1. Implementing Recovery Oriented Interventions with Diverse Populations Piper S. Meyer, Ph.D. University of North Carolina at Chapel Hill USA

2. Special Thanks:  Susan Gingerich, MSW  Kim Mueser, Ph.D.  Kerry Arnold

3. Overview  Focus on challenging populations Cognitive impairments and developmental disability Persons on an inpatient unit  Defining Recovery  Strategies to implement recovery and adaptations for challenging populations Recovery goals Motivational Strategies  Integrating recovery in treatment IMR as an example

4. IMR and Diverse Populations  Inpatient units Long and short-term Forensic  Persons with Developmental Disabilities  Outpatient settings Persons with cognitive impairments

5. Recovery Challenges-Inpatient units  Too sick to understand or believe in recovery.  Too symptomatic to pay attention.  Not enough time to make any progress while they are here. Just focus on getting them out of the hospital.  They will just come back here in a week.  Once they go back to the community no one to follow-up with recovery  Just another phase like many of the other treatments that have been implemented.  This conflicts with current treatment protocols.

6. Recovery Challenges- Developmental Disabilities  Too difficult a concept to understand.  Difficult to remember and track progress.  Some problems with attendance  Difficulty understanding even basic concepts  Problems staying on topic  Giving very brief answers  Directing most comments to class leader  Limited interaction among class members

7. Challenges to the Recovery Model in Diverse Populations  Helping persons understand recovery Taking ownership for their recovery  Finding a role in personal recovery  Integrating recovery in treatment and life  Educating practitioners about recovery Helping practitioners identify a role in the recovery process  Working within a symptom-focused climate

8. Recovery can be a SUCCESS  Despite these common challenges we have been able to implement recovery: Short-term inpatient unit with and without successful IMR implementation 2 different facilities with persons with developmental disabilities Helped re-write simplified handouts Long-term inpatient units with the most difficult clients

9. Defining Recovery

10. What is Recovery?  Do you believe in Recovery?  Even for the most ill, symptom impaired, high needs, filled with pain and anguish person you work with?

11. What is Recovery?  Outcome?  Process?  Both?

12. One definition of Recovery  “Recovery is a process, a way of life, an attitude, and a way of approaching the day’s challenges. It is not a perfectly linear process. At times our course is erratic and we falter, slide back, regroup, and start again...

13. Patricia Deegan (1988)  …The need is to reestablish a new and valued sense of integrity and purpose within and beyond the limits of the disability; the inspiration is to live, work, and love in a community in which one makes a significant contribution.”

16. Marie illness Family Friends Values & Beliefs Spirituality School Politics Work Culture Sexuality Hopes & Dreams Goal of IMR: Putting the Person in the Center IMR IMR Supporters

17. Recovery in Diverse Populations  Important to consider all possible roles in person’s life  Consider how person can take ownership over recovery  What are the areas that are most important?  Strongly emphasize there is more to a person than his/her illness  Keep coming back  If person unable to discuss it the first attempt, wait a few days and try again

18. Challenge-staying on topic  As much as possible, stay with content of the handout  Write topic on flip chart or whiteboard  Validate clients ’ responses, but bring back to the topic of the day  Direct clients to main points (or pictures) on flip chart or white board  Use consistent format for structure and timing of each class

19. Recovery & Hope “ If people are treated as capable, they often surprise everyone and live up to expectations. ” Ken Steele “ The Day the Voices Stopped. ”

20. In IMR  People define what recovery means to them, as individuals.  People set their own personal recovery goals.

21. Strategies to Implement Recovery

22. Benefits of pursuing long-term meaningful goals  What happens if a person has no goal?  Goals can: Provide a sense of purpose and feeling of control Improve self-esteem and confidence Add structure and meaning to daily lives Help learn to better use time Help cope better with problems Involve engaging with other people (Lyubomirsky, 2008)

23. Goals and Challenging Populations  Don’t need to be complicated Begin with 1 short-term goal with 2-3 simple steps Think about something they can feel good doing immediately Add structure/purpose to the day  Share these with everyone involved in treatment Celebrate successes Build on motivation

24. Challenge-improving attention and comprehension  Help clients understand how topic relates to them  Keep our speech simple and brief  Check in every 3 to 5 sentences to make sure clients are understanding  Use examples and “ illustrations ” or “ demonstrations ”  Stay focused on one topic at a time  Ask clients to repeat what they heard in their own words

25. Recovery Goals  Individualized  Personally meaningful  Range from the modest to the ambitious  Exploration of personally meaningful goals often needed to engage consumer before introducing IMR program

26. IF the person has participated in treatment a long time:  Help clients to understand: Setting a recovery goal is not treatment as usual. Setting a a recovery goal has nothing to do with what they think you the practitioner want them to say. Instead, it has everything to do with what is important to them in their life.

27. Educating Practitioners and Clients about Recovery  How to discuss recovery? Definitions Individual recovery goal  Taking ownership  Making goal achievable  Commitment to goals begins with goal setting Follow-up in every session

28. Challenges  People are too “sick” Set goals on short-term inpatient unit for 80% clients within 24-48 hours of admission  People don’t understand recovery Developed concrete goals for persons with developmental disabilities and cognitive impairments  Goals will be outrageous or unreachable Goal can be individualized to be both achievable and reasonable given current situation

29. Recovery Goals  Determine if the person is ready to work on the goal.  Insure that the goal is important to the person Freely chosen  Determine if the person is confident they can achieve their goal.  Enlist support in achieving their goal

30.  Used to explain conditions that foster intrinsic motivation  Why is that important in recovery?  Intrinsic motivation/optimal functioning occurs when psychological needs of autonomy, competence, and relatedness are met. Self-motivation less likely when needs are thwarted  People who are intrinsically motivated show better Performance, creativity, self-esteem, vitality, and general well- being Self-Determination Theory

31. Strategies to increase motivation  Encourage ways to make goals more interesting Remind client how much goal is valued Help client identify with the goal Help client find meaning in the goal Find ways to make the steps toward achieving the goal more rewarding  Increase commitment toward goals Make a public commitment Encourage follow through (Lyubomirsky, 2008)

32. Strategies to increase motivation cont’d  Create confidence for change Encourage person to just try it out  Be flexible Modify as needed Normalize the goal process  Break down into even smaller steps Help to create a plan with concrete steps (Lyubomirsky, 2008)

33. Implementing Recovery in Diverse Populations

34. Recovery Strategies  Helping individual define what recovery means to him or her  Identifying areas of his or life that are satisfying, and areas that are not satisfying  Choosing an area of life that is not satisfying and identifying a meaningful goal in that area  Breaking down that goal into manageable steps

35. Example-Modification of Recovery Strategies for Inpatient Unit

37. Tips for Introducing Recovery  Define recovery Or what is a “big deal” Living a happy, healthy life, what would that look like?  Review the different areas of satisfaction and identify discrepancies Identify area that are most important

39. How could this look different working with a challenging population?

41. And if goals had been followed up on?

43. Example of poster for Inpatient unit describing treatment

45. What approaches are effective?  Small groups (or one-to-one)  Opportunities for repetition of main points and skill building Increased session frequency  Assistance with generalization  Multiple sources of reinforcement

46. Effective Interventions, cont’d  Hands-on assistance with practice in both session and home settings  Calling on concrete versus abstract thinking  Focusing on functional skills application

47. Modifications to IMR  Agency treating individuals with developmental disabilities Developed easier to read handouts and clinical guidelines Developed homework sheets to guide the supporter Supporters for each individual in group Attended every group and took notes Practiced skills with individual and helped with homework

49. Modifications to IMR  Short-term inpatient settings Goals set within 24-48 hours admission Goals set individually using simplified method Goal-follow-up daily Steps can be completed on the unit Handouts for persons cognitive impairments Focus on key modules/information Integration with all disciplines

50. Recovery not limited to group sessions Look for opportunities to incorporate into:  Assessments  Rounding and check ins  Treatment groups  One-to-one meetings  Family meetings  Evening and weekends  Responding to challenging situations  Discharge planning

51. Recovery-What have we learned?  Defining recovery is possible given the right tools and being persistent  Develop goals that are achievable Steps that are successful while in treatment Given the situation and resources Build on success  Always follow-up on goals  Incorporate goals in all areas of treatment when possible

52. Recovery-Next Steps  How can recovery become self- sustaining?  Peer led movements  Working with forensic populations Implementing within restrictive environment

53. Concluding Remarks  Recovery is individualized  Implementing treatment using a recovery orientation takes practice  Recovery can be integrated at all levels of treatment