| Featured Practice
A Web Application to Support Recovery and Shared Decision Making, by Pat Deegan, Ph.D.
CommonGround is a Web-based application created by people in recovery from major mental disorders. The program helps support recovery and shared decision making between the psychiatric practitioner and client. Currently, 10,644 people use CommonGround in public sector mental health clinics, ACT teams, peer centers, and inpatient settings in New York, Massachusetts, Pennsylvania, California, Oregon, and Kansas.
In clinics using CommonGround, efforts are taken to make the program accessible to people who may not have prior experience with computers. Typically, the waiting area is converted into a peer-run Decision Support Center (DSC). Clients arrive at a CommonGround clinic 30 minutes before their appointment with the doctor and are greeted by peer staff with a warm welcome, a beverage, and an invitation to use the Web application. Peer staff members support clients using the software to complete a one-page, computer-generated health report that is taken to the medication consultation. Following the consultation, peer staff are available for further support, such as finding local AA meetings or watching a multimedia tutorial on managing diabetes. Although peer services and medical services are billed separately, the "enhanced medication visit" is experienced as a single, seamless appointment.
The role of peer staff is central to the CommonGround approach, as they have had firsthand experience with recovery and are trained to support clients using the program. They also help clients access the online recovery library for information. Perhaps most importantly, peer staff take time to listen and provide support.
Peer staff members strive to maintain their unique role, but also become valued members of the medical team. After one-on-one time with the consumer, practitioners often seek out peer staff to perform a variety of tasks that cannot be completed during the 15-minute consultation. For example, to help a client remember to take medication, peer staff might work with him or her to set up reminders.
There is a wide range of general, health, and computer literacy levels among people who use psychiatric medication clinics, and CommonGround is user friendly, relevant, and accessible. On average (in our experience), clients use CommonGround at nine out of ten appointments, despite disability. Touch screens eliminate the need for typing, though if preferred, a mouse and keyboard can be used. Headphones are available so clients can read or listen to the CommonGround application. The survey is also being translated into Spanish and recovery library videos and documents are made available in Spanish whenever possible.
The main tool used by clients in the DSC is the Web application, which can be accessed through a computer with a modern Web browser and high-speed Internet connection. The program can be used at the clinic or from remote sites such as a home or public library, allowing mobile outreach teams and ACT teams to use it in the field. People can also access the online recovery library from home or in the community.
The CommonGround Web application has a number of components, including a survey, database, recovery library, health report, shared decision report, "graph my recovery" function, and module that displays aggregate data on usage statistics. It also has various views, depending on the user's role. Clients have their unique view of the application, as do peer staff, medical staff, administrators, and support staff, such as therapists and case managers. Although each user group has a unique perspective on the program, complete transparency is maintained: what the doctor can see, the client can see, and what the client can see is available to authorized members of the individual's treatment team.
To read the rest of this article, please click here.
| Training and Technical Assistance
This year, RTP will feature a four-part Webinar series on assessing and addressing key dimensions of recovery-oriented practice. Each Webinar will begin with a description of tools or approaches for assessing certain aspects of a person's life. The presentation will then describe ways to address those aspects through interventions and support. Final speakers in each Webinar will be people in recovery with lived experience on the session's topic.
The first Webinar in the 2012 series, "Assessing for and Addressing Trauma in Recovery-Oriented Practice," was broadcast January 25. During the session, three presenters shared perspectives and demonstrated ways trauma-informed systems differ from other systems of care. One example was how assessment adopts universal precautions and practices that avoid conflict and violence, ensure safety, meet consumers' needs, and minimize traumatic events that could hurt the client or staff.
Practitioner Kevin Ann Huckshorn, RN, MSN, CADC, spoke about assessing trauma in an outpatient setting. Paula Panzer, M.D., presented on trauma-informed care interventions. Finally, Eric Arauz, MLER, a member of APNA's RTP Steering and Curriculum Committees, discussed interventions and supports that have helped facilitate his trauma-informed recovery. You can download the presentation and listen to the Webinar recording at www.dsgonline.com/rtp/webinars/1.25.2012.html.
The second Webinar, "Understanding and Building on Culture and Spirituality in Recovery-Oriented Practice," will be held in March. This session will describe approaches to culturological and spiritual assessments as well as a range of strategies to ensure care is responsive to a person's cultural identity. Presentations will discuss methods for fostering an individual's cultural strengths and spirituality in care planning and recovery-oriented practice.
We plan to conduct our third Webinar, "Identifying and Integrating Strengths in Recovery-Oriented Practice," this June. The Webinar will present tools for identifying personal strengths (both internal and external) and strategies for integrating and building on these strengths in care planning and recovery-oriented practice.
The fourth and final Webinar of the fiscal year, "Evaluating for and Using Medications in Recovery-Oriented Practice," is planned for September. This session will present an approach for evaluating a person's situation and condition before potentially introducing psychiatric medications. Presenters will offer guidelines for the effective and safe use of medicine (when indicated and selected by the consumer) as a tool in his or her recovery.
Watch your email for Webinar dates, times, and registration details!
Technical Assistance. RTP Technical Assistance (TA) provides valuable resources that support strategies for implementing recovery-oriented care in practical and sustainable ways. We have an extensive library of recovery-oriented articles, personal stories and anecdotes, curricula, videos, and links to relevant publications and professional sources. To access TA, contact RTP TA staff Monday through Friday from 9 a.m. to 5:30 p.m. at 877.584.8535, or email requests to firstname.lastname@example.org. We will respond to each request within 48 hours of receipt. Arrangements for longer consultations are available on a case-by-case basis.
Although behavioral health practitioners are RTP's primary audience, anyone interested in promoting the cause of recovery transformation is welcome to access RTP training and TA.
| Project Update
RTP wishes everyone a happy New Year! Since the publication of our October 2011 e-newsletter, Weekly Highlights have covered topical issues on the implementation of recovery-oriented practice. While behavioral health professionals have shared accounts of how recovery is becoming part of their practice and described tools for making recovery concepts more concrete, a variety of personal stories have relayed powerful messages about the critical, often life-changing nature of recovery-oriented care.
We are keenly interested in your feedback as we strive to address these conceptual and practical issues. What are your thoughts about our weekly features? Our goal is to illustrate real-time field experiences and provide appropriate resources to profession-specific practitioners. If there are particular nuances of recovery implementation you would like to read about or share, please email us at email@example.com.
In December, the RTP Steering Committee held their semiannual meeting. Members reviewed and discussed topics for upcoming Webinars and proposed appropriate presenters. An invitation was extended to nominate Steering Committee members from the greater behavioral health field, specifically experts on substance use recovery. The majority of the meeting was devoted to the professional disciplines, who provided progress updates on curricula development. (See Professional Discipline Training Awards.)
When launched, the new RTP Web site will offer readers the convenience of searching a library full of recovery-oriented care resources, which has expanded to nearly 750 articles, personal stories, videos, and more. If you're looking for a particular item or would like us to search a specific topic, please send a request to firstname.lastname@example.org. We welcome the opportunity to connect you with current "how to" guides on implementing recovery in your practice. Additional technical assistance is also available. Contact us with your specific need.
| Guest Columnist
Insight, by Gina Duncan, M.D.
As defined within the context of psychiatry, insight is the ability to recognize that one has a mental illness or is experiencing symptoms of mental illness.1
Working with someone who appears to lack insight into having a mental illness—a person who denies or refuses to acknowledge the condition—is often among the most difficult issues facing mental health care providers and loved ones. When speaking in the community, one of the most frequent questions I receive is how to help a loved one realize he or she could benefit from treatment. The challenge may seem daunting, but it remains incumbent on us as providers to cultivate insight by reaching out to people who are suffering and disengaged from care.
A pertinent question, however, is insight into what?
A deficit-oriented approach would focus on a person's recognition and acceptance of a diagnostic label such as schizophrenia; acceptance of the fact that he or she has an illness; and acceptance of the limitations this illness might impose, i.e., accepting there will be things he or she cannot have, do, or achieve as a result. A recovery-oriented approach seeks to foster insight into the possibilities as well as the challenges associated with mental illness.
Not having reliable research data or a crystal ball to predict the long-term outcome of a person's illness (there is tremendous heterogeneity of outcomes for these disorders), it is best to stay away from definitive pronouncements about what a person will or won't be able to have or do in the future. When trying to help someone accept the reality of having a mental illness, suggestions for how to approach the situation and person are included below.
Start with the individual's understanding of the situation. This does not mean the practitioner should ignore or downplay the illness, but recognize that trying to force someone to identify with a diagnostic label he or she rejects is likely to be unproductive and lead to an impasse. This is especially true in the case of diagnostic labels that have been stigmatized by society for centuries, some that are associated with discrimination and suggest to people they have lost their minds or are dangerous. A very common and understandable response to being told one has an illness called "schizophrenia," for example, is for the person to protest that he or she is not a serial killer or doesn't have a "split personality."
Rather than fighting such a lose–lose battle, find out what is meaningful for the person and connect with the goals he or she wants to achieve. What dictates a meaningful life is subjective and unique to each individual, whether the person has a mental illness or not. If we are to help promote significant growth in another person, we must be cognizant of and sensitive to this. What are the individual's unique life goals? What would he or she want life to look like if all current challenges could be magically erased?
Without judgment, positively affirm any goals the person has that would be constructive to pursue. Your own opinion of how realistic the goal is (for example, getting a Ph.D. if the person has yet to complete high school) is not nearly as important as the fact that this individual has a goal he or she is willing to work toward. This offers the two of you a basis for discussing what would help the person progress toward the goal (e.g., a first step might be getting a GED).
Avoid diagnostic labels or terms. Instead, describe elements of the individual's life (over which he or she has some control) that conflict with his or her expressed life goals. Then elicit the person's observations and sense of whether these things are perceived as personally problematic. For example, "You said your goal is to have a job so you can leave the group home and support yourself independently, but as I see it, staying in bed all day and drinking are actively working against that goal. What do you think?"
Find the person's "buy-in." What aspects or byproducts of the illness can you both agree are problematic? Even if the person rejects the diagnosis, he or she may still be able to agree that a painful byproduct of the current situation has been fractured family relationships or job loss. Once these issues are identified as problematic, the two of you can begin to explore ways to improve them.
Inspire hopefulness by highlighting past successes and available strengths and resources. Rather than focusing on limitations, help the person develop insight into what it will take to achieve a specific goal, using past successes as examples. Specifically noting how treatment can aid in this process could also be helpful. If the goal is to have a job, you might point out that when the person took medication in the past, he or she was able to get adequate sleep and had the energy to work and concentrate.
Engage in a discussion about what needs to happen for the person to reach his or her goals. For some people, this might take a long time and the process may stall after you state your concerns. However, do not let this deter you from returning to the discussion on future occasions. You never know when a turning point might present itself. For the person who is ready to engage in this discussion, focus on hopeful and realistic steps. In the above example of an individual with no high school diploma interested in pursuing a doctorate, this means finding resources to connect the person with a GED course.
Be mindful that what concerns you in terms of a person's experience of symptoms may not be significantly concerning to him or her, and accept that what is meaningful to you may not be meaningful to someone else. For example, if the individual's voices have a special spiritual meaning, he or she may not agree the voices are hallucinations that should be treated with medication. Similarly, someone who feels artistic creativity is dampened by medication may choose not to take it. For that person, the ability to creatively express him or herself may be more important than not hearing voices, holding a job, or experiencing other side effects.
As providers, we all too often focus on the complete eradication of symptoms, to the point of excluding other elements of well-being. But it is critical to remember recovery can occur in the illness, not just from the illness—something both the person and the practitioner should know.
Do we seek to foster insight into limitations or possibilities? Regardless of a person's level of impairment, we can strive to offer insight into the possibilities of a meaningful life.
Gina Duncan is Assistant Professor in the Department of Psychiatry and Health Behavior at Georgia Health Sciences University.
Charmaine C. Williams and April Collins. 2002. Factors Associated with Insight Among Outpatients with Serious Mental Illness. Psychiatric Services, 53, 96–98. Retrieved 2012 from http://ps.psychiatryonline.org/article.aspx?articleid=86973.
| Professional Discipline Training Awards
The professional disciplines are developing training manuals from outlines finalized last fall. Technical content in their curricula follows a uniform framework to ensure consistency while being shaped by profession-specific characteristics. For example, each profession's curriculum includes the history of recovery; is based on SAMHSA's 10 recovery components; addresses trauma and cultural competency; reflects consumer involvement throughout the assessment, design, and delivery process; and addresses organizational systems through which training is conducted. The design and order of materials, marketing and dissemination, and delivery methods will ultimately reflect each discipline's unique findings as documented in the Situational Analyses. Although each discipline's curriculum will appear in a customized format and be delivered in strategic settings consistent with their target audience, the initial manuals will be ready for pilot testing by summer 2012. In addition, those who participate in the final training will receive educational credit, either continuing medical education or continuing education units, as appropriate.
Instead of a standard didactic approach to delivery, the American Psychiatric Association (ApA) and its partner, the American Association of Community Psychiatrists (AACP), plan to start their first training module with a video of a panel dialogue between psychiatrists and consumers. All nine modules will incorporate a video component to stimulate interaction and group discussion. The ApA/AACP target audience is divided into two primary groups: direct service providers and trainers/supervisors. Training of trainers who will teach the curriculum will produce a network of psychiatrist and consumer specialists who can conduct training in various organized settings. Additionally, the curriculum will be delivered in 60–75-minute online Webinars. Pilot testing formally begins May 2012, although much of the material has been tested in select ways since October 2011. Learn more.
The American Psychiatric Nurses Association (APNA) plans to submit their first complete training manual draft by February 2012 and finalize the manual in March. The training, which targets psychiatric mental health nurses who provide direct care in inpatient units, will be piloted in person at urban, rural, and university-based hospitals starting May 2012. Both private and public organizations will participate. The training program will ultimately be offered as online Webinars in two modules, totaling six hours. APNA's team, comprised of an RTP Steering Committee, Consumer Advisory Panel, and Curriculum Workgroup, is using an Appreciative Inquiry approach for the entire RTP project. They have titled the training, "Acute Care Psychiatric Mental Health Nurses: Becoming Experts in Recovery." Visit their RTP resources page for more information.
The American Psychological Association (APA) has submitted drafts for five of the planned 15 training modules. Their initial target audience is Training Directors (TDs), who will be trained to teach qualified and adjunct faculty at their institutions. Faculty members will teach curriculum modules in classroom settings in conjunction with consumers and doctoral and postdoctoral students. Based on the array of training programs for psychologists and nature of the curriculum, strategies exist for working with TDs to incorporate RTP modules into the curricula, with a balance between clinical and research programs. APA and the TDs will also reach out to State, Provincial, and Territorial Psychological Associations to identify qualified regional individuals willing to conduct visiting lectures. (Long-term plans will adapt curricula for online delivery.) Pilot testing begins this summer. Click here for more information about APA's RTP curriculum and other project activities.
The National Association of Peer Specialists (NAPS) Working Certified Peer Specialists, who form the relatively new and continually evolving profession, are the target audience for training. Given the dynamic nature of the field, which has yet to possess universal standards for training in particular competencies, the NAPS curriculum offers new opportunities to formalize career paths. The curriculum is designed by subject matter experts and training process experts and will be delivered in person at local, regional, and national meetings. Eight modules are planned: the first module has been submitted for review; the next three are expected soon. During creation of module 1, the NAPS curriculum development team realized an originally scoped 2-hour session would not be adequate (given the fundamental necessity for individual reflection and group dialogue). Each module will now span 4 hours and include pretests and posttests to evaluate effectiveness of the learning process. Read the Situational Analysis and final training outline on the NAPS Web site, and learn about pilot testing that will begin April 2012.
Finally, the Council on Social Work Education (CSWE) is developing their curriculum with the guidance of its Steering Committee, an active and diverse group. A subcommittee is finalizing the document on competencies and will link the competencies with accreditation standards this month. The target audience for training is field instructors—social work practitioners who supervise students in the field. In addition, a training package with resources specific to the target audience and educational programs (faculty and field directors) will use course content to present recovery-oriented practice materials to students in the classroom and in the field through field assessment. Training will be delivered via three Webinars (each 90 minutes) and six quizzes (three pretests and posttests) over a 4-month period. As a unique feature of the RTP project, CSWE plans to offer support to education contacts (program directors and field directors) and field instructors, using resources on their Web site and establishing Learning Collaboratives following training. Learn more.
| Personal Story
From Denial to Recovery Through Advocacy, by Victoria Costello
At age 17, my son Alex lost his ability to finish an entire sentence, wear shoes, get even a half night's sleep, or face other kids at school. The doctors who examined him at UCLA Neuropsychiatric Institute told me Alex should stay in the hospital's adolescent ward for a month so they could make a proper diagnosis and stabilize what they described as psychotic symptoms. Having raised two athletic sons to their early teens, I had been in an emergency room more than once. Still, I couldn't imagine any two words from someone in a white coat that would instill more terror in a mother's heart than "psychotic symptoms."
Before I left the hospital that day, Alex's doctor asked me to provide a family mental health history. I presumed this was to determine who might have bestowed the fatal genetic flaw that had brought my son to this precipice. As it turns out, there were several candidates from among the three generations of mental illness and addiction that had plagued my family, and at least one likely suicide I would go on to describe to answer the interviewer's probing questions. Like most people, I had always considered this private family business—best forgotten and not at all suitable for public airing.
I now see there is a natural tendency to avoid the stark reality of such portraits of collective misery for as long as possible. Because of my son's crisis, I no longer could. Alex, with his particular "lethal inheritance," which he worsened by smoking pot in the months before his hospitalization, had put himself in a category that mental health researchers now call "ultra-high risk."
The information I unearthed from my family mental health history—especially after I learned how to interpret it—became critical for our decision making in the treatment of Alex's paranoid schizophrenia. He benefitted by undergoing treatment in 1998, a time when doctors understood the concept of "early intervention" for the initial psychosis symptoms that can lead to schizophrenia.
With 2 years of psychotherapy and a brief course of antipsychotic medication, Alex returned to school and completed his education at a prestigious art college. Today, he is independent and living a full life with no symptoms. The important lesson to learn from Alex's situation is early intervention often depends on practitioners' full knowledge of the affected person's family mental health history. As Dr. Terrie Moffitt, a renowned pioneer in family mental health studies, said, "Family history can make the difference between 'treat now' or 'wait and see.' "
Seeing Alex on the path to recovery also helped me deal with my own lifelong major depression and alcohol dependence. I recognized and treated my younger son's depression and anxiety disorder without making him wait the three decades I had taken to help myself. I finally stopped the family legacy of denial that had continued for much too long. Knowing I'd stayed in a depressed state until my sons reached adolescence—and in the process raised their risks for mental disorders—filled me with deep regret.
Only in the last few years have I realized guilt had become my final and most tenacious addiction. The cure was letting go of the facade of "normalcy" and publicly telling my story. That led to a professional U-turn, where I quit trying to write the next Great American Novel and became a full-time mental health care advocate. By speaking out I felt other women might act sooner to help themselves, knowing by doing so they were also helping their children—a correlation that is now supported by elegant research. I now channel my advocacy efforts into my work as a board member and anti-stigma speaker for the Mental Health Association of San Francisco and in media outreach and in-person workshops to support publication of my soon-to-be-released memoir. The topic I explore most is how families can prevent or reduce mental illness through knowledge of their mental health history.
Victoria Costello is an Emmy award-winning science writer, blogger for PsychologyToday.com, and author of A Lethal Inheritance: A Mother Uncovers the Science Behind Three Generations of Mental Illness.
| Resource Spotlight
The Patient Centered Primary Care Collaborative (PCPCC) is a 900-member alliance of employers, consumer groups, hospitals, clinicians, and many other participants working together to develop and advance the patient centered medical home (PCMH). Created in 2006, the coalition seeks to improve interaction between patients and physicians and build a more efficient model of health care delivery.
PCMH will broaden access to primary care and enhance the quality of treatment by increasing clinicians' responsibility and accessibility to patients. Ideally, health care providers will be more flexible and accommodating—expanding office hours and seeing patients on short notice when necessary, conducting some consultations by phone and email, incorporating the latest technology and evidence-based medical approaches for optimal treatment, and practicing preventative care to avoid expensive emergency procedures.
The PCPCC Education and Training Task Force is promoting the preparation of a well-trained workforce that will practice PCMH principles to provide personalized care:
The task force aims to share information about education and available programs through Webinars and outreach efforts, develop a repository of training resources, address faculty development needs for teaching about the PCMH, and advocate for educational resources.
- Developing effective and caring relationships with patients
- Assessing biopsychosocial needs across the life span
- Planning patient-centered care, including collaborative decision making and patient self-management
- Advocating for patient-centered integrated care
| Related Links
SAMHSA's 2-day meeting in January convened more than 30 participants at its Rockville, Md., headquarters to discuss next steps for the Wellness initiative. Joint efforts with the FDA Office of Women's Health and Million Hearts™ Campaign are calling attention to the link between cardiovascular disease and behavioral health problems. At a National Press Club briefing with WomenHeart: The National Coalition for Women with Heart Disease, Million Hearts™ Executive Director Janet Wright shared statistics on cardiovascular and behavioral health, information she learned from the Wellness Steering Committee.
The Eleventh Judicial Circuit Criminal Mental Health Project (CMHP) was established in 2000 to divert people with serious mental illness away from the criminal justice system and into community-based treatment and support services. As an effective, humane, and cost-efficient solution to a community problem, CMHP offers hope to people who have been misunderstood and faced substantial discrimination. Once engaged in treatment and community care services, these individuals can progress toward community integration and recovery, thereby reducing recidivism rates. Recovery peer specialists are members of the jail diversion team who assist participants with community re-entry, housing, ongoing treatment, and services.
Through education, South Carolina Share (SC SHARE) offers the potential for recovery to people with mental illness. The organization started in 1985 and eventually became South Carolina's only statewide consumer-run mental health organization. Open to anyone who suffers from mental illness, SC SHARE provides members with guidance for living a "recovered" life. Their flagship program, "Recovery for Life: Helping Others Help Themselves," has produced two workbooks that address important components of healing, including overcoming obstacles, preventing a relapse, defining personal boundaries, and deciding to be okay.