Realizing the Promise of Community Support Services in the idea of (Mental Health) Recovery

1
Realizing the Promise of Community Support
Services in the idea of (Mental Health) Recovery

• Jerry Floersch, Ph.D., LISW
• Jeffrey Longhofer, Ph.D., LSW
• Paul Kubek, M.A.
• Lisa Oswald, M.S.S.A.
• Case Western Reserve University
• Mandel School of Applied Social Sciences

2
Emptying Hospitals Presented Challenges

• Housing
• Education
• Jobs
• Medication
• Mental Health and Social Services
• In sum, basic quality of life issues

3
In the 1970s, NIMH responded with Community
Support Services (CSS). Since then,

• case management and CSS models have proliferated,
  each with specialized languages and approaches
• Strengths
• Assertive Community Treatment
• Clubhouse Model
• Family Psychoeducation
• Medication Management
• AND MOST RECENT, RECOVERY

4
In the last 15 years, 5 major developments have
occurred in Community Support Services

• Evidence-based practice--Research Point of View
• Recovery--Policy or Advocate Point of View
• Caregiver ExperienceCaregiving Point of View
• Client/Consumer Experience--Client /Consumer
  Point of View
• Cultural competence--Multicultural Point of View

5
Evidence-Based PracticeResearch point of view

• Illness Management Recovery
• Medication Management
• Assertive Community Treatment
• Family Psychoeducation
• Supported Employment
• Integrated Dual Disorders Treatment

6
Caregiver Experience practitioner/family/friend
point of view

• What do caregivers, professionals, friends,
  family, and peers do?
• How do caregivers experience mental health
  caregiving?

7
Client Experience client point of view

• How is mental health caregiving experienced?
• How are caregiving relationships experienced?
• What is the everyday experience of a severe
  mental illness?

8
Cultural Competencemulticultural point of view

• Do CSS models and practices apply across the
  diverse cultural groups present in our society?
• How can specialized languages be cross-cultural?

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Recoverypolicy or advocate point of view

• The most recent
• It is not yet a practice, but a point of view or
  philosophy
• Yet, it is gaining in popularity
• And, the word Recovery gets a lot of use in our
  everyday life

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During the last month, 160 New York Times
articles used the word Recovery to describe
business, sports, and war experiences

• In a Tournament of Upsets, White Misses a
  Recovery By ROBERT BYRNE   (NYT)   News  
• The Stage May Be Set for a Tech Recovery By
  KENNETH N. GILPIN   (NYT)   News
• Samsung Profits Fall 41, but Investors See
  Recovery Ahead By DON KIRK   (NYT)   News  
• Driving Along a Virtual Road to Recovery By ABBY
  ELLIN   (NYT)   News  
• A NATION AT WAR THE RECOVERY Relief Agencies
  Are Forced to Wait as Chaos Reigns By ELIZABETH
  BECKER   (NYT)

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Moreover, without an accepted criterion for
deciding which of the 5 points of view should be
centered in CSS practice, must we learn each
specialized language in order to accrue their
unique benefits?
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Thus, with 5 credible Points of View, and often
competing, must we learn all 5 specialized
languages?

• In other words, does the client sometimes wonder
  are you (that is, practitioner, policymaker, or
  researcher) speaking to me from your illness
  management recovery, medication management,
  assertive community treatment, supported
  employment, strengths, dual diagnosis, or
  recovery standpoint?

13
Researchers often claim to have an objective
standpoint for selecting practices, thus they
offer us

• Evidence-based practices
• Yet, this centers the need to generalize
  findings, or find some practice that works for
  everyone.
• I dont question the standard research methods
  here

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Instead, I argue that of the 5 CSS developments,
Recovery is conceptually robust to represent all
points of view.
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Clients have wanted jobs and less stigmatizing
services, thus the rise of supported employment
and clubhouse models.
16
Parents and siblings have asked to be heard and
incorporated into treatment, thus the rise of
family psychoeducation.
17
Practitioners have recognized that some clients
lack awareness or motivation to engage the CSS
system, thus the rise of assertive community
outreach.
18
Researchers have desired fidelity to empirically
based interventions, thus the rise of
evidence-base practice.
19
Policymakers have needed accountability and
information systems, thus the rise of outcomes
data management.
20
Cross-cultural advocates have argued for services
that respect and understand cultural difference,
thus the rise of culturally competent practice.
21
Consequently, it is impossible to ignore any one
of the related, but separate, CSS standpoints.
22
WHAT IS RECOVERY IN MENTAL HEALTH?

• self-mastery
• self-control
• empowerment
• hope
• a non-linear and small-step approach
• self-responsibility
• partnership
• and renewed social roles

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Ohio Department of Mental Health

• . . . recovery is an internal, ongoing process
  emphasis added requiring adaptation and coping
  skills, promoted by social supports, empowerment
  and some form of spirituality or philosophy that
  gives hope and meaning to life (Beale Lambric,
  1995, p. 8).

24
William AnthonyBoston Center for Psychiatric
Rehabilitation

• a deeply personal, unique process of changing
  ones attitudes, values, feelings, goals, skills
  and/or roles. It is a way of living a
  satisfying, hopeful, and contributing life even
  with limitations caused by the illness. Recovery
  involves the development of new meaning and
  purpose in ones life as one grows beyond the
  catastrophic effects of mental illness (Anthony,
  1993, p.7).

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National Alliance for the Mentally Ill

• TRIAD or, Treatment/Recovery Information and
  Advocacy Database
• In collaboration with other stake-holders, NAMI
  will collect a variety of data that characterizes
  the gap between the services, supports, and
  environment we all agree are necessary for
  recovery and what exists in each state.

26
The Robert Wood Johnson Foundation and Substance
Abuse and Mental Health Service Administration

• http//www.mentalhealthpractices.org/index.html

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Thus, various CSS stakeholder groups clients,
policymakers, family members, researchers, and
practitioners evidenced by the examples above,
use the idea of Recovery to organize community
work by (inter)connecting their specific
stakeholder objectives with the client Recovery
goals of empowerment, self-mastery, hope, and
living beyond the disability.
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Research on the process of Recovery

• Most of the early research has been qualitative
• Start near the experience
• Thus, Recovery is being built from the ground up

29
Participant-Observation Research

• Colleagues and I observed caregiving
  relationships negotiate the acquisition of
  community goods, vocational services, health and
  mental health services.
• We participated like case managers in
  transporting clients to appointments, helping
  them access resources (e.g., grocery shopping),
  and staying in continuous contact to experience
  everyday life.
• We observed service providers and other
  caregivers as they interacted with clients.

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Coding Observations

• Borrowed from my previous findings, Strengths
  case managers often talked about doing for and
  doing with clients.
• Meds, Money, and Manners (2002) Columbia
  University Press
• Added categories by comparing mental health
  caregiving with the everyday caregiving among
  parents, and their sons and daughters.

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Four Processes of Self-Mastery

• Doing for
• Doing with
• Standing by to admire
• Doing for oneself

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Doing For

• There is the doing for process, with the
  caregiver doing the caring for the individual who
  essentially enjoys being done for

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Doing With

• Next comes the doing with process, where
  caregiver and recipient, in varying proportion,
  share in the tasks

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Standing by to Admire

• Then comes the standing by to admire process,
  where the individual is doing some aspect of
  self-care without any assistance

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Doing for Oneself

• The final process is doing for oneself, where
  the individual has internalized both the
  caregiving of himself and the satisfaction it
  brings to such an extent that caregivers bodily
  presence and emotional investment are no longer
  required.

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4 Forms of Recovery Relatedness

• Underscores the importance of relationships
• Is a commonsense language that does powerful work
• It provides a framework for understanding
  caregiving

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Internal or Emotional Recovery Process (4 Forms)

• Overwhelmed by disability
• Struggling with disability
• Living with symptoms of disability
• Living beyond disability
• Spaniol et al. (2002). The process of recovery
  from schizophrenia. International Review of
  Psychiatry (14) 327-336

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Overwhelmed by the disability

• Overwhelmed by the disability is an ongoing and
  recurrent debilitating anxiety, it often begins
  at the onset of illness, and it can last for
  months or years. Daily life can be a struggle
  mentally and even physically. The person tries
  to understand and control what is happening, but
  often feels confused, disconnected from the self
  and others, out of control, and powerless to
  control his or her life in general (Spaniol et
  al., 2002, p. 328).

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Struggling with the disability

• In struggling with the disability the person
  recognizes the need to develop ways of coping
  in order to have a satisfactory life (Spaniol et
  al., 2002, p. 330).

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Living with the disability

• The phase of living with the disability is
  exemplified by a stronger sense of self and the
  idea that a confident self is recovered from
  the illness.

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Living beyond the disability

• Identifies the person who feels well connected
  to self, to others, to various living, learning
  and working environments, and experiences a sense
  of meaning and purpose in life (Spaniol et al.,
  2002, p. 331).

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Correlate 4 forms of relatedness with client
internal experience

• Vygotsky theorized that mental development is
• the distance between the actual development
  level, as determined by independent problem
  solving, and the level of potential development
  as determined through problem solving under adult
  guidance or in collaboration with more capable
  peers (Wertsch, 1979, p 2)

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Vygotsky argued that

• that higher mental functions appear first on the
  interpsychological (i.e., social) plane and
  only later on the intrapsychological (i.e.,
  individual) plane (Wertsch, 1979, p. 2).
• Thus, we theorized that the 4 forms of
  relatedness are the means by which clients
  internalize new mental functions.

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Mapping the work of Recovery Relationships
External (social relations) experience Feeling Thinking Action Internal or Emotional Process Feeling Thinking Action Internal or Emotional Process Feeling Thinking Action Internal or Emotional Process Feeling Thinking Action Internal or Emotional Process
4 forms of relatedness O overwhelmed by disability SW struggling with disability LW living with disability LB living beyond disability
DFO doing for oneself
SBA standing by to admire
DW doing with
DF doing for
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Zone of Recovery Relatedness

• The matrix was used in field research to track
  caregivers interactions with clients. It was
  observed that client emotional experience
  fluctuated from event to event and even within
  particular events.

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Zone of Recovery Relatedness

• Just as internal (emotional) experiences
  fluctuated, so did the 4 forms of relatedness
  indeed in using the ZRR to map caregiver and
  client interactions, the changing relationship
  between the clients internal and external worlds
  was revealed.

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Case Illustration
x x Action x x Action x x Action x x Action
Lisa and Roberts friend pack and move boxes for Robert. Lisa and Roberts friend pack and move boxes for Robert. Lisa and Roberts friend pack and move boxes for Robert. Lisa and Roberts friend pack and move boxes for Robert.
O overwhelmed by disability SW struggling with disability LW living with disability LB living beyond disability
doing for oneself
standing by to admire
doing with
doing for x
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Case Illustration
Feeling x x Feeling x x Feeling x x Feeling x x
Lisa monitors and names Roberts feelings. Lisa monitors and names Roberts feelings. Lisa monitors and names Roberts feelings. Lisa monitors and names Roberts feelings.
O overwhelmed by disability SW struggling with disability LW living with disability LB living beyond disability
doing for oneself
standing by to admire
doing with
doing for x
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Case Illustration
Thinking x Action Thinking x Action Thinking x Action Thinking x Action
Lisa monitors Roberts spending in the grocery store. Lisa monitors Roberts spending in the grocery store. Lisa monitors Roberts spending in the grocery store. Lisa monitors Roberts spending in the grocery store.
O overwhelmed by disability SW struggling with disability LW living with disability LB living beyond disability
doing for oneself
standing by to admire
doing with
doing for x
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Case Illustration
Feeling x x Feeling x x Feeling x x Feeling x x
Robert reports that he missed the last appointment with his psychiatrist and has stopped taking medication. He reports being afraid of getting in trouble. Robert reports that he missed the last appointment with his psychiatrist and has stopped taking medication. He reports being afraid of getting in trouble. Robert reports that he missed the last appointment with his psychiatrist and has stopped taking medication. He reports being afraid of getting in trouble. Robert reports that he missed the last appointment with his psychiatrist and has stopped taking medication. He reports being afraid of getting in trouble.
O overwhelmed by disability SW struggling with disability LW living with disability LB living beyond disability
doing for oneself x
standing by to admire
doing with
doing for
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Case Illustration
x Thinking x x Thinking x x Thinking x x Thinking x
Lisa helps Robert develop a plan to contact his psychiatrist and get more medication. Lisa helps Robert develop a plan to contact his psychiatrist and get more medication. Lisa helps Robert develop a plan to contact his psychiatrist and get more medication. Lisa helps Robert develop a plan to contact his psychiatrist and get more medication.
O overwhelmed by disability SW struggling with disability LW living with disability LB living beyond disability
doing for oneself
standing by to admire
doing with x
doing for
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Doing For

• In moving to a new apartment, Robert was
  overwhelmed and as consequence, he benefits from
  doing for caregiving. Thus, it is theorized
  that when caregivers are doing for they
  introduce the recipient to a communicative/action
  context involving other-regulation (or
  regulation-by-others). In doing for
  interactions, the individual does not take on
  strategic responsibility but engages instead in a
  communicative act of identifying or naming the
  task (e.g., in Roberts case, I am moving but I
  am not packing). Here, the person in Recovery
  leans on the hopefulness and initiative of the
  other. Robert, for example, needed to lean on a
  caregiver in order to successfully complete his
  move into an apartment.

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Doing With

• In this second form of relatedness, doing with,
  the recipient of help is aware of naming the task
  but requires someone to stand alongside and do
  with. While the person in Recovery is not
  functioning as an independent problem solver, he
  or she is developing an intersubjective sense for
  the type of feeling, thinking, and action
  necessary for independent activity. A caregiver
  helped Robert develop a plan to contact her
  psychiatrist and get more medication, for
  example.
• This intersubjective sense of self-sufficiency is
  a necessary experience in the Zone of Recovery
  Relatedness because it allows the individual to
  experience interdependency as positive. The
  desired outcome of this form of relatedness is a
  sense of pleasure in doing with others, an
  internal feeling state that can protect against
  the most common negative effects of mental
  illness, namely social isolation and stigma.

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Standing by to admire

• In the third form of relatednessstanding by to
  admireRobert achieves the feeling, thinking,
  and action steps needed for task achievement.
  Reflected in personal awareness statements (i.e.,
  I did), Robert accounts for performance while
  taking on a significant share of task
  responsibility. Caregivers, in turn, no longer
  have to stand alongside, or do for.
  Other-admiration can reinforce feelings of
  personal accomplishment.
• The desired outcome of using this form of
  relatedness is for the one receiving the
  caregiving to internalize the admiration of the
  other and use the other-admiration as a scaffold
  for building personal self-esteem, a necessary
  internal subjective state that provides
  protection from overwhelming feelings of
  powerlessness.

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Doing for Oneself

• In the fourth form of relatedness, Robert takes
  over from others the problem-solving effort. The
  process shifts from the interpsychological to the
  intrapsychological plane and the transition from
  other-regulation to self-regulation is completed.
  The person masters Recovery tasks.
• And when individuals internalize the feelings of
  mastery, the 4 forms of relatedness go
  underground and become hidden by the personal
  sense that I produced and mastered the task.
  In other words, the person in Recovery
  internalizes the people in the helping network.

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Tools for Recovery Practice

• Clients
• Caregivers (formal and informal)
• Supervisors
• Administrators, Researchers, and Policymakers