Assertive Community Treatment Working with Natural Supports and Community Integration Oregon Center of Excellence for Assertive Community Treatment Contact: Heidi Herinckx hherinckx@optionsonline.org

ACT is recovery oriented Recovery is defined differently for each person Recovery is a process and a journey

Recovery Focus on wellness Doesn’t mean absence of symptoms but regaining many things that give a sense of purpose, value and improved quality of life

Recovery from what? In addition to recovering from the mental illness itself, what are some of the other things that individuals you are working with in ACT recovering from?

Complex Issues What are some of the consequences or co-issues that a person is recovering from in addition to mental illness? Medical issues Trauma Substance abuse issues Stigma Isolation Poverty and debt Criminal justice involvement Trauma from those who served them in the past Forced treatment or perceived forced treatment

Recovery involves Hope Restoration of social roles (parent, worker, girlfriend, leader of garden club) Having a purpose in life Community integration Being a respected member of the community Building and rebuilding social support networks Having self determination

Community Integration The opportunity to live in the community and be valued for one’s uniqueness and abilities, like everyone else (Mark Salzer, 2006) This is the core of recovery based services

Community Integration Think about and name the variety of all the places you go in a day

Community Based Services The Community Based Services in ACT are NOT just visiting a person in their home. The main idea of community based services is to expanding the places in the community where people feel comfortable and confident in their functioning. Community based services should occur in the grocery store, in churches, in community centers, in parks, places of employment

Recovery and Community Integration The goal of community integration is in many ways inseparable from the goal of recovery. In fact, it has been referred to as “the external, concrete manifestation” of the recovery experience (Bond, 2004) Community integration involves building a strong natural support system

Natural Supports Natural supports usually involve relationships with family members, friends, co-workers, neighbors and acquaintances, and are of a reciprocal (give-and-take) nature. Such supports helps one to develop a sense of social belonging, dignity and self-esteem.

Consider the relationship Recovery   Natural Social Supports Community Integration

Promoting Recovery Emphasis is full community integration and improved quality of live Focus on skill building to increase and improve functioning Delivered in context of helping relationship in community settings Restoring/Regaining valued social roles meaningful lives Focus on personal goals and preferences

Community Integration: Natural Supports Community Integration involves working with natural community supports: (who?) Housing Employment Education Physical Health Leisure/Recreation Spiritual/Religious Community Friends, family Civic and Citizenship organizations

Promoting Community Integration Expand the range of opportunities to participate in their community as an equal member Identify barriers to community integration and target obstacles that prevent people from being full members of their community Provide supports that bring about meaningful changes in the lives of people with psychiatric disabilities

Explore Self and Values Provide opportunities to explore values, beliefs, cultural identity This may lead to ideas for involvement in a cultural community, groups that speak a particular language, spiritual community, political group, social activism

Help Promote Social Participation Social isolation is common Fewer friends, supportive relationships, social activities. Potential barriers that you may have to address: Stigma of mental illness Skill deficits Lack of supports in the community Lack of community education (understanding, acceptance, support)

Types of social participation Employment, education, leisure, social activities, parent, neighbor Civic engagement Volunteering Taking up a cause Educating the community about a topic of interest Advocating Voting

Goal: I want a new friend Help a person develop a plan, identify the steps needed and help the person carry out the plan 1) what are the opportunities to make a friend 2) how does the person perceive these opportunities (hopeful, impossible) 3)What are the strengths the person has to accomplish this goal (friendly, outgoing) 4)Needs/ skills to be developed (how to give appropriate eye contact or start and stop a conversation) How will the team support and provide services (role model, coach, identify resources) How well is it working (changes in barriers, perceptions, celebrate successes and try new things, take it to the next level)

I want a new friend What’s common Limiting the realm of possibilities to opportunities to meet people within the mental health agency/activities Focusing on social circles the person already has What’s needed Expanding opportunities to mainstream activities in the community based on individual’s interests Exploring new social opportunities

I want a friend In working with the individual in making a new friend: 1) location of the activity – outside of mental health agency- community based and natural setting with others in the community that do not experience a disability 2) self determination- participation reflects individuals choice 3) mainstream interactions with a wide variety of members of the community

ACT Services Service category Description of the content in the process Consumer outcomes Mental health treatment/co-occurring TX Alleviating symptoms and distress (medications, therapy, IDDT, evidenced based practices) Symptom Relief/Improved mental well-being Crisis Intervention Controlling and resolving critical or dangerous problems Personal safety assured Case management Obtaining the services and coordinating care wanted and needed Service access REHABILITATION Developing skills and supports related to individual’s goals ROLE FUNCTIONING ENRICHMENT Engaging individuals in fulfilling and satisfying activities SELF-DEVELOPMENT/EFFICACY Rights protection Advocating to uphold one’s rights Equal opportunity Basic support Providing the people places and things needed to survive (shelter, food, medical care) Personal survival assured Self-help Exercising a voice and choice in one’s life Empowerment Wellness/Prevention Promoting healthy lifestyles Health status improved

Importance of Psychiatric Rehabilitation Processes If the desired outcome is increased role functioning then psychiatric rehabilitation is the service provided to help develop an individual’s skills and support them to reach their goals

Psychiatric Rehabilitation Process 1) evaluation phase: Set rehabilitation goal (I want a new friend) Readiness Assessment and Development Behavioral description of person’s self –determined readiness to work on achieving this goal This phase may involve helping a person develop readiness to work on developing the skills needed to reach the goal Functional Assessment Evaluate current skill level and strengths Identify needs and deficits Dig deep and get specific Resource Assessment Identify what is needed to be successful

Psychiatric Rehabilitation Process 2) Planning Phase Identify the specific skills and supports needed Locations in the community to practice skill development Identify high-priority skills Resource development objectives

Psychiatric Rehabilitation Process 3) Intervention Phase Identify and work on changes needed to a person’s personal environment to meet goal Develop personal skills Environmental supports Resource acquisition or coordination 4) Monitor skill learning and assess effectiveness

I want a new friend Assessment Phase Planning Phase Intervening Phase Assess communication skills Formulate a plan Role model communication skills Assess eye contact Provide person with support in preparation and planning of specific activities Discuss conversation starter topics and personal boundaries Explore opportunities and locations to meet new people and comfort level with these options Choose how and where the friendship development activity will take place Accompany individual to activities and help to identify opportunities to engage in conversation Explore other skills necessary to make and maintain friendships and learning style  Helping to build self-efficacy and confidence to get ready to meet people Provide education on the characteristics of a healthy relationship (friendship) Identify resources needed (funds for social activity, transportation assistance)   Providing feedback during social interactions to help identify strengths and areas that need development

Social Integration Development ACT teams can use a similar process for identifying opportunities for social integration as employment specialists do for job development Identify social organizations in the community and work with them to forge the way for incorporating an individual into their community- identifying the strengths and value, unique skills and contributions of the person

Working with Natural Supports Gather information about public and community resources as a compendium of community and natural supports. Developing trusting relationships Provide training to natural supports on how to be supportive to ACT clients and provide instruction on how to navigate the service system. Designing activities in natural settings consistent with individual needs interests, choices

Groups run by the MH agency Groups create great opportunities to prepare individuals for community integration BUT don’t stop there Help to expand these skills in natural community settings Demonstrate/model skills used in group in a wide variety of community settings ACT staff are gradually pulling back their support and letting people fly solo

Vision for Recovery Belief that recovery is possible Uncover abandoned hopes and dreams Discover self through strengths, values, culture, skills Reclaim a meaningful live and valued social roles Full community integration

The ultimate goal for an ACT program The ultimate goal for you as an ACT team is to “work yourself out of a job” Help someone get to a point of recovery where they don’t need ACT services any longer and are not dependent upon the MH service delivery system Live, thrive, in the community Research demonstrates that one of the most important factors to successful transition from ACT services was establishing a strong natural social support system

Organizational Assessment How much focus does your ACT team have on psychiatric rehabilitation? Teaching skills in the community? Do all ACT staff serve in this capacity? Examine your organizational structure: does it promote community integration or does it still continue to segregate individuals by focusing on interactions with only other peers?

Discussion Describe some successes you have had working with/building informal supports and promoting community integration for ACT participants

Discussion What are some of the challenges?

Discussion Do you feel that recovery is attainable for some people more than others?

Resources Boston University Center for Psychiatric Rehabilitation http://cpr.bu.edu/resources/newsletter/assessing-developing-readiness-rehabilitation Anthony, W. A., & Farkas, M. D. (2009). Primer on the psychiatric rehabilitation process. Boston: Boston University Center for Psychiatric Rehabilitation.