Realizing the Promise of Community Support Services in the idea of (Mental Health) Recovery

1. Realizing the Promise of Community Support Services in the idea of (Mental Health) Recovery Jerry Floersch, Ph.D., LISW Jeffrey Longhofer, Ph.D., LSW Paul Kubek, M.A. Lisa Oswald, M.S.S.A. Case Western Reserve University Mandel School of Applied Social Sciences

2. Emptying Hospitals Presented Challenges • Housing • Education • Jobs • Medication • Mental Health and Social Services • In sum, basic quality of life issues

3. In the 1970s, NIMH responded with Community Support Services (CSS). Since then, • case management and CSS models have proliferated, each with specialized languages and approaches • Strengths • Assertive Community Treatment • Clubhouse Model • Family Psychoeducation • Medication Management • AND MOST RECENT, RECOVERY

4. In the last 15 years, 5 major developments have occurred in Community Support Services • Evidence-based practice--Research Point of View • Recovery--Policy or Advocate Point of View • Caregiver Experience—Caregiving Point of View • Client/Consumer Experience--Client /Consumer Point of View • Cultural competence--Multicultural Point of View

5. Evidence-Based Practice[Research point of view] • Illness Management & Recovery • Medication Management • Assertive Community Treatment • Family Psychoeducation • Supported Employment • Integrated Dual Disorders Treatment

6. Caregiver Experience [practitioner/family/friend point of view] • What do caregivers, professionals, friends, family, and peers do? • How do caregivers experience mental health caregiving?

7. Client Experience [client point of view] • How is mental health caregiving experienced? • How are caregiving relationships experienced? • What is the everyday experience of a severe mental illness?

8. Cultural Competence[multicultural point of view] • Do CSS models and practices apply across the diverse cultural groups present in our society? • How can specialized languages be cross-cultural?

9. Recovery[policy or advocate point of view] • The most recent • It is not yet a practice, but a point of view or philosophy • Yet, it is gaining in popularity • And, the word Recovery gets a lot of use in our everyday life

10. During the last month, 160 New York Times’ articles used the word Recovery to describe business, sports, and war experiences • In a Tournament of Upsets, White Misses a Recovery By ROBERT BYRNE   (NYT)   News   • The Stage May Be Set for a Tech Recovery By KENNETH N. GILPIN   (NYT)   News • Samsung Profits Fall 41%, but Investors See Recovery Ahead By DON KIRK   (NYT)   News   • Driving Along a Virtual Road to Recovery By ABBY ELLIN   (NYT)   News   • A NATION AT WAR: THE RECOVERY; Relief Agencies Are Forced to Wait as Chaos Reigns By ELIZABETH BECKER   (NYT)

11. Moreover, without an accepted criterion for deciding which of the 5 points of view should be centered in CSS practice, must we learn each specialized language in order to accrue their unique benefits?

12. Thus, with 5 credible Points of View, and often competing, must we learn all 5 specialized languages? • In other words, does the client sometimes wonder: are you (that is, practitioner, policymaker, or researcher) speaking to me from your illness management & recovery, medication management, assertive community treatment, supported employment, strengths, dual diagnosis, or recovery standpoint?

13. Researchers often claim to have an objective standpoint for selecting practices, thus they offer us • Evidence-based practices • Yet, this centers the need to generalize findings, or find some practice that works for everyone. • I don’t question the standard research methods here

14. Instead, I argue that of the 5 CSS developments, Recovery is conceptually robust to represent all points of view.

15. Clients have wanted jobs and less stigmatizing services, thus the rise of supported employment and clubhouse models.

16. Parents and siblings have asked to be heard and incorporated into treatment, thus the rise of family psychoeducation.

17. Practitioners have recognized that some clients lack awareness or motivation to engage the CSS system, thus the rise of “assertive” community outreach.

18. Researchers have desired fidelity to empirically based interventions, thus the rise of evidence-base practice.

19. Policymakers have needed accountability and information systems, thus the rise of outcomes data management.

20. Cross-cultural advocates have argued for services that respect and understand cultural difference, thus the rise of culturally competent practice.

21. Consequently, it is impossible to ignore any one of the related, but separate, CSS standpoints.

22. WHAT IS RECOVERY IN MENTAL HEALTH? • self-mastery • self-control • empowerment • hope • a non-linear and small-step approach • self-responsibility • partnership • and renewed social roles

23. Ohio Department of Mental Health • . . . recovery is an internal, ongoing process [emphasis added] requiring adaptation and coping skills, promoted by social supports, empowerment and some form of spirituality or philosophy that gives hope and meaning to life (Beale & Lambric, 1995, p. 8).

24. William AnthonyBoston Center for Psychiatric Rehabilitation • a deeply personal, unique process of changing one’s attitudes, values, feelings, goals, skills and/or roles. It is a way of living a satisfying, hopeful, and contributing life even with limitations caused by the illness. Recovery involves the development of new meaning and purpose in one’s life as one grows beyond the catastrophic effects of mental illness (Anthony, 1993, p.7).

25. National Alliance for the Mentally Ill • TRIAD or, Treatment/Recovery Information and Advocacy Database • In collaboration with other stake-holders, NAMI will collect a variety of data that characterizes the gap between the services, supports, and environment we all agree are necessary for recovery and what exists in each state.

26. The Robert Wood Johnson Foundation and Substance Abuse and Mental Health Service Administration • http://www.mentalhealthpractices.org/index.html

27. Thus, various CSS stakeholder groups— clients, policymakers, family members, researchers, and practitioners —evidenced by the examples above, use the idea of Recovery to organize community work by (inter)connecting their specific stakeholder objectives with the client Recovery goals of empowerment, self-mastery, hope, and living beyond the disability.

28. Research on the process of Recovery • Most of the early research has been qualitative • Start “near” the experience • Thus, Recovery is being built from the ground up

29. Participant-Observation Research • Colleagues and I observed caregiving relationships negotiate the acquisition of community goods, vocational services, health and mental health services. • We participated like case managers in transporting clients to appointments, helping them access resources (e.g., grocery shopping), and staying in continuous contact to experience everyday life. • We observed service providers and other caregivers as they interacted with clients.

30. Coding Observations • Borrowed from my previous findings, Strengths case managers often talked about “doing for” and “doing with” clients. • Meds, Money, and Manners (2002) Columbia University Press • Added categories by comparing mental health caregiving with the everyday caregiving among parents, and their sons and daughters.

31. Four Processes of Self-Mastery • Doing for • Doing with • Standing by to admire • Doing for oneself

32. Doing For • There is the “doing for” process, with the caregiver doing the caring for the individual who essentially enjoys being done for

33. Doing With • Next comes the “doing with” process, where caregiver and recipient, in varying proportion, share in the tasks

34. Standing by to Admire • Then comes the “standing by to admire” process, where the individual is doing some aspect of self-care without any assistance

35. Doing for Oneself • The final process is “doing for oneself,” where the individual has internalized both the caregiving of himself and the satisfaction it brings to such an extent that caregiver’s bodily presence and emotional investment are no longer required.

36. 4 Forms of Recovery Relatedness • Underscores the importance of relationships • Is a commonsense language that does powerful work • It provides a framework for understanding caregiving

37. Internal or Emotional Recovery Process (4 Forms) • Overwhelmed by disability • Struggling with disability • Living with symptoms of disability • Living beyond disability • Spaniol et al. (2002). “The process of recovery from schizophrenia.” International Review of Psychiatry (14): 327-336

38. Overwhelmed by the disability • Overwhelmed by the disability is an ongoing and recurrent debilitating anxiety, it often begins at the onset of illness, and it can last for months or years. “Daily life can be a struggle mentally and even physically. The person tries to understand and control what is happening, but often feels confused, disconnected from the self and others, out of control, and powerless to control his or her life in general” (Spaniol et al., 2002, p. 328).

39. Struggling with the disability • In struggling with the disability “the person recognizes the need to develop ways of coping … in order to have a satisfactory life” (Spaniol et al., 2002, p. 330).

40. Living with the disability • The phase of living with the disability is exemplified by a stronger sense of self and the idea that a confident “self” is recovered from the illness.

41. Living beyond the disability • Identifies the person who “feels well connected to self, to others, to various living, learning and working environments, and experiences a sense of meaning and purpose in life” (Spaniol et al., 2002, p. 331).

42. Correlate 4 forms of relatedness with client internal experience • Vygotsky theorized that mental development is: • “the distance between the actual development level, as determined by independent problem solving, and the level of potential development as determined through problem solving under adult guidance or in collaboration with more capable peers” (Wertsch, 1979, p 2)

43. Vygotsky argued that • “that higher mental functions appear first on the ‘interpsychological’ (i.e., social) plane and only later on the ‘intrapsychological’ (i.e., individual) plane” (Wertsch, 1979, p. 2). • Thus, we theorized that the 4 forms of relatedness are the means by which clients internalize new mental functions.

44. Mapping the work of Recovery Relationships

45. Zone of Recovery Relatedness • The matrix was used in field research to track caregiver’s interactions with clients. It was observed that client emotional experience fluctuated from event to event and even within particular events.

46. Zone of Recovery Relatedness • Just as internal (emotional) experiences fluctuated, so did the 4 forms of relatedness; indeed in using the ZRR to map caregiver and client interactions, the changing relationship between the client’s internal and external worlds was revealed.

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