1. Janine Burton (CNS) MHSOP
RECOVERY MODEL
Utilisation in chronic conditions to reduce distress in the elderly
Janine Burton (CNS)
MHSOP

2. Contents
The assault cycle
Recovery model 101
WRAP plans
Case studies

3. Assault cycle The pattern of someone in acute distress
We will be focusing on the trigger phase and the importance of this in developing effective WRAP plans which will help identify triggers and how to deal with them and avoid escalation phase
The assault cycle is an important part of understanding acute distress in mental health nursing. It provides understanding about the pattern someone is likely to follow and what interventions are most appropriate in each phase.
For example
talking someone ‘down’ and providing a less stimulating environment in the escalating phase is helpful and may indeed head off crisis, but your approach for someone in full crisis phase, in acute mental health would likely be quiet different.
While this model is really only used in acute mental health it still has relevance for you in the community when dealing with someone whom is experiencing distress such as anxiety. Understanding what the “trigger phase is” is an important part of how you can help develop a plan that identifies these and empowers the person to either minimise exposure or manage them.

4. Recovery model
This is the guiding model for Waikato DHBs mental health and addictions service

5. Service User Movement
Ultimately it is about the patient having primary control over the decision made about their own care.
John Perceval dairies 1830
“The concept of recovery can be traced back as far as 1830, when John Perceval, son of one of England’s prime ministers, wrote of his personal recovery from the psychosis that he experienced from 1830 until 1832, a recovery that he obtained despite the “treatment” he received from the “lunatic” doctors who attended him. His remarkable experiences are chronicled in the book Perceval's Experience.”
But really the concept of the recovery model we use today is from the service user movement. Its birth place was in the united states in the 1980’s and 1990s.
New Zealand were very forward thinking and took up the mantel in the 1990’s.

6. Principals of Recovery Model
Hope
Personal Responsibility
Education
Self Advocacy
Support
Five principals of effective recovery work = transfer this to elderly with chronic condition

7. Hope
People who experience mental health difficulties get well, stay well and go on to meet their life dreams and goals .
Chronic conditions:
"Hope to find a feeling of wellbeing and living the best they can with the health constraints they have“
Clinician Tips
Reassurance that what they are experiencing is normal
holding hope for those that are struggling to find it themselves
Helping others to find ‘their’ hope
Acknowledging the little things

8. Personal Responsibility
That the power sits with the individual to work toward recovery to self reflect and act when they notice changes in themselves and to utilise the tools they have identified to help when triggered.
Clinician Tips
Everyone has a different level of health literacy
Be very careful to never take this as a literal quote – “NO BLAME CULTURE”
Your role is to help the individual in front of you find their personal resourcefulness

9. Education
Learning all you can about what you are experiencing so you can make good decisions about all aspects of your life.
Clinician Tips
We have a responsibility to provide education about disease processes and medication
Also we have a responsibility to be familiar with concepts of stigma and discrimination, we so often remove ourselves from what is going on for our clients but the reality is we all experience changes in our mental health
Upskilling yourself about understanding the disease process they have and how their chronic disease might impact on them as an individual
Concordance vs compliance

10. Self advocacy
Effectively reaching out to others so that you can get what it is that you need and deserve to support your wellness and recovery.
Clinician Tips
Building respect and trust in the patient-nurse relationship so that they can
feel able to reach out to you
Feel Safe to express how they are feeling and what is effective for them
You need to place all 'your' thought and 'your' ideas on the shelf
This is about the patient NOT about you
Therapeutic use of self
Therapeutic use of self
What does that mean?
Ultimately it is very simple - you are the tool that allows someone to explore themselves
I really don’t like the statement “non-judgemental”
You suspend your judgements your ways of doing and being
and you simply sit with a patient and be their “computer”
They enter information into you and you process that information and present it back to them
HUGH TOPIC but will touch base on one thing here:
The most important thing I can say around that is that if you are not genuinely interested in helping the person then get someone else to do it.
Insincerity is picked up on very quickly and will erode any chance of a worthwhile therapeutic relationship
its okay to acknowledge that you are not the right person for this situation.
If your it – then you will have to be even more aware of yourself and how you approach things
Actively have to work on keeping neutral facial expressions, maintaining eye contact (or not if culturally appropriate) you will have to work harder and you will have to “hold your tongue”

11. Support
While working toward recovery that you allow yourself to receive support from others
Clinician Tips
Help the person identify what support they may need
Helping the individual to understand that asking for help is not failing
That you utilise the ‘therapeutic use of self’ to support the individual – communication, active listening, accepting,
Walking beside NOT leading
That the persons care-giver/support person has access to support and resources and can identify when they might be facing ‘burnout’ themselves.

12. Recovery is Discovery
NOT your discovery but the patients SELF DISCOVERY you are simply the tool to help this happen

13. Dementia
ALL of the recovery principals can be applied to patients with cognitive impairment and/or dementia. But that you will have a more active role in applying the principals.
Hope
Giving a sense of purpose through techniques such as validation
Self advocacy
Cognitive impairment
means that while they self identify they may not remember their action plan and need assistance to do this – walk beside them, talk them through it. Be patient.
giving as much power back to the person as you possibly can to allow for self responsibility i.e. “choice between tops”
Advanced care planning
Supporting and educating
family members

14. WRAP Wellness Recovery Action Plan

15. A WRAP includes: developing a Wellness Toolbox, and then
1. Evolving a daily maintenance plan
2. Understanding triggers and what I can do about them
3. Identifying early warning signs and an action plan
4. Signs that things are breaking down and an action plan
5. Crisis planning
6. Post crisis planning

16. A WRAP includes developing a Wellness Toolbox, and then
1. Evolving a daily maintenance plan
2. Understanding triggers and what I can do about them
3. Identifying early warning signs and an action plan
4. Signs that things are breaking down and an action plan
5. Crisis planning
6. Post crisis planning

17. Case study one Mrs R; 68 Year old woman with a psychotic depression.
Anxiety & low mood
When very unwell gets delusional thoughts which impact markedly on her ability to attend to her ADL’s
This illness has affected her personal relationships

18. Wellness toolbox
What does it look like for the patient when they are well?
When I am well I “feel” “look” “do” like this
What do they find enjoyment in doing?
What gives them a feeling of purpose?

19. Evolving a daily maintenance plan
Developing achievable goals
Exploring ways to build resilience
Small steps
“Living document”
Strengths based - What are their strengths they can pull on
Honesty can be very uncomfortable but highly important in the development of realistic and achievable plans
You don’t want to set someone up to fail

20. Look at “effective housewife” – what was the meaning of an effective housewife to her

21. Understanding triggers and what I can do about them
What happened leading up to the episode?
What situations or thoughts increase distress
What situations or thoughts decrease distress – make them feel better

22. Identifying early warning signs and an action plan
“out of control” “overwhelmed” “frustrated” “scared” “anxious”
Learning to identify how this looks and feels for them
How did their body react? How do they feel this in their body?
Increased respirations, churning stomach, foggy brain, shaky, weak
what makes it better? What have they done in the past to help in situations
Distraction - mindfulness, reading, praying, knitting, colouring, crosswords
Or do they have to concentrate on what is going on in their body and talk it down

24. Signs that things are breaking down and an action plan
Exacerbation of illness and timely use of advanced care plan wishes

26. Crisis and post crisis planning
Advanced care planning

27. CASE STUDY TWO What do we do next? Mrs D; 78 year old woman
You sit down and talk with her she tells you that she is claustrophobic. And that she is getting very SOBOE when she walks the distance to the bathroom.
What do we do next?
Hx COPD, HT, anxiety New to your facility and refusing to shower becoming agitated with staff and snaps when they approached her and suggest a shower.

28. You ASK her what does she think will help in this situation?
Offer potential solutions
if the person is unable to come to their own solutions or
you think that you have an idea that might help.
Key word is ‘offer’

29. Placing the Ethos of the Recovery Model into the “Medical Model”
Concordance vs Compliance
Crucial elements of concordance
Sharing of power
Decision making is a combination of patients and professionals viewpoints
Values the patients expertise in his or her own body
Recognises that their personal knowledge of self is different to a professionals knowledge but is just as relevant

30. Take home message Its not about you
You are simply a tool for the patient to find their own answers
Its about giving back as much control and power to patient as you can
Its about the patient understanding themselves and figuring out ways to keep their wellbeing at an optimum in any given situation
Utilising a tools such as a WRAP can be useful for some individuals
Do not underestimate the simple plans and solutions they can make the biggest difference
There is multiple ways you can adapt the recovery principals in the care we provide
It will resonate with some of more than others
I challenge you to start thinking concordance NOT compliance
Concordance verses compliance argument
The recovery model will resonate with some of you and a percent of you may pick it up and utilise in your practice.
And a percentage of you might pick up bits of it and others it wont fit at all – its you guys that I would I challenge to start seeking concordance with your patients and move away from expectations around compliance.

31. Articles
Mary O’Hagan (2009) Health%20Today.pdf
The Blueprint for Mental Health Services in New Zealand
Recovery Competencies for New Zealand Mental Health Workers (2001) mental health commission, New Zealand. file:///C:/Users/Janine%20Burton/AppData/Local/Microsoft/Windows/INetCache/IE /KLNUDA13/recovery-competencies-for-new-zealand-mental-health-workers- march-2001.pdf

32. Useful websites
Mental Health addiction and disability up workforce development; Te Pou o Te Whakaaro Nui
Mental Health Foundation of New Zealand