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Title: Transforming Mental Health Systems to Promote Recovery for Persons with Serious Mental Illness:


1
Transforming Mental Health Systems to Promote
Recovery for Persons with Serious Mental
Illness Key Components for Implementation and
Sustainability Mary A. Jansen, Ph.D. Bayview
Behavioral Consulting, Inc. Vancouver, BC
2
Why Is Change Important? Isnt The System Ok As
It Is?
  • Why should we care about providing a system
    dedicated to actually helping people recover and
    achieve the life they want to live?
  • Most people with schizophrenia get no or
    virtually no care, little of the care is
    delivered consistent with the best evidence, and
    people with schizophrenia are overrepresented in
    most of lifes worst circumstances Incarcerated,
    homeless, disabled, or dying early. Hogan, M.
    (2010). Updated schizophrenia PORT treatment
    recommendations A commentary. Schizophrenia
    Bulletin, 36, 1, 104 106.
  • We have an ethical responsibility to change
    mental health systems to ensure people receive
    the full range of services they want and need
  • Requires a fundamental shift in thinking a
    paradigm shift/changing the organizational
    culture

3
This Presentation
  • We will review
  • Challenges involved in changing systems
  • Key components of a recovery oriented system
  • Essential elements for change and for
    sustainability
  • Suggestions for moving to a system that is
    focused on helping people recover and regain a
    satisfying and productive life

4
CHALLENGES AHEAD
5
What Is So Difficult?
  • While many recognize the need to change mental
    health systems to be
  • consumer and family driven
  • with a focus on helping people recover from the
    traumatic effects of serious mental illness (SMI)
    and achieve the potential they have
  • Accomplishing such transformational change and
    sustaining it, has proven to be exceptionally
    difficult
  • Some of the challenges include
  • Convincing staff to change their long held
    beliefs and practices
  • Re-allocating available resources
  • Helping administrators and providers understand
    and support proposed changes
  • Ensuring a comprehensive plan for evaluation of
    changes

6
Key Component Person Centered Planning
  • The individual with lived experience is in the
    drivers seat
  • Based on seeing and working with people in a
    completely different manner
  • Balance of power is shifted and decision making
    is shared
  • Individuals are fully integrated into the
    communities of their choice
  • Requires a shift in thinking its not business
    as usual anymore!

7
Key Component Person Centered Planning
  • CHALLENGES
  • Mental Health System
  • Providers tend to resist change
  • Lack of willingness to change attitudes, biases
    and beliefs about individuals with SMI
  • Inability to adapt to new way of providing
    services
  • Individual with SMI
  • Individuals do not ask for or are not ready to
    participate in services
  • May not be able to easily identify desired goals
  • Uncomfortable with making choices and translating
    needs and wants in to supporting services

8
Key Component Engaging People as Partners
Reasons People are Reluctant to Engage the MH
System
  • FROM THE SYSTEM ITSELF
  • Prior Negative Experiences and Possible Trauma
  • FROM THE INDIVIDUAL
  • Severity of Illness
  • Multiple social barriers
  • Poverty, homelessness, criminal history, ill
    physical health, social stigma, poor social
    skills, and social isolation. Need wide range of
    services
  • IMMIGRANT AND NON-MAJORITY POPULATIONS
  • Language barriers
  • Social stigma of behavioral health problems /
    Religious beliefs on the origin of mental illness
  • Cultural beliefs and practices related to
    decision making
  • Distrust of authority / Previous abuse from those
    in authority

9
Key Component Strengths Based Assessment
  • TRADITIONAL CLINICAL ASSESSMENTS
  • STRENGTHS BASED ECOLOGICAL ASSESSMENTS
  • Focus on strengths, not deficits
  • Gains information about skills resources needed
    to achieve goals
  • Cultural knowledge, spirituality
  • Family stories
  • Knowledge gained from adversities, occupational
    or parenting roles
  • Psychiatric diagnosis
  • Problematic symptoms and behaviors
  • Failures in social, educational vocational
    pursuits
  • Difficulties in life

10
Community / Social Inclusion
  • Downward Spiral of Marginalization

11
Community / Social Inclusion
  • Intrinsic and Extrinsic Sources of Stigma
  • INTRINSIC FACTORS
  • Odd Behavior Poor Hygiene
  • Fear of Rejection Uncomfortable around others
  •   EXTRINSIC FACTORS
  • Media that portrays people with SMI as dangerous
  • MH system that encourages segregation and stigma
  • Community advocates for segregation
  • Community rules for acceptable behavior
  • General intolerance

12
A Note about Services
  • Importantly, research evidence has been
    accumulating that
  • an integrated approach combining multiple
    interventions
  • within a recovery oriented context
  • May be the most effective approach
  • It also appears to be increasingly clear that
  • cognitive impairment is at the heart of the
    functional skill deficits so commonly experienced
    by people with serious mental illnesses
  • Although no definitive combination of approaches
    has been determined to be most effective
  • some combination of cognitive therapies
    (cognitive remediation, cognitive behavioral
    therapy), along with supported employment,
    psychoeducation (client/family approaches,
    illness management approaches), and social and
    communication skills training
  • Seems to be most promising!

13
Forensic Related Systems Issues
Homelessness, Substance Abuse, Trauma, Gender,
Race, Culture
  • Forensic Issues
  • Criminal justice many forensic systems
    antithetical to concept of recovery
  • Little treatment, emphasis on risk reduction
  • Respect, person centered, cultural
    considerations, EBPs not the norm in forensic
    settings
  • Justice settings are extremely re-traumatizing
  • Trauma is the norm, especially for women
    virtually all women in the forensic system have
    experienced severe trauma most men have as well
  • Forensic systems are universally re-traumatizing
  • Few resources, no training, dual stigma SMI
    criminality

14
Forensic Related Systems Interventions,
Transition Planning, Follow Up
  • Transition Planning and Follow up - Essential but
    Usually Lacking
  • Inadequate transition planning puts people with
    co-occurring disorders who enter jail in a state
    of crisis back on the streets in the middle of
    the same crisis
  • The period immediately after release is critical
    the first hour, day or week can determine
    success or failure - high intensity interventions
    that support the person during this time are
    essential
  • Without immediate monitoring and follow up many
    miss the first crucial health and social service
    appointments
  • Do not have medications
  • End up on the street
  • Quickly return to the forensic system

15
Change Whats Involved
  • Recovery Environment
  • True partnership with person and family
  • Believing that people will choose services they
    need to achieve a satisfying life
  • Overcoming provider resistance
  • Commitment and Leadership by All Everyone Must
    be There
  • All must be committed clients, families, staff,
    leaders, politicians
  • Change must be implemented in total - not
    piecemeal
  • Long term process will not take hold overnight
  • There are frequent changes in leadership -
    Processes must be put in place that will continue
    when leaders change
  • Careful hiring, continual staff training

16
Essential Elements for Sustainability
  • Collaboration With All Stakeholders
  • Genuine partnership with recipients, families,
    professionals
  • Development of person and family leadership
  • Provider resistance
  • Ongoing monitoring of process
  • Provider resistance
  • Ongoing training and supervision
  • Provider resistance
  • Careful Hiring
  • Must ensure the right personnel are in place and
    receive on-going supervision

17
Essential Elements for Sustainability, contd
  • Allocation of Sufficient Resources
  • Follows from commitment
  • Shifting of resources priorities may be
    necessary
  • Provider resistance
  • Appropriate Services
  • A comprehensive system to meet the needs and
    wishes of people with serious mental illnesses
    within a person centered, recovery oriented
    perspective
  • Evidence based practices (EBPs)
  • Promising practices
  • Supporting services
  • FIDELITY!!!!!!

18
Essential Elements for Sustainability, contd
  • Data Collection
  • Absolutely necessary
  • Requires a system to gather information and data
  • IMMEDIATELY
  • Assess attitudes, vision, concerns of moving to a
    system that truly promotes recovery
  • Willingness to make changes based on data and
    feedback

19
After Accomplishing Change, Then What?
  • Critical for Sustainability
  • In systems where change has taken place,
    sustaining those changes has proven exceptionally
    difficult
  • Necessary
  • Clinical measurement, cost comparison, and
    feedback system
  • Provisions for informing managers and
    administrators of results on a regular basis
  • Willingness to make further changes based on
    results

20
Ensuring Success
  • Sustainability
  • The job isnt finished when new services are in
    place
  • Frequent changes in mental health leadership are
    a continual threat
  • Sustainability requires careful attention to
    transcend leadership changes
  • Requires diligence!
  • Need
  • Processes that will transcend leadership changes
  • Active partnerships
  • Data, data, and more data
  • What happens when there are no data - ??

21
What Can I Do?
  • 6 Simple Things to Get Started
  • Speak to supervisor about 1 program to be used as
    a pilot or test case
  • Choose a program you manage and where change can
    be measured EASILY
  • Talk it up among colleagues, clients, family
    members
  • Design VERY SIMPLE pre-post evaluation outcome,
    satisfaction, staff perception, etc. perhaps 2
    questions per category
  • Present results honestly!
  • Use results to make change permanent

22
Scientific Foundations
  • Research Methods Mixed Methods Designs
  • Traditional research methods (quantitative
    qualitative) have advantages and challenges
    neither captures effects of community
    interventions well
  • True mixed method research combines quantitative
    and qualitative data collection and analysis in
    the same study not in sequential processes, but
    as part of one overall research design
  • This method broadens the questions that can be
    asked and answered, and offers the possibility to
    do so all within the same study
  • Possible to answer both exploratory
    confirmatory questions in the same study.
    Permits verification generation of theory in
    the same study

23
Curriculum Modules
  • Instruction Module
  • 1. Introduction to Recovery
  • 2. Recovery, Health Reform and Psychology
  • 3. Assessment
  • 4. Partnership and Engagement
  • 5. Person Centered Planning
  • 6. Health Disparities
  • 7. Interventions I
  • 8. Interventions II
  • 9. Interventions III
  • 10. Forensic and Related Issues I
  • 11. Forensic and Related Issues II
  • 12. Community Inclusion
  • 13. Peer Delivered Services
  • 14. Systems Transformation
  • 15. Scientific Foundations

24
Citation for this Module American Psychological
Association Jansen, M. A. (2014). Introduction
to Recovery Based Psychological Practice.
Reframing Psychology for the Emerging Health Care
Environment Recovery Curriculum for People with
Serious Mental Illnesses and Behavioral Health
Disorders. Washington, DC American
Psychological Association. www.apa.org/pi/rtp C
itation for the full Curriculum American
Psychological Association Jansen, M. A. (2014).
Reframing Psychology for the Emerging Health
Care Environment Recovery Curriculum for People
with Serious Mental Illnesses and Behavioral
Health Disorders. Washington, DC American
Psychological Association. mjansen_at_bayviewbehavi
oral.org
25
Mary A. Jansen, Ph.D. Bayview Behavioral
Consulting, Inc. Vancouver, BC mjansen_at_bayviewbeh
avioral.org
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