The Development of Recovery Competencies for In-patient Mental Health Providers Working with People with Serious Mental

1. The Development of Recovery Competencies for In-patient Mental Health Providers Working with People with Serious Mental Illness Shu-Ping Chen, Ph. D. Candidate, School of Rehabilitation Therapy, Queen’s University Terry Krupa, PhD, OT Reg (Ont), Professor, School of Rehabilitation Therapy, Queen’s University

2. Introduction

3. Background – three levels

4. I. The In-patient context The downsizing and/or closures of psychiatric hospitals and the increase of community-based services • Acute units: People admitted to acute in-patient units can be vulnerable and in extreme distress. • Long-term units: Althoughthe number of long-stay patients in tertiary psychiatric hospitalsdeclined during the past three decades,a group of patients are still served in these hospitals.

5. Characteristics of the in-patient context • Restrictions • Unpredictability • Control • maintaining stabilization by means of rules and routines • Medical model • symptom reduction • problem-oriented interventions

6. II. Recovery • The vision of recovery has become the foundation for mental health services worldwide. • Many countries have adopted recovery as a basic principle for mental health policy making and service providing system at a national level. • Canada • The United States • New Zealand • Australia • The United Kingdom • Ireland • ……

7. Recovery Concepts • Definition of recovery: 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”(SAMHSA, 2006) • Recovery is a continuous and non-linear process, occurring even when an individual experiences intense forms of health services, such as hospitalization.

8. Recovery Concepts • Recovery means that a person can live a satisfying, hopeful, and productive life no matter what limitations are caused by illness. • Recovery is about personal awareness and individual ways of coping. • Recovery doesn’tmean: • There is a cure. • People will never have to take medication again.

9. Recovery-oriented Mental Health System • A recovery-oriented mental health system is characterized by program structures such as mission, policies, procedures, record keeping, and quality assurance that are consistent with fundamental recovery value. Farkas, et al, 2005 • Mental health providers’ understanding, beliefs, values, and attitudes about recovery are one of the key elements in the system transformation towards recovery orientation

10. III. Providers’ competency • Some hospital-based providers demonstrated fewer recovery attitudes, because • fewer opportunities to observe successful consumers in the community • the population they served tended to be more severely ill • There are numerous competency documents that exist in the mental health field. However, only a few of them are recovery-focused.

11. Existing recovery competency frameworks Generic Recovery Competency Frameworks • Coursey et al (2000) • Young et al (2000) • Ohio Department of Mental health (1999) • O'Hagan, 2001 (New Zealand) • NHS Education for Scotland, 2007

12. Generic

13. Existing recovery competency frameworks Specific Recovery Competency Framework • NHS Education for Scotland: “A capability framework for working in acute mental health care” • Acute mental health care in Scotland: resolution teams, crisis centers, and intensive home care mostly in the community settings • 1) rights, values and recovery focused practice; • 2) supporting recovery from acute crisis; • 3) making a difference in acute care; • 4) sharing positive risk taking

14. Problem Statement

15. Problem Statement (Cont.) • No recovery competency frameworks addressed the competencies specifically for in-patient providers has been developed.

16. Problem Statement (Cont.) • There are still some gaps in in-patient providers’ competencies in a recovery-oriented practice. • Therefore, an increase of competencies among in-patient service providers is imperative to working within a recovery-orientated system.

17. Definition • Recovery competency • the mental health providers’ attitudes, knowledge, skills, and behaviours required for effective performance in a recovery-oriented service. • Mental health providers • mental health professionals who provide clinical services and include occupational therapists, psychologists, nurses, social workers, psychiatrists, and managers. • In-patient context • Ontario tertiary mental health hospitals

18. Purpose The purpose of this study was to: 1. identify the most salient recovery competencies required of in-patient providers to inform the development of an educational program 2. develop a shared understanding of recovery by providers

19. Methods

20. Study design

21. Phase One: The Development of Recovery Competency Framework

22. Qualitative research design -- Literature review -- Key informant interviews Develop a recovery competency framework for in-patient providers

23. Step One: Data Collection • Literature review: The literature review addressed the following issues: • 1) the therapeutic environment and culture of in-patient settings • 2) in-patient providers’ recovery competencies • 3) the challenges or barriers for providers to develop recovery competencies and deliver recovery-oriented services

24. Step One: Data Collection Key Informants Interviews • 3 consumers • with serious mental illness, who had previous experience with the Ontario provincial psychiatric hospitals in the last two years • 3 family members • who have a significant family member who was diagnosed with serious mental illness and admitted to the psychiatric hospitals in the last two years • 2 community mental health providers • who have previous experience in in-patient programs • 5 in-patient providers • who currently provide clinical services and have worked in these psychiatric hospitals for at least two years • 2 educators • with knowledge of recovery who are in strategic positions in workforce training in these psychiatric hospitals.

25. Step One: Data Collection • The interviews were semi-structured, individual, and occurred face-to-face. Each interview was audio recorded and lasted for 30 to 70 minutes. • The participants were asked to discuss: • their views of recovery • the recovery competencies that they believed to be most important to in-patient providers • particular challenges providers may face in demonstrating recovery competencies.

26. Step Two: Data converging and analysis

27. Step Three: Competence modeling • A “tension-practice-consequence” model was developed to organize the first theme (tensions) and explain their relationships • A corresponding model illustrating the recovery enabling process was developed to address the tensions and explain the processes of enabling providers

28. Findings

29. The participant profile

30. The tension-practice-consequence model Tensions inherent in delivering recovery-oriented services in in-patient context

31. Tensions Personal level tensions 1. Psychotic symptom 2. Behavioral problem 3. Cognitive impairment 4. Emotional distress 5. Lack of motivation 6. Refractory to treatment 7. Side effects of medications Providers’ own tensions 1. Various recovery competencies 2. Inefficient knowledge transformation 3. Pressure, tension, frustration 4. Low motivation 5. Inadequate colleague support 6. Negative belief toward SMI Environmental level tensions 1. Poor physical environment 2. Inflexible routines 3. Unsafe atmosphere 4. Limited resources and support 5. Hierarchical power structure 6. Institutionalization Medical model Custodial framework Risk control Action & Practice Limited engagement: segregation, restriction, constrained communication, passivity of patients Consequences Hopeless Powerless Compromised relationships

32. The recovery enabling framework for in-patient providers

35. Reduce providers’ tensions Reduce environmental level tensions Reduce personal level tensions Build relationship Challenge 1. The environmental level tensions Critical tension: Patients perceive the in-patient environment as non-humanistic, inflexible, unsafe, and lacking in stimulation. a. non humanistic physical environment b. inflexible ward routines c. unsafe atmosphere d. lack of resources e. hierarchical power structure f. institutionalization

36. Reduce providers’ tensions Reduce environmental level tensions Reduce personal level tensions Build relationship • Engage with patients in creating an environment in which they feel safe, accepted, helped, and nurtured while also maintaining an ordered inpatient setting

37. Reduce providers’ tensions Reduce environmental level tensions Reduce personal level tensions Build relationship • Competency 1: Reducing environmental tensions • create a warm and vital physical environment • create an environment in which patients’ privacy is respected • develop a flexible ward schedule and integrate balanced routine of self-care, productivity, and leisure activities • create a safe, supportive, and accepting atmosphere • provide initial orientation of all in-patient services to patients and families • involve community resources and support • ensure that patients have access to updated and good quality of activity resources • be willing to share information, knowledge, responsibility, and power with patients and significant others • control the environmental stimulation which is suitable for patients’ current status

38. Reduce providers’ tensions Reduce environmental level tensions Reduce personal level tensions Build relationship Challenge 2. The personal level tensions Critical tension: Patients may be experiencing acute illness or other experiences of distress which prevents them from engaging in recovery planning. a. psychotic symptoms b. behavioral problems c. cognitive impairment d. emotional distress e. lack of motivation f. treatment-refractory illness g. side-effects of the medications

39. Reduce providers’ tensions Reduce environmental level tensions Reduce personal level tensions Build relationship • Engage patients in equipping themselves with knowledge and skills to manage their health and well-being in their preferred ways

40. Reduce providers’ tensions Reduce environmental level tensions Reduce personal level tensions Build relationship • Competency 2: Reducing patients’ personal level tensions • integrate bio-psycho-social models of interventions through implementing evidence-based and best practices, such as psycho-pharmacotherapy, cognitive therapy, CBT, supportive therapy, reinforcement therapy, temporary controlling therapy, family psychoeducation, group therapy, activity health intervention … • apply motivational enhancement strategies • understand patients and their stages of recovery • provide patients with information

41. Reduce providers’ tensions Reduce environmental level tensions Reduce personal level tensions Build relationship Challenge 3. Providers’ own tensions Critical tension: Providers do not demonstrate recovery attitudes, knowledge, skills, and behaviors in their daily practice. a. various recovery competencies (belief in medical model, non recovery-oriented attitude…) b. Inefficient knowledge transformation c. feelings of pressure, tension, and frustration as a result of patients’ conditions, as well as apparent conflicts between human rights and some interventions d. low motivation to change e. inadequate colleague support f. negative beliefs toward patients with serious mental illness

42. Reduce providers’ tensions Reduce environmental level tensions Reduce personal level tensions Build relationship • Become a practitioner who believes in and is knowledgeable of recovery, and who is able to self-reflect and encourage changes

43. Reduce providers’ tensions Reduce environmental level tensions Reduce personal level tensions Build relationship • Competency 3: Reducing provider level tensions • demonstrate recovery attitudes/beliefs • demonstrate a holistic understanding of recovery knowledge • be able to build collaborative and trustful relationships with patients and their significant others • practice in the role of recovery guide, coach, mentor, and facilitator • be able to self-reflect • use understandable, respectful, and empowering verbal and body language • advocate recovery within the impatient teams • be able to resolve conflicts or issues raised in recovery-oriented services, and facilitate interdisciplinary communication • convey attitude of active respect and dignity for patients’ rights and freedoms in all environments

44. Engage patients in setting goals and planning Provide choices and individualized services Challenge 4. Setting goals and planning and providing individually tailored services Critical tension: Intervention and decision making are based on the medical model. Patients are not empowered to take responsibility. a. stakeholders’ goals are different or don’t support recovery b. patients insist on goals that appear unrealistic /unfeasible c. patients depend on hospital care and don’t appear to move forward d. time challenge 1- patients’ high turnovers. Acute inpatients do not have enough time to implement recovery planning e. time challenge 2- practitioners’ time constraints. Practitioners do not have enough time to offer time-consuming services or cannot satisfy different patients’ needs at the same time

45. Engage patients in setting goals and planning Provide choices and individualized services • Engage patients as collaborators in setting their own goals and planning, and help them work toward these goals

46. Engage patients in setting goals and planning Provide choices and individualized services • Competency 4: Setting goals and planning with patients and providing individually tailored services • demonstrate a holistic understanding of patients by assessing people and their context objectively • interpret perceived deficits within a strengths and resiliencies framework • be able to effectively communicate to patients and significant others • incorporate stakeholders’ goals and involve them in decision making • educate significant others and involve them in interventions and approaches • help patients reframe situations and plan concrete next steps, along with specific timelines • set individual recovery outcome indicators • prioritize patients’ goals and needs • develop and lead groups which are organized to meet individualized goals for each patient

47. Engage patients in setting goals and planning Provide choices and individualized services Challenge 5. Provide choices based on individual needs Critical tension: It is difficult to address different patients’ needs in a restricted environment. a. tensions exist between patients’ needs/rights/choices and the structure of the units b. patients’ decisions may lead to harmful/negative outcomes

48. Engage patients in setting goals and planning Provide choices and individualized services • Address the unique needs of patients and find the balance between respecting patients’ choices and maintaining ward structure through negotiation of positive risk taking

49. Engage patients in setting goals and planning Provide choices and individualized services • Competency 5: Engaging patients in decision making and satisfy their needs • demonstrate an understanding of patients’ experiences and be able to negotiate the dilemmas between patients’ choices and the ward structure • promote safety and positive risk taking • help people articulate their needs and voices • provide a wide range of options, activities, and education according to patients’ needs and current stages of recovery • encourage patients to make choices and help them through the decision-making process • engage patients at their own pace • support patients’ interim setbacks after they choose to take risks

50. Challenge 6. Foster a positive recovery cycle Critical tension: patients can be in a negative cycle of hopelessness, powerlessness, vulnerability, and repeated relapse. a. patients can be extremely fragile/have extremely low self-esteem hope Advocacy Empower-ment network skills readiness