Welcome to this two months’ combined edition of TIPS and TOPICS. The summer vacation lethargy has slowed this edition from a promised early month issue to a just-before-the-end-of-the-month publication date. But here it is.

The talk of “recovery” is another increasing interest in behavioral health that supports and fuels person- centered services. The addiction treatment field has had recovery as a goal for years, but there is a lot more talk of recovery also in mental health. I say “talk”, because there is still a struggle to really actualize a recovery-driven, person-centered system versus a pathology and diagnosis-driven system. Clinicians want to be person-centered, but there are clinical and system’s dilemmas that make the “walk” challenging.

Tips:

• When a system is moving to integrated co- occurring, recovery-oriented services, consider some of the challenges to attitudes, knowledge, skills and policies and procedures.

> What do we even mean by “recovery”?
Most understand addiction recovery to mean more than white-knuckle abstinence, or successful detoxification. We understand addiction recovery and sobriety to be mental, emotional, social and spiritual growth – that there is a difference between a “dry drunk” and sober, recovering person.

> But what is recovery in mental health?
For many years mental health has been satisfied when psychotic symptoms are stabilized; when hallucinations, suicidal or homicidal or violent behavior are absent, and depressed or manic mood volatility is smoothed out. Achieving these challenging goals has been felt ‘victory’ enough, especially when a client thinks you are after them and trying to poison them with pills. A broader view of recovery would be nice, but seems a distant reality.

> How can you write consumer-driven, recovery- oriented treatment and service plans you expect a client to sign (as an active participant), when the person doesn’t even think they have a drug and/or a mental health problem?
Why would they be interested in relapse prevention, AA attendance or medication compliance when what they really want is to stay out of jail, get independent housing, or keep getting their disability money?

> What do you do in co-occurring disorders treatment if your policy and procedure is zero tolerance for substance use, but not zero tolerance for a relapse of depression, psychosis or mania?

Imagine a person who arrives depressed or psychotic to an individual or group session. I have never heard of a policy that requires them to leave until they are more stable, and then return to a later session for treatment. I have rarely seen someone discharged fully from a treatment program because they repeatedly had psychotic, manic or depressive episodes.

> What do you do if you want your treatment plans to be a living, collaborative, meaningful document, understood by the client? But you feel you have to be more worried about CARF, JCAHO accreditation standards, or State licensure or funding regulations?
For example, consider a client who really doesn’t think he has an addiction or mental health problem. You document that as the “problem/need” with the accompanying goal: “To demonstrate to the court and others that I have no problem with drugs or violent behavior.”
Will funders and managed care really pay for that motivational enhancement work? Or will they or the court demand a plan that states specific goals about abstinence or medication compliance in order to be accepted or funded?

Before you get too depressed considering all these challenges, let’s move on to some possible solutions and suggestions.

• Understand what you believe about mental health recovery.

Mental health’s focus on symptom stabilization and pathology-oriented illness management all too easily can place medication compliance as Goal number 1. Clients especially with severe and persistent mental illness are considered to be doing well if they are showing up, and taking their medication. And that certainly is better than being mentally disorganized, dangerously psychotic and homeless. The message to the client however can come across as: “Just take your medication and show up” – a message that encourages passivity and low expectations or hope for anything more fulfilling.

Here’s how one mental health consumer defined “recovery” from serious mental illness:

“Recovery occurs when people with mental illness discover, or rediscover, their strengths and abilities for pursuing personal goals and develop a sense of identity that allows them to grow beyond their mental illness”
(Pat Deegan, a consumer leader, and psychologist with schizophrenic disorder)

A 2001 paper in Psychiatric Services nicely summarized a conceptual model on recovery. It referred to both internal conditions (“the attitudes, experiences and processes of change of individuals who are recovering”) and external conditions (“the circumstances, events, policies and practices that may facilitate recovery”).

Recovery – A Conceptual Model
Internal Conditions

 Hope – belief that recovery is possible; it lays the groundwork for healing to begin

 Healing – recovery is not synonymous with cure; active participation in self-help activities; locus of control is with consumer

 Empowerment – corrects a lack of control, sense of helplessness, and dependency; aim is to have consumers assume increasing responsibility for themselves in making choices and taking risks; full empowerment requires that consumers live with consequences of their choices

 Connection – recovery is a social process; a way of being in the company of others; to find a role to play in the world

Recovery – A Conceptual Model
External Conditions

 Human rights – reducing and eliminating stigma, discrimination against psychiatric disabilities; equal opportunities in education, employment, housing; access to needed resources

 Positive Culture of Healing – a culture of inclusion, caring, cooperation, dreaming, humility, empowerment, hope

 Recovery-oriented services – best practices of clinical care, peer and family support, work, community involvement to be implemented by consumers, clinicians, and community; services that facilitate individual recovery and personal outcomes; collaborative services; consumers for consumers

References:
Jacobson N, Greenley D (2001): “What Is Recovery? A Conceptual Model and Explication” Psychiatric Services. April 2001, Volume 52; No. 4:482-485.
In Google, type in Psychiatric Services journal. Locate the April 2001 edition and download the paper.

Also, check out a commentary on that paper: Peyser H (2001): “What Is Recovery? A Commentary” Psychiatric Services. April 2001, Volume 52; No. 4:486-487.

• Learn what each field can teach the other: >addiction treatment field’s experience with recovery,accountability and responsibility; >mental health field’s experience with continuity of care and illness management.

> In addiction treatment, detoxification and withdrawal stabilization has always been seen as only an initial early goal. The strong emphasis has been on personal growth and responsibility, to work towards helping others and giving back to the community. Mental health also can focus beyond stabilization and symptom relief to empower people to embrace a life beyond their diagnosis - to strive for goals beyond stabilization and symptom control.

> Addiction counselors are good at confronting “stinking thinking”; helping a person identify what their “budding” (Building Up to a Drink or Drug) signs are; or sending clear messages that it is not OK to use substances if they are messing up your life. Mental health can learn from this focus on responsibility and accountability. Rather than explain away or excuse a person’s behavior as just chronic psychosis or other mental disorder, they too could actively address the client’s role in relapse.

On the other hand------------------------

> Mental health treatment has been vigilant about moving people into the real world community as soon as possible. It has developed many avenues to increase consumer support and continuity of care (intensive case management, assertive community treatment teams, home visitation, shelters and temporary housing, clubhouses and consumer advocacy etc.). Addiction treatment could learn much to wean itself off a preoccupation with intensive residential and long-term models where aftercare is too often an after-thought. The gaps between intensive addiction treatment and community recovery are too great. When there are few structures to support a person in chronic addiction illness management, a successful outcome is compromised.

> Mental health sees relapse as an assessment and treatment issue, not willful misconduct for which there must be consequences, suspension from treatment, or even outright discharge. Addiction treatment, especially with co-occurring disorders, can learn how to use slips and relapse as an opportunity for progress, not a violation of perfection.

And these are just a beginning on what productive cross-fertilization could be between mental health and addiction treatment systems.

Tips:

• To develop consumer-driven recovery plans and services does not mean you must abdicate your professional training, assessment and recommendations.

Or to say that in a more colorful way: What the consumer wants to focus on is not dictated from the client’s mouth directly to your hand that is writing on the treatment plan paper while bypassing your brain.

In their zeal to be consumer-driven and person- centered, some clinicians interpret the above this way: I listen to what the client wants and immediately scurry around fulfilling that request as soon as possible. Example - if the client states she wants independent housing, the clinician somewhat blindly makes arrangements for that, without assessing and addressing what happened the previous three times housing was found.

“I want to help you get independent housing. But I want to help you get and keep your housing. So before we get started, let’s understand how you got your housing the last three times, but after two months you were evicted for yelling at the neighbors you were convinced were against you; or for trashing the place with a lot of friends who were either using or selling drugs from your apartment.”

Your diagnostic evaluation and multidimensional assessment then become important - not to impose some expert evaluation and plan onto a passive client who is expected to comply. Your assessment is in the service of helping the client get what they want.

“So to help you get, and keep, your independent housing, what should we do about the fact that you are drunk or high almost every day, and that gets you evicted? Do you find the medication helps you to not be so worried about the neighbors spying on you so you don’t have to threaten them anymore? Do all these friends help you stay in your apartment; or are they partly responsible every time you have been evicted?”

In other words, assessing the client’s acute intoxication or withdrawal potential; emotional, behavioral or cognitive status; readiness to change; recovery environment etc are not assessment dimensions external to the client. They are intimately tied in with a consumer-driven approach which wants to help this individual achieve independent living and the freedoms we all want. However, along with freedom and empowerment comes responsibility and accountability- behaviors to demonstrate the ability to handle those rights and privileges.

• Gather your team together. Brainstorm on all the policies, procedures, and agency culture traditions that interfere with integrated co-occurring, recovery-oriented services.

This can be tricky because you often don’t know what you don’t know. “This is the way we have always done it here.” “I think it is in a policy somewhere, but I couldn’t tell you where for sure.” “Doesn’t everybody handle this situation this way?”

Brainstorm list might look something like this:

> We really do treat substance use and relapse differently from depression, anxiety, psychosis and mania relapse, don’t we?

> When our mental health client hasn’t been taking his medication and gets psychotic again, we never say there needs to be consequences: example- suspend the client for two days to avoid contaminating or triggering others in the group.

> We rarely have a joint treatment planning team meeting with mental health and addiction clinicians where we focus together on clients we both share, and these clients bounce back and forth between our systems. How come?

> What would happen if we gave a copy of the treatment plan to the client? What if clients actually knew their treatment plan better than us clinicians? What if we expected clients to come to a group or individual session with specific tasks they want to complete?

> But if we write these consumer-driven plans, will it pass accreditation surveys or managed care?

Hint: Documentation that is truly consumer-driven and recovery-oriented will meet CARF and JCAHO accreditation standards. It will demonstrate specificity and reliance on outcomes and progress that funders and managed care want.

Treatment plans that make sense to clients are individualized, participatory, fashioned to the client’s goals and preferences, matched to their assessed needs, desires, cultural sensitivities and resources, accountable, measurable and help the client achieve what they want. Example- You can’t get/keep your housing without addressing your fear of the neighbors, your drug-using, the friends you hang out with.

Your brainstorming list may actually be much longer than this. But you will begin to see where you and your team might wish to start improving your knowledge, skills, policies and services.

Well I am not really going to bore you with a lot of details and six hundred photos about our family trip to Sicily and southern Italy. But I did notice a couple of things that reminded me again how different cultures shape our thinking and behavior.

We stayed in a charming family-run hotel in Siracusa, Sicily. There was basic daily maid service to empty the trash and replenish crackers and juice provided for breakfast. However on Saturday, we were told nobody would be stopping by tomorrow as Sunday was family time. So if there was anything extra that we needed, we should stock up and get it taken care of today. I smiled to myself thinking how I had gotten used to the work-centered USA culture. Not a lot of hotel guests in the USA would accept second place to the owner’s family – after all, doesn’t my place as a consumer and customer rank more importantly than your family time off?

For his entire college junior year, my son roomed with four Italian young people. They all were likeable, social, hip, young college students. But it was the expected and desired practice for them to go home for the weekend and holidays whenever their studies and exams permitted. Living at home with their family was not at all seen as a sign of separation anxiety, unhealthy enmeshment, or codependency. In this country, USA, it is almost mandatory to leave home as soon as possible; or to declare how you can’t wait to leave; or what a drag your family or your parents are (even if you don’t really feel that way). I’m sure that family life in Italy is not all roses. But is the push to leave the family nest as quickly as possible all it’s cracked up to be? Or if the family is such a drag on young peoples’ independent strivings, how did that happen?

When I was trying to find the correct train in a Frankfurt Airport connection, a gentleman went to great lengths to help me. He was not content to merely point me in the right direction and suggesting I ask someone else when I got a little closer to the next turn. He actually accompanied me quite a distance to the correct station, and would have bought my train ticket had I not insisted that was kind of him, but completely unnecessary. Did I swim in the milk of human kindness and graciously accept his helping hand? Not fully. All the time I was suspicious and thinking what was his scheme or scam. Why was he being so kind and helpful? Would he try to pickpocket me? Was he going to grab my bags and run away when I was in a vulnerable moment?

What a sad commentary on trust, and accepting people for who they are. I’m not beating myself up on that. A few weeks later, at the end of our trip in Rome, good friends with whom we met up, crowded onto an early-morning train on our way to the Coliseum. When squeezing into the carriage as the doors slammed shut, one of the fellow passengers warned our friends to watch their wallets and purses for pickpockets. When we emerged from the subway, two of our friends had lost a coin purse, a room key and about $25.
In retrospect, we think one of the pickpockets was the person who warned them.

Talk about cultural competence. What a fascinating world!

Take a look at www.ncaddnj.org/maketreatmentcount.html

If you live in Australia, or would like to visit and attend our Aussie conferences in November in Sydney, Melbourne or Brisbane (my home town), check out the links from the Home Page of PsychOz at www.psychotherapy.com.au or go to www.psychotherapy. com.au/community/? events03/millermeelee05.html

Hope to see you there.

David