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Implementing Recovery Oriented Interventions
with Diverse PopulationsPiper S. Meyer, Ph.D.
University of North Carolina at Chapel HillUSA
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
IMR and Diverse Populations
Inpatient units
• Long and short-term
• Forensic
Persons with Developmental Disabilities
Outpatient settings
• Persons with cognitive impairments
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.
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
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
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
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?
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. . .
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.”
Marie
illness
Family
Friends
Values&Beliefs
Spirituality
SchoolP
olitics
Wo
rk
Cul
ture
SexualityHopes&Dreams
Goal of IMR:
Putting the Person in the Center
IMRIM
R Supporters
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
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
Recovery & Hope
“If people are treated as capable, they often surprise
everyone and live up to expectations.”
• Ken Steele “The Day the Voices Stopped.”
In IMR
People define what recovery means to them, as individuals.
People set their own personal recovery goals.
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)
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
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
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
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.
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
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
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
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
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)
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)
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
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
IMR Personal Goal Tracking Sheet
Name:___Jacob____________ Date Personal Goal Set:___7/29/09_________ Personal Goal: To have a conversation with my brother First Short-term Goal related to achieving your Personal Goal:
1._Have at least 1 conversation per day _________________
Steps: 1. _Make a list of coping skills for when I feel stressed Completed ____
2._Practice using a coping skill when I am around others Completed ____
3._Review steps of skill for starting a conversation__ Completed ____
4._Practice starting a conversation at least once a day_ Completed ____
Goal Follow-up: It’s important to track how your goals are going. Please check off the steps you have completed on your first short-term goal. Then write down your new steps below. Next or New Steps:
Steps: 1. ____________________________________ Completed ____
2.____________________________________ Completed ____
3._____________________________________ Completed ____
4._____________________________________ Completed ____
IMR Personal Goal Tracking Sheet
Name:___Jacob____________ Date Personal Goal Set:___7/29/09_________ Personal Goal: To have a conversation with my brother First Short-term Goal related to achieving your Personal Goal:
1._Have at least 1 conversation per day _________________
Steps: 1. _Make a list of coping skills for when I feel stressed Completed _X_
2._Practice using a coping skill when I am around others Completed ____
3._Review steps of skill for starting a conversation__ Completed ____
4._Practice starting a conversation at least once a day_ Completed ____
Goal Follow-up: It’s important to track how your goals are going. Please check off the steps you have completed on your first short-term goal. Then write down your new steps below. Next or New Steps:
Steps: 1. _Practice deep breathing when I am around others Completed ____
2._Say Hello to 3 people on the unit each day_____ Completed ____
3._Make a list of topics to talk about with brother Completed ____ with a staff member 4._Review steps of starting a conversation with brother Completed ____ with a staff member
Illness Management and Recovery: Coping With Stress
How can coping with stress help you?
Monday Class-What is Stress
• Goal-To identify at least one situation that you find stressful
Agenda
1. What is Stress?
2. What kinds of situations make you feel under stress?
3. How do you feel when you are under stress?
Ideas for Skills Practice
1. Describe a stressful situation that occurred over the past couple of days.
2. Make a chart to track stressful events over the next 2-3 days. Include information about the
situation and how you felt before and after the event.
Tuesday Class-Signs that You are Under Stress• Goal-Identify at least 1 sign you are under stress
Agenda
1. Different signs of stress-physical and emotional
2. Stress can also affect thinking, mood, and behavior
3. Become aware of your own signs of stress.
4. Did you have any signs of stress in the last few days? If yes, what were they?
Ideas for Skills Practice
1. Briefly describe a sign of stress that you experienced recently.
2. Fill out the Signs of Stress Checklist.
Wednesday Class-Preventing Stress
● Goal-Identify at least 1 strategy you can use to prevent stress
Agenda
1. Figure out at least one situation that is stressful to you or has caused you stress in the past.
2. What is a strategy for handling the situation so that it won’t be as stressful in the future?
3. Develop a routine of doing activities that you enjoy.
4. What activities do you enjoy doing or find relaxing?
5. How can you participate in this activity more often?
6. Who would you feel comfortable talking to if you feel you are under stress?
Ideas for Skills Practice
1. Choose a strategy for preventing stress. Write down the strategy and note when and where
you plan to use this strategy over the next few days.
2. Try out a a new strategy for preventing stress. How did it go?
Stress is the feeling of pressure or tension that comes from dealing with challenging
situations
Being aware of signs of stress can help you take steps to prevent it from getting worse.
Thursday Class-Strategies for Coping With Stress
● Goal-Identify at least one strategy you can use to cope with stress.
Agenda
Strategies for coping with stress:
1. Talk to someone about the stress that you have been feeling.
2. Use positive self talk, for example, “This is hard, but if I take this one step I can do it.”
3. Do meaningful activities.
Ideas for Skills Practice
1. Choose a strategy for preventing stress. Write down the strategy and note when and where
the you plan to use this strategy over the next few days.
2. Try out a a new strategy for preventing stress. How did it go?
Friday Class-Relaxation Strategies
● Goal-Use at least one relaxation strategy in session (relaxed breathing, muscle relaxation, or
imagining a peaceful scene) and identify a situation where using the coping strategy may help you
cope with stress
Agenda
1. Go through the steps of at least one relaxation strategy (relaxed breathing, muscle relaxation, or
imaging a peaceful scene)
2. What is an example of a common situation in your life when you could use relaxed breathing,
muscle relaxation or imagining a peaceful scene to help with tension in your body?
Ideas for Skills Practice
1. Practice the relaxation strategy (relaxed breathing, muscle relaxation, or imaging a peaceful
scene) with a staff member.
2. Make a plan to practice muscle relaxation on your own. Write down and note when and where
you plan to use this strategy in the coming week..
Additional Class-Making a Plan for Coping with Stress
● Goals-Identify what strategies are helpful to you to cope with stress and develop an individual plan
for coping with stress.
Agenda
1. What strategies are helpful to you when you are feeling stressed?
2. Fill out the Plan for Coping with Stress including the sections: stressful situations I am aware of,
signs that I am under stress, my strategies for preventing stress, and my strategies for coping with
stress once it happens.
3. Role play how you will use your plan.
Ideas for Skills Practice
1. Make a plan to do something from your “Coping with Stress Plan.”
2. Role play how to use a strategy in your plan.
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
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
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
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
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
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
Recovery-Next Steps
How can recovery become self-sustaining?
Peer led movements
Working with forensic populations
• Implementing within restrictive environment