Advancing Recovery Webinar Series · Overview Strengths Model Practices ... About the Webinar...

Advancing RecoveryWebinar Series

ModeratorKarin Kalk, Associate Director, CIBHS

PresenterRick Goscha, Executive Director, University of Kansas,Center for Mental Health Research and Innovation 1

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• There will be a brief evaluation at the end of this session2

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Session I: Overview & Orientation1. Elizabeth’s Story2. Why a Focus on Recovery3. Overview Strengths Model Practices 4. Organizational Alignment with Recovery5. About the Webinar Series6. Preparing for Next Time7. Wrap‐Up

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Introducing Rick Goscha• Director, Kansas University Center for Mental Health Research

and Innovation

• Co‐author with Charles Rapp on the book The Strengths Model: A Recovery‐Oriented Approach to Mental Health Services (now in its 3rd edition)

• Has been practicum student, case manager, team leader, program manager, and directorof an agency. Now involved in systemicimplementation of evidence‐based practices,policy, research, and program design.

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Introducing Elizabeth

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Overview of Elizabeth at the beginning of her road to recovery (2010)

33 year old, white, heterosexual woman

Living with mother and step‐father.

Mostly isolated from community.

Frequent hospitalization (7 times in 2009)

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Frequent calls to crisis services (suicidal ideation)

History of childhood physical, sexual, and emotional abuse.

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₋ Only lived once on her own (lasted 5 months)

₋ Evicted from apartment and was homeless for two months

₋ Re‐entered the hospital₋ Returned to living with mom and

stepfather

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Where Elizabeth is now (2015)

₋ Own apartment for five years₋ Sings in a church choir₋ Helps out occasionally at nursery during

Sunday school classes₋ Has a close friend at her apartment

complex₋ Has a dog

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Where Elizabeth is now (2015)

₋ Has been hospitalized twice in the past five years

₋ Calls the crisis line periodically (3‐4 times a year)

₋ Still struggles at times with depression, disassociation, voices, and suicidal thoughts, although less frequent

₋ Is considering employment

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What shifts created the environment to help Elizabeth recover?

Elizabeth: “I am not worth anything. Therefore, this is bestlife will ever be.”

“A better life is possible.”

Case Manager:

“I am not sure she can live on her own.”

“I’m nervous about it, but maybeshe can do it.”“

CMHC:

“We have to be careful getting people excited

about hopes and dreams that are unrealistic.” –and–“Taking risk is a liability for

the organization.”

“I’m nervous about it, but maybeshe can do it.”

“If people do not dream and take risks, there’s no way we can help them recover.”

Hope12

Elizabeth:

“I’m just trying to cope. Others are making life difficult for me.”

“I want my own place. I want to prove to myself and others

I can do this.”

“I want my own place. I want to prove to myself and others

I can do this.”

Case Manager:

“Once you’re stable, we can try to work on a goal like getting your own place.”

““I’m not sure what it is going to take to achieve this goal, but if it is important to you, I will help you explore it and

take steps to achieve it.”

CMHC:

“Make sure every goal on the

treatment plan meets the criteria for medical necessity.”

“Make sure every goal on the treatment plan is clearly something the person is passionate about and then make sure your role in that goal meets the criteria for medical necessity”

“I’m not sure what it’s going to take to achieve this goal, but if it’s

important to you, I’ll help you explore it and take steps to achieve it.”


“Make sure every goal on the treatment plan is clearly something the person is passionate about and then make sure your role in that goal meets the criteria

for medical necessity.”

Meaningful and Important Goal 13

Elizabeth: “I am mentally ill.”

“I’m a singer, a friend, a daughter, a member of a faith community, who also struggles at times with distressing thoughts.”


CMHC:

“We serve people with severe and persistent mental

illnesses.”



“We help people with the lived experience of mental illness build and/or

rebuild lives that have meaning and purpose.”

Case Manager:

“She is mentally ill.”


“She’s a singer, a friend, a daughter, a member of a faith community, who also struggles at times with distressing thoughts.”

Identity and Focus 14

Elizabeth: Passive

recipient of services


Active participant in her own health and wellness

CMHC: Ensuring deficits are documented



Ensuring that documentation of barriers to goal achievement also

includes effective interventions based on use of a person’s strengths.

Case Manager:

Need to care for someone with a multitude of

deficits


Constant attention to identify and build on the well aspects of her life as a way of overcoming

multiple challenges

Highly Useable Strengths15

Shared Decision Making:

No control overthe medications and care she received


Expert of her own experiences, including what works and what doesn’t

A Change

in Anchors:

Most anchors withinformal systems

of care


Other shifts that helped create an environment for Elizabeth to recover?

Most anchors within the community

Use of meds:

Rejecting medications and their side effects


Finding a role for medications and deciding her level of tolerance of

symptoms and side effects

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Where do shifts need to occur to help advance recovery?

• Client level• Direct service worker level• Supervisory level• Organizational/program/leadership level• Policy/Funding level

“While some people heroically recover despite these shifts, systematic advancement of recovery only occurs when these shifts are all aligned

towards recovery.”

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What shifts have you experienced?And how have you seen clients benefit

from these shifts?

At the organizational level

At a personal level

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Organizational Behaviors and Messages

Most organizational messages are not explicit:

But what we do… communicates a very explicit message.

“Don’t help people set goals that involve any amount of risk”

“Make sure people take

their medications because

medications work for all people, all of the time”

“The most important thing is to meet your productivity standards”

“Most people with mental illness cannot

recover, especially those that are low‐functioning”

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At times our behaviors can contradict the most beautifully crafted vision,

mission, and value statements

There can at times be a substantial disparity between what we

believe we do and what we actually do

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We often underestimate the power of messages within a single client

encounter

Each encounter is an opportunity to convey a message about what

we believe about recovery

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Example MessagesWhat I said My inadvertent message

The main problem is the client and his unwillingness to do anything to help himself.

I have several low functioning people on my caseload

If you say no, well no wonder things are going poorly. If you say yes, you are probably not telling the truthI do not feel comfortable when you express any intense emotion.

I’m not sure you can achieve that goal. Idon’t have the energy to help you with something I don’t think is achievable.

He is unmotivated.

I have several low functioning people on my caseload.

Did you take your meds?

Being angry about it isn’t going to help.

Maybe we should focus on something else right now.

The main problem is the client and his unwillingness to do anything to

help himself. I have low expectations for several

people on my caseload. If you say no, well no wonder things are going poorly. If you say yes, you are probably not telling the truth.I do not feel comfortable when you

express any intense emotion.

I’m not sure you can achieve that goal. I don’t have the energy to help you with something I don’t think is achievable.

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• Sincerely being in the presence of another even when things are chaotic, messy, or uncertain

• Taking the time to uncover what is meaningful and important to people even in the presence of immediate concerns

• Never discounting a trulymeaningful goal a personshares with you, butrather acknowledgingit and exploring it

Behaviors that Align with Recovery

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• Taking the time to organize the strengths people possess to either achieve the goal or remove barriers to achieve the goal

• Walking alongside people as they try to achieve a goal even if we don’t know how to achieve it

• Being transparent in everything we do (writing treatment plan goals and objectives, the interventions we use, what we write or plan to write in our progress notes, etc.)

Behaviors that Align with Recovery

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What is Recovery?

A process of change through which individuals improve their health and wellness, live a self‐directed life, and strive to reach their full potential. (SAMHSA, 2011)

A life worth living beyond the mental health system which brings meaning, purpose, and a positive sense of self‐identity.(Rapp & Goscha, 2009)

Recovery is a deeply personal, unique process changing one’s attitude, values, feelings, goals, skills, and/or roles. It is a way of living a satisfying, hopeful, and contributing life. Recovery involves the development of new meaning and purpose in one’s life as one grows beyond the catastrophic effects of psychiatric disability. (Anthony, 1993)

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What do we believe is possible?

Stabilization

Recovery(moving beyond stabilization)

We have historically underestimated the abilityof people with a mental illness to thrive

outside of formal systems of care

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Why should we invest in recovery?

• Untapped potential for people to make contributions to the lives of others

• Effectiveness of our work is inseparable from the impact we have on people

• Cost of not advancing recovery is very high!– Human costs (suicide, loss of human potential, high morbidity and

mortality)– System costs (acute care and crisis services, high physical health care

utilization, premature need for long term care, avoidable incarceration, long duration of services, risk of future loss of funding due to lack of outcomes)

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• Multiple connected actions must align that focus on client‐centered recovery‐oriented goals

• And, since we are a publically‐funded mental health system, there is need to justify our involvement in these goals coming from a skilled mental health professional using effective evidence‐based interventions.

Shifts toward recovery must be more than philosophical

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Meaningful andImportant Goals

Role ofMentalHealth

Professionals

Succinctly tied together through documentation

Removal of Barriers to

Achievementof Goals

Client Goals

Medical Necessity

Documentation

ProviderIntervention

How the Pieces Work Together• Client goals: Everything must be within the context of goals

that are meaningful and important to the person

• Provider role/medical necessity: Answering the question ‐“why is a mental health professional needed to help with this goal?”

• Provider interventions: Focused on removal of barriers to people’s goals

• Documentation: Tells a story weaving all three above elements together

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Organizational Alignment with Recovery

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Jefferson County Mental Health Center

Began implementing Strengths Model case management in 2010.

All members of the team had received Basic Strengths Model training by March 2010.

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Jefferson County Mental Health Center (2010)

After training, all case managers practiced using the Strengths Assessment with at least one client

Went reasonably well with five of the first seven clients (generated lots of discussion and learning)

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Jefferson County Mental Health Center (2010)

Question: Would using the Strengths Assessment work with someone like Elizabeth?

Elizabeth’s case manager(Rynette)did a case presentationon Elizabeth at strengths‐basedgroup supervision(part of Strengths Modelimplementation)

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Elizabeth’s Case Manager in 2010

Good practitioner. Believed recovery was possible. Good at developing relationship. Building skill set (fairly new to the field)

Acknowledged feeling frustrated with Elizabeth. Constantly in crisis. No ownership of responsibility for actions. Had goal to live on her own, but worker did not think she was ready. Mother and step‐father not supportive.

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Engaging Elizabeth

Introducing the concept of recovery…..and the initial Strengths Assessment.

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Strengths Assessment

For Elizabeth W.

Current Strengths: What are my current strengths? (i.e.

talents, skills, personal and environmental strengths)

Individual’s Desires, Aspirations: What do I want in my life?

Past Resources – Personal, Social, & Environmental:

What strengths have I used in the past?

Home/Daily Living- Currently living with parents (nice to have someone to eat meals with and do things with) - has own room: a place to get away if needed - grocery store close by

- “I’m able to almost everything on my own”

“I want my own apartment at Hitchcock Towers”

- Had own apartment in Stillwell, OK for 5 months in 2004

- Did my own laundry, cooking cleaning, etc.

Assets - Financial/Insurance- Currently receives $573 in SSI - Has Medicaid - Mom is rep payee (nice not to have to think about paying all the bills)

- Will qualify for food stamps if I get my own place

“I want to be able to make my own decisions about what I spend my money on”

- When in own apartment was able to pay my bills on my own

Employment/Education/Specialized Knowledge - Have been searching for a job on my own

- Knowledgeable and skilled around housekeeping responsibilities

- Knowledgeable about basic childcare

- Knows basic first aid

“I want to get a job in a daycare center or some type of job working with kids”

- Worked with mother doing housekeeping at several different motels

- Graduated from high school in Mississippi

- Took childcare course when I was a teenager

- Has done babysitting for family members and others

Supportive Relationships- Mom (Sarah) is my biggest support (listens to me and can cheer me up) - Brother (Roy) can take me places if I need anything

- Friend (Hanna in Oklahoma) – we still talk on the phone occasionally

“I would like to have more friends here in Kansas”

“I have always been close with my mom and brother” Ex-boyfriend (Kevin) used to be good support (“He helped build my confidence in myself”) 39

For Elizabeth W. Wellness/Health

- Lamictal helps with the depression – “I don’t feel suicidal as much” “Talking to others about how I’m feeling helps with depression” “Doing something active helps me feel healthy”

“I want to continue to be healthy”

“Going out and doing things made me feel better about myself” (e.g movies, sporting events, shopping, etc.)

Leisure / Recreational - Enjoys music (Country), listing to radio, singing, and dancing (two-step, line dancing) - Talking on the phone

“I want to make more friends and spend time with them”

- used to be in girl scouts - went out for track and basketball in high school - used to go camping and canoeing

Spirituality/Culture-Spending holidays with family is important to me, especially when we visit my mom’s side of the family in Mississippi. -I have a strong faith in God, which has helped me overcome difficult times.

“I would like to find a church home where I felt accepted”

- Having the entire family together for Easter, Thanksgiving, and Christmas dinner has always been an important part of our family. -Going to Sunday church service as a family.

What are my priorities? 1. I want my own apartment 3. I would like to have more friends to do things with 2. I want a job working with children 4. Additional comments or important things to know about me: It is really important to me to have my own place. I still want my family in my life, but I want to show others I can do things on my own. Someday, I would like to have my own family. This is an accurate portrait of the strengths we have identified so far in my life. We will continue to add to these over time in order to help me achieve the goals that are most important to me in my recovery journey. __________________________________________ My Signature Date

I agree to help this person use the strengths identified to achieve goals that important and meaningful in their life. I will continue to help this person identify additional strengths as I learn more about what is important to their recovery. _________________________________________ Service Provider’s Signature Date

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Strengths Model Practice(one way of doing recovery‐oriented work)

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Continual attention to find out what is meaningful and important to people


Our intervention strategies should be relevant to the person in relation to

these goals.

“Make sure every goal on the treatment plan is clearly something the person is

passionate about and then make sure your role in that goal meets the criteria for

medical necessity”

Client‐Centered Goal Identificationand Achievement

Problems, barriers, and challenges are not ignored, but rather viewed in the context of how they

impact the achievementof meaningful and important goals.

Being able to live on her own was important to Elizabeth (even though she doubted

it was possible)

Learning how to better manage distressing thoughts and regulating mood raised in

importance for Elizabeth once initial steps were taken toward her goal of getting her

own apartment.

Looking at the five months that Elizabeth lived on her own provided learning about what worked and what did not. Elizabeth’s fears about being on her own were explored

(loneliness, distressing voices, suicidal thoughts, fear of failing, etc.)

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Continual attention to getting strengths in their most useable form in order to help a person achieve a goal. Or remove a

barrier to a specific step towards goal achievement.

at times with distressing thoughts.”Elizabeth’s love of country music and singing became

important sources of “personal medicine”

Helping people find the “perfect niche” medical necessity”

Identification and Use of a Person’s Strengths

Importance of helping people see and use their own strengths. Shifting to a recovery narrative.

Seeing power in what is seemingly ordinary.

Singing in the church choir

Elizabeth's worker helped her identify several country

songs with strong messages for women.

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Use of shared decision‐making techniques (i.e. reviewing multiple options, considering pros/cons of various

possibilities, primacy on choice and autonomy)

Goal planning is seen as an iterative process

rather than an annual or semi‐annual event.

Goal Planning

Each meeting was an opportunity to add objectives underneath the goal or even

change the focus of the goal.(Housing ‐> strategies to manage distressing thoughts ‐> create relapse plan ‐> identify

triggers related to suicidal thoughts ‐> strategies to manage anxiety in specific situations)

Mutual decisions were made before any step was written on the Personal Recovery Plan. Even if the decision was just to not decide anything that day.

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Contact with people is derived from the work that needs to be done to help a person make progress

toward a goal.

Since recovery happens in the community, a majority of contacts should be in

the community.


Contact with Individuals

Strategies related to distressing thoughts, mood dysregulation, suicidal thoughts, depression and anxiety were taught, applied, and evaluated in the contexts where those skills would be used.

Over 90% of contacts werein the community

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• Helping people achieve a life of meaning and purpose outside of the system is a key outScome of services

• Continually finding ways to help people become “anchored” within the community

Individual Movement Through the System

• Continuously being aware of and exploring what it might take for a person to graduate from any particular service

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• Elizabeth’s anchors started shifting over time• In 2010, her primary anchors were her case manager, therapist, crisis services, the hospital, her mom and the house she lived in

• In 2015, her primary anchors are her own apartment, her church, her neighbor, her friend in Oklahoma, and her case manager and therapist

• The shifting of anchors helps make movement through the system possible

Individual Movement Through the System: Elizabeth’s Story

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Questions?

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ABOUT THE WEBINAR SERIES

A Case‐Based Approach to Learning About Practices and Organizational Designs that Advance Recovery

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What to Expect from This SeriesTeams understand how to – from a provider and an organizationalview:• Use critical reflection to identify where you are in relation to

innovative recovery‐oriented services• Conceptualize where you want to be in relation to recovery• Get help with decisions on future efforts and how to begin shaping

programs toward a greater recovery orientation• Take next steps toward designing a recovery‐oriented program• Understand how recovery‐oriented services can adhere to current

documentation standards

The Series• Session I: Overview & Orientation

• Session II: Amplifying the Well‐Aspects of the Person ‐ Identifying and Mobilizing a Person’s Strengths

• Session III: Identifying Meaningful Goals and Developing a Plan to Achieve Them

• Session IV: Using Shared Decision‐Making

• Session V: Achieving Goals and Advancing Recovery

• Session VI: Supporting Individuals to Prepare to and then Exit the System

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PREPARING TO GET THE MOST OUT OF THIS SERIES

Strengths Model Practice Orientation Scale

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Where are you and your organization in relation to recovery?

• It’s a continuum of moving from being stabilization‐focused to recovery‐driven.

• This movement is achieved by linking client‐centered goals with effective provider interventions that are medically necessary and explained through documentation

VClient Goals

Medical Necessity Documentation

ProviderIntervention

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Strengths Model Practice Orientation Scale

• Developed to generate discussion related to how our practices are currently oriented

• Help to focus agency policy, system redesign and practice development

• Five Elements/Items1. Client centered goal identification and achievement 2. Identification and Use of Client Strengths3. Goal Planning4. Contacts with Individuals5. Individual Movement through the System

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Strengths Model Practice Orientation ScaleComponents Level D Level C Level B Level A

Client Centered Goal Identification and Achievement

Considering all the clients you serve:Focus of the work is on diagnosis and treatment of illness and/or problem behavior. Goals are written in clinical terms and focus on diagnosis and symptoms (medical necessity and functional impairment) rather than goals than are meaningful and important to the person.

Considering all the clients you serve:Focus of the work is on diagnosis and treatment of illness and/or problem behavior. Client centered goals are acknowledged, but subservient to deficit‐based/symptom focused goals.

Considering all the clients you serve:Focus of the work takes into account both client‐centered and deficit‐based/symptom focused goals, but it is not always clear how the two are integrated/related.

Considering all the clients you serve:Focus of the work is on client‐centered goal identification and achievement. Problems, barriers, and challenges are discussed in the context of meaningful and important goals and in relation to their relevancy to these goals.

0 1 2 3 4 5 6 7 8 9 10 11

Identification and Use of Client Strengths

Identification of client strengths occurs primarily at intake or initial assessment. Strengths are fairly vague and loosely tied to goal achievement.

Identification of client strengths occurs at least annually or during treatment plan updates. Strengths vary in specificity and are loosely tied to goal achievement.

Identification of client strengths occurs in routine practice with clients but not in any systematic way. Strengths vary in specificity and are often tied to goal achievement.

The work revolves around continuous identification, organization, and mobilization of highly specific strengths to achieve a meaningful and important goal or remove a barrier to a specific step toward goal achievement

0 1 2 3 4 5 6 7 8 9 10 11

Goal Planning

Goal planning occurs annually as a part of treatment planning. Goals and objectives rarely change until this formal process occurs.

Goal planning occurs quarterly or bi‐annually as a part of treatment planning. Goals and objectives rarely change until this formal process occurs.

Goal planning occurs monthly (in addition to formal treatment planning). Goals may or may not remain the same from one month to the next, but objectives are continuously evolving.

Goal planning occurs during every contact with a person (it is an iterative process; each week’s work determines next week’s steps toward achieving a goal)

0 1 2 3 4 5 6 7 8 9 10 11

Contacts with Individuals

Most contacts tend to be crisis/reactive driven. Little evidence of proactive, planned, purposeful contact in relation to goal achievement. Most contacts are in the office

Most contacts tend to be crisis/reactive driven. Some evidence of proactive, planned, purposeful contact in relation to goal achievement. Some interactions are out in the community.

Most contacts are proactive, planned, and purposeful in relation to goal achievement (outside of crises). Crisis/reactive interactions are no longer the main focus. At least half of interactions with clients in out in the community.

Most contacts are proactive, planned, and purposeful in relation to goal achievement (outside of crises). Crisis/reactive interactions are infrequent and associated mainly with new clients. More than 75% of contacts with client are out in the community.

0 1 2 3 4 5 6 7 8 9 10 11

Individual Movement through the System

Stabilization and maintenance is considered a positive outcome of services. Few individuals exit from services or graduate to a lower level of care.

Stabilization and maintenance is considered a positive outcome of services, with focus on individual achieving a life of meaning and purpose outside of the formal system of care considered for some with less than 1% of individuals exiting from services or graduating to a lower level of care each month.

Individual achieving a life of meaning and purpose outside of the formal system of care is considered an important outcome of services with 1‐3% of individuals exiting from services or graduating to a lower level of care each month.

Individual achieving a life of meaning and purpose outside of the formal system of care is considered a key outcome of services. High rates (more than 3%) of individuals exiting from services or graduating to a lower level of care.

0 1 2 3 4 5 6 7 8 9 10 1155

For Next Time: Use the Scale

• Have individual team members score their practice orientation for each element

• Come together as a team and agree on a team score for each element

• Be prepared to share your scores (anonymously) during future webinars

• Consider scoring yourself again after the final session

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Next WebinarSESSION DATE AND TIME

Session IOverview & Orientation

Wednesday, January 6, 201612:00 – 1:30 pm

Session IIAmplifying the Well‐Aspects of the Person ‐Identifying and Mobilizing a Person’s Strengths

Wednesday, February 3, 201612:00 – 1:30 pm

Session IIIIdentifying Meaningful Goals and Developing a Plan to Achieve Them

Wednesday, March 2, 201612:00 – 1:30 pm

Session IVUsing Shared Decision‐Making

Wednesday, April 6, 201612:00 – 1:30 pm

Session VAchieving Goals and Advancing Recovery

Wednesday, May 4, 201612:00 – 1:30 pm

Session VISupporting Individuals to Prepare to Enter and then Exit the System

Wednesday, June 201612:00 – 1:30 pm

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Webinar Recording

• This webinar has been recorded• The recording will be available within 24‐hours(CIBHS will send you a link)

• You may also review the recording on the CIBHS YouTube channel within a week

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Thank You!

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Advancing Recovery Webinar Series · Overview Strengths Model Practices ... About the Webinar...

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