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May 24, 2012 Volume 3, Issue 19
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Call for Papers


RTP is calling for personal and practitioner articles that illustrate the principles and potential of recovery. Whether they describe how self-directed care has changed the nature of your practitioner–client relationship, your journey of healing and recovery, a recovery-oriented tool or strategy, or how peer involvement has influenced your workplace, your stories deeply touch our readers and continue to make a difference in advancing the mission and values of Recovery to Practice.

To submit an article or recovery resource, please contact us at 877.584.8535, or email recoverytopractice@dsgonline.com.

Resident Training in Recovery
by Stephanie LeMelle, M.D., and Jules Ranz, M.D.
The Accreditation Council of Graduate Medical Education (ACGME) Psychiatry Residency Review Committee requires teaching in systems-based practice (SBP) and community psychiatry. Although recovery training is not mandatory, Columbia University's Public Psychiatry Education Program supports recovery principles as a foundation for teaching SBP and community psychiatry.

ACGME's definition of community psychiatry refers to people with "persistent and chronic" illness. Although recovery was popularized in part by compelling accounts from people with severe mental illness, the concept has expanded to include all patients receiving care in public and community settings. Accordingly, discussions with ACGME to broaden its definition of community psychiatry are ongoing.

Many residency programs do not provide dedicated didactic or clinical training in SBP, community psychiatry, or recovery, nor do they have faculty trained in these areas. To address these deficits, Columbia's Department of Psychiatry has developed a recovery-oriented training program that incorporates SBP in community psychiatry settings. The program's structure is based on a study that defined SBP in psychiatric care as four roles performed by psychiatrists: Patient Care Advocate, Team Member, Information Integrator, and Resource Manager.

Educational modalities include didactic classes, clinical rotations, supervision, and oral and written case presentations. Teaching in each setting will unfold over the course of the 4-year training program.

Didactics
Each lecture uses clinical examples to illustrate key points and recovery principles, and links directly to residents' clinical experiences and site visits. The seminars emphasize SBP and highlight the psychiatrist's role in each system presented. Residents are encouraged to participate by applying their clinical experiences to support ideas and arguments.

The PGY1 lectures establish a historical framework for understanding the current state of community mental health systems. These lectures cover 200 years of community psychiatry in the U.S. and review three system changes that led to downsizing state hospitals: new treatments (psychotherapy and pharmacology), the Civil Rights Movement, and shifts in funding streams.

PGY2 lectures focus on recovery-oriented and evidence-based practices (EBPs). Designed to expose residents to the different systems people with mental illness navigate, lectures build the foundation of knowledge residents need to perform the main SBP roles. EBPs discussed in the PGY2 lectures are Housing First, Supported Employment, and Wellness Self-Management; the PGY3 lectures cover Co-Occurring Substance Abuse Treatment and Assertive Community Treatment Teams. Lectures emphasize the psychiatrist's responsibilities as Patient Care Advocate and Team Member. Person-centeredness and shared decision making are needed to carry out these roles, which require a recovery orientation. Students are encouraged to identify the roles in inpatient systems of care where they have participated as PGY1 and PGY2 residents.

PGY3 residents work primarily in outpatient settings, where they tend to act more independently. Consequently, their ability to work with multiple systems of care becomes increasingly important. PGY3 lectures focus on integrated systems of care, which combine mental health treatment, substance abuse and physical health care, criminal justice involvement, and peer-run programs.

Serving as junior attendings, PGY4 residents become more involved in management and mental health policy development. Because it is crucial for residents to understand the administrative, financial, and political mechanisms that govern mental health care, PGY4 lectures focus on the psychiatrist's role in leadership and administration. Lectures demonstrate the SBP roles of Information Integrator and Resource Manager as well as clinical practices for recovery and policies for systems change. A final meeting is held with the New York State Office of the Mental Health Commissioner.

Clinical Rotations
SBPs are relevant in all clinical settings, including inpatient, emergency services, and outpatient programs, as well as in private practice. The Public Psychiatry Education Program has developed inservice training for supervisors on SBP roles and we expect these principles will be taught in clinical settings.

We have conceptualized the four SBP roles as milestones to measure progress at the end of each year and to be cumulatively achieved throughout all training years. At the end of PGY1, residents should be skilled in the Patient Care Advocate role. PGY1 residents spend much of the year in medicine rotations and often become the clinicians responsible for direct patient care. At the end of PGY2, residents should be proficient as Team Members. PGY2 is primarily an inpatient year for residents, who participate as members of multidisciplinary teams. After completing PGY3, residents should be competent as Information Integrators. PGY3 residents are in outpatient clinics and act as boundary spanners to obtain information from multiple systems of care, analyze the information, and help patients formulate comprehensive treatment plans. At the end of PGY4, residents should be proficient as Resource Managers. PGY4 residents spend most of the year in electives and act as junior attendings in various programs. They often take leadership roles and have the opportunity to affect policy and management.

Each resident is assigned to a community psychiatry site and accompanied by a supervisor who is familiar with the conceptual model for SBP. In this setting, residents have the opportunity to observe how people with mental illness live and function at their baseline in the community.

Person-Centered Systems Evaluation
Each resident chooses one patient from his or her caseload and reviews with the patient the various systems of care he or she navigates. The review is split into eight parts: mental health, physical health, substance use and abuse, social and family life, vocational and educational needs, housing, legal issues, and financial issues. During the initial review, residents incorporate recovery principles by helping patients prioritize these systems, which will become the focus of treatment throughout the year. As they work with patients, residents are encouraged to actively use all four SBP roles. If one role does not achieve the expected goal, they will try a different role and approach to meet the objective.

Supervision
An important component of medical education is clinical supervision. The supervisor–supervisee relationship in psychiatry is generally focused on psychotherapy and medication management. An SBP and recovery approach broadens the psychiatrist's traditional roles and emphasizes the whole person and the systems of care he or she navigates. To ensure proper supervision, we have developed inservice training for clinical supervisors. Training reviews the four SBP roles and focuses on measurable objectives for clinical rotations. It uses vignettes and evaluation tools, which have been developed to measure a resident's knowledge and clinical ability to perform SBP roles.

The Public Psychiatry Education Program incorporates a curriculum model in community psychiatry that can be adapted to meet the needs of any residency training program. Because its principles are systems based and recovery oriented, the program can be modified to fit urban and rural settings, special populations, and training programs with limited resources.

Stephanie LeMelle is Co-Director of the Public Psychiatry Education Program at Columbia University in New York, N.Y., and can be contacted at sml35@columbia.edu. Jules Ranz is Director of Columbia University's Public Psychiatry Fellowship and Public Psychiatry Education Program. He can be contacted at jmr1@columbia.edu.

Register Now Recovery Resource
The National Association of State Mental Health Program Directors is offering a course designed for mental health practitioners who are new to the field of prevention science. Becoming a Preventionist is a self-guided teaching tool designed to help providers incorporate prevention in everyday practice.

See the guide.

Celebrate Mental Health Awareness Month
How can peer support specialists and service providers honor a consumer's spiritual health during crisis? The Support, Technical Assistance and Resources (STAR) Center's Spiritual Wellness Webinar will address family members, friends, and behavioral health professionals as presenters discuss ways to comfort loved ones and consumers while acknowledging their diverse spiritual backgrounds.

Register online for the May 31 Webinar and explore the STAR Center's many resources, including guidelines on multicultural competence, intense spiritual experiences, and mental health.

How Your Differences Make You Exceptional
A new book by psychiatrist Dale Archer, M.D., is rethinking the principles that constitute mental health. Better Than Normal is a New York Times Best Seller that examines eight behavioral traits traditionally seen as weaknesses.

Dr. Archer challenges conventional perceptions of mental health, encouraging people to embrace their differences. "We've become a society that feels that any type of emotion, any type of quirkiness is abnormal," he said in the Advocate. "We don't want to feel these pesky emotions."

Redefining common disorders, Dr. Archer associates strengths and creativity with unique personality traits. People with bipolar disorder are "high energy." And those diagnosed with attention deficit hyperactivity disorder are "adventurous," not distracted.

Read more about Dr. Archer and his book, Better Than Normal.

RTP Wants to Hear From
Recovery-Oriented Practitioners!
We invite practitioners to submit personal stories that describe how they became involved in
recovery-oriented work and how it has changed the way they practice.
RTP Wants to Hear From You, Too!
We invite you to submit personal stories that describe recovery experiences. To submit stories or other recovery resources, please contact us at 877.584.8535, or email recoverytopractice@dsgonline.com.

We welcome your views, comments, suggestions, and inquiries.
For more information on this topic or any other recovery topic,
please contact RTP at
877.584.8535, or email recoverytopractice@dsgonline.com.


The views, opinions, and content of this Weekly Highlight are those of the authors, and do not necessarily reflect
the views, opinions, or policies of SAMHSA or the U.S. Department of Health and Human Services.