enhancement techniques are based on 7 POSITIVE Assumptions: Motivation is: A key to change Multidimensional Dynamic and fluctuating Influenced by social interactions Can be modified Influenced by the clinician’s style The clinician’s task is to elicit and enhance motivation.

32. People engage when: They can trust They feel respected They are “heard” They are understood They feel safe They are valued What type of environment helps you to engage?

33. Traits of a “Motivator” Observant Flexible Confident Fully present Consistent Empathic listener Curious Humor Unconditional Positive Regard Patient Open

34. Barriers to Engagement  One primary or main barrier is our Assumptions We assume that because the person has come to us for services, they must: Have hope that they can change. Have insight that they need assistance in making the desired change. Already accept you as a guide to lead them in the process of desired change. Already have most of the resources necessary to make the change.

35. Other Important Barriers to Engagement Include Beliefs about people Inability to establish trust Real or perceived demonstration of respect Lack of needed skills Lack of confidence Other Barriers?

36. The benefits of using Motivational Enhancement techniques Inspiring motivation to change Preparing clients to enter treatment Engaging and retaining clients in treatment Increasing participation and involvement Improving treatment outcomes Encouraging a rapid return if relapse occurs

37. The FRAMES Approach Researchers have identified six elements of effective intervention and coined the acronym FRAMES to summarize them: Feedback is given to the client throughout treatment Responsibility for change is placed on the client Advice about behavior is given in a non-judgmental manner Menus of treatment options are offered Empathic Counseling is emphasized byshowing warmth, respect and understanding Self-efficacy/empowerment is developed within the client to encourage change

38. Other key elements of effective motivational approaches include: Decisional Balancing – exploring pros and cons of change Discrepancies between personal goals and current behavior Flexible pacing – tailor pacing through the stages of change to the client’s need Personal contact with clients not in treatment – working to maintain contact with clients not currently in treatment to encourage them to recommit to making a change

39. Complete the Listening: A Self Assessment Activity 6

40. 5 Basic Strategies of Motivational Enhancement Open-ended questions (requesting information) Affirming Reflective listening (reflecting) Summarizing Eliciting or reinforcing self-motivational statements

41. 5 Basic Strategies of Motivational Enhancement 1 - Open-ended questions Help the clinician understand the client’s point of view Elicit client’s feelings about a given topic or situation Facilitate dialog: they cannot be answered with a single word or phrase and not require a particular response Solicit additional information in a neutral way Encourage the client to do most of the talking Help the clinician avoid making prejudgments Keep a communication moving forward

42. 5 Basic Strategies of Motivational Enhancement 2 - Affirm Supports and promotes their sense of self-efficacy Acknowledges their difficulties Validates their experiences and feelings Increases their confidence to take action and change their behavior

43. 5 Basic Strategies of Motivational Enhancement 3 - Listen Reflectively Reflective listening involves the clinician’s making a reasonable guess about what the client means AND rephrasing the client’s statement to reflect what the clinician thinks they heard. Provides clients a different way of considering what they have said Reduces the likelihood of resistance Encourages the clients to talk Communicates respect Cements the therapeutic alliance Clarifies exactly what clients mean Reinforces motivation

44. 5 Basic Strategies of Motivational Enhancement 4 - Summarize Summarizing consists of condensing the elements of what clients have expressed AND communicating it back to them. Reinforcing what they said Demonstrating that the clinician has been listening carefully Helping clients consider their responses and experiences Preparing clients to move forward

45. 5 Basic Strategies of Motivational Enhancement 5 - Elicit and Reinforce Self-Motivational Statements When used successfully, motivational interviewing techniques ensure that clients, not the clinician, identify the changes that are needed to improve their lives. One signal that clients’ ambivalence and resistance are diminishing is the self-motivational statement.

46. Complete the Basic Strategies of Motivational Enhancement Exercise Activity 7

47. 4 Types of Self-Motivational Statements: Cognitive recognition of the problem Affective expression of concern about the perceived problem (emotional response) A direct or implicit intention to change the behavior Optimism about one’s ability to change Clinicians can reinforce a client’s self-motivational statement and encouraging the possibility of change by: Reflecting the statement Nodding or making approving facial expressions Making affirming statements Asking for elaboration, explicit examples, or more details about remaining concerns

48. 5 Principles of Motivational Interviewing Express empathy – key component is reflective listening Develop discrepancy between clients’ goals or values and their current behavior Avoid arguments/power struggles and direct confrontation Support self-efficacy and optimism Roll with resistance Resistance can be identified by 4 basic behaviors: Arguing Interrupting Denying Ignoring

49. Responding to Resistance Simple reflection – respond with nonresistance, reflect the client’s statement in a neutral form Amplified reflection – reflect in an exaggerated form – stated in an extreme way but without sarcasm Double-sided reflection – acknowledge what client has said but also state contrary things they’ve said in the past Shifting focus – from obstacles and barriers and affirm clients’ choices regarding the conduct of their lives Agreement with a twist – involves agreeing with the client but with a slight twist or change of direction that propels the discussion forward Reframing – offers a new and positive interpretation of negative information provided by the client

50. Complete the Resistance Response Exercise Activity 8