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Transforming a System Transforming People Transforming Lives Exploring and Implementing Recovery-based Care

For FHC Health Systems of Puerto RicoFebruary 19, 2007Caguas, Puerto Rico. WHO statistics. 450 million people worldwide are affected by mental, neurological or behavioral problems at any time. About 873,000 people die by suicide every yearMental illnesses are common to all countries and caus

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Transforming a System Transforming People Transforming Lives Exploring and Implementing Recovery-based Care

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    1. Transforming a System Transforming People Transforming Lives Exploring and Implementing Recovery-based Care Cheryl A Clark, MD Diplomate, American Board of Psychiatry and Neurology Distinguished Fellow, American Psychiatric Association Medical/Clinical Director The Mental Health Center of Denver 4141 E. Dickenson Place Denver, CO 80222 www.mhcd.org The question is proposed: what is Recovery oriented care and what does this have to do with mental health and mental illness and why does anyone care. The question is proposed: what is Recovery oriented care and what does this have to do with mental health and mental illness and why does anyone care.

    2. For FHC Health Systems of Puerto Rico February 19, 2007 Caguas, Puerto Rico

    3. WHO statistics 450 million people worldwide are affected by mental, neurological or behavioral problems at any time. About 873,000 people die by suicide every year Mental illnesses are common to all countries and cause immense suffering. People with these disorders are often subjected to social isolation, poor quality of life and increased mortality. One in four patients visiting a health service has at least one mental, neurological or behavioral disorder but most of these disorders are neither diagnosed nor treated. Well, the most recent World Health Organization statistics that I could find just a few days ago reports that 450 million people (slide) These are sobering statistics, I think and even more sobering when you consider the Global Burden of Disease statistics. So how is one to think about these statistics in light of mental health care as we know it in private and community settings? 873.000 die by suicide every year including 7.2 per 100,000 here in Puerto Rico with 65% of those deaths achieved by hanging according to the Pan American Health Organization Statistics last reported in 2003 Well, the most recent World Health Organization statistics that I could find just a few days ago reports that 450 million people (slide) These are sobering statistics, I think and even more sobering when you consider the Global Burden of Disease statistics. So how is one to think about these statistics in light of mental health care as we know it in private and community settings? 873.000 die by suicide every year including 7.2 per 100,000 here in Puerto Rico with 65% of those deaths achieved by hanging according to the Pan American Health Organization Statistics last reported in 2003

    4. Global Burden of Disease Based on a mid-1990s collaboration between WHO, the World Bank and Harvard which measured Disability Adjusted Life Years. The Disability Adjusted Life Year is the only quantitative indicator of burden of disease that reflects the total amount of healthy life lost, to all causes, whether from premature mortality or from some degree of disability during a period of time. Possibly the most striking finding of the landmark Global Burden of Disease study is that the impact of mental illness on overall health and productivity in the United States and throughout the world is profoundly underrecognized. Today, in established market economies such as the United States, mental illness is the second leading cause of disability and premature mortality. Mental disorders collectively account for more than 15 percent of the overall burden of disease from all causes and slightly more than the burden associated with all forms of cancer. So worldwide mental illnesses cut Based on a mid-1990s collaboration between WHO, the World Bank and Harvard which measured Disability Adjusted Life Years. The Disability Adjusted Life Year is the only quantitative indicator of burden of disease that reflects the total amount of healthy life lost, to all causes, whether from premature mortality or from some degree of disability during a period of time. Possibly the most striking finding of the landmark Global Burden of Disease study is that the impact of mental illness on overall health and productivity in the United States and throughout the world is profoundly underrecognized. Today, in established market economies such as the United States, mental illness is the second leading cause of disability and premature mortality. Mental disorders collectively account for more than 15 percent of the overall burden of disease from all causes and slightly more than the burden associated with all forms of cancer. So worldwide mental illnesses cut

    5. Burden of Mental Illness In the United States, mental disorders collectively account for more than 15 percent of the overall burden of disease from all causes and slightly more than the burden associated with all forms of cancer (Murray & Lopez,1996). These data underscore the importance and urgency of treating and preventing mental disorders and of promoting mental health in our society.

    6. Surgeon General’s Report Fortunately we have some lampposts in the last few years that help to focus on the devastation that significant mental illness creates In 1999 the Surgeon General of the US released the first ever Report on Mental Health. Contributors to the report reviewed more than 3,000 research articles and other materials, including first-person accounts from individuals who have experienced mental disorders. The Report highlights many important issues including these 3: <slilde> We know the mind and the body are inseparable but we still use language that perpetuates a sense of separation or isolation between the body and the mind. We know that stigma continues to plague those afflicted with mental illness especially if they do not have the option to “disclose” or “not to disclose.” We also know that the difficulty in understanding precisely the causes of psychiatric disorders can lead to a sense of hopelessness that can decrease opportunities for recovery. Fortunately we have some lampposts in the last few years that help to focus on the devastation that significant mental illness creates In 1999 the Surgeon General of the US released the first ever Report on Mental Health. Contributors to the report reviewed more than 3,000 research articles and other materials, including first-person accounts from individuals who have experienced mental disorders. The Report highlights many important issues including these 3: <slilde> We know the mind and the body are inseparable but we still use language that perpetuates a sense of separation or isolation between the body and the mind. We know that stigma continues to plague those afflicted with mental illness especially if they do not have the option to “disclose” or “not to disclose.” We also know that the difficulty in understanding precisely the causes of psychiatric disorders can lead to a sense of hopelessness that can decrease opportunities for recovery.

    7. Themes of the Surgeon General’s report The Surgeon General’s report acknowledged that it is also imperative that <slide> Stigma and that a Solid…………. That mental health policy <slide> And that a public health model <slide> and that disparities in mental health funding must be eliminated in order to increase availability of and access to its services. A public health model can seek to identify risk factors; to mount preventive interventions (Voz y Corazon) and to actively promote good mental health. The Surgeon General’s report acknowledged that it is also imperative that <slide> Stigma and that a Solid…………. That mental health policy <slide> And that a public health model <slide> and that disparities in mental health funding must be eliminated in order to increase availability of and access to its services. A public health model can seek to identify risk factors; to mount preventive interventions (Voz y Corazon) and to actively promote good mental health.

    8. “. . . built into any definition of wellness . . . are overt and covert expressions of values. Because values differ across cultures as well as among subgroups (and indeed individuals) within a culture, the ideal of a uniformly acceptable definition of the construct is illusory. . .” (Cowen, 1994). The Report acknowledged the culturally bound issues that contribute to and influence the lens through which we see mental health and illness. In other words, what it means to be mentally healthy is subject to many different interpretations that are rooted in value judgments that may vary across cultures. Thus designing a system that is culturally competent and that is recovery oriented will be somewhat different in every setting. There is no “one size fits all” approach. While there are EBPs each may need adaptation for a specific population and locale. The Report acknowledged the culturally bound issues that contribute to and influence the lens through which we see mental health and illness. In other words, what it means to be mentally healthy is subject to many different interpretations that are rooted in value judgments that may vary across cultures. Thus designing a system that is culturally competent and that is recovery oriented will be somewhat different in every setting. There is no “one size fits all” approach. While there are EBPs each may need adaptation for a specific population and locale.

    9. Report of the Surgeon General, US, 1999 Mental health—the successful performance of mental function, resulting in productive activities, fulfilling relationships with other people, and the ability to adapt to change and to cope with adversity; from early childhood until late life, mental health is the springboard of thinking and communication skills, learning, emotional growth, resilience, and self-esteem. Mental illness—the term that refers collectively to all mental disorders. Mental disorders are health conditions that are characterized by alterations in thinking, mood, or behavior (or some combination thereof) associated with distress and/or impaired functioning. For our discussion today we need to define some terms The 1999 Surgeon General Report defined mental health and illness as follows: <slide> For our discussion today we need to define some terms The 1999 Surgeon General Report defined mental health and illness as follows: <slide>

    10. Evidence-based practice Is defined in several way as: "Evidence based clinical practice is an approach to decision making in which the clinician uses the best evidence available, in consultation with the patient, to decide upon the option which suits that patient best".

    11. Evidence-based practice Or as: "This description of what evidence-based medicine is helps clarify what evidence-based medicine is not. Evidence-based medicine is neither old-hat nor impossible to practice. The argument that everyone already is doing it falls before evidence of striking variations in both the integration of patient values into our clinical behaviour [7] and in the rates with which clinicians provide interventions to their patients

    12. SAMSHA Evidenced-based practices are practices that have been proven by research to be effective. They are vital to the mental health and substance abuse professions in an age of increased accountability and tightened budgets SAMSHA defines EBP more simply as <slide>SAMSHA defines EBP more simply as <slide>

    13. So What is Recovery? President’s New Freedom Commission Report defines recovery as: “The process in which people are able to live, work, learn, and participate fully in their communities. For some individuals, recovery is the ability to live a fulfilling and productive life despite disability. For others, recovery implies the reduction or complete remission of symptoms. Science has shown that having hope plays an integral role in an individual’s recovery.” Sounds suspiciously like Freud’s perspective on stable mental health: Apparently there is no evidence that he actually said this, but according to the Freud museum: Tolstoy, in a letter to Valerya Aresenyev, November 9, 1856, said, "One can live magnificently in this world if one knows how to work and how to love…" (Troyat, 1967, p. 158). Freud is purported to have said that the goal of psychotherapy is to allow the patient to love and to work (Erikson, 1963). The themes of love and work are central to some of the most influential theories of psychological well-being (e.g., Erikson, 1963; Maslow, 1954; Rogers, 1961); their importance for healthy functioning has been empirically documented (e.g., Baruch, Barnett, & Rivers, 1983; Gurin, Veroff, & Feld, 1960; Lee & Kanungo, 1984; Vaillant, 1977). Study after study has shown that satisfaction in one domain is associated with satisfaction in the other. But how are love and work related? What is the nature of the connection? Love and Work An Attachment-Theoretical Perspective Author: Hazan, Cindy; Shaver, Phillip R. Source: Journal of Personality and Social Psychology August 1990 Vol. 59, No. 2, 270-280 ISSN: 0022-3514 Number: psp592270 Copyright: For personal use only-not for distribution Sounds suspiciously like Freud’s perspective on stable mental health: Apparently there is no evidence that he actually said this, but according to the Freud museum: Tolstoy, in a letter to Valerya Aresenyev, November 9, 1856, said, "One can live magnificently in this world if one knows how to work and how to love…" (Troyat, 1967, p. 158). Freud is purported to have said that the goal of psychotherapy is to allow the patient to love and to work (Erikson, 1963). The themes of love and work are central to some of the most influential theories of psychological well-being (e.g., Erikson, 1963; Maslow, 1954; Rogers, 1961); their importance for healthy functioning has been empirically documented (e.g., Baruch, Barnett, & Rivers, 1983; Gurin, Veroff, & Feld, 1960; Lee & Kanungo, 1984; Vaillant, 1977). Study after study has shown that satisfaction in one domain is associated with satisfaction in the other. But how are love and work related? What is the nature of the connection? Love and Work An Attachment-Theoretical Perspective Author: Hazan, Cindy; Shaver, Phillip R. Source: Journal of Personality and Social Psychology August 1990 Vol. 59, No. 2, 270-280 ISSN: 0022-3514 Number: psp592270 Copyright: For personal use only-not for distribution

    14. Is Recovery Cure? Recovery does not mean cure Recovery is not about symptoms or absence of symptoms Recovery is about having as complete a life as possible, even in the face of continuing symptoms or consequences of illness Diamond RJ. Recovery from a psychiatrist’s viewpoint. New Directions in Schizophrenia. A Special Report from Postgraduate Medicine. 2006; 54-62

    15. Brief Case Presentation J. S. is a 25 year old young man with a history of schizophrenia starting at the age of 16 with his first onset of psychotic symptoms. He also abuses ETOH, MJ, is addicted to nicotine and periodically goes off his medications while on a binge with cocaine, methamphetamine, etc. What helped him to get into recovery: ACT services, integrated substance abuse focus, support from his family and an ACT team effort to get him on to clozapine.What helped him to get into recovery: ACT services, integrated substance abuse focus, support from his family and an ACT team effort to get him on to clozapine.

    16. “…Americans must understand and send this message: mental disability is not a scandal-it is an illness. And like physical illness, it is treatable, especially when the treatment comes early.” President George W. Bush So, the President gave his marching orders and established his commission to review mental health care.So, the President gave his marching orders and established his commission to review mental health care.

    17. Everyone understands that mental health is essential to overall health. Mental health care is consumer & family driven. Disparities in mental health services are eliminated. Early mental health screening, assessment, and referral to services are common practice Excellent mental health care is delivered and research is accelerated Technology is used to access mental health care and information. So what can we do as professionals in the mental health field to help to provide treatments and environments that foster recovery and resilience? The President’s Freedom Commission provides guidance in this area for what a recovery oriented mental health system should look like. The Commission held that a transformed system would provide services and supports that actively facilitate recovery and build resilience to face life’s challenges. The Commission identified 6 Core elements for focus and research:So what can we do as professionals in the mental health field to help to provide treatments and environments that foster recovery and resilience? The President’s Freedom Commission provides guidance in this area for what a recovery oriented mental health system should look like. The Commission held that a transformed system would provide services and supports that actively facilitate recovery and build resilience to face life’s challenges. The Commission identified 6 Core elements for focus and research:

    18. Freedom Commission Goal #1 Mental Health is Essential to Overall Health Increase educational efforts to reduce stigma use national and local campaigns to educate and reduce stigma in seeking care. (Real men, Real Depression). Sadly, only 1 out of 2 people with a serious form of mental illness seeks treatment for the disorder. Suicide prevention strategies: Suicide is the leading cause of death by violence worldwide, outnumbering homicide or war-related deaths. (WHO data) Suicide claims approx. 30,000 lives each year in the US. Treat mental health with the same urgency as physical health Mental disorders frequently co-exist with other medical disorders thus the importance of coordinating care with primary care providers. There must be full parity between insurance coverage for mental health care and for physical health care. Depression increases the risk of dying from heart disease by as much as three-fold. President’s New Freedom Commission Report: Achieving the Promise: Transforming Mental Health Care in America. July 22, 2003 The commission identified 6 major goals which we will review together. Increase awareness in communities via multi-faceted approaches that include public education strategies, dialog meetings, speakers bureaus, media campaigns According to PAHO: in Puerto Rico In 1999, the mortality rate due to suicide was 8 per 100,000 (14 per 100,000 males and 2 per 100,000 females). The highest suicide rates were in the 65 years and older age group (35 per 100,000), the 20-64 years age group (22 per 100,000), and the 10-19 years age group (4 per 100,000). The leading method was hanging (62%), followed by firearms (19%). The mortality rate from mental and behavioral disorders decreased from 12 per 100,000 population in 1990 to 11 per 100,000 in 1999 (18 per 100,000 males and 4 per 100,000 females). In 1999, mental and behavioral disorders due to the use of psychoactive substances accounted for 78% of the total; of these, those due to alcohol use represented 66% (13 per 100,000 males and 1 per 100,000 females). At MHCD we have Voz y Corazon Air Force Initiative to Prevent Suicide: Alarming rate of suicide from 1990-1994 1 out of 4 deaths among active duty US Air Force personnel was due to suicide. Career enhancing v. career-hindering approach to dealing with mental health issues was instituted at all levels in the chain of command. As providers we must confront our own tendency to stigmatize the people we treat.The commission identified 6 major goals which we will review together. Increase awareness in communities via multi-faceted approaches that include public education strategies, dialog meetings, speakers bureaus, media campaigns According to PAHO: in Puerto Rico In 1999, the mortality rate due to suicide was 8 per 100,000 (14 per 100,000 males and 2 per 100,000 females). The highest suicide rates were in the 65 years and older age group (35 per 100,000), the 20-64 years age group (22 per 100,000), and the 10-19 years age group (4 per 100,000). The leading method was hanging (62%), followed by firearms (19%). The mortality rate from mental and behavioral disorders decreased from 12 per 100,000 population in 1990 to 11 per 100,000 in 1999 (18 per 100,000 males and 4 per 100,000 females). In 1999, mental and behavioral disorders due to the use of psychoactive substances accounted for 78% of the total; of these, those due to alcohol use represented 66% (13 per 100,000 males and 1 per 100,000 females). At MHCD we have Voz y Corazon Air Force Initiative to Prevent Suicide: Alarming rate of suicide from 1990-1994 1 out of 4 deaths among active duty US Air Force personnel was due to suicide. Career enhancing v. career-hindering approach to dealing with mental health issues was instituted at all levels in the chain of command. As providers we must confront our own tendency to stigmatize the people we treat.

    19. Freedom Commission Goal # 2 Mental Health Care is Consumer & Family Driven Develop an individualized plan of care for every adult with a serious mental illness & child with a serious emotional disturbance. Involve consumers & families fully in orienting the mental health system toward recovery. Align relevant funding programs to improve access & accountability for mental health services. Create a comprehensive national & local mental health plan. Protect and enhance the rights of people with mental illness MHCD involves consumers directly in the development of an indivdiualized service plan MHCD actively engages consumers in consumer satisfaction surveys and evaluations of how we are doing in involving them in their individualized care plans. What does this mean to skeptics??? The Commission heard testimony from consumers who reported the importance of participating in their recovery. ( think surgery and then rehab). Active participation fostered hope for recovery. Are there EBPs Wraparound Services @ MHCD that are part of EBP? Model program at MHCD??? Voz y Corazon!!! Consumer satisfaction survey 2Succeed!!!! Regarding funding the federal government as the largest mental health aide for services since one must make the necessary range of services, available in easily accessible. Beneficiaries must be able to exercise choice, self-direction, in control over their health care services In addition Supportive Employment services should be funded and supported broadly. Supported employment programs assigned employment specialists to treatment team. That specialists helps consumers by conducting assessments and rapid job searches, and by providing ongoing, on-the-Joe Bork. Studies of supported employment showed that 60 to 80% people in serious mental illnesses obtain at least one competitive job-he or his successor. MHCD has a supporter one room. Our program is called 2Succed in Education and Employment. The program is successful in currently and he in a national research project with the Social Security Administration. MHCD through 2Succeed is one of 21 sites national participating in the Mental Health Treatment Study. (insert description and give brief summary). To me supported employment loses more widely available the Center for Medicaid and Medicare Services (CMS) should provide technical assistance to the states on how to effectively use the That he rehabilitation Services option defined as the eye of supported employment that are consistent with a Medicaid policy. In addition public and private agencies could moved into the agency demonstration projects designed to eliminate employment news in recent when things were youth and adults with mental illnesses MHCD involves consumers directly in the development of an indivdiualized service plan MHCD actively engages consumers in consumer satisfaction surveys and evaluations of how we are doing in involving them in their individualized care plans. What does this mean to skeptics??? The Commission heard testimony from consumers who reported the importance of participating in their recovery. ( think surgery and then rehab). Active participation fostered hope for recovery. Are there EBPs Wraparound Services @ MHCD that are part of EBP? Model program at MHCD??? Voz y Corazon!!! Consumer satisfaction survey 2Succeed!!!! Regarding funding the federal government as the largest mental health aide for services since one must make the necessary range of services, available in easily accessible. Beneficiaries must be able to exercise choice, self-direction, in control over their health care services In addition Supportive Employment services should be funded and supported broadly. Supported employment programs assigned employment specialists to treatment team. That specialists helps consumers by conducting assessments and rapid job searches, and by providing ongoing, on-the-Joe Bork. Studies of supported employment showed that 60 to 80% people in serious mental illnesses obtain at least one competitive job-he or his successor. MHCD has a supporter one room. Our program is called 2Succed in Education and Employment. The program is successful in currently and he in a national research project with the Social Security Administration. MHCD through 2Succeed is one of 21 sites national participating in the Mental Health Treatment Study. (insert description and give brief summary). To me supported employment loses more widely available the Center for Medicaid and Medicare Services (CMS) should provide technical assistance to the states on how to effectively use the That he rehabilitation Services option defined as the eye of supported employment that are consistent with a Medicaid policy. In addition public and private agencies could moved into the agency demonstration projects designed to eliminate employment news in recent when things were youth and adults with mental illnesses

    20. Freedom Commission Goal #3 Disparities in Mental Health Services Are Eliminated Improved access to quality care that is culturally competent Improved access to quality care in rural and geographically remote areas Minority populations are underserved in the current mental health system. This may be less of an issue in PR, however policy and practices applied United States are likely to be erroneously applied in territories such as Puerto Rico. One example at MCHD is Voz y Corazon of a model developed to address a cultural need in our community. In geographically remote areas the emergence of telehealth technologymay include access and of yourMinority populations are underserved in the current mental health system. This may be less of an issue in PR, however policy and practices applied United States are likely to be erroneously applied in territories such as Puerto Rico. One example at MCHD is Voz y Corazon of a model developed to address a cultural need in our community. In geographically remote areas the emergence of telehealth technologymay include access and of your

    21. Freedom Commission Goal #4 Early Mental Health Screening, Assessment, and Referral to Services are Common Practice Promote the mental health of young children Improve and expand school mental health programs Screen for co-occurring mental and substance use disorders and link with integrated treatment strategies Screen for mental disorders in primary health care, across the lifespan, and connect to treatment and supports Emerging research indicates that early identification and intervention can sharply improve outcomes and that longer periods of abnormal thoughts and behavior have cumulative effects and can limit capacity for recovery. Early detection, assessment, and links with treatment and supports can prevent mental health problems from worsening. As many as half of the adults who have a diagnosable mental disorder will also have a substance use disorder at some point during their lifetime. Discuss MHCD’s School-based programs here. Discuss MHCD’s emphasis on Medical Hx updates and integration of screening for metabolic syndromeEmerging research indicates that early identification and intervention can sharply improve outcomes and that longer periods of abnormal thoughts and behavior have cumulative effects and can limit capacity for recovery. Early detection, assessment, and links with treatment and supports can prevent mental health problems from worsening. As many as half of the adults who have a diagnosable mental disorder will also have a substance use disorder at some point during their lifetime. Discuss MHCD’s School-based programs here. Discuss MHCD’s emphasis on Medical Hx updates and integration of screening for metabolic syndrome

    22. Freedom Commission Goal # 5 Excellent Mental Health Care is Delivered and Research is Accelerated Accelerate research to promote recovery and resilience, and ultimately to cure and prevent mental illnesses. Advance evidence-based practices using dissemination and demonstration projects and create a public-private partnership to guide their implementation. Evidence-based practice is defined by the Institute of Medicine as-the integration of best-researched evidence and clinical expertise with patient values. Improve and expand the workforce providing evidence-based mental health services and supports. We must move what we know into what we do. We must move science to services. Develop the knowledge base in four understudied areas: mental health disparities, long-term effects of medications, trauma, and acute care. Too few benefit from available treatment. It is vital to educate, train and mobilize the work force in evidence-based practices. Organizations providing mental health services must strive to constantly provide education in evidence based practices to their staff when those practices have been disseminated. -Specific medications for specific conditions -Cognitive and interpersonal therapies for depression -Preventive interventions for children at risk for serious emotional disturbances -Treatment foster care -Multi-systemic therapy -Parent-child interaction therapy -Medication algorithms (MHTS at MHCD) -Family psycho-education -Assertive community treatment, and -Collaborative treatment in primary care Workforce development in mental healthcare needs a comprehensive strategic plan to improve workforce recruitment, retention, diversity, and skills training. Plan must address the workforce crisis within formal mental health system, the plan must into training caregivers and other systems that provide mental health services, including the primary health care system, the corrections system, and schools. Training and education should address: -evidence based approaches to practice -use teaching methods that demonstrate the effective -offer a curriculum that incorporates the competencies that are central to practice in contemporary health services -building skills and treating people with ago occurring mental and addictive disorders -educate consumers, families and providers of mental illnesses and about the concepts of recovery and resiliency -engage consumers and families as educators of other health-care providers -emphasize developing cultural confidence in practice -ensure that the diversity the community is reflected among trainees and in the training experience -prepare students and trainees to work and interdisciplinary environments. Too few benefit from available treatment. It is vital to educate, train and mobilize the work force in evidence-based practices. Organizations providing mental health services must strive to constantly provide education in evidence based practices to their staff when those practices have been disseminated. -Specific medications for specific conditions -Cognitive and interpersonal therapies for depression -Preventive interventions for children at risk for serious emotional disturbances -Treatment foster care -Multi-systemic therapy -Parent-child interaction therapy -Medication algorithms (MHTS at MHCD) -Family psycho-education -Assertive community treatment, and -Collaborative treatment in primary care Workforce development in mental healthcare needs a comprehensive strategic plan to improve workforce recruitment, retention, diversity, and skills training. Plan must address the workforce crisis within formal mental health system, the plan must into training caregivers and other systems that provide mental health services, including the primary health care system, the corrections system, and schools. Training and education should address: -evidence based approaches to practice -use teaching methods that demonstrate the effective -offer a curriculum that incorporates the competencies that are central to practice in contemporary health services -building skills and treating people with ago occurring mental and addictive disorders -educate consumers, families and providers of mental illnesses and about the concepts of recovery and resiliency -engage consumers and families as educators of other health-care providers -emphasize developing cultural confidence in practice -ensure that the diversity the community is reflected among trainees and in the training experience -prepare students and trainees to work and interdisciplinary environments.

    23. Freedom Commission Goal # 6 Technology Is Used to Access Mental Health Care and Information Use health technology and telehealth to improve access and coordination of mental health care, especially for Americans in remote areas or in underserved populations Develop and implement integrated electronic health record and personal health information systems. The Commission found that technology and communications infrastructure in public and private mental health care lags far behind other sectors and the commission recommended that: Emerging technologies provide mean to overcome geographical distances that often hinder access to care. (discuss some of the CMHC’s in Colorado use of tele-psychiatry to meet rural needs due to distance and resources) Provide access to reliable health information. Health technology can provide e-mail reminders, transmits results by telephone and assist provider follow up (how doses FHC do this?) Veterans Administration Health Information and Communication Technology System Using hospital barcodes to administer medication reduces med errors and thus improves patient safety Internet assessment services are availabe to support access to on-line assessments and use these systems to Research tools to: Evaluate the quality of care provided Particiapte in on-line support groups Evaluate best practices Learn aout the most recent reatment breakthroughs and determine how to best use resources they manage. The Network of Care for Mental Health www.networkofcare.orgThe Commission found that technology and communications infrastructure in public and private mental health care lags far behind other sectors and the commission recommended that: Emerging technologies provide mean to overcome geographical distances that often hinder access to care. (discuss some of the CMHC’s in Colorado use of tele-psychiatry to meet rural needs due to distance and resources) Provide access to reliable health information. Health technology can provide e-mail reminders, transmits results by telephone and assist provider follow up (how doses FHC do this?) Veterans Administration Health Information and Communication Technology System Using hospital barcodes to administer medication reduces med errors and thus improves patient safety Internet assessment services are availabe to support access to on-line assessments and use these systems to Research tools to: Evaluate the quality of care provided Particiapte in on-line support groups Evaluate best practices Learn aout the most recent reatment breakthroughs and determine how to best use resources they manage. The Network of Care for Mental Health www.networkofcare.org

    24. SAMSHA launched A Life in the Community for EveryoneSAMSHA launched A Life in the Community for Everyone

    26. 10 Fundamental Components of Recovery Individualized and Person-Centered Self-Direction Hope Responsibility Empowerment Respect Peer Support Strengths-Based Non-Linear Holistic To clearly define recovery, SAMHSA, within the U.S. Department of Health and Human Services, and the Interagency Committee on Disability Research in partnership with six other Federal agencies convened the National Consensus Conference on Mental Health Recovery and Mental Health Systems Transformation on December 16-17, 2004. More than 110 expert panelists participated, including mental health consumers, family members, providers, advocates, researchers, academicians, managed care representatives, accreditation organization representatives, State and local public officials, and others. A series of technical papers and reports were commissioned that examined topics such as recovery across the lifespan, definitions of recovery, recovery in cultural contexts, the intersection of mental health and addictions 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. To clearly define recovery, SAMHSA, within the U.S. Department of Health and Human Services, and the Interagency Committee on Disability Research in partnership with six other Federal agencies convened the National Consensus Conference on Mental Health Recovery and Mental Health Systems Transformation on December 16-17, 2004. More than 110 expert panelists participated, including mental health consumers, family members, providers, advocates, researchers, academicians, managed care representatives, accreditation organization representatives, State and local public officials, and others. A series of technical papers and reports were commissioned that examined topics such as recovery across the lifespan, definitions of recovery, recovery in cultural contexts, the intersection of mental health and addictions 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.

    27. Self-Direction By definition, the recovery process must be self-directed by the individual, who defines his or her own life goals and designs a unique path toward those goals. Consumers lead, control, exercise choice over, and determine their own path of recovery by optimizing autonomy, independence, and control of resources to achieve a self-determined life.Consumers lead, control, exercise choice over, and determine their own path of recovery by optimizing autonomy, independence, and control of resources to achieve a self-determined life.

    28. Individualized and Person-Centered There are multiple pathways to recovery based on an individual's unique strengths and resiliencies as well as his or her needs, preferences, experiences (including past trauma), and cultural background in all of its diverse representations. Individuals also identify recovery as being an ongoing journey and an end result as well as an overall paradigm for achieving wellness and optimal mental health. as well as his or her needs, preferences, experiences (including past trauma), and cultural background in all of its diverse representations. Individuals also identify recovery as being an ongoing journey and an end result as well as an overall paradigm for achieving wellness and optimal mental health.

    29. Empowerment Consumers have the authority to choose from a range of options and to participate in all decisions—including the allocation of resources—that will affect their lives, and are educated and supported in so doing. They have the ability to join with other consumers to collectively and effectively speak for themselves about their needs, wants, desires, and aspirations. Through empowerment, an individual gains control of his or her own destiny and influences the organizational and societal structures in his or her life. They have the ability to join with other consumers to collectively and effectively speak for themselves about their needs, wants, desires, and aspirations. Through empowerment, an individual gains control of his or her own destiny and influences the organizational and societal structures in his or her life.

    30. Holistic Recovery encompasses an individual's whole life: Mind Body Spirit Community Recovery embraces all aspects of life, including housing, employment, education, mental health and health care treatment and services, complementary and naturalistic services, addictions treatment, spirituality, creativity, social networks, community participation, and family supports as determined by the person. Families, providers, organizations, systems, communities, and society play crucial roles in creating and maintaining meaningful opportunities for consumer access to these supports. Recovery embraces all aspects of life, including housing, employment, education, mental health and health care treatment and services, complementary and naturalistic services, addictions treatment, spirituality, creativity, social networks, community participation, and family supports as determined by the person. Families, providers, organizations, systems, communities, and society play crucial roles in creating and maintaining meaningful opportunities for consumer access to these supports.

    31. Non-Linear Recovery is not a step-by-step process but one based on continual growth , occasional setbacks, and learning from experience. Recovery begins with an initial stage of awareness in which a person recognizes that positive change is possible. This awareness enables the consumer to move on to fully engage in the work of recovery. , occasional setbacks, and learning from experience. Recovery begins with an initial stage of awareness in which a person recognizes that positive change is possible. This awareness enables the consumer to move on to fully engage in the work of recovery.

    32. Strengths-Based Recovery focuses on valuing and building on the multiple capacities, resiliencies, talents, coping abilities, and inherent worth of individuals. By building on these strengths, consumers leave stymied life roles behind and engage in new life roles (e.g., partner, caregiver, friend, student, employee). The process of recovery moves forward through interaction with others in supportive, trust-based relationships. By building on these strengths, consumers leave stymied life roles behind and engage in new life roles (e.g., partner, caregiver, friend, student, employee). The process of recovery moves forward through interaction with others in supportive, trust-based relationships.

    33. Peer Support Mutual support—including the sharing of experiential knowledge and skills and social learning—plays an invaluable role in recovery. Consumers encourage and engage other consumers in recovery and provide each other with a sense of belonging, supportive relationships, valued roles, and community.Consumers encourage and engage other consumers in recovery and provide each other with a sense of belonging, supportive relationships, valued roles, and community.

    34. Respect Community, systems, and societal acceptance and appreciation of consumers—including protecting their rights and eliminating discrimination and stigma—are crucial in achieving recovery. Self-acceptance and regaining belief in one’s self are particularly vital. Respect ensures the inclusion and full participation of consumers in all aspects of their lives. Self-acceptance and regaining belief in one’s self are particularly vital. Respect ensures the inclusion and full participation of consumers in all aspects of their lives.

    35. Responsibility Consumers have a personal responsibility for their own self-care and journeys of recovery. Taking steps toward their goals may require great courage. Consumers must strive to understand and give meaning to their experiences and identify coping strategies and healing processes to promote their own wellness. How many times have you thought to yourself or out-loud: “I really wish this person would take responsibility for him/herself??? Well, according to consumer-led recovery advocates they feel the same way…..in other words that they should take responsibility for themselves.How many times have you thought to yourself or out-loud: “I really wish this person would take responsibility for him/herself??? Well, according to consumer-led recovery advocates they feel the same way…..in other words that they should take responsibility for themselves.

    36. Hope Recovery provides the essential and motivating message of a better future—that people can and do overcome the barriers and obstacles that confront them. Hope is internalized, but can be fostered by peers, families, friends, providers, and others. Hope is the catalyst of the recovery process. Mental health recovery not only benefits individuals with mental health disabilities by focusing on their abilities to live, work, learn, and fully participate in our society, but also enriches the texture of American community life. America reaps the benefits of the contributions individuals with mental disabilities can make, ultimately becoming a stronger and healthier Nation. Mental health recovery not only benefits individuals with mental health disabilities by focusing on their abilities to live, work, learn, and fully participate in our society, but also enriches the texture of American community life. America reaps the benefits of the contributions individuals with mental disabilities can make, ultimately becoming a stronger and healthier Nation.

    37. The personal and community qualities that enable us to rebound from: Adversity Trauma Tragedy Threats or other stresses in order to go on with life with a sense of mastery, competence, and hope. Achieving the Promise: Transforming Mental Health Care in America. Pub No SMA-03-3832.Rockville, Md, Department of Health and Humans Services, Presiddent’s New Freedom Commission on Mental Health, 2003. So, let’s go back to a couple of the “components” were resilience is mentioned: <strengths based and individualized/person-centered components. So what is resilience and how does it dove-tail with recovery? Resilience is defined by Achieving the Promise as <slide>So, let’s go back to a couple of the “components” were resilience is mentioned: <strengths based and individualized/person-centered components. So what is resilience and how does it dove-tail with recovery? Resilience is defined by Achieving the Promise as <slide>

    38. Resilience Science informs us that resilience is fostered by a positive childhood and includes positive individual traits, such as optimism, good problem-solving skills, and treatments. Closely-knit communities and neighborhoods are also resilient, providing supports for their members. Achieving the Promise: Transforming Mental Health Care in America. Pub No SMA-03-3832.Rockville, Md, Department of Health and Humans Services, President's New Freedom Commission on Mental Health, 2003.

    39. Resilience Ability to cope with stress which varies over time, context, age, gender and cultural origin. Connor KM and Zhang Wei. Resilience: Determinants, Measurement, and Treatment Responsiveness. CNS Spectrum 11:10 (Suppl 12); 5-12 Kathryn Connor, MD, who is an associate professor, along with Dr. Zhang who is the director of Duke University Medical Centers Anxiety & Traumatic Stress Program write eloquently in the October 2006 CNS Spectrums Supplement that the study of resilience has emerged from a change in orientation that focuses on finding treatment for illness to attempts to promote wellness. Resilience focuses on present strengths and not on weaknesses and what is absent. Past successes serve as wellsprings; stress is viewed as challenge. Tell L. P. story here: Let me tell you a story of incredible resilience and recovery from my 23 years of psychiatric practice and training. I think this person’s story epitomizes the importance of resilience, recovery and a treatment process that focused on strengths and self-determination and a cooperative treatment approach……………………… Psychiatric advanced directives………… Kathryn Connor, MD, who is an associate professor, along with Dr. Zhang who is the director of Duke University Medical Centers Anxiety & Traumatic Stress Program write eloquently in the October 2006 CNS Spectrums Supplement that the study of resilience has emerged from a change in orientation that focuses on finding treatment for illness to attempts to promote wellness. Resilience focuses on present strengths and not on weaknesses and what is absent. Past successes serve as wellsprings; stress is viewed as challenge. Tell L. P. story here: Let me tell you a story of incredible resilience and recovery from my 23 years of psychiatric practice and training. I think this person’s story epitomizes the importance of resilience, recovery and a treatment process that focused on strengths and self-determination and a cooperative treatment approach……………………… Psychiatric advanced directives…………

    40. Determinants of Resilience Connor KM and Zhang Wei. Resilience: Determinants, Measurement, and Treatment Responsiveness. CNS Spectrum 11:10 (Suppl 12); 5-12 1. Biological Stress can be characterized in several ways: duration (acute, chronic), responsiveness (adaptive, hyperadaptive, nonresponsive), and severity (mild, moderate, severe, and extreme). The effects of stress can be manifested in psychological symptoms, physiological symptoms, or both. Much of the neurobiological research in the field has focused on the consequences of severe psychological stress and stress-related psychopathology, such as posttraumatic stress disorder (PTSD) and depression in treatment-seeking populations. Little work has focused on neurobiological processes related to resilience and vulnerability to psychological stress, in general, and to specific forms of psychopathology, in particular. 1. Biological Stress can be characterized in several ways: duration (acute, chronic), responsiveness (adaptive, hyperadaptive, nonresponsive), and severity (mild, moderate, severe, and extreme). The effects of stress can be manifested in psychological symptoms, physiological symptoms, or both. Much of the neurobiological research in the field has focused on the consequences of severe psychological stress and stress-related psychopathology, such as posttraumatic stress disorder (PTSD) and depression in treatment-seeking populations. Little work has focused on neurobiological processes related to resilience and vulnerability to psychological stress, in general, and to specific forms of psychopathology, in particular.

    41. Resilience characteristics Commitment Dynamism Humor in the face of adversity Patience Optimism Faith Altruism Connor KM and Zhang Wei. Resilience: Determinants, Measurement, and Treatment Responsiveness. CNS Spectrums. The International Journal of Neuropsychiatric Medicine. CNS Spectr. 2006;11:10(Suppl 12):5-12 . We can all think of people who have these qualities and whom we would consider as resilient, but this is not just something that comes of good character, but we do know that resilient childhoods and adolescence are associated with + outcomes in adulthood. But, of course a question is how does someone become resilient??? Resilience theory holds that there is a force within every individual that drives them to seek self-realization, unselfishness, wisdom, and harmony with a spiritual wellspring of strength Dynamism-Continuous change, activity, or progress; vigor We can all think of people who have these qualities and whom we would consider as resilient, but this is not just something that comes of good character, but we do know that resilient childhoods and adolescence are associated with + outcomes in adulthood. But, of course a question is how does someone become resilient??? Resilience theory holds that there is a force within every individual that drives them to seek self-realization, unselfishness, wisdom, and harmony with a spiritual wellspring of strength Dynamism-Continuous change, activity, or progress; vigor

    42. Resilience Shifts the focus of psychological inquiry to increasing the positive rather than reducing the negative Connor KM and Zhang Wei. Resilience: Determinants, Measurement, and Treatment Responsiveness. CNS Spectrum 11:10 (Suppl 12); 5-12 In other words: people want to be great and it works better to focus on their strengths rather than their weaknesses. This is the premise of Strengths based case management and of the recovery-oriented mental health approach.In other words: people want to be great and it works better to focus on their strengths rather than their weaknesses. This is the premise of Strengths based case management and of the recovery-oriented mental health approach.

    43. Evidence-Based Practices Specific medications for specific conditions Cognitive and interpersonal therapies for depression Preventive interventions for children at risk for serious emotional disturbances Treatment foster care Multi-systemic therapy Parent-child interaction therapy Medication Algorithms Family psycho-education Assertive community treatment (ACT) Collaborative treatment in primary care MHCD is currently one of 21 research sites across the United States participating in a research study sponsored by the Social Security Administration and Dartmouth University. The research project called Mental Health Treatment Study seeks to evaluate the impact of supported employment services and managed medication monitoring for Social Security Disability recipients with the primary diagnosis of schizophrenia, bipolar disorder or major depressive disorder. The study seeks to understand and evaluate whether supported employment services and systematic medication management in this population will result in a return to employment. Both supported employment services and managed medication monitoring are recognized evidence based practices by SAMHSA. NEED MORE INFO ABOUT THESE EBPsMHCD is currently one of 21 research sites across the United States participating in a research study sponsored by the Social Security Administration and Dartmouth University. The research project called Mental Health Treatment Study seeks to evaluate the impact of supported employment services and managed medication monitoring for Social Security Disability recipients with the primary diagnosis of schizophrenia, bipolar disorder or major depressive disorder. The study seeks to understand and evaluate whether supported employment services and systematic medication management in this population will result in a return to employment. Both supported employment services and managed medication monitoring are recognized evidence based practices by SAMHSA. NEED MORE INFO ABOUT THESE EBPs

    44. Emerging Best Practices Treatments and services that are promising but less thoroughly documented than evidence-based practices: MHCD consumer operated services include Sally’s Café-a well run commercial café and catering service. Great food! MHCD consumer operated services include Sally’s Café-a well run commercial café and catering service. Great food!

    45. Overcoming Barriers to the Recovery Model LEADERSHIP LEADERSHIP LEADERSHIP LEADERSHIP LEADERSHIP Communicate the vision and leadership through stories that build on the personal recovery stories and the science! Tell inspiring stories of fighting the fight and winning on a daily, monthly or yearly basis. Tell J.S. story here including his current feelings about possibly going to jail as an opportunity to stop smoking, etcCommunicate the vision and leadership through stories that build on the personal recovery stories and the science! Tell inspiring stories of fighting the fight and winning on a daily, monthly or yearly basis. Tell J.S. story here including his current feelings about possibly going to jail as an opportunity to stop smoking, etc

    46. The Principles of Mental Health Leadership Leaders communicate a shared vision and motivate employees Leaders centralize by mission and decentralize by operations. Leaders create an organizational culture that identifies and tries to live by key values. Leaders create an organizational structure and culture that empowers their employees. Leaders use a human technology to translate vision into reality Leaders relate constructively to employees Leaders access and use information to make change a constant ingredient of their organization. Leaders build their organization around exemplary performers. Dr. Anthony is the ED of the Boston University Center for Psychiatric Rehabilitation and the PI for the Research Infrastructure Support Program. Leaders should consider how each decision is consistent with or antagonistic to recovery values and wellness. A clinical process that values self-determination cannot co-exist with a management process that values obedience and control. Dr. Anthony is the ED of the Boston University Center for Psychiatric Rehabilitation and the PI for the Research Infrastructure Support Program. Leaders should consider how each decision is consistent with or antagonistic to recovery values and wellness. A clinical process that values self-determination cannot co-exist with a management process that values obedience and control.

    47. Case presentation L.P. is now a 59 year old woman with schizoaffective disorder. She had an early onset of psychotic and affective illness in her late teens and spent the next 20-30 years of her life in and out of public and private mental health treatment. She made multiple suicide attempts many of which were near fatal. She had multiple admits to the hospital with episosdes of seculsion and restraints for dangerousness to self. She had a lot of self inflicted knife and razor-blade cuts all over her arms, legs and abdomen. What helped her recovery: Supportive friends and family Native intelligence and hope Education Right medication Psychiatric Advanced Directive letter Where is she now……somewhere that there at no snakes!What helped her recovery: Supportive friends and family Native intelligence and hope Education Right medication Psychiatric Advanced Directive letter Where is she now……somewhere that there at no snakes!

    48. Top Ten Concerns about Recovery Encountered in Mental Health System Transformation 10. Recovery is old news. “What’s all the hype? We’ve been doing recovery for decades.” Recovery pertains to the role & responsibility of the person with a serious mental illness and Recovery-oriented care pertains to the role and responsibility of mental health providers Recovery is a process which can be informed by evidence-based practices. Davidson L., O’Connell M., Tondora J. et al: The top ten concerns about recovery encountered in mental health system transformation. Psychiatric Services 57: 640-645, 2006 Correlate Recovery to the Independent Living Movement for people with mobility impairments. The ADA established that a person with paraplegia need not regain use of his or her legs and a person with a visual or auditory impairment need not regain use of his or her eyes or ears for that person to have access to save, dignified, a full life in the community. The concerns were culled from a series of presentations, dicsussions and training sessions Talk about “recovery in” serious mental illness v. “recovery from”Correlate Recovery to the Independent Living Movement for people with mobility impairments. The ADA established that a person with paraplegia need not regain use of his or her legs and a person with a visual or auditory impairment need not regain use of his or her eyes or ears for that person to have access to save, dignified, a full life in the community. The concerns were culled from a series of presentations, dicsussions and training sessions Talk about “recovery in” serious mental illness v. “recovery from”

    49. Top Ten Concerns about Recovery Encountered in Mental Health System Transformation 9. Recovery-oriented care adds to the burden of mental health professionals who are already stretched thin by demands that exceed resources. “You mean I not only have to care for and treat people, but now I have to do recovery too? Davidson L., O’Connell M., Tondora J. et al: The top ten concerns about recovery encountered in mental health system transformation. Psychiatric Services 57: 640-645, 2006 Not true, recovery requires resource allocation. What services are being provided that do not have a good evidence base and aren’t helping? Recovery is not contradictory to evidenced based practices. If there is no evidence supporting the effectiveness of a given practice in promoting an individual’s ability to manage, overcome, or live with his or her mental Thomas, then why should scarce resources be used to fund?Not true, recovery requires resource allocation. What services are being provided that do not have a good evidence base and aren’t helping? Recovery is not contradictory to evidenced based practices. If there is no evidence supporting the effectiveness of a given practice in promoting an individual’s ability to manage, overcome, or live with his or her mental Thomas, then why should scarce resources be used to fund?

    50. Top Ten Concerns about Recovery Encountered in Mental Health System Transformation Recovery means that the person is cured. “What do you mean your clients are in recovery? Don’t you see how disabled they still are? Isn’t that a contradiction? Davidson L., O’Connell M., Tondora J. et al: The top ten concerns about recovery encountered in mental health system transformation. Psychiatric Services 57: 640-645, 2006 Recovery is not cure. Recovery is not cure.

    51. Top Ten Concerns about Recovery Encountered in Mental Health System Transformation 7. Recovery happens for very few people with serious mental illness. “You’re not talking about the people I see. They’re too disabled. Recovery is not possible for them.” Davidson L., O’Connell M., Tondora J. et al: The top ten concerns about recovery encountered in mental health system transformation. Psychiatric Services 57: 640-645, 2006 Recovery story re Joe S. and clozapineRecovery story re Joe S. and clozapine

    52. Top Ten Concerns about Recovery Encountered in Mental Health System Transformation 6. Recovery in mental health is an irresponsible fad. “This is just the latest flavor of the month, and one that sets people up for failure.”

    53. Top Ten Concerns about Recovery Encountered in Mental Health System Transformation Recovery only happens after, and as a result of, active treatment and the cultivation of insights. “My patients won’t even acknowledge that they’re sick. “How can I talk to them about recovery when they have no insight about being ill?” Davidson L., O’Connell M., Tondora J. et al: The top ten concerns about recovery encountered in mental health system transformation. Psychiatric Services 57: 640-645, 2006 In other words---do you have to believe in insight or recovery for it to work???? This is like having to believe in a medication for it to work……sounds like voodoo!In other words---do you have to believe in insight or recovery for it to work???? This is like having to believe in a medication for it to work……sounds like voodoo!

    54. Top Ten Concerns about Recovery Encountered in Mental Health System Transformation 4. Recovery can be implemented only through the introduction of new services. “Sure, we’ll be happy to do recovery, just give us the money it will take to start a (new) recovery program.” Recovery is not new! Our consumers have been doing it with or without our help for a long time, but more can be done to support consumers and to provide recovery oriented services. Yes, money does need to be allocated differently for recovery, but some money can be found in looking at services that we may now provide that do not have enough evidence to continue to support treatments without evidence.Recovery is not new! Our consumers have been doing it with or without our help for a long time, but more can be done to support consumers and to provide recovery oriented services. Yes, money does need to be allocated differently for recovery, but some money can be found in looking at services that we may now provide that do not have enough evidence to continue to support treatments without evidence.

    55. Top Ten Concerns about Recovery Encountered in Mental Health System Transformation 3. Recovery-oriented services are neither reimbursable nor evidence based. “First it was managed care, then it was evidence-based practice, and now it’s recovery. But recovery is neither cost-effective nor evidence based.” Davidson L., O’Connell M., Tondora J. et al: The top ten concerns about recovery encountered in mental health system transformation. Psychiatric Services 57: 640-645, 2006 Providers who argue that they must provide treatment first and can then perhaps focus on offering rehabilitation should be asked: if what you are offering is not oriented to promoting recovery, then what is it for? And if there are ways in which what you offer could be more recovery-oriented, and thereby more effective at achieving its aims, would you not want to learn about it and try it?Providers who argue that they must provide treatment first and can then perhaps focus on offering rehabilitation should be asked: if what you are offering is not oriented to promoting recovery, then what is it for? And if there are ways in which what you offer could be more recovery-oriented, and thereby more effective at achieving its aims, would you not want to learn about it and try it?

    56. Top Ten Concerns about Recovery Encountered in Mental Health System Transformation 2. Recovery approaches devalue the role of professional intervention. “Why did I just spend ten years in training if someone else, with no training, is going to make all the decisions?” Davidson L., O’Connell M., Tondora J. et al: The top ten concerns about recovery encountered in mental health system transformation. Psychiatric Services 57: 640-645, 2006

    57. Top Ten Concerns about Recovery Encountered in Mental Health System Transformation 1. Recovery increases providers’ exposure to risk and liability. “If recovery is the person’s responsibility, then how come I get the blame when things to wrong?” Davidson L., O’Connell M., Tondora J. et al: The top ten concerns about recovery encountered in mental health system transformation. Psychiatric Services 57: 640-645, 2006 Recovery is a process in which the person engages to figure out to how to manage and live with the his/her disorder. It is not a fad, an added burden, or a new and as yet unproven practice imposed on already stretched mental health providers. As such, it is neither something providers can do to or for people with mental illness, nor is it something that can be promoted after or separate from treatment and other clinical services. Rather, the New Freedom Commission has argued for recovery to be adopted as the overarching aim of all mental health services. Recovery requires refraining the treatment enterprise from the professionals perspective to the person’s perspective. In this regard, the issue is not what role recovery plays in treatment but what role treatment plays in recovery. It is ideally left up to the person in his or her loved ones to make informed decisions about care. It is not the practitioners role to make such health care decisions for the person. This in no way devalues the expertise of the professional. To the contrary a recovery oriented approach brings psychiatry closer to other medical specialties in which it is the specialist role to assess the persons functioning, diagnose his or her condition, educate the person about the costs and benefits of the effective interventions available to treat the condition, and then, with provision of informed consent and permission to treat, competently provide the appropriate interventions. If mental illness is an illness like any other, it should be treated as such, by medical staff as well is the general public. If this basic tenet is excepted, it is difficult to understand how providers could view their roles as any less important, or as requiring any less skill, and those of other specials, such as cardiologists or oncologist. Recovery is a process in which the person engages to figure out to how to manage and live with the his/her disorder. It is not a fad, an added burden, or a new and as yet unproven practice imposed on already stretched mental health providers. As such, it is neither something providers can do to or for people with mental illness, nor is it something that can be promoted after or separate from treatment and other clinical services. Rather, the New Freedom Commission has argued for recovery to be adopted as the overarching aim of all mental health services. Recovery requires refraining the treatment enterprise from the professionals perspective to the person’s perspective. In this regard, the issue is not what role recovery plays in treatment but what role treatment plays in recovery. It is ideally left up to the person in his or her loved ones to make informed decisions about care. It is not the practitioners role to make such health care decisions for the person. This in no way devalues the expertise of the professional. To the contrary a recovery oriented approach brings psychiatry closer to other medical specialties in which it is the specialist role to assess the persons functioning, diagnose his or her condition, educate the person about the costs and benefits of the effective interventions available to treat the condition, and then, with provision of informed consent and permission to treat, competently provide the appropriate interventions. If mental illness is an illness like any other, it should be treated as such, by medical staff as well is the general public. If this basic tenet is excepted, it is difficult to understand how providers could view their roles as any less important, or as requiring any less skill, and those of other specials, such as cardiologists or oncologist.

    58. Recovery: a psychiatrist’s view & review of the literature Recovery refers both to internal conditions---the attitudes, experiences, and process of change of individuals who are recovering---and external conditions-----circumstances, events, policies and practices that may facilitate recovery. Jacobson N, Greenley D: What is recovery? A Conceptual Model and Explication. Psychiatric Services 52(4): 482-485, 2001. Jacobson and Greenley state that the HOPE that leads to recovery is at it’s most basic level, the individual’s belief that recovery is possible. HOPE: Recognizing and accepting that there is a problem Committing to change Focusing on strengths rather than on weaknesses or the possibility of failure Looking forward rather than ruminating on the past Celebrating small steps rather than expecting seismic shifts in a short time Reordering priorities Cultivating optimism Healing: Concept of recovery is better captured by the notion of healing-defining self apart from illness and control Empowerment: This emerges from inside the self, but can be facilitated by external conditions Comes from ability to act independently Courage and willingness to take risks and living with the consequences of one’s choices. Connection: Recovery is a social processJacobson and Greenley state that the HOPE that leads to recovery is at it’s most basic level, the individual’s belief that recovery is possible. HOPE: Recognizing and accepting that there is a problem Committing to change Focusing on strengths rather than on weaknesses or the possibility of failure Looking forward rather than ruminating on the past Celebrating small steps rather than expecting seismic shifts in a short time Reordering priorities Cultivating optimism Healing: Concept of recovery is better captured by the notion of healing-defining self apart from illness and control Empowerment: This emerges from inside the self, but can be facilitated by external conditions Comes from ability to act independently Courage and willingness to take risks and living with the consequences of one’s choices. Connection: Recovery is a social process

    59. internal conditions- Hope- gaining hope is transcendent Healing-better concept of recovery Empowerment-comes from inside Connection- “getting a life” HOPE: Recognizing and accepting that there is a problem Committing to change Focusing on strengths rather than on weaknesses or the possibility of failure Looking forward rather than ruminating on the past Celebrating small steps rather than expecting seismic shifts in a short time Reordering priorities Cultivating optimism Healing: Concept of recovery is better captured by the notion of healing-defining self apart from illness and control Empowerment: This emerges from inside the self, but can be facilitated by external conditions Comes from ability to act independently Courage and willingness to take risks and living with the consequences of one’s choices. Connection: Recovery is a social process with a focus on “getting a life” HOPE: Recognizing and accepting that there is a problem Committing to change Focusing on strengths rather than on weaknesses or the possibility of failure Looking forward rather than ruminating on the past Celebrating small steps rather than expecting seismic shifts in a short time Reordering priorities Cultivating optimism Healing: Concept of recovery is better captured by the notion of healing-defining self apart from illness and control Empowerment: This emerges from inside the self, but can be facilitated by external conditions Comes from ability to act independently Courage and willingness to take risks and living with the consequences of one’s choices. Connection: Recovery is a social process with a focus on “getting a life”

    60. external conditions- Human rights-fighting stigma Positive culture of healing-key component is collaborative relationships such as shared medication decision making Recovery-oriented services Education and supported employment Crisis intervention Case Management Self-helpEducation and supported employment Crisis intervention Case Management Self-help

    61. Myths about Schizophrenia Myth 1: Schizophrenia has an inherently downhill course----- Reality: The course of schizophrenia is variable along a continuum and it is difficult to predict who will go on to do well and who will not. Diamond RJ, Recovery from a psychiatrist’s viewpoint. New Directions in Schizophrenia-A postgraduate medicine special report. 2006:54-62 Tell L.P. story and someone else.Tell L.P. story and someone else.

    62. Myths about Schizophrenia Myth 2: People with Schizophrenia can only work at low-level jobs------- Reality: Boston University has assembled a database of approximately 500 people with major mental illness who are able to work in professional or supervisory jobs. Diamond RJ, Recovery from a psychiatrist’s viewpoint. New Directions in Schizophrenia-A postgraduate medicine special report. 2006:54-62 www.bu.edu/cpr/research/recent/rtc1999 Introduction It is well known that many people with psychiatric conditions make outstanding contributions to society through their lives and livelihood. Nonetheless, professionals in the mental health system, employers, and the public often cast a dispirited and pessimistic eye to those who, despite a severe mental illness, aspire to careers as professionals or managers. People with psychiatric conditions often discuss being told that they will "never work again," or that they must resign themselves to the simplest, least rewarding, and lowest paying work. Even professionals in the psychiatric rehabilitation field have developed work entry systems that peg their clients into low wage and menial work, the three f's "food, filth, and filing." These attitudes persist despite well-articulated approaches in rehabilitation that emphasize understanding the true aptitudes, talent, and aspirations of people with any disability. The Center for Psychiatric Rehabilitation at Boston University has conducted a national survey with nearly 500 individuals who have held a professional or managerial job after experiencing psychiatric problems. This study sheds light on the circumstances surrounding those who have attained managerial and professional employment while having or having had a psychiatric condition. Although the study is not based on a representative sample, the survey results help demonstrate that people with psychiatric conditions hold well paying positions with significant responsibilities. This evidence helps to break preconceptions of vocational rehabilitation that is oriented toward low wage or dead-end employment. These study results carve out new territory by presenting the achievements of people who have had serious mental illness and who have succeeded in acquiring and maintaining well paying, high level careers. This research provides a map of hope for others who are combating personal and societal barriers as well as stereotypes about the impact of mental illness on careers. The survey explores how people with psychiatric conditions obtain and retain professional or managerial levels of employment. Details of findings are presented below. Work achievements of survey participants Overall participants portray considerable success in their work status. Seventy-three percent of all participants reported full-time employment. Another 6 % of all participants have been self-employed. Sixty-two percent of all participants have held their current position for more than two years. Twenty-nine percent of all participants kept the same job for more than five years. The yearly income of most participants (79%) was above $20,000. The income of 35% of all respondents was above $40,000, and 22% made more than $50,000 per year. More than half of all participants (61%) are satisfied with their current job and are not presently considering a job change. The sample was well educated with 83% having a college degree or higher attainment. Nature of psychiatric condition This employment was attained by individuals who had and/or who continue to have significant psychiatric problems. Participants in the survey have learned how to maintain a professional or managerial career despite the challenges of a serious psychiatric condition: The psychiatric diagnosis of study participants shows no significant relationship to their professional status, educational attainment and current employment. Participants in the survey have reported various psychiatric conditions: of the 458 individuals who reported their psychiatric diagnosis, 43.5% reported bipolar illness, 29% - major depression, 11.5% - schizophrenia /schizo-affective disorder 10% - post traumatic stress disorder/dissociative identity disorder, and 6% - anxiety/other disorders. Seventy-eight percent of all participants have been hospitalized in the past for psychiatric reasons; of them 64% have been hospitalized three or more times. Twenty-five percent of the participants have been hospitalized in the past three years. Thirty-four percent of all participants received social security benefits for their disability at some time in their lives. Eighty-eight percent of all participants are currently taking psychothopic medications; of them 80% take medications continuously and 8% take them intermittently. Work supports The supports people used to maintain their employment were much like those of other managers and professionals. Reasonable accommodations were not costly and often came informally or with the nature of the job. Most individuals (62%) use the strategy of 'taking a break' as a means of coping with stress at the work place. Supports to help keep the job that were most frequently mentioned were: use of medications (49%), support of spouse/partner (34%), and support of psychiatrist/therapist (33%). Aspects of the job that most frequently contributed to job tenure were interest in and satisfaction with job duties (73%). Participants attributed their job tenure to their performance (56%), to their own drive and will power (53%), and to their ability to manage their condition (50%). Common accommodations used were flexibility to modify daily duties (49%) and flexible schedules (33%). However, in general accommodations were not formally negotiated and for many they were received irrespective of their psychiatric condition. Once the psychiatric condition was disclosed, the most frequently acquired accommodations were flexibility in which hours were worked (19%); permanent modifications to work schedule (18%); how many hours were worked (15%); and extra feedback or supervision time (15%). Work challenges Among the interpersonal experiences that challenge the ability to work was feeling like they have to fit in and act like everyone else (41%) and having to assert themselves regarding job responsibilities (39%). Most study participants (74%) also reported feeling tired on the job. A high majority (86%) of the individuals in this sample had disclosed the nature of their psychiatric condition on the job, and many had done so with few or no regrets (63%). A majority of the study participants reported receiving some benefits from disclosing such as having more understanding or support on the job (44%). However, 27% of the study participants who did disclose their condition expressed some regrets about disclosing; 15% of the study participants chose not to disclose. www.bu.edu/cpr/research/recent/rtc1999 Introduction It is well known that many people with psychiatric conditions make outstanding contributions to society through their lives and livelihood. Nonetheless, professionals in the mental health system, employers, and the public often cast a dispirited and pessimistic eye to those who, despite a severe mental illness, aspire to careers as professionals or managers. People with psychiatric conditions often discuss being told that they will "never work again," or that they must resign themselves to the simplest, least rewarding, and lowest paying work. Even professionals in the psychiatric rehabilitation field have developed work entry systems that peg their clients into low wage and menial work, the three f's "food, filth, and filing." These attitudes persist despite well-articulated approaches in rehabilitation that emphasize understanding the true aptitudes, talent, and aspirations of people with any disability. The Center for Psychiatric Rehabilitation at Boston University has conducted a national survey with nearly 500 individuals who have held a professional or managerial job after experiencing psychiatric problems. This study sheds light on the circumstances surrounding those who have attained managerial and professional employment while having or having had a psychiatric condition. Although the study is not based on a representative sample, the survey results help demonstrate that people with psychiatric conditions hold well paying positions with significant responsibilities. This evidence helps to break preconceptions of vocational rehabilitation that is oriented toward low wage or dead-end employment. These study results carve out new territory by presenting the achievements of people who have had serious mental illness and who have succeeded in acquiring and maintaining well paying, high level careers. This research provides a map of hope for others who are combating personal and societal barriers as well as stereotypes about the impact of mental illness on careers. The survey explores how people with psychiatric conditions obtain and retain professional or managerial levels of employment. Details of findings are presented below. Work achievements of survey participants Overall participants portray considerable success in their work status. Seventy-three percent of all participants reported full-time employment. Another 6 % of all participants have been self-employed. Sixty-two percent of all participants have held their current position for more than two years. Twenty-nine percent of all participants kept the same job for more than five years. The yearly income of most participants (79%) was above $20,000. The income of 35% of all respondents was above $40,000, and 22% made more than $50,000 per year. More than half of all participants (61%) are satisfied with their current job and are not presently considering a job change. The sample was well educated with 83% having a college degree or higher attainment. Nature of psychiatric condition This employment was attained by individuals who had and/or who continue to have significant psychiatric problems. Participants in the survey have learned how to maintain a professional or managerial career despite the challenges of a serious psychiatric condition: The psychiatric diagnosis of study participants shows no significant relationship to their professional status, educational attainment and current employment. Participants in the survey have reported various psychiatric conditions: of the 458 individuals who reported their psychiatric diagnosis, 43.5% reported bipolar illness, 29% - major depression, 11.5% - schizophrenia /schizo-affective disorder 10% - post traumatic stress disorder/dissociative identity disorder, and 6% - anxiety/other disorders. Seventy-eight percent of all participants have been hospitalized in the past for psychiatric reasons; of them 64% have been hospitalized three or more times. Twenty-five percent of the participants have been hospitalized in the past three years. Thirty-four percent of all participants received social security benefits for their disability at some time in their lives. Eighty-eight percent of all participants are currently taking psychothopic medications; of them 80% take medications continuously and 8% take them intermittently. Work supports The supports people used to maintain their employment were much like those of other managers and professionals. Reasonable accommodations were not costly and often came informally or with the nature of the job. Most individuals (62%) use the strategy of 'taking a break' as a means of coping with stress at the work place. Supports to help keep the job that were most frequently mentioned were: use of medications (49%), support of spouse/partner (34%), and support of psychiatrist/therapist (33%). Aspects of the job that most frequently contributed to job tenure were interest in and satisfaction with job duties (73%). Participants attributed their job tenure to their performance (56%), to their own drive and will power (53%), and to their ability to manage their condition (50%). Common accommodations used were flexibility to modify daily duties (49%) and flexible schedules (33%). However, in general accommodations were not formally negotiated and for many they were received irrespective of their psychiatric condition. Once the psychiatric condition was disclosed, the most frequently acquired accommodations were flexibility in which hours were worked (19%); permanent modifications to work schedule (18%); how many hours were worked (15%); and extra feedback or supervision time (15%). Work challenges Among the interpersonal experiences that challenge the ability to work was feeling like they have to fit in and act like everyone else (41%) and having to assert themselves regarding job responsibilities (39%). Most study participants (74%) also reported feeling tired on the job. A high majority (86%) of the individuals in this sample had disclosed the nature of their psychiatric condition on the job, and many had done so with few or no regrets (63%). A majority of the study participants reported receiving some benefits from disclosing such as having more understanding or support on the job (44%). However, 27% of the study participants who did disclose their condition expressed some regrets about disclosing; 15% of the study participants chose not to disclose.

    63. BU study Work achievements of survey participants: Overall participants portray considerable success in their work status. Seventy-three percent of all participants reported full-time employment. Another 6 % of all participants have been self-employed. Sixty-two percent of all participants have held their current position for more than two years. Twenty-nine percent of all participants kept the same job for more than five years. The yearly income of most participants (79%) was above $20,000. The income of 35% of all respondents was above $40,000, and 22% made more than $50,000 per year. More than half of all participants (61%) are satisfied with their current job and are not presently considering a job change. The sample was well educated with 83% having a college degree or higher attainment.

    64. Case presentation O.A. is a 26 year old male diagnosed at the age of 19 with bipolar disorder with psychosis following the onset of a severe depression with psychotic features. Progressed through his illness with several more episodes of psychosis and mania which ultimately resulted in him dropping out of medical school following a particularly severe episode while overseas in medical school. His parents had to retrieve him from an inpatient facility and return him to Colorado. At the time that I first saw him upon his admit to MHCD his family had exhausted all resources to provide care for him privately and could no longer afford to do so. He entered treatment on Depakote, high dose Zyprexa and trazodone for sleep. He could hardly function he was so sedated from these meds, but he’d also just come out of a month long inpatient hospitalization. Now he is in pharmacy school, doing well and stable. Tragically, his brother who would not received any treatment developed the same illness following a very successful college career in sports and shot himself a year later in the midst of a psychotic depression.Progressed through his illness with several more episodes of psychosis and mania which ultimately resulted in him dropping out of medical school following a particularly severe episode while overseas in medical school. His parents had to retrieve him from an inpatient facility and return him to Colorado. At the time that I first saw him upon his admit to MHCD his family had exhausted all resources to provide care for him privately and could no longer afford to do so. He entered treatment on Depakote, high dose Zyprexa and trazodone for sleep. He could hardly function he was so sedated from these meds, but he’d also just come out of a month long inpatient hospitalization. Now he is in pharmacy school, doing well and stable. Tragically, his brother who would not received any treatment developed the same illness following a very successful college career in sports and shot himself a year later in the midst of a psychotic depression.

    65. Myths about Schizophrenia Myth 3: Consumers need to be told to take medications for the rest of their lives. Reality: Yes, the majority of people with schizophrenia stop their medications at some point and deteriorate. Our job is to support the goals of medication usage through education, support, & understanding the reasons for discontinuation. Diamond RJ, Recovery from a psychiatrist’s viewpoint. New Directions in Schizophrenia-A postgraduate medicine special report. 2006:54-62

    66. Myths about Schizophrenia Myth 4: The only treatment that can help reduce the symptoms of schizophrenia is medication. Reality: Research supports the efficacy of many psychosocial interventions, including Skills training Psychoeducation Family interventions CBT ACT Diamond RJ, Recovery from a psychiatrist’s viewpoint. New Directions in Schizophrenia-A postgraduate medicine special report. 2006:54-62 Skills training: Psychoeducation Family interventions CBT ACTSkills training: Psychoeducation Family interventions CBT ACT

    67. Recovery Enhancing Environment Measure Designed to gather consumer’s reports on: Where they are in the process of mental health recovery What Elements of mental health practice they believe contribute to their personal mental health recovery How well their mental health agency is performing in delivering mental health recovery-enhancing services & providing a recovery-enhancing organizational climate. REE was created in 1999. The content of the measure was developed based on: 1) an examination of first person accounts of the process of mental health recovery and the services and supports people say enhance their recovery; 2) a review of emerging promising practices that promote recovery drawn from informal literature, workshop descriptions, and progressive programs; and, 3) a literature review of factors that facilitate resilience, or that help people rebound from adversity, in general. The REE measure was reviewed and pre-tested by Kansans involved in a Consumer-as-Provider training program, and later by persons served by a day treatment program. Items were revised, dropped, and added based on consumer input. The measure underwent technical edits and the format was refined based on the input of colleagues Allan Press and Patricia E. Deegan. Two formal pilot tests were conducted on the REE. In 2002, the Kansas Department of Social and Rehabilitation Services funded a mail survey of those served in the seven largest community support programs in the state. It was conducted by the Kansas University Office of Mental Health Research and Training in collaboration with participating community mental health centers (Ridgway, Press, Ratzlaff, Davidson, & Rapp, 2003). More recently, Pat Deegan & Associates trained a cadre of mental health consumers to gather REE data in face-to-face interviews with nearly half of those served by a large Massachusetts mental health agency (Ridgway, Press, Anderson, & Deegan, in preparation). More than 500 people completed the REE in the two pilots. Preliminary statistical analyses indicate that the instrument is psychometrically sound. REE was created in 1999. The content of the measure was developed based on: 1) an examination of first person accounts of the process of mental health recovery and the services and supports people say enhance their recovery; 2) a review of emerging promising practices that promote recovery drawn from informal literature, workshop descriptions, and progressive programs; and, 3) a literature review of factors that facilitate resilience, or that help people rebound from adversity, in general. The REE measure was reviewed and pre-tested by Kansans involved in a Consumer-as-Provider training program, and later by persons served by a day treatment program. Items were revised, dropped, and added based on consumer input. The measure underwent technical edits and the format was refined based on the input of colleagues Allan Press and Patricia E. Deegan. Two formal pilot tests were conducted on the REE. In 2002, the Kansas Department of Social and Rehabilitation Services funded a mail survey of those served in the seven largest community support programs in the state. It was conducted by the Kansas University Office of Mental Health Research and Training in collaboration with participating community mental health centers (Ridgway, Press, Ratzlaff, Davidson, & Rapp, 2003). More recently, Pat Deegan & Associates trained a cadre of mental health consumers to gather REE data in face-to-face interviews with nearly half of those served by a large Massachusetts mental health agency (Ridgway, Press, Anderson, & Deegan, in preparation). More than 500 people completed the REE in the two pilots. Preliminary statistical analyses indicate that the instrument is psychometrically sound.

    68. Recovery Enhancing Environment Measure Gather empirical data on the most important services and supports that serve to support personal recovery Educate consumers & agency staff about emerging recovery practice. Asess whether resilience-enhancing enivronmental factors found through another thread of research were important to person in mental health recovery. Begin to shape recovery-oriented practice under the principle “what gets measured gets done.” Ridgway designed the instrument based on consumer’s lived experience using personal narratives of recovery, consumers forums along with contemporary “emerging best practice” understanding.Ridgway designed the instrument based on consumer’s lived experience using personal narratives of recovery, consumers forums along with contemporary “emerging best practice” understanding.

    69. Recovery Enhancing Environment Measure Ridgway’s Domains of REE Stages of Recovery based on Prochaska’s stages of change (Pre-contemplation, contemplation, preparation, action, maintenance & sometimes, setback. 24 Elements of Recovery with subscales ratings of 3 indicator of staff performance Special Needs Areas (minority status, sexual preference, trauma history, parent status, dual diagnosis, & rating of staff performance addressing each issue. Organizational Climate: elements drawn from literature on resilience. Stage 1: Precontemplation Precontemplators haven't yet decided to make a change. You know exercise is healthy, but you aren't quite convinced the benefits outweigh the trouble of getting started. Strategy: Put On Your Thinking Cap This isn't the time to "just do it." Instead, start educating yourself about how exercise will benefit you. Start with a tip from Prochaska: "Your couch can kill you." List your reasons for wanting to exercise and weigh these benefits against the consequences of staying sedentary. Once your pluses outnumber the minuses, you'll be ready to move forward. Stage 2: Contemplation Now you're seriously considering change, but you're not ready to start yet. This is a stage of inertia; some people spend years stuck here. Relax. Your next step is planning. If you keep sliding back to the contemplation stage, it's probably because you flung yourself straight into action too soon -- don't. Strategy: Figure Out What's Blocking You Take an honest look: what's really preventing you from getting started? Get committed. Promise yourself you'll overcome those obstacles. Stage 3: Preparation You've made a commitment and you're planning to take action soon, probably within the next month. Strategy: Make Yourself a Plan Think through all the details: Will you walk or swim? Where and when will you exercise? What kind of clothing or equipment do you need? Draw up a contract with yourself. Set three goals: one for the next month, one for six months, and one for a year. Reward yourself for each goal accomplished. Set an initial goal you're sure to attain; early success will propel you onward. Develop a detailed contingency plan. Where will you walk if it rains? How will you exercise when you visit your in-laws? What will you do on days you're tired? Make a public commitment. Ask for support from your friends and have them follow up on your progress. Stage 4: Action Now it's time to "just do it." Strategy: Put Your Plan in Motion Make your environment conducive to exercise. Leave notes reminding yourself to work out, for instance, and have your clothes ready ahead of time. Reward yourself for sticking to your plan. Think long-term. You're forming a lifelong habit here. No need to fret about a missed day; you have the next 50 years to make it up. Stage 5: Maintenance You've been exercising regularly for six months, and you've realized you can do it. Strategy: Work Out the Kinks Create a mental image of yourself exercising and think of it often. This "exercise identity" will help the habit stick. Learn from your mistakes, and figure out how to avoid them next time. Watch for the benefits to happen -- less huffing and puffing, more energy -- and relish them. Stage 6: Termination You've done it! You've terminated your sedentary habits and replaced them with healthy ones. It's the end of the inactive you. Strategy: Pat yourself on the back! Stage 1: Precontemplation Precontemplators haven't yet decided to make a change. You know exercise is healthy, but you aren't quite convinced the benefits outweigh the trouble of getting started. Strategy: Put On Your Thinking Cap This isn't the time to "just do it." Instead, start educating yourself about how exercise will benefit you. Start with a tip from Prochaska: "Your couch can kill you." List your reasons for wanting to exercise and weigh these benefits against the consequences of staying sedentary. Once your pluses outnumber the minuses, you'll be ready to move forward. Stage 2: Contemplation Now you're seriously considering change, but you're not ready to start yet. This is a stage of inertia; some people spend years stuck here. Relax. Your next step is planning. If you keep sliding back to the contemplation stage, it's probably because you flung yourself straight into action too soon -- don't. Strategy: Figure Out What's Blocking You Take an honest look: what's really preventing you from getting started? Get committed. Promise yourself you'll overcome those obstacles. Stage 3: Preparation You've made a commitment and you're planning to take action soon, probably within the next month. Strategy: Make Yourself a Plan Think through all the details: Will you walk or swim? Where and when will you exercise? What kind of clothing or equipment do you need? Draw up a contract with yourself. Set three goals: one for the next month, one for six months, and one for a year. Reward yourself for each goal accomplished. Set an initial goal you're sure to attain; early success will propel you onward. Develop a detailed contingency plan. Where will you walk if it rains? How will you exercise when you visit your in-laws? What will you do on days you're tired? Make a public commitment. Ask for support from your friends and have them follow up on your progress. Stage 4: Action Now it's time to "just do it." Strategy: Put Your Plan in Motion Make your environment conducive to exercise. Leave notes reminding yourself to work out, for instance, and have your clothes ready ahead of time. Reward yourself for sticking to your plan. Think long-term. You're forming a lifelong habit here. No need to fret about a missed day; you have the next 50 years to make it up. Stage 5: Maintenance You've been exercising regularly for six months, and you've realized you can do it. Strategy: Work Out the Kinks Create a mental image of yourself exercising and think of it often. This "exercise identity" will help the habit stick. Learn from your mistakes, and figure out how to avoid them next time. Watch for the benefits to happen -- less huffing and puffing, more energy -- and relish them. Stage 6: Termination You've done it! You've terminated your sedentary habits and replaced them with healthy ones. It's the end of the inactive you. Strategy: Pat yourself on the back!

    70. Prochaska’s stages of change Precontemplators haven't yet decided to make a change. You know exercise is healthy, but you aren't quite convinced the benefits outweigh the trouble of getting started. Strategy: Put On Your Thinking Cap This isn't the time to "just do it." Instead, start educating yourself about how exercise will benefit you. Start with a tip from Prochaska: "Your couch can kill you." List your reasons for wanting to exercise and weigh these benefits against the consequences of staying sedentary. Once your pluses outnumber the minuses, you'll be ready to move forward. Stage 2: Strategy: Figure Out What's Blocking You Take an honest look: what's really preventing you from getting started? Get committed. Promise yourself you'll overcome those obstacles. Precontemplators haven't yet decided to make a change. You know exercise is healthy, but you aren't quite convinced the benefits outweigh the trouble of getting started. Strategy: Put On Your Thinking Cap This isn't the time to "just do it." Instead, start educating yourself about how exercise will benefit you. Start with a tip from Prochaska: "Your couch can kill you." List your reasons for wanting to exercise and weigh these benefits against the consequences of staying sedentary. Once your pluses outnumber the minuses, you'll be ready to move forward. Stage 2: Strategy: Figure Out What's Blocking You Take an honest look: what's really preventing you from getting started? Get committed. Promise yourself you'll overcome those obstacles.

    71. Prochaska’s stages of change Stage 3: Preparation You've made a commitment and you're planning to take action soon, probably within the next month. Stage 4: Action Now it's time to "just do it Stage 3: Preparation Strategy: Make Yourself a Plan Think through all the details: Will you walk or swim? Where and when will you exercise? What kind of clothing or equipment do you need? Draw up a contract with yourself. Set three goals: one for the next month, one for six months, and one for a year. Reward yourself for each goal accomplished. Set an initial goal you're sure to attain; early success will propel you onward. Develop a detailed contingency plan. Where will you walk if it rains? How will you exercise when you visit your in-laws? What will you do on days you're tired? Make a public commitment. Ask for support from your friends and have them follow up on your progress. Stage 4: Action Strategy: Put Your Plan in Motion Make your environment conducive to exercise. Leave notes reminding yourself to work out, for instance, and have your clothes ready ahead of time. Reward yourself for sticking to your plan. Think long-term. You're forming a lifelong habit here. No need to fret about a missed day; you have the next 50 years to make it up. Stage 3: Preparation Strategy: Make Yourself a Plan Think through all the details: Will you walk or swim? Where and when will you exercise? What kind of clothing or equipment do you need? Draw up a contract with yourself. Set three goals: one for the next month, one for six months, and one for a year. Reward yourself for each goal accomplished. Set an initial goal you're sure to attain; early success will propel you onward. Develop a detailed contingency plan. Where will you walk if it rains? How will you exercise when you visit your in-laws? What will you do on days you're tired? Make a public commitment. Ask for support from your friends and have them follow up on your progress. Stage 4: Action Strategy: Put Your Plan in Motion Make your environment conducive to exercise. Leave notes reminding yourself to work out, for instance, and have your clothes ready ahead of time. Reward yourself for sticking to your plan. Think long-term. You're forming a lifelong habit here. No need to fret about a missed day; you have the next 50 years to make it up.

    72. Prochaska’s stages of change Stage 5: Maintenance You've been exercising regularly for six months, and you've realized you can do it. Stage 6: Termination You've done it! You've terminated your sedentary habits and replaced them with healthy ones. It's the end of the inactive you. Stage 5: Strategy: Work Out the Kinks Create a mental image of yourself exercising and think of it often. This "exercise identity" will help the habit stick. Learn from your mistakes, and figure out how to avoid them next time. Watch for the benefits to happen -- less huffing and puffing, more energy -- and relish them Strategy: Pat yourself on the back! Stage 5: Strategy: Work Out the Kinks Create a mental image of yourself exercising and think of it often. This "exercise identity" will help the habit stick. Learn from your mistakes, and figure out how to avoid them next time. Watch for the benefits to happen -- less huffing and puffing, more energy -- and relish them Strategy: Pat yourself on the back!

    73. 24 Elements of Recovery Positive sense of personal identity beyond disorder Up-to-date knowledge of disorder/effective treatment Health & Wellness Active consumerims/directing my own services Meaningful activities Positive relationships Developing new skills 8. Sense of control/empowerment She used 2 initial group pilots: there were 2 groups of 45 consumer “experts” and on group of 21 more typcial Community Support Program Clients.She used 2 initial group pilots: there were 2 groups of 45 consumer “experts” and on group of 21 more typcial Community Support Program Clients.

    74. 24 Elements of Recovery 9. Normal social roles 10. Challengiing stigma/discrimination 11. Crisis assistance 12. Sufficient care/helping relationship 13. Sense of meaning in life Symptom self-management 15. Rights respected & upheld 16. Self-help/peer support 17. Community involvement

    75. 24 Elements of Recovery 18. Personal strengths 19. Basic needs mets 20. Spirituality 21. New Challenges 22. Recovery role models 23. Intimacy/Sexuality 24. Hope

    76. Ridgway’s REE Organizational Climate Promotion of learning, striving, growth Hopeful/promotes positive expectations Enough resources to meet needs Opportunities for meaningful contribution Connections among people Staff are welcoming Inspiring and encouraging

    77. Ridgway’s REE Safe/attractive Compassionate staff Feel valued/respected Consumer feedback Creative/interesting activities

    78. The Mental Health Center of Denver’s Model of Care to Support Recovery of Adults with Serious Mental Illness Focus on consumer recovery Consumer strengths Consumer choices The hallmark of MHCD’s system of care is its emphasis on consumer recovery, strengths and choice. Our outreach and engagement strategies focus on linking people to services that interest them. Consumers choose treatment goals they believe will promote their recovery. Our use of evidence-based interventions is designed to build on consumer strengths and help them develop skills that will allow them to reduce dependence on the service system. And, the basic assumption underlying our utilization management system is that consumers recover and their needs change over time. The following sections offer details about these and other essential components of our system of care. Outreach for a Vulnerable Population Persons with serious mental illness often find it difficult to seek appropriate treatment and support. Many are used to being turned away from traditional services, and some are suspicious of anything that appears to be organized. This is particularly true for individuals who are homeless, and/or who have co-occurring substance use disorders. MHCD combines traditional outreach practices with non-traditional strategies in order to increase the number of individuals who engage effectively with our system of care. The hallmark of MHCD’s system of care is its emphasis on consumer recovery, strengths and choice. Our outreach and engagement strategies focus on linking people to services that interest them. Consumers choose treatment goals they believe will promote their recovery. Our use of evidence-based interventions is designed to build on consumer strengths and help them develop skills that will allow them to reduce dependence on the service system. And, the basic assumption underlying our utilization management system is that consumers recover and their needs change over time. The following sections offer details about these and other essential components of our system of care. Outreach for a Vulnerable Population Persons with serious mental illness often find it difficult to seek appropriate treatment and support. Many are used to being turned away from traditional services, and some are suspicious of anything that appears to be organized. This is particularly true for individuals who are homeless, and/or who have co-occurring substance use disorders. MHCD combines traditional outreach practices with non-traditional strategies in order to increase the number of individuals who engage effectively with our system of care.

    79. Innovative Engagement Programs Outreach in homeless shelters Recovery Connection Housing First Denver Court to Community Treatment The Mental Health Center of Denver’s Model of Care to Support Recovery of Adults with Serious Mental Illness MHCD collaborates with local shelters and the Colorado Coalition for the Homeless (CCH) on three innovative programs that seek to engage homeless persons with serious mental illness who might not otherwise accept treatment. They are: Outreach in Homeless Shelters – involves co-locating MHCD case managers at three Denver homeless shelters — a women's day shelter, a co-ed shelter which has evening and overnight hours but no sleeping accommodations, and an overnight shelter. Our co-located staff members provide case management services while building relationships that allow them to eventually move consumers into traditional services. For example, in 2003 and 2004, one shelter worker identified 63 people who were subsequently admitted to the Assertive Community Treatment programs. Recovery Connection – uses access to vocational services as the entry point into mental health treatment. Its mission is to promote recovery of chronically homeless persons with severe mental illness by providing psychosocial rehabilitation services as an incentive to participate in integrated service planning including: housing services and physical, mental health, and substance abuse treatment services. An overarching goal is to encourage consumers to transition to more traditional, long term mental health and health care services. Housing First – MHCD collaborates with the Colorado Coalition for the Homeless to implement this program which focuses on housing individuals whether or not they participate in treatment. The hope is to eventually engage them in needed care by first securing housing and developing relationships with the Housing First case managers. Since housing is a major interest of many consumers, MHCD offers another engagement incentive by prioritizing MHCD housing resources for homeless consumers who meet Goebel need requirements. Denver Court to Community Treatment – MHCD is working closely with the Denver County Special Service Court, the Denver Crime Prevention and Control Commission (CPCC), the Denver Sherriff, and the Colorado Coalition for the Homeless to enhance access to intensive outreach and mental health treatment services for individuals who frequently commit minor offenses due to their co-occurring mental illness and substance abuse problems. This innovative project is partially funded by the Colorado Health Foundation and the DCPCC. MHCD collaborates with local shelters and the Colorado Coalition for the Homeless (CCH) on three innovative programs that seek to engage homeless persons with serious mental illness who might not otherwise accept treatment. They are: Outreach in Homeless Shelters – involves co-locating MHCD case managers at three Denver homeless shelters — a women's day shelter, a co-ed shelter which has evening and overnight hours but no sleeping accommodations, and an overnight shelter. Our co-located staff members provide case management services while building relationships that allow them to eventually move consumers into traditional services. For example, in 2003 and 2004, one shelter worker identified 63 people who were subsequently admitted to the Assertive Community Treatment programs. Recovery Connection – uses access to vocational services as the entry point into mental health treatment. Its mission is to promote recovery of chronically homeless persons with severe mental illness by providing psychosocial rehabilitation services as an incentive to participate in integrated service planning including: housing services and physical, mental health, and substance abuse treatment services. An overarching goal is to encourage consumers to transition to more traditional, long term mental health and health care services. Housing First – MHCD collaborates with the Colorado Coalition for the Homeless to implement this program which focuses on housing individuals whether or not they participate in treatment. The hope is to eventually engage them in needed care by first securing housing and developing relationships with the Housing First case managers. Since housing is a major interest of many consumers, MHCD offers another engagement incentive by prioritizing MHCD housing resources for homeless consumers who meet Goebel need requirements. Denver Court to Community Treatment – MHCD is working closely with the Denver County Special Service Court, the Denver Crime Prevention and Control Commission (CPCC), the Denver Sherriff, and the Colorado Coalition for the Homeless to enhance access to intensive outreach and mental health treatment services for individuals who frequently commit minor offenses due to their co-occurring mental illness and substance abuse problems. This innovative project is partially funded by the Colorado Health Foundation and the DCPCC.

    80. The Mental Health Center of Denver’s Model of Care to Support Recovery of Adults with Serious Mental Illness Adopting Evidence-based practices Assertive Community Treatment (ACT) Integrated Dual Disorders Treatment (IDDT) Dialectical Behavior Therapy (DBT) Assertive Community Treatment (ACT) – Mental health policy experts call ACT the most well-defined, evaluated and influential treatment in the field of community mental health care[1]. The model delivers intensive, multi-disciplinary services in community-based settings to high-need consumers with serious mental illness. It is characterized by small caseloads served by a team of case managers, therapists, nurses, a psychiatrist and a clinical supervisor. Our system of care includes four High Intensity Treatment teams that follow the original ACT protocol fairly precisely with client to clinical staff ratios 12:1. One additional Independent Living Team, and a Supported Living Team provide Intensive Case Management (ICM) services based on the ACT model but at a lower level of intensity of 15:1. Three additional Community Treatment Teams provide case management services at a moderate level of intensity with ratios of 22:1. Lastly, the lowest intensity of case management services is provided with a 40:1 client to staff ratio. This graduated system of case management services was designed to support a recovery oriented approach where people with serious mental illness who receive the right level of services are expected to and do get better. [1] Drake, R. E., & Burns, B. J. (1995). Special section on assertive community treatment. An introduction. Psychiatric Services, 46(7), 667-668. Integrated Dual Disorders Treatment (IDDT)[1] Research shows that without treatment, people with serious mental illness and co-occurring substance abuse frequently require high-cost services such as emergency room and psychiatric inpatient treatment.[2] Integrated treatment of the mental illness and the substance use disorder by the same clinician or treatment team has been shown to be superior to other approaches.[3] MHCD’s Substance Use Recovery Gaining Empowerment (SURGE) program is based on the evidence-based Integrated Dual Disorders Treatment (IDDT) model developed by Minkoff.[4] Because of its initial success, MHCD recently expanded this program, which now has the capacity to serve about 370 in outpatient services. In addition, MHCD can serve 23 consumers who require residential treatment services which promote recovery from co-occurring substance use and mental illness. Dr. Minkoff recently visited the SURGE program to provide technical assistance. Following his visit, he commented, “the SURGE program compares favorably with the best IDDT programs in the country.” [1] Minkoff, K. (1989). An integrated treatment model for dual diagnosis of psychosis and addiction. Hospital and Community Psychiatry, 40, 1031-1036. [2] NASMHPD/NASADAD. (1999). The new conceptual framework for co-occurring mental health and substance use disorders.Washington, D.C.: National Association of State Mental Health Program Directors & National Association of State Alcohol and Drug Abuse Directors. [3] Drake, R. E., McHugo, G. J., & Clark, R. E. (1998). Assertive community treatment for patients with co-occurring severe mental illness. Psychiatric Services, 52(4), 496-476. [4] Minkoff, K. (1991). Program components of a comprehensive integrated care system for serious mentally ill patients with substance disorders. New Directions for Mental Health Services., 50, 13-27. Dialectical Behavioral Therapy (DBT)[1] – MHCD offers three weekly DBT groups for persons with borderline personality disorders with serious mental illness. DBT has been shown to be particularly cost-effective for persons who have difficulty with emotional regulation that causes them to be high utilizers of crisis/emergency and law enforcement resources. [1] Linehan, M., Cochran, B. N., & Kehrer, C. A. (2001). Dialectic Behavioral Therapy for Borderline Personality Disorder. In D. H. Barlow (Ed.), Clinical handbook of psychological disorders: A step-by-step treatment manual (3rd ed.) (3rd ed., pp. 470-522). New York, NY: Guildford Press.Assertive Community Treatment (ACT) – Mental health policy experts call ACT the most well-defined, evaluated and influential treatment in the field of community mental health care[1]. The model delivers intensive, multi-disciplinary services in community-based settings to high-need consumers with serious mental illness. It is characterized by small caseloads served by a team of case managers, therapists, nurses, a psychiatrist and a clinical supervisor. Our system of care includes four High Intensity Treatment teams that follow the original ACT protocol fairly precisely with client to clinical staff ratios 12:1. One additional Independent Living Team, and a Supported Living Team provide Intensive Case Management (ICM) services based on the ACT model but at a lower level of intensity of 15:1. Three additional Community Treatment Teams provide case management services at a moderate level of intensity with ratios of 22:1. Lastly, the lowest intensity of case management services is provided with a 40:1 client to staff ratio. This graduated system of case management services was designed to support a recovery oriented approach where people with serious mental illness who receive the right level of services are expected to and do get better.

    81. The Mental Health Center of Denver’s Model of Care to Support Recovery of Adults with Serious Mental Illness A comprehensive array of treatment and supports: Strengths-Based Case Management Options The “Denver Approach” to Psychosocial Rehabilitation 2Succeed in Education 2Succeed in Employment Strengths-Based Case Management Options. To enhance our case management outcomes, MHCD has recently begun to use the Strengths Model of Case Management [1], an evidence-based practice that provides specific tools (i.e., strengths assessment, personal planning, and group supervision) designed to enhance the recovery outcomes of consumers. An important principle of this approach is that the clinician helps the consumer identify natural community supports (e.g., friends at church, friendly co-workers, or supportive family members) and attempts to mobilize these natural supports to help the consumer reach his or her recovery goals. With the Strengths Model, a key outcome is that consumers learn strategies for reducing their dependence on “professional” mental health providers. Case management services are offered in a wide range of intensities. For the most part, these services are delivered based on the ACT model described in the previous section. The level of intensity is determined through a utilization management process which is described later in this document. This process assures that each consumer receives the right level of care to meet his/her needs. [1] Rapp, C. A. (1998). The Strengths Model of Case Management.New York: Oxford University Press. 2 Succeed in Education – offers classes in academics such as GED preparation, basic literacy, the performing arts, computers, customer service, culinary arts, hospitality, transportation, and wellness. There are also social programs during the evenings and on weekends. The program focuses on the individual’s strengths rather than their illness and represents a move away from the traditional, sheltered clubhouse model to full community integration. Participants who enroll in specialty education programs such as computer skills have an 80% graduation rate. If they don’t graduate, they can take the class again. 2Succeed in Education serves over 1000 consumers annually with 500-600 people actively involved at any given time. 2 Succeed in Employment – is a partnership with local businesses focused on obtaining and maintaining competitive employment for consumers. This program recognizes that people with serious mental illness want and need to work. 2Succeed provides vocational assessment and counseling, transitional employment experiences, job seeking skills development, job placement services, and ongoing support to assist in keeping a job. Rather than sheltered employment at an MHCD-managed enterprise, our supported employment is actually a competitive job with ongoing programmatic support. The 2Succeed database has over 1000 employers, and employment choice is entirely consumer-driven. The program serves about 550 people annually, and, in 2005, about 375 people were successfully placed in jobs. Further, in a comparison of 2Succeed’s outcomes in supported employment with national “best-practice” benchmarks commonly cited in the supported employment literature, it was found that 2Succeed outperformed the national benchmarks in five of the seven indicators.[1] [1] Starks, R. D., Zahniser, J. H., Maas, D., & McGuirk, F. (2000). The Denver approach to rehabilitation services. Psychiatric Rehabilitation Journal, 24(1), 59-64.Strengths-Based Case Management Options. To enhance our case management outcomes, MHCD has recently begun to use the Strengths Model of Case Management [1], an evidence-based practice that provides specific tools (i.e., strengths assessment, personal planning, and group supervision) designed to enhance the recovery outcomes of consumers. An important principle of this approach is that the clinician helps the consumer identify natural community supports (e.g., friends at church, friendly co-workers, or supportive family members) and attempts to mobilize these natural supports to help the consumer reach his or her recovery goals. With the Strengths Model, a key outcome is that consumers learn strategies for reducing their dependence on “professional” mental health providers. Case management services are offered in a wide range of intensities. For the most part, these services are delivered based on the ACT model described in the previous section. The level of intensity is determined through a utilization management process which is described later in this document. This process assures that each consumer receives the right level of care to meet his/her needs. [1] Rapp, C. A. (1998). The Strengths Model of Case Management.New York: Oxford University Press. 2 Succeed in Education – offers classes in academics such as GED preparation, basic literacy, the performing arts, computers, customer service, culinary arts, hospitality, transportation, and wellness. There are also social programs during the evenings and on weekends. The program focuses on the individual’s strengths rather than their illness and represents a move away from the traditional, sheltered clubhouse model to full community integration. Participants who enroll in specialty education programs such as computer skills have an 80% graduation rate. If they don’t graduate, they can take the class again. 2Succeed in Education serves over 1000 consumers annually with 500-600 people actively involved at any given time. 2 Succeed in Employment – is a partnership with local businesses focused on obtaining and maintaining competitive employment for consumers. This program recognizes that people with serious mental illness want and need to work. 2Succeed provides vocational assessment and counseling, transitional employment experiences, job seeking skills development, job placement services, and ongoing support to assist in keeping a job. Rather than sheltered employment at an MHCD-managed enterprise, our supported employment is actually a competitive job with ongoing programmatic support. The 2Succeed database has over 1000 employers, and employment choice is entirely consumer-driven. The program serves about 550 people annually, and, in 2005, about 375 people were successfully placed in jobs. Further, in a comparison of 2Succeed’s outcomes in supported employment with national “best-practice” benchmarks commonly cited in the supported employment literature, it was found that 2Succeed outperformed the national benchmarks in five of the seven indicators.[1] [1] Starks, R. D., Zahniser, J. H., Maas, D., & McGuirk, F. (2000). The Denver approach to rehabilitation services. Psychiatric Rehabilitation Journal, 24(1), 59-64.

    82. The Mental Health Center of Denver’s Model of Care to Support Recovery of Adults with Serious Mental Illness Wishing Well Enterprises Resource Center The Drop-in Center The Resource Shoppe & Donations Center Employment Program Client Trust Fund Benefits Acquisition Management 2Succeed Website???? Wishing Well Enterprises Resource Center – offers diverse programs for individuals with serious mental illness. Each participant is encouraged and empowered to participate in social and vocational programs of their choice designed to increase their readiness for full participation in the larger community. Programs include: - The Drop-In Center where participants encounter a safe and welcoming environment for socializing and recreational activities in a comfortable non-structured environment - The Resource Shoppe and Donations Center where MHCD consumers can shop free-of-charge for furniture, clothing, household items, electronics, etc solicited from a wide variety of community sources. The availability of these resources is essential in supporting reintegration into community living for persons recovering with mental illness - Employment Program where a range of employment opportunities are available to individuals to promote progression in their recovery. Paid full and part-time opportunities include: janitorial, landscaping, transportation and moving services Client Trust Fund where MHCD consumers who receive disability benefits or other public assistance income receive assistance in: developing a personal budget, paying their monthly bills, and managing their discretionary funds Benefits Acquisition Management – MHCD provides consumers extensive counseling and assistance in obtaining and managing the benefits for which they are eligible. This recovery-oriented, program helps expedite benefits applications and determinations while supporting consumers in making informed choices about returning to work. 2Succeed Website???? Wishing Well Enterprises Resource Center – offers diverse programs for individuals with serious mental illness. Each participant is encouraged and empowered to participate in social and vocational programs of their choice designed to increase their readiness for full participation in the larger community. Programs include: - The Drop-In Center where participants encounter a safe and welcoming environment for socializing and recreational activities in a comfortable non-structured environment - The Resource Shoppe and Donations Center where MHCD consumers can shop free-of-charge for furniture, clothing, household items, electronics, etc solicited from a wide variety of community sources. The availability of these resources is essential in supporting reintegration into community living for persons recovering with mental illness - Employment Program where a range of employment opportunities are available to individuals to promote progression in their recovery. Paid full and part-time opportunities include: janitorial, landscaping, transportation and moving services Client Trust Fund where MHCD consumers who receive disability benefits or other public assistance income receive assistance in: developing a personal budget, paying their monthly bills, and managing their discretionary funds Benefits Acquisition Management – MHCD provides consumers extensive counseling and assistance in obtaining and managing the benefits for which they are eligible. This recovery-oriented, program helps expedite benefits applications and determinations while supporting consumers in making informed choices about returning to work.

    83. The Mental Health Center of Denver’s Model of Care to Support Recovery of Adults with Serious Mental Illness Supportive Housing and Residential Care 18 dispersed residential housing units throughout Denver county housing between 6-12 persons per site Park Place which is our open transitional housing program for consumers “stepping-down” from the inpatient setting or utilized to prevent hospitalization. MHCD operates over 20 facilities for adult consumers who require supervised residential settings. This broad array of housing resources allows MHCD to serve consumers with distinct needs, including women- and men-only facilities, older adults, and male consumers with a history of assaultive behavior or persistent substance abuse problems. However, in keeping with the system of care’s recovery orientation, the preferred residential approach is supported housing. Providing supportive services to people in housing is effective in achieving residential stability, improving mental health and recovery from substance abuse, and reducing the costs of homelessness to the community[1], [2]. Through this service, individuals live in their own home (a room, apartment or other location of their choice) and receive supportive clinical and rehabilitation services to help them achieve and maintain stability. Assistance with living skills may be provided at the mental health clinic or are brought directly to the consumer at home. Disputes with landlords and other tenants are addressed through direct interventions, mediation and social skills training. Sixty five percent of Goebel consumers live independently and receive intensive case management (ICM) services to help them maintain housing. Further, MHCD’s Housing services provides Section 8 vouchers, Shelter Plus Care Vouchers, and Supported Housing Services to an additional 465 consumers. [1] Culhane, D.P., Metraux, S., & Hadley, T. (2002). Public service reductions associated with placement of homeless persons with severe mental illness in supportive housing. Housing Policy Debate 13(1): 107-163. [2] Corporation for Supportive Housing. (2002). Guide to re-entry supportive housing. New York, NY: Corporation for Supportive Housing.MHCD operates over 20 facilities for adult consumers who require supervised residential settings. This broad array of housing resources allows MHCD to serve consumers with distinct needs, including women- and men-only facilities, older adults, and male consumers with a history of assaultive behavior or persistent substance abuse problems. However, in keeping with the system of care’s recovery orientation, the preferred residential approach is supported housing. Providing supportive services to people in housing is effective in achieving residential stability, improving mental health and recovery from substance abuse, and reducing the costs of homelessness to the community[1], [2]. Through this service, individuals live in their own home (a room, apartment or other location of their choice) and receive supportive clinical and rehabilitation services to help them achieve and maintain stability. Assistance with living skills may be provided at the mental health clinic or are brought directly to the consumer at home. Disputes with landlords and other tenants are addressed through direct interventions, mediation and social skills training. Sixty five percent of Goebel consumers live independently and receive intensive case management (ICM) services to help them maintain housing. Further, MHCD’s Housing services provides Section 8 vouchers, Shelter Plus Care Vouchers, and Supported Housing Services to an additional 465 consumers.

    84. The Mental Health Center of Denver’s Model of Care to Support Recovery of Adults with Serious Mental Illness Utilization Management (UM)- a model of care management focused on ensuring that consumers receive the right level of service at the right time. Right Service Right time Right Staff Right Duration Right Outcome Right Intensity In addition, the program emphasizes the need to create access for new individuals to enter services by creating movement for existing consumers to levels of service well-matched to their recovery needs. It is based upon the premise that as people recover from mental illness, their need for treatment services will be less. The program’s aim is to ensure that each consumer receives the highest quality treatment services according to the following formula of “rights:” Right Service Right Time Right Staff Right Duration Right Outcome Right Intensity The utilization management process supports our recovery and strengths-based service philosophy by promoting consumers’ decreased reliance on mental health services as they become more engaged in natural community activities and resources. It defines recovery as a self-directed process of healing and transformation which supports consumers in setting and achieving their life goals while, at the same time, coping successfully with their mental illness.In addition, the program emphasizes the need to create access for new individuals to enter services by creating movement for existing consumers to levels of service well-matched to their recovery needs. It is based upon the premise that as people recover from mental illness, their need for treatment services will be less. The program’s aim is to ensure that each consumer receives the highest quality treatment services according to the following formula of “rights:” Right Service Right Time Right StaffRight Duration Right Outcome Right Intensity The utilization management process supports our recovery and strengths-based service philosophy by promoting consumers’ decreased reliance on mental health services as they become more engaged in natural community activities and resources. It defines recovery as a self-directed process of healing and transformation which supports consumers in setting and achieving their life goals while, at the same time, coping successfully with their mental illness.

    85. MHCD Utilization Management Level One – Highest level of Assertive Community Treatment services paired with medium- or long-term residential placement. This level is for consumers with the highest level of need. Level Two – Next Highest level of Assertive Community Treatment for consumers in independent living situations. Level Three – Medium level of Assertive Community Treatment for consumers who live independently. Level Four – Traditional outpatient services, including case management, treatment and supports for consumers with the lowest level of need. The system provides a method for consumers to move among four levels of MHCD treatment services according to their current needs. The system provides a method for consumers to move among four levels of MHCD treatment services according to their current needs.

    86. MHCD Recovery Needs Level Instrument (RNL) The Global Assessment of Functioning Score Hospitalizations/emergency room visits Basic needs Risk of nursing home placement Legal issues Substance abuse Residential situation/homelessness Harm to self or others Engagement in treatment Medication effectiveness Symptom management Case management needs Level of stress in consumer’s environment Community support One of the most interesting features of our UM system is the Recovery Needs Level (RNL) instrument, which rates each consumer on a variety of clinical criteria that correlate with the four levels of services described above. One of the most interesting features of our UM system is the Recovery Needs Level (RNL) instrument, which rates each consumer on a variety of clinical criteria that correlate with the four levels of services described above.

    87. MHCD’s Recovery Needs Level (RNL) The RNL (Recovery Needs Level) is administered at: admission at three months at six months after admission every six months thereafter It is used to assess consumer’s current status and progress in achieving his/her recovery goals. It is completed and scored electronically, which reduces rater and reviewer bias. A computer algorithm automatically scores the instrument and notes the level of service that matches the consumer’s needs. Based on the results of this process, the consumer’s case manager may recommend that he/she move to a higher or lower level of service intensity. The Consumer Appeal Process The Utilization Management program also has a detailed, three-level appeals process that includes written notification to consumers that they may appeal any proposed change in their service level. To support this process, MHCD has developed a team of paid consumer providers whose role is to educate their peers on the utilization management process, with specific information about their rights and how to appeal. To date, this peer-based team has successfully outreached and educated over 1000 consumers. MHCD’s utilization management system is one of the first in the country to operate within the context of a large-scale service system that utilizes an Intensive Case Management/Assertive Community Treatment approach. It is unique in matching consumer needs to defined levels of services rather than approving a series of individual services for each consumer. The system also makes innovative use of computer technology to assess needs and progress, and recommend service levels. This technology allows ongoing information tracking which facilitates data analysis and program evaluation. In addition, we have developed on-line support for the program, including training tools for providers and consumers, and procedures for ensuring clinically-sound transitions to new levels of service. Finally, consumers have been integrally involved as paid consultants during program design and educating their peers about the process. It is completed and scored electronically, which reduces rater and reviewer bias. A computer algorithm automatically scores the instrument and notes the level of service that matches the consumer’s needs. Based on the results of this process, the consumer’s case manager may recommend that he/she move to a higher or lower level of service intensity. The Consumer Appeal Process The Utilization Management program also has a detailed, three-level appeals process that includes written notification to consumers that they may appeal any proposed change in their service level. To support this process, MHCD has developed a team of paid consumer providers whose role is to educate their peers on the utilization management process, with specific information about their rights and how to appeal. To date, this peer-based team has successfully outreached and educated over 1000 consumers. MHCD’s utilization management system is one of the first in the country to operate within the context of a large-scale service system that utilizes an Intensive Case Management/Assertive Community Treatment approach. It is unique in matching consumer needs to defined levels of services rather than approving a series of individual services for each consumer. The system also makes innovative use of computer technology to assess needs and progress, and recommend service levels. This technology allows ongoing information tracking which facilitates data analysis and program evaluation. In addition, we have developed on-line support for the program, including training tools for providers and consumers, and procedures for ensuring clinically-sound transitions to new levels of service. Finally, consumers have been integrally involved as paid consultants during program design and educating their peers about the process.

    88. Measuring Recovery Outcomes MHCD Recovery Markers Inventory (RMI) Recovery Markers are indicators that are usually associated with an individual’s recovery but are not necessary for recovery. In order to implement a system-wide recovery agenda, MHCD felt it was important to monitor the impact of recovery-oriented practices as they occurred throughout the organization. Currently MHCD is using three instruments to measure recovery oriented outcomes for adult consumers receiving services in our clinics[1]: [1] Olmos, P.A. Huff, S., Starks, R., (April, 2006). Measuring Recovery from the Consumer’s Perspective. Presented at the National Council for Community Behavioral Healthcare's Annual Training Conference. Orlando, FL. The Recovery Markers Inventory (RMI) was empirically developed by members of MHCD’s Recovery Implementation Committee which includes consumers and staff members. This instrument measures the factors associated with recovery from mental illness and consists of eight questions completed by the clinician every other month. The questions address the consumer’s current status in employment, education and training, personal growth, level of psychiatric symptom interference, relationship with service providers, housing and substance abuse (level of use and readiness for recovery). The RMI is used to ascertain the status and progress of the consumer in his/her recovery. Clinicians receive bimonthly reports for each client and utilize this outcome information to inform their clinical practice. In order to implement a system-wide recovery agenda, MHCD felt it was important to monitor the impact of recovery-oriented practices as they occurred throughout the organization. Currently MHCD is using three instruments to measure recovery oriented outcomes for adult consumers receiving services in our clinics[1]:

    89. MHCD Consumer Recovery Measure 16 item measure with 5 domains Completed by consumers Active growth and orientation Hope Mental illness symptoms Safety Social Networks The Consumer Recovery Measure (CRM) was also empirically developed by members of MHCD’s Recovery Implementation Committee and is used to assess the consumer’s opinion of their own recovery level in a self-report 16 item measure. The five domains are designed to measure mental health recovery in the following areas: active growth and orientation (“Recently, I have been motivated to try new things”), hope (“I have hope for the future”), mental illness symptoms (“My life is often disrupted by my symptoms”), safety (“There are some people who cause me a lot of fear”), and social networks (“I get a lot of support during the hard times”)[1]. Consumers are asked to complete the measure every six months. Clinicians receive regular reports showing client perceptions of progress in the different domains to help them be more responsive to the client’s needs. [1]Olmos, P.A. Huff, S., Starks, R., Flynn, J. (February, 2006). The Recovery Implementation Initiative at the Mental Health Center of Denver: Lessons Learned by a Recovery Oriented Community Mental Health Center. Presented at the 16th Annual Conference on State Mental Health Agency Services Research, Program Evaluation and Policy. Baltimore, MD.The Consumer Recovery Measure (CRM) was also empirically developed by members of MHCD’s Recovery Implementation Committee and is used to assess the consumer’s opinion of their own recovery level in a self-report 16 item measure. The five domains are designed to measure mental health recovery in the following areas: active growth and orientation (“Recently, I have been motivated to try new things”), hope (“I have hope for the future”), mental illness symptoms (“My life is often disrupted by my symptoms”), safety (“There are some people who cause me a lot of fear”), and social networks (“I get a lot of support during the hard times”)[1]. Consumers are asked to complete the measure every six months. Clinicians receive regular reports showing client perceptions of progress in the different domains to help them be more responsive to the client’s needs.

    90. Recovery Enhancing Measure Ridgeway developed MHCD gives randomly to selected adult consumers Use of these three recovery-focused outcomes measures affords MHCD the ability to measure information empirically associated with increasing mental health recovery, but is not in and of itself a direct measure of recovery. Further, use of these instruments allows MHCD to track and analyze changes over-time, as well as potential characteristics (e.g., gender, ethnicity, diagnosis, length of time as clients, etcetera) that might influence outcomes. Data from all three instruments is being integrated into a comprehensive outcome that will be used for the evaluation of mental health recovery. The anticipated impact of this integration will be the development of better clinical practices that will be more efficient and effective from both clinical and organizational points of view. Use of these three recovery-focused outcomes measures affords MHCD the ability to measure information empirically associated with increasing mental health recovery, but is not in and of itself a direct measure of recovery. Further, use of these instruments allows MHCD to track and analyze changes over-time, as well as potential characteristics (e.g., gender, ethnicity, diagnosis, length of time as clients, etcetera) that might influence outcomes. Data from all three instruments is being integrated into a comprehensive outcome that will be used for the evaluation of mental health recovery. The anticipated impact of this integration will be the development of better clinical practices that will be more efficient and effective from both clinical and organizational points of view.

    91. Consumer Involvement At all levels of the system: Recovery Implementation Initiative 2 MHCD Board members are consumers 2 MHCD Board members have immediate family members who are impacted by serious mental illness MHCD consumers are playing a leadership role in furthering the development and application of recovery-oriented practices through MHCD’s Recovery Implementation Initiative. In May 2002, MHCD formed a committee of ten consumers, staff, and consultants to develop a conceptual framework for implementing recovery-oriented practices at MHCD and to identify ways to measure the impact of these practices. As described above, consumer members of this Recovery Implementation Committee have significantly informed the design, selection, and piloting of the three recovery measurement instruments in use at MHCD. MHCD consumers are playing a leadership role in furthering the development and application of recovery-oriented practices through MHCD’s Recovery Implementation Initiative. In May 2002, MHCD formed a committee of ten consumers, staff, and consultants to develop a conceptual framework for implementing recovery-oriented practices at MHCD and to identify ways to measure the impact of these practices. As described above, consumer members of this Recovery Implementation Committee have significantly informed the design, selection, and piloting of the three recovery measurement instruments in use at MHCD.

    92. Consumer involvement Consumer role in organizational decision making through the Office of Consumer and Family Affairs Consumer and Family Advocate Consumer/Staff Partnership Council Consumer Survey Teams The Consumer Advocate also chairs the Consumer/Staff Partnership Council whose purpose is to create opportunities for consumers and staff members to work together to develop operating policies and strategies for the organization. The OCFA also dispatches Consumer Survey Teams staffed by consumers who interview other consumers to gather their feedback about the strengths and weaknesses of the service delivery system and these findings inform our continuous quality improvement efforts. Results from these surveys are combined with consumer complaint data collected by the Consumer Advocate to inform policy and program changes. Presently, the Consumer Survey Team is administering the REE to a sample of adult consumers. At the individual level, all MHCD consumers are strongly encouraged to participate fully in planning the types of services they will need to be successful in recovering from mental illness. The Consumer Advocate also chairs the Consumer/Staff Partnership Council whose purpose is to create opportunities for consumers and staff members to work together to develop operating policies and strategies for the organization. The OCFA also dispatches Consumer Survey Teams staffed by consumers who interview other consumers to gather their feedback about the strengths and weaknesses of the service delivery system and these findings inform our continuous quality improvement efforts. Results from these surveys are combined with consumer complaint data collected by the Consumer Advocate to inform policy and program changes. Presently, the Consumer Survey Team is administering the REE to a sample of adult consumers. At the individual level, all MHCD consumers are strongly encouraged to participate fully in planning the types of services they will need to be successful in recovering from mental illness.

    93. Consumer Involvement Individualized Service Plans Staff training in Strengths-based approaches Peer Mentor Program Annual Recovery Conference ISPs are written with the consumer and clinician or case manager At the systems level, all training and supervision of MHCD clinical staff emphasizes client-centered, strengths-based approaches to care which promote self-sufficiency and recovery MHCD has developed the Peer Mentor Program as part of the resources available at 2Succeed in Education and Employment which affords consumers a structured opportunity to receive support from other persons living with serious mental illness. Fifteen trained peer mentors provide strengths-based coaching, life skills training, and support with the goal of assisting consumers in identifying and utilizing natural community support networks. Participants have the opportunity to create a meaningful connection with others in the community and bring enjoyment into their lives. ISPs are written with the consumer and clinician or case manager At the systems level, all training and supervision of MHCD clinical staff emphasizes client-centered, strengths-based approaches to care which promote self-sufficiency and recovery MHCD has developed the Peer Mentor Program as part of the resources available at 2Succeed in Education and Employment which affords consumers a structured opportunity to receive support from other persons living with serious mental illness. Fifteen trained peer mentors provide strengths-based coaching, life skills training, and support with the goal of assisting consumers in identifying and utilizing natural community support networks. Participants have the opportunity to create a meaningful connection with others in the community and bring enjoyment into their lives.

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