Outline of Entire Presentation

1. Using the Empowerment Scale In Treatment: an Educational Program for Consumers, Clinicians and Supervisors

2. Hope! Outline of Entire Presentation • Part One: Setting the stage for personal growth and Recovery through Hope, Empowerment and Preparation: An Overview • Part Two: Using the Empowerment Scale to plan and monitor treatment aimed at Empowerment and Recovery

3. Hope! Part One • Setting the stage for personal growth and Recovery through Hope, Empowerment and Preparation: An Overview • Review conditions necessary for Empowerment to take place

4. Hope! Learning Objectives:Part One • Define Recovery & Empowerment • Describe how Recovery and Empowerment apply to all consumers • Describe the conditions for Empowerment

5. Hope! Resilience & Recovery • Ideally during youth, people acquire resilience, “an innate capacity that when facilitated and nurtured empowers children, youth, and families to successfully meet life’s challenges with a sense of self-determination, mastery and hope” From: Resiliency Workgroup • People can build resilience even as adults • If an adult becomes mentally ill, they will use what resilience they have to Recover • One goal of treatment may be to build resilience to avoid future mental health problems

6. Hope! Hope • Hope is a desire accompanied by confident expectation. Having a sense of hope is the foundation for ongoing recovery from mental illness. Even the smallest belief that we can get better, as others have, can fuel the recovery process. • Early in the recovery process, it is possible for a treatment provider, friend, and/or family member to carry hope for a consumer.  At some point, however, consumers must develop and internalize their own sense of hope From: MHRecovery.com

7. Hope! Hope and Recovery • Without Hope, why would anyone proceed in mental health treatment? • Recovery from Schizophrenia is possible: 55.5% achieved recovery in multiple studies* With many other less serious disorders there are similar or higher improvement rates • We should offer hope to consumers! *From Liberman, R.P. & Kopelwicz (2005) Recovery from Schizophrenia: A concept in Search of Research. Psychiatric Services.

8. Hope! Our Hope: Recovery • Refers to the process in which individuals are able to live, work, learn and participate fully in their communities • Recovery is the ability to live a fulfilling and productive life despite a disability • Recovery also implies the reduction or complete remission of symptoms. Science has shown that having hope plays an integral role in an individual's recovery (President's New Freedom Commission on Mental Health)

9. Hope! Another View of Recovery “Instead of focusing primarily on symptom relief…recovery casts a much wider spotlight on restoration of self-esteem and identity and on attaining meaningful roles in society. The definitions do not, however, imply full recovery, in which full functioning is restored and no medications are needed. Instead they suggest a journey or process, not a destination or cure”Patricia Deegan, 1997

10. Hope! People are Labeled with Mental Illness Due to: • Many reasons including: • Severe emotional distress • Insufficient social supports/resources/ coping skills to maintain the major social roles expected of them during that phase of their life • Those who have adequate resources to cope with their symptoms may not be labeled as mentally ill

11. Hope! THEREFORE: • “The goal of treatment here is assisting people in gaining greater control of their lives and assisting them in regaining valued roles in society”Dan Fisher, MD • Recovery is made possible through a combination of SUPPORTS needed to re-establish social roles and SELF-MANAGEMENT needed to take control of major decisions

12. Hope! Treatment With Recovery Focus • Mental illness is not a life-long process • Builds assets that can help consumers get on with their lives despite potentially continuing symptoms of mental illness • Empowerment is a key asset that can be built in the presence of symptoms • Empowerment is negatively correlated with symptom distress (Stewart & Kopache, 2003 IASPRS Conference Presentation)

13. Hope! Recovery is for Everyone The processes of recovery as described above can happen for everyone despite level of functioning or types of symptoms

14. Hope! What is Empowerment? • The process of investing with power • Recovery does not occur without Empowerment

15. Hope! Empowerment Process • The process of increasing personal, interpersonal and political power to enable individuals or collectives to improve their life situation. It requires the full participation of people in the formulation, implementation and evaluation of decisions determining the functioning and well-being of the society.http://www.polity.org.za

16. Hope! Empowerment Helps Everyone • The components of empowerment are part of the healing process for everyone, not just those with severe mental illness • Empowerment issues (low self-esteem, sense of powerlessness, etc.) are present in almost all cases, regardless of diagnosis • For those with mental illness, empowerment can be a tool to enhance a consumer’s decision-making capacity

17. Hope! Each Person Must Become Empowered Themselves • Empowerment is not something that can be given to a person or that can be done for a person • BUT clinicians can and must aid in establishing the conditions necessary for Empowerment • Empowerment in life cannot be gained without empowerment in treatment

18. Hope! Conditions for Empowerment • Managed Psychiatric Symptoms • Participation Skills • Psychological Readiness • Mutual Trust and Respect • Reciprocal Concrete Incentives • Availability of Choices • Participation Structures and Processes • Access to Resources • Supportive Culture David Linhorst, 2006, Empowering People with Severe Mental Illness: A Practical Guide

19. Hope! Conditions for Empowerment • Empowerment can begin even with a minimum level of these conditions • Clinicians should proceed assuming that empowerment is possible and work to establish the necessary conditions

20. Hope! Condition: Managed Psychiatric Symptoms • Consumers can participate in treatment planning even with symptoms present • Symptoms do not impact all areas of decision-making; assume that persons can participate

21. Hope! Condition:Participation Skills • People must have some level of participation skills to meaningfully participate in treatment • Many systems have access to Climbing into the Driver’s Seat training that helps prepare consumers to take part in treatment planning • Even with symptoms, a person can acquire participation skills needed to take part in treatment planning • Give opportunities for decision making; making even small decisions builds skills • Honoring consumer choices, sometimes even poor ones, fosters a sense of confidence in their ability to make decisions

22. Hope! Condition:Psychological Readiness • Hope for change is needed, but hope is fragile • Psychological readiness can be inhibited by past failed attempts to change, feelings of powerlessness, lack of hope, and other reasons • Motivational interviewing (characterized by active listening, empathy, non-argumentative style, open-ended questioning) can be useful in fostering readiness • Small successes build readiness

23. Hope! Condition:Mutual Trust and Respect • Consumer believes clinician wants what’s best and respects consumer’s abilities, choices and basic worth as a person • Clinician believes consumer can make good decisions and is willing to cooperate • Mutual trust and respect build the therapeutic alliance, which has been shown to improve treatment outcomes (Crane-Ross, Lutz & Roth, 2005)

24. Hope! Condition:Reciprocal Concrete Incentives • Both consumer and clinician must have concrete and meaningful incentives to participate in treatment • Consumers have incentive of better life as a result of successful treatment • Clinicians have the incentive that the consumers they serve will have positive changes in their life • Sometimes the incentives have to be pointed out to be recognized, or put in place if not there already

25. Hope! Condition:Availability of Choices • In order for decision-making to be meaningful, valid choices must be available • These choices can be in style of treatment modalities, additional services, or goals of treatment • Even bad choices can be empowering; however, more failure—brought about by not being ready—may foster powerlessness rather than empowerment • A decision to defer decision-making is also OK—it does not indicate a general inability or unwillingness to make decisions • People make choices all the time; show consumers that everyday choices are evidence of their power

26. Hope! Condition:Participation Structures and Processes • Empowerment should be a part of the formal processes in a service setting • Involving families and/or significant others—at the consumer’s discretion—is empowering • Individualized treatment planning implies that the consumer is present and participates

27. Hope! Condition:Access to Resources • Ability of consumers to identify and access resources will enhance treatment effectiveness • In order to recover, a consumer must be able to learn to identify and access resources, including: • Peer Support • Mediation • Community events as social opportunities • Educational materials

28. Hope! Condition:Access to Resources • Clinicians also need resources: • Training • Time to conduct meaningful engagement (it takes longer to write treatment plans with the consumer taking part) • Tools such as Outcomes reports • Evidence-based practice models

29. Hope! Condition: Supportive Culture • Clinicians do not work in isolation: the culture of the agency either supports or inhibits empowerment • A supportive culture: • Has empowered clinicians that instill hope and set an example for consumers • Minimizes stigma • Assumes consumers are self-reliant or can grow into self-reliance • Has Mission and Vision statements that support Empowerment and Recovery • Has leaders that support Empowerment and Recovery

30. Hope! Conditions Only Set the Stage • The effectiveness of treatment depends on how much of each condition is present • The conditions provide a structure for nurturing consumer empowerment • To the extent possible, all conditions should be present

31. Hope! Empowerment Requires Actual Change • Increasing consumer’s self-esteem, self-efficacy, and sense of power are necessary but not sufficient conditions for growth • These subjective changes must be accompanied by objective or actual changes in order for progress to be sustained

32. Hope is the seed that can start and sustain the recovery process Empowerment is essential to recovery because it enables the consumer to lead their own recovery Empowerment is up to the consumer, but clinicians can set the stage by fulfilling the conditions of Empowerment Hope! Part One Summary

33. Hope! Part Two • Using the Empowerment Scale to plan and monitor treatment aimed at Empowerment and Recovery • Review Reports that Incorporate Empowerment Sub-Scales and Items • Review how to use the Reports in the various phases of treatment

34. Hope! Learning Objectives:Part Two • Explain the components of the Empowerment Scale • Know which reports incorporating Empowerment can be used in treatment • Give specific suggestions about how to use the Empowerment Scale in treatment

35. Hope! The Empowerment Scale • The Adult Consumer Survey of the Ohio Outcomes System Includes: • The Boston University “Making Decisions” Empowerment Scale has 5 components • Self-Esteem • Optimism and Control Over the Future • Community Activism and Autonomy • Power/Powerlessness • Righteous Anger

36. Hope! Empowerment Exercise • Complete and score the Empowerment Scale • Special hand-scoring version included--Do not use this version in treatment! • Leave about 15 minutes for this task • Consider what you would like to work on if it were your treatment plan

37. Hope! Finding the Positive • The amount of self-esteem, power, righteous anger, community activism and optimism/control over the future can vary in different areas of life • Part of the clinical process must be to find areas of life where empowerment exists • These scales and the individual items can help find areas of strength and find areas where improvement is still needed

38. Hope! About Normative Data… • Normative data are usually constructed from scores representative of the population we are measuring; norms provide a standard with reference to a population of interest • Some norming data are included in subsequent slides to provide a general sense of the Empowerment scale scores

39. Hope! About Normative Data… • The primary use of the Empowerment data in treatment is to compare the person to themselves over time • Norms are not Targets! These are what exist in a Grade B system (NAMI state ratings, 2006) “If you always do what you always did, you always get what you always got” -Martha Hodge

40. Hope! Self-Esteem/Efficacy • Loss of self-esteem is a major concern for virtually all consumers • Without some sense of self worth, a person’s reason to live or participate in treatment may be lost “Every new adjustment is a crisis in self-esteem” -Eric Hoffer “If you put a small value on yourself, rest assured that the world will not raise your price” -Unknown

41. Hope! Self-Esteem/Efficacy Items 38. I have a positive attitude toward myself 39. I am usually confident about the decisions I make 42. I see myself as a capable person 45. I am often able to overcome barriers 47. When I make plans, I am almost certain to make them work 51. I am able to do things as well as most other people 52. I generally accomplish what I set out to do 57. I feel I am a person of worth, at least on an equal basis with others 59. I feel I have a number of good qualities

42. Hope! Self-Esteem/Efficacy “Low self-esteem is like driving through life with your hand-break on” -Maxwell Maltz

43. Hope! Optimism and Control Over the Future • Sense of the future is a key component of mental health • Without optimism, there is no reason to expect results in treatment “If you think you can, you can. And if you think you can't, you're right” -Mary Kay Ash

44. Hope! Optimism and Control Over the Future Items 34. I can pretty much determine what will happen in my life 35. People are limited only by what they think is possible 46. I am generally optimistic about the future 60. Very often a problem can be solved by taking action

45. Hope! Optimism and Control Over the Future

46. Hope! Community Activism and Autonomy • Fulfilling positive roles gives life meaning, an essential component of Recovery • Activism can build safety nets • Being part of a community gives consumers a chance to build social assets outside the mental health system “Never doubt that a small group of thoughtful, committed people can change the world: indeed it's the only thing that ever has!” • - Margaret Mead

47. Hope! Community Activism and Autonomy Items 36. People have more power if they join together as a group 44. People working together can have an effect on their community 53. People should try to live their lives the way they want to 58. People have a right to make their own decisions, even if they are bad ones 60. Very often a problem can be solved by taking action 61. Working with others in my community can help to change things for the better

48. Hope! Community Activism and Autonomy

49. Hope! Power/Powerlessness • Presence or absence of belief that personal efforts will produce meaningful results • In order to achieve the outcomes of treatment, the consumer needs to have a sense of personal power • Consumer participation in treatment will hinge on the power a consumer has or is given by the clinical team “Power can be taken, but not given. The process of the taking is empowerment in itself” -Gloria Steinem

50. Hope! Power/Powerlessness Items 40. People have no right to get angry just because they don’t like something 41. Most of the misfortunes in my life were due to bad luck 43. Making waves never gets you anywhere 49. Usually I feel alone 50. Experts are in the best position to decide what people should do or learn 54. You can’t fight city hall (authority) 55. I feel powerless most of the time 56. When I am unsure about something, I usually go along with the rest of the group