1. Implementing Recovery Concepts in Public Health Bob Bohanske, Ph. D
Implementing Recovery Concepts in Public Health Bob Bohanske, Ph.D., FNAP Chief of Clinical Services and Clinical Training Southwest Behavioral Health

3. The Recovery Revolution
True revolutions in social services are rare. They involve changes in our values, practices, relationships, cultures, systems, and communities.
Some of the main revolutions in our era have been:
12 step recovery
Deinstitutionalization
Hospice
Mainstreaming special education kids
…and now Recovery with mental illnesses

4. …..and the next challenge
Integrated Care
(how does this fit with the implementation of recovery
concepts)

5. Recovery is a Health Care Culture Change
How we view consumers (patients)
How and what we “assess”
How we design programs and services
How we provide services and supervise staff
How we view success

6. Reasons to adopt and implement a Recovery culture
It’s the latest “transformation”
Other systems of healthcare are doing it
Its politically correct
Its effective
Its efficient
It leads to real OUTCOMES

8. Programmatic Spectrum
Directive
Paternalistic
Recovery-Oriented
Paternalistic
Reward Focus
Incentives for dependency
Medication emphasis
Some individualization in treatment
Clinician-driven treatment (w/ input from consumer)
Moderate choice
Directive
Compliance focus
Enforced dependency
Mandated medication
Boilerplate treatment plans
Directed treatments (threats of hospitalization, restraints, OP commitment)
Recovery Oriented
Recovery focus
Non-contingent
Incentives for autonomy and personal accountability
Medications part of overall treatment plan
Individualized
Consumer-driven
Consumer as source of control

9. Finding the Heroic Client
A word on assessment……
In traditional Illness models we look at what's WRONG with someone
This AM we heard its better to ask what's happened to you
Might I suggest we focus on ..
What's Right With You
Identify the strengths thru the
Stories and dialogue we share

10. As Part of our Culture Change
We did away with traditional “Intake Interviews” or Initial Assessments
We Developed an Initial ENGAGEMENT SESSION
Driven by the clients voice as reflected in their scores on the Outcome Rating Scale (ORS)

11. The Fundamental Components of Recovery include:
1. Self-Direction
2. Individualized and Person-Centered
3. Empowerment
4. Holistic
5. Non-Linear
6. Strengths-Based
7. Peer Support
8. Respect
9. Responsibility
10. Hope
allpubs/sma /

12. SAMHSA’s Working Definition of Recovery (Just a bit longer than “Living as well as possible”)

13. Recovery
A process of change through which individuals improve their health and wellness, live a self-directed life, and strive to reach their full potential.

14. Four major dimensions
Through the Recovery Support Strategic Initiative, SAMHSA has delineated four major dimensions that support a life in recovery:

15. Health: overcoming or managing one’s disease(s) and for everyone in recovery, making informed, healthy choices that support physical and emotional wellbeing.

16. Home: a stable and safe place to live;

17. Purpose: meaningful daily activities, such as a job, school, volunteerism, family caretaking, or creative endeavors, and the independence, income and resources to participate in society; and

18. Community: relationships and social networks that provide support, friendship, love, and hope.

19. Guiding Principles of Recovery

20. ILLNESS CENTERED friends (social support network)
housing (treatment setting)
illness
vocational class (therapeutic activity)
family

21. PERSON CENTERED employment housing (home) person illness
(a part of me)
friends
family

22. PERSON CENTERED ILLNESS CENTERED
The relationship is the foundation
The diagnosis is the foundation
Begin with welcoming – outreach and engagement
Begin with illness assessment
Services are based on personal suffering and help needed
Services are based on diagnosis and treatment needed
Services work towards quality of life goals
Services work towards illness reduction goals
Treatment and rehabilitation are goal driven
Treatment is symptom driven and rehabilitation is disability driven
Personal recovery is central from beginning to end
Recovery from the illness sometimes results after the illness and then the disability are taken care of
Track personal progress towards recovery
Track illness progress towards symptom reduction and cure
Use techniques that promote personal growth and self responsibility
Use techniques that promote illness control and reduction of risk of damage from the illness
Services end when the person manages their own life and attains meaningful roles
Services end when the illness is cured
The relationship may change and grow throughout and continue even after services end
The relationship only exists to treat the illness and must be carefully restricted throughout keeping it professional

23. Person Centered Treatment
The foundation of a good treatment is a good relationship, not a good diagnosis.
The purpose of mental health treatment, including medication, is not just to treat mental illnesses. It’s to help people with mental illnesses have better lives.
Medications should be quality of life goal directed instead of just symptom relief directed

24. 1. Recovery emerges from Hope:
The belief that recovery is real provides the essential and motivating message of a better future – that people can and do overcome the internal and external challenges, barriers, and obstacles that confront them.

25. Hope is internalized and can be fostered by peers, families, providers, allies, and others. Hope is the catalyst of the recovery process.

26. 2. Recovery is person-driven:
Self-determination and self-direction are the foundations for recovery as individuals define their own life goals and design their unique path(s) towards those goals. Individuals optimize their autonomy and independence to the greatest extent possible by leading, controlling, and exercising choice over the services and supports that assist their recovery and resilience.

27. In so doing, they are empowered and provided the resources to make informed decisions, initiate recovery, build on their strengths, and gain or regain control over their lives.

28. 3. Recovery occurs via many pathways:
Recovery is built on the multiple capacities, strengths, talents, coping abilities, resources, and inherent value of each individual. Recovery pathways are highly personalized. They may include professional clinical treatment; use of medications; support from families and in schools; faith-based approaches; peer support; and other approaches. Recovery is non-linear,

29. 4. Recovery is holistic:
Recovery encompasses an individual’s whole life, including mind, body, spirit, and community. This includes addressing: self-care practices, family, housing, employment, education, clinical treatment for mental disorders and substance use disorders, services and supports, primary healthcare, dental care, complementary and alternative services, faith, spirituality, creativity, social networks, transportation, and community participation.

30. 5. Recovery is supported by peers and allies:
Consumers have a personal responsibility for their own self-care and journeys of recovery. With others, consumers identify coping strategies and healing processes to promote their own wellness.

31. 6. Recovery is supported through relationship and social networks:
An important factor in the recovery process is the presence and involvement of people who believe in the person’s ability to recover; who offer hope, support, and encouragement; and who also suggest strategies and resources for change.

32. 7. Recovery is culturally-based and influenced:
Culture and cultural background in all of its diverse representations including values, traditions, and beliefs are keys in determining a person’s journey and unique pathway to recovery.

33. 8. Recovery involves individual, family, and community strengths and responsibility:
Individuals should be supported in speaking for themselves. Families and significant others have responsibilities to support their loved ones, especially for children and youth in recovery. In addition, individuals have a personal responsibility for their own self-care and journeys of recovery.

34. 9. Recovery is based on respect:
There is a need to acknowledge that taking steps towards recovery may require great courage. Self-acceptance, developing a positive and meaningful sense of identity, and regaining belief in one’s self are particularly important.

35. 10. Empowerment
Empowering consumers voice and choice in determining their goals and services.

36. RESULTS

37. year
% cut out
2007
30.6
2008
15.2
2009
12.5
2010
8.5
2011
5.1  
N=6089
the
implementation
curve

38. While not cost intensive …it does require commitment to the concept…

39. In both child and adult services we demonstrated increased efficiency…
In both child and adult services we demonstrated increased efficiency….. And………

42. Across all diagnostic groups we demonstrated effectiveness
And not only in out patient services

43. Mandated (forensic) Clients
LOS = days
# of Sessions: 10.2
% No Progress
Effect Size d= RCI = 48.2%
N=694

46. Thank You for your attention and all the things you do to build the Trust in your patients and THE TRUST

48. Traditional Model vs. Recovery Model
A brief outline of transforming Behavioral Health Care

49. 1. Engagement Traditional Model:
crisis intervention, isolated outreach,
Recovery Model: (welcoming), emphasis on outreach

50. 2. View of Motivation
Traditional Model: Pre-condition for treatment, absence defined as “resistance”, responsibility/blame-- client
Recovery Model: Seen as outcome of services, emphasis on pre-action stages of change (“recovery priming”, responsibility/blame--service milieu)

51. 3. Screening/Assessment
Traditional Model: Categorical, Intake Activity, Deficit-based (problem oriented treatment plan)
Recovery Model: Global, Continual (stages of change assumptions), Strength-based (assets to recovery plan); Inclusion of family network: Consumer defines family.

52. 4. Service Goals
Traditional Model: Professionally defined in treatment plan; Focus on reducing pathology.
Recovery Model: Consumer-defined in Recovery Plan; Recovery vision reflected in mission.

53. 5. Service Timing
Traditional Model: Focus on crisis/problem resolution; Reactive
Recovery Model: Focus on post-crisis recovery support activities; Proactive; Commitment to continued availability

54. 6. Service Emphasis Traditional Model: Stabilization
Recovery Model: Recovery coaching, monitoring with feedback and support, early re-intervention

55. 7. Locus of Services
Traditional Model: Institution-based--”How do we get the client into Tx?”
Recovery Model: “How do we keep the process of recovery within the client’s natural environment?” (community)

56. 8. Service Technologies
Traditional Model: Focus on “programs”; Limited individualization; Biomedical stabilization
Recovery Model: Focus on service and support; High degree of individualization; Greater emphasis on physical/social recovery

57. 9. Management of Co-morbidity
Traditional Model: Exclusion, extrusion, recidivism, iatrogenic injury; Experiments with parallel/sequential Tx
Recovery Model: Concept of “serial recovery”; Integrated model of care, multi-unit/agency, generic resources

58. 10. Service Roles
Traditional Model: Specialization of clinical roles, emphasis on professional/technical expertise; Resistance to consumer movement
Recovery Model: “A-disciplinary”; Role cross-training; Peer-Supports in paid and volunteer support roles; Emphasis on mutual aid; Role of primary care physician

59. 11. Service Relationship
Traditional Model: (Dominator-Expert Model). Hierarchical, time-limited, transient.
Recovery Model: (Partnership-Consultant Model). Less Hierarchical, potentially time-sustained, continuity of contact.

60. 12. Consumer Involvement
Traditional Model: Passive role-- professionally prescribed; Consumer dependency.
Recovery Model: Consumer involvement/direction of service policies, goal-setting, delivery, and evaluation. Focus on illness self-management. Consumers as volunteers & employees. Consumer-led support groups/services.

61. 13. Relationship to Community
Traditional Model: Community defined in terms of other agencies
Recovery Model: Focus on how to diminish need for professional services; Emphasis on hospitality and supports within the natural community; Emphasis on generic supports

62. 14. View of Aftercare
Traditional Model: Aftercare as an afterthought (less than 30%) or maintenance for life.
Recovery Model: Eliminate concept of “aftercare”: all care is continuing care; Emphasis on community resources; Role of guide or recovery coach.

63. 15. Service Evaluation
Traditional Model: Focus on professional review of short-term outcomes of single episodes of care; Recent emphasis on social cost factors--impact on hospitalizations, arrests, etc.
Recovery Model: Focus on long term effects of service combinations & sequences on client/family/community; Consumer-defined outcomes & review

64. 16. Advocacy
Traditional Model: Advocacy often limited to that related to institutional funding; Marketing and PR approach.
Recovery Model: Emphasis on policy advocacy, community education (stigma) and community resource development; Community organization approach.

65. QUESTIONS