Mark M. Lowis, LMSWMember: International Motivational Interviewing Network of

TrainersRay Rais, LMSW

Quality Improvement Coordinator – Macomb County Community Mental Health

Transitioning to Recovery Based Treatment

Tolstoy:

“I know that most men, including those at ease with problems of the greatest complexity, can seldom accept even the simplest and most obvious truth if it be such as would oblige them to admit the falsity of conclusions which they have delighted in explaining to colleagues, which they have proudly taught to others and which they have woven, thread by thread, into the fabrics of their lives.”

Give me5 Minutes

to learn Names

Transition?From What? To What?Institutional MemoryGoal is to Maintain

Stability in within the System

What the Agency Offers

Prescribing/tellingCompliance BasedMonitoring complianceMandating BehaviorDeficit Based

Targeted TreatmentGoal is to Exit the

System through Amelioration

Individualized IssuesAssistive InterventionsCollaborativeGuiding Incremental

changeManageableRecovery based

ExerciseWork in groups at tableSelect a scribe for your table Select a speaker to represent you table

Together brainstorm a list of deficit based terms

Start by saying; “I see you as….” and finish with the deficit based term/label. (IE: I see you as lazy.)

Facilitator gathers list from speaker

ExerciseWork in groups at tableSelect a scribe for your table Select a speaker to represent you tableTogether brainstorm a list of strength

based terms Start by saying; “I see you as….” and

finish with the deficit based term/label. (IE: I see you as protecting yourself.)

Facilitator gathers list from speaker

“Strength Based” means “Making Sense” out of

Resistance!

Some Kinds of Plans

Behavioral –Uses Behavioral Modification

Awards PointsPrivilegesIncentivesConsequences

Some Kinds of PlansInstitutional –

Uses levels of functioning to determine privileges within the institution

Deficit based – Professional determines a person’s needs based on inability

takes over decisionsstruggles to control or managecontest between system and free will of client.

Some Kinds of PlansAgency –

Converts a person’s desire (what they want from treatment) to what the agency offers

says what the client can and can’t haveStaged –

Work is collaborative and assistive Step-by-step process toward recovery Steps are manageable for the person being served

The pace of recovery is determined by readiness

Throughout the process the focus is on transition

Institutional Memory• Historical Approach to Treatment in which the

need is to protect the public • Identify Persons with Mental Illness based upon

dangerous, aberrant or abhorrent behavior• Remove from Mainstream• Place in institution• Stabilize Symptoms• Maintained forever

–State Facility–Forensic Center– Jail

Institutional

•Take Possession•Remove•Place•Depersonalize•Stabilize•Maintain•Ineffective•Costly

DeinstitutionalizeHome SettingSmaller InstitutionsLess ConfiningMore personalPlacementStabilizeMaintain Costly

•Community Based•Group Homes•Same Approach•Smaller Institutions•Resistance from CommunitySeeking full citizenship

Person Centered Planning

•Institutional • Assess• Diagnose• Prescribe

•Person Centered• Facilitate• Collaborate• Assist

Goals and Objectives are still Maintenance and Institutional

Strength BasedIts not looking for their

strengths. Its knowing that they are there

•Honors autonomy•Emphasizes choice and control•What assistance are they seeking•What do they already understand•How do they see us working with them

Strength Based

The individual has the right to dignity and respect from the

practitioner(s) and every person whom they

encounter at the agency(Mutuality)

Push BackExamplesA job is not a serviceWe aren’t an employment agencyWe don’t do housingWe don’t do thatThe CMH has cut our funding so we can’tThey don’t know what they wantSome of them just want us to tell themThe just want medicationThey’re just trying to get…

Maintenance Approach (Institutional Memory)• Prescribed Goals and Objectives• Encounters are cumulative and general• Time frames are subjective• Consumer must accept expert advise• Consumer must match expectations of system• Confront Resistance

– Guardianship – Consequences– More Restrictive– Seclusion and Restraint– Behavior Management Committee

Recovery Approach Good agreement on Goals, Objectives and

InterventionsConsumer has total choice and controlProfessional is assistive and collaborative partnerEncounters are specificResistance is understood from consumer

perspectiveProfessional has interventions for any level of

readinessGoal is to achieve amelioration and dischargeConsumer is welcome back if necessaryTime frames are realistic

Maintenance Plan• Problem #2 – The consumer lacks coping skills• Goal #2 – The consumer will Develop Coping Skills• Objective #1 – The consumer will attend all

therapy sessions AEB therapist documentation• Intervention #1 – Therapy 1x/week• Objective #2 – The Consumer will make 3 positive

self-statements per week AEB therapist documentation

• Intervention #2 – Therapy 1x/week• Objective #3 – The consumer will identify 3 coping

skills AEB therapist documentation• Intervention #3 – Therapy 1x/week

Now What?

What would the Problem Statement Become?

What would an Objective Look Like?What would an Intervention look like?

Recovery Plan• Targeted issue – Symptoms interfere with

keeping job• Goal – Stop symptoms from interfering with

ability to keep job• Objective 1 – Meet with psychiatrist to discuss

and describe symptoms and the way in which they interfere with ability to keep a job

• Objective 2 – Be able describe medication including dosage, how taken, possible side effects, how it will help with Goal

• Objective 3 – Develop agreement with psychiatrist on medication

Recovery Interventions (Us)Intervention – Psychiatric Evaluation to

determine medication to support goal for sustaining employment

Intervention – Demonstrate way in which medication will assist with goal

Intervention – Periodic medication review to determine how used, effects/side effects, reaffirm usefulness toward goal and adjust if necessary.

Intervention - Assist with any concerns or barriers

Intervention

What we do that is

assistive and collaborative in helping the person with

objectives for achieving the goal

Dean FixenThe

TherapistIs

The Intervention!

Sufficiency Standards and Authorization

Amount – number of units needed to provide the service

Scope - How the service will meet the need addressed (Think of Medical Necessity)

Duration – How long the service will be provided based on attaining the objective

Service – Psychiatric Evaluation, Medication Review, Group/Individual/Family Therapy, Case Management, etc.

Deficit Based Transition Goals

• Maintain reduction in symptoms for 12/months

• Maintain medication compliance for 12/months

• Comply with treatment• Stay at Par for 12/months!!• Intervention – Monitor for compliance

Transition GoalsRecovery

Find a home that provides more independence. Person’s description of the goal: “I want my own place”

Assist Primary Health Care Provider in transfer of medication Person’s description of the goal: “I don’t need help to take my medication”

Intervention – Assist in connecting, scheduling, attending and adjusting to a resource

(Warm Transfer)

Recovery Based Supports and Services

EXAMPLES:Psycho-EducationHealth EducationIndividual, Family, Group TreatmentPharmacologicalCase ManagementPrimary Health Care Physician-Community ClinicCommunity ResourcesReferral to Human Service AgenciesCommunity Living SupportsDischarge by Warm TransferCollaborative Welcome back

Recovery Based Discharge Queues

• “Person's” treatment goals are attained “to their satisfaction”

• On-going care is achievable through Primary Health Care Physician-Community Clinic

• On-going issues are able to be provided through other human service agencies (MRS, Work First, DHS, etc) or support network

• Consumer is not attending “for a reason”• Consumer attends only to protect SSI/D• Consumer cannot be contacted

– Leaves area– Refuses services– Receiving services elsewhere

Planning Process

1st Identify the “Person’s” Targeted IssuesSymptoms of Mental Illness (specific) Impact

on…Co-occurring Substance Use (specific) Interferes

with…Co-occurring Health Issues (specific) affect…Safe and Affordable Housing impacted by one or

more life conditions (specific).Employment-Income-Resources impacted by one

or more life conditions (specific).Social (specific) and Community Participation

(specific) affected by…Self Care (specific) interrupted by…Issues compounded by 2 or more conditions

Planning Process2nd Identify Goals for Amelioration of each of the Person's Targeted Issues3rd Identify the Person's Stage of Readiness for working

on each Goal4th Design Objectives based on the Person's Readiness5th Design interventions in collaboration with the client to

achieve Objectives6th Establish accurate, sensible time frames for achieving Objectives7th Be willing to adjust Plan when necessary8th Discharge Goal is always part of plan

Process for Strength Based – Recovery Oriented

Treatment Planning

ID Item to be addressed

Goal Level of Readiness Objectives Interventions

Stage Matched

Effect on Presenting Problem

New Item to be addressed

Assessment Domain

Presenting Problem

Goal Level of Readiness Objectives Interventions

Identified Strength

No An identified need that will not be addressed by the service agency must be documented in the interpretive summary and indicate where it will be addressed. IE: under care of primary health care physician and currently stable.

Process continues through each assessment domain. Each domain is assessed to determine if/how it impacts the presenting problem for any new item that will need to be addressed. If any assessment domain identifies a need that must be addressed, the assessor must determine if it will be address by the agency in the plan or by an outside resource/agency. If the need will be addressed b y the agency it must be included in the Individual Plan of Service (IPOS). If the need will be addressed by an outside resource it must be documented in the comprehensive summary at the end of the assessment. Each item in the IPOS must include the level of readiness of the individual to work on that item, and must have stage matched interventions. Goals and objectives are the person receiving services. Interventions are the serving agency.

Staging – Block II

Refer to “Stage to Intervention” Power Point