RTP Newsletter Header - Issue No. 5, April 29, 2011
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 Featured Practice
Supported Parenting. Among the various areas in which recovery supports have been developed (employment, education, housing), one important domain of adult living that has been sorely overlooked has been the rights of individuals with serious mental illnesses to fully embrace and assume their identity as parents.

Research shows that women diagnosed with serious mental illnesses have children at the same or higher rate as women without mental health disorders, and that the majority of these women play an active role in raising their children. These women, however, often mother without sufficient support or recognition of their parenting role by psychiatric and behavioral health providers. Prevailing stigma and discrimination that hold that individuals with mental illnesses should not be parents, coupled with fear about losing their children if they mention even routine childrearing concerns, have made many mothers hesitant to tell providers about their parenting needs. The failure of behavioral health systems to acknowledge clients’ relationships with children only serves to exacerbate the “don’t ask, don’t tell” policy enshrouding parenting concerns. The childrearing needs of fathers are even more overlooked in our current systems of care.

Researchers, including Dr. Joanne Nicholson and the late Dr. Carol Mowbray, have long advocated for recognition of the parenting needs and rights of mothers diagnosed with serious mental health concerns. The time has arrived for behavioral health systems throughout the country to listen to these calls and to embrace the reality that many clients are, in fact, parents. Adopting statewide policies recognizing the parenting needs and rights of individuals with mental illness would be an important first step. Developing cost-effective supports that improve outcomes, such as on-site parenting education, supportive parenting pamphlets, and child care, are also key.

By recognizing the joy and importance that parenting holds for individuals with mental health concerns, our behavioral health systems can become increasingly recovery-oriented and true to their mission of supporting individuals as they assume full, adult roles in their communities.

—Daryn H. David, Ph.D., Postdoctoral Fellow, Yale Program for Recovery and Community Health

Additional reading:
Mowbray, C.T., Oyserman, D., & Bybee, D. (2000). Mothers with serious mental illness. New Directions for Mental Health Services, 88, 73–91.

Nicholson, J., Biebel, K., Hinden, B., Henry, A., & Stier, L. (2001). Critical issues for parents with mental illness and their families. Rockville, Md.: Substance Abuse and Mental Health Services Administration, Center for Mental Health Services.

Nicholson, J., & Deveney, W. (2009). Why not support(ed) parenting? Psychiatric Rehabilitation Journal, 33(2), 79–82.

Nicholson, J., & Henry, A.D. (2003). Achieving the goal of evidence-based psychiatric rehabilitation practices for mothers with mental illnesses. Psychiatric Rehabilitation Journal, 27(2), 122–30.

Ritsher, J. E. B., Coursey, R.D., & Farrell,E.W. (1997). A survey on issues in the lives of women with severe mental illness. Psychiatric Services, 48(10), 1273–82.
 Training and Technical Assistance
Training. RTP provides quarterly training Webinars on topics relating to recovery-oriented practice. On April 11, 2011, RTP conducted the first Webinar in Year 2, the second of a four-part series (and the fourth for the RTP Project), “Step 2 in the Recovery-Oriented Care Continuum: Person-Centered Care Planning.”

This Webinar described one of the cornerstones of recovery-oriented practice: the recovery-oriented care planning process and its generation of an individualized recovery plan. In recovery-oriented systems of care across the country, individualized recovery planning is taking the central place previously occupied by traditional treatment, service, or care planning. Shifting from a traditional treatment plan to an individual recovery plan requires much more than a change in the language used to describe the process or the resulting document. This Webinar covered the essential components of the individualized recovery plan, the principles and practices used to develop and implement the plan, the role of culture in shaping the plan, the increased and active role of the person with a mental illness in driving and enacting the plan, and the ways in which this process and plan differs from previous practice. Three national leaders in the development and implementation of recovery planning presented: Janis Tondora, Sadé Ali, and Kimberly Guy.

Janis Tondora, Psy.D., presented an overview of the principles, practices, and key components of recovery planning, with a central emphasis on the role of the person with the mental illness in driving and enacting the plan. Then, Sadé Ali, M.A., CAC, CCS, addressed recovery planning from the perspective of cultural responsiveness and competence, including both cultural components of recovery planning and adaptations to the process required by more collectivist cultures, in which the person is viewed in relation to the family and to the community at large. Finally, Kimberly Guy described her experiences of participating in both traditional treatment planning and individualized recovery planning, drawing examples from her own life of how this shift has made a significant difference in her recovery.

You can conveniently download the presentation slides and the complete recorded session from the RTP Resources Web page at: http://www.dsgonline.com/rtp/resources.html/.

The next RTP Webinar will take place in June. The topic will be “Step 3 in the Recovery-Oriented Care Continuum: Promoting Recovery Through Psychological and Social Means.” Watch your email for the date, time, and details on where and how to register!

Technical Assistance. RTP technical assistance (TA) provides valuable resources that support learning strategies for implementing recovery-oriented care in practical and sustainable ways. We have an extensive library of recovery-oriented articles, personal stories and anecdotes, curricula, videos, and links to relevant publications and professional sources. To access TA, contact RTP TA staff, Monday through Friday, from 9:00 a.m. to 5:30 p.m., at 1.877.584.8535, or email requests to RTP_TA@dsgonline.com. Each request will be responded to within 48 hours of receipt. Arrangements for more lengthy consultation are available on a case-by-case basis.

Although mental health practitioners are the Resource Center's primary audience, anyone interested in promoting the cause of recovery transformation is welcome to access RTP training and TA.
 Project Update
Since our last e-news issue in January, in addition to the hard work among the professional discipline awardees (see “Professional Discipline Training Awards”), RTP has been active in helping to move recovery forward through the RTP Resource Center. Weekly Highlights every Friday present a variety of recovery-oriented topics from a range of authors; we continue to receive high marks for the personal stories from a myriad of stakeholders, analysis of policies and practices, and references to useful resources. Everyone is welcome—and invited—to submit an essay, story, or other written account about a recovery-oriented topic, for inclusion in this popular communication aimed primarily at behavioral health professionals. It's circulated to nearly 4,500 subscribers. Send us your contributions to recoverytopractice@dsgonline.com.

More than 600 people attended our Webinar on April 11, “Step 2 in the Recovery-Oriented Care Continuum: Person-Centered Care Planning.” (For more details and to download the Webinar recording and PowerPoint presentation, see “Training and Technical Assistance.”) RTP's Webinar series on the recovery-oriented care continuum continues in June, with “Step 3 in the Recovery-Oriented Care Continuum: Promoting Recovery Through Psychological and Social Means.” It will describe a few approaches to promoting recovery that involve psychological and social interventions, including cognitive–behavioral psychotherapeutic approaches to serious mental illnesses, psychiatric rehabilitation, and consumer-run programs and businesses as alternatives to traditional programs and settings. The exact date, time, and registration details will be announced in June.

The final Webinar in this series will air this fall with a look at the “back door” of the service system: the ways to facilitate people moving on and beyond specialty behavioral health care. Please watch for an announcement on the dates, times, and registration details for RTP's future Webinars.

The RTP Resource Center provides technical assistance to primarily behavioral health professionals—and to all others interested in learning more about recovery-oriented care. We continually develop and maintain an extensive database of nearly 600 resources—from journal articles and publications to personal stories and videos to curricula. Currently, you can access our resources by sending us an email with a request for a particular item, or for what exists within a specific topic. We also engage a number of subject-matter experts whom we consult for their perspective and input. Send requests to recoverytopractice@dsgonline.com.

When the RTP Web site is launched, the database will be easily navigable across the three RTP categories: For the resource database to continue growing and become an even richer repository for the community, we need your help! To assist us in building this invaluable collection, please submit recovery resources to http://www2.dsgonline.com/rtp_cf/.
 Guest Columnist
Eduardo Vega PictureSelf-Determination and Responsibility in Transformation. When it comes to services and supports for people with mental health challenges, implementing the values of self-determination and personal responsibility presents both social and structural dilemmas. The issues are central to recovery but challenging because, to many people, they are paradoxical in the context of mental health services.

Because of personal and social bias and stigma, many people feel, as I once did, that seeking services or help represents giving up one's self-determination and personal responsibility—that you become a “mental patient” only when you are willing to say that you do not trust yourself, and you are willing to give responsibility for your life to someone else. By this viewpoint, simply by becoming a client, there is a very real possibility that you are giving away the very things that can help you recover.

Research has shown that not everyone is so subject to stigma as I was, and that many people's self-image is not tarnished by being a client. For others, though, the moment they walk—or are taken—into a treatment facility as a client, their concept of themselves as self-determining people who are responsible for their own lives is fundamentally altered.

So we have the consumers, who may feel that their self-determination and personal responsibility have failed them and who are looking to professionals to make up for that failure. And we have the mental health professionals and systems, who are given institutional power—and, I would argue, a surplus of “perceived” power—over clients’ lives by our systems, society, families, and more.

Power and responsibility go hand in hand, and self-determination exists squarely at their center. So the crucial role that self-determination plays in recovery must be made clearer for both clients (who may think they are giving it away) and for mental health professionals (who are inducted into a system in which they feel both the authority and the responsibility to determine which decisions clients may make for themselves).

At root, many of our debates about how to balance the roles of mental health professionals and clients rights and dignity center on two issues: power over consumer’s lives, and blame for the hope-robbing stigma surrounding mental illness that undermines self-determination and recovery. The mental health service provider system, because it is right in between the consumer and society, probably gets too much of both of these.

It is too easy, though, to overlook the role of culture and society—the effect of public stigma and the associations we tend to make between mental illness symptoms and irresponsibility. We cannot escape, nor should we avoid, the truth that our society—both in passive ways and through the very active mechanisms of public policy, funding, and more—is profoundly ambivalent about mental health and mental illness and the people affected by it. Yes, power and responsibility are taken by individuals, professionals, and systems—but in many ways, it is society that gives it.

Transformation to a recovery reality means each piece must be actively changing—society's biased views; mental health systems' tendency to support these view, avoid risk, or manage people through restrictions on personal choices for consumers; and our (consumers') impulses to give away more self-determination and thus more responsibility than we should, thinking that our personal internal resources are not relevant or insufficient. For recovery transformation to happen, action for change in all three of these areas needs to happen, simultaneously and continually.

We can clarify how to this might occur by examining the role of each of these players—the consumer, the mental health provider system, and society—in preserving hope/countering stigma, providing truly beneficial services and supports grounded in the principles of recovery, and advancing opportunities for empowerment. Further, having clear examples of practices that empower people and foster self-determination will allow us to more easily perceive a different situation—one that aligns with our program, advocate, and activist roles. (To view a table that offers some examples of empowerment practices that consumers, mental health providers, and society can implement, click here.)

Power is needed to recover. Indeed, power over one's own life is the only practice for an empowered life, and recovery is not real without it. This does not mean that we live without symptoms, distress, or even disability. It does mean, however, that systems, mental health professionals, and clients must work actively together to continually push power, choice, and responsibility back to the clients. And we must collaborate to change the social environment, to engage in powerful dialogue with our communities, our leaders, and social institutions to reinforce the truth that mental health is a part of everyone's life and that mental health challenges are, if not real positive opportunities, at least a core piece of our human nature.

My feeling is that in the end, recovery is about personal dignity. In our culture, this is synonymous with self-determination and personal responsibility. If we support the notion that mental health symptoms degrade people and deprive them of these in an enduring way, we are committing people to death and despair. But we can work to change this, by shifting what we are doing and how we are doing it. We can support this transformation by acknowledging our own role and taking the challenge of personal responsibility one step further by embracing the role of a “transformation agent” who seeks never to take power from others, but to advance the effective, positive, and just use of it everywhere.

—Eduardo Vega, M.A., Executive Director, Mental Health Association of San Francisco, Calif.
 Professional Discipline Training Awards
The professional discipline awardees—the American Psychiatric Association, the American Psychiatric Nurses Association, the American Psychological Association, the Council on Social Work Education, and the National Association of Peer Specialists—have completed their Situational Analyses. All awardees garnered dedicated participation on the Analyses from their team staffs and advisory and/or steering committees, including consumers and family members who have been actively involved in every step of their RTP projects. These documents reflect thoughtful attention to and comprehensive synthesis of their yearlong research and assessment of the extent to which recovery is practiced within their professions. They serve as a benchmark of their professions regarding their internal and external environments, noting how historical trends have shaped current priorities and establishing parameters for the upcoming training curriculum. In this way, the training that will ultimately be disseminated and implemented will be customized for the respective professions and the target audiences within the professions.

Over the next several months, the professional organizations will develop draft training outlines that respond to findings from their Situational Analyses. In early April, the group met in person at SAMHSA, shared each other’s lessons learned, discussed opportunities for how training will incorporate strengths and overcome barriers, and began structuring goals and objectives. Consumers who are actively participating in each project—including leadership, data collection and synthesis, preparation of the Situational Analysis, and training design and delivery—provided valuable perspectives about criteria that will allow training to be successful. Leaders from Development Services Group, Inc.'s (DSG's) subcontractor partners also attended, asked pertinent questions, and contributed to the multidisciplinary conversations. These participants included Harvey Rosenthal, Executive Director, New York Association of Psychiatric Rehabilitation; Stephen Kiosk, Director, the National Alliance on Mental Illness's Support, Technical Assistance, and Resources Center (or STAR) Center; and Paul Warren, Program Manager, National Development and Research Institutes.

During the meeting, peer support was named as central to the change process. Larry Davidson, Ph.D., RTP Project Director for DSG, clarified the importance of building peer support into the workplace. “When it works,” Larry remarked, “stigma dies.” Everyone reported gaining great insight into how recovery is practiced across the professions and where leverage points exist to support the adoption of recovery principles and practices. Moreover, the conversations among individuals led to some plans for collaborating in training design, pilot testing, and delivery. Such strategies will certainly contribute to more thorough and sustainable change in advancing recovery-oriented care. Kathryn Power, M.Ed., Director of the Center for Mental Health Services, reinforced the critical nature of the professions' goals for RTP and inspired all with her presentation about SAMHSA's priorities to take a whole health approach to co-occurring health conditions.
 Personal Story
Ann Rider PictureAs a child, I saw my father committed to the Arizona State Hospital, and as a young adult was myself diagnosed with schizoaffective disorder. A long list of labels followed that one, because I wasn't the most compliant patient! Seeing my father's experience convinced me I should never allow anyone to lock me up, so I endured multiple medications and unbearable additional medication effects for many years and managed to avoid the hospital.

As a teenager, I found a way to numb the effects of severe childhood trauma: street drugs. My drug use escalated to full-blown heroin addiction for close to 8 years. I managed to stop using drugs in 1985, but without adequate trauma treatment, I continued to despair and began to self-injure. About 6 years into recovery, I stumbled across a counselor (social worker) who understood trauma and got me into the treatment I needed. For the first time in my life—at age 40—I began to feel hope.

After some years of this kind of treatment, I began to understand that posttraumatic stress disorder was more accurate for me than any other diagnostic category. I weaned myself off all my medications and began to feel alive again. I had tried college four times and hadn't previously been able to keep up—I had convinced myself I would never be quite sane enough for college, but now I believed I could find a way to cope with the stress. I started back to school, thinking I could get a chemical dependency counseling certificate. One of my instructors—another social worker—told us in an advocacy class: “If you intend to serve people who are oppressed, you have a moral obligation also to work to change the system that oppresses them. Otherwise, all you are doing is helping people endure oppression.”

Those words hit me like a bolt of lightning. I realized I needed a bachelor's degree, and I started studying mediation while I finished my undergrad work. A year later, I was enrolled in graduate school, studying for my masters in social work.

Since graduation, I've been allowed to teach a few classes in the School of Social Work at Arizona State University, specializing in behavioral health. But my real job is with Recovery Empowerment Network, of which I’m executive director. We employ people recovering from psychiatric disability, and support people on that journey. We also organize people statewide to engage in legislative advocacy and system transformation efforts in their community.

As a teenager in the 1960s, I believed we could change the world. Although I lost sight of that dream for a while, I still believe it—and I work with my peers and other social workers every day, doing just that.

—Ann Rider, MSW, CPRP, Executive Director, Recovery Empowerment Network, Phoenix, Ariz.
 Resource Spotlight
Gale Bluebird Guidebook on Peer Roles, Video on Alternatives to Restraint. “Paving New Ground” (2006) is a "lessons learned" guidebook written for both peer specialists and providers on how to develop peer roles for in-patient settings. A variety of roles are presented, with anecdotal stories by individuals who are working in groundbreaking roles throughout the country. Though the examples illustrate that there is no one way of doing things, some common themes and best practices have emerged from them. Implementation strategies and tips, as well as suggested guidelines, are included. An accompanying video, “Paving New Ground,” featuring interviews with peer specialists, is also available.

In development is “Paving New Ground II,” a training guide for peers just beginning work in in-patient settings. This guide features helpful tips on what to wear; how to work with challenging clients; what to say when, and where; and working as a team with professional providers.

These, and other, resources are available on the National Association of State Mental Health Program Directors Web site, at: http://www.nasmhpd.org/consumernetworking.cfm/.

Finally, SAMHSA has released “Leaving the Door Open,” a video that presents alternatives to the use of seclusion and restraint. Filmed in Pittsburgh at Mayview State Hospital (which has subsequently closed), the video includes a role play scenario that presents the wrong—and right—ways to escort an escalating client away from a recovery group meeting, and also discusses humor techniques, comfort rooms, and the use of art and creativity.

The free video is available from SAMHSA's Web site, at: http://store.samhsa.gov.

—Gayle Bluebird, Peer Services Director, Delaware Psychiatric Center, New Castle, Del.
 Related Links
The National Association of State Mental Health Program Directors, whose resource is highlighted in the Resource Spotlight, houses many other publications and products that it has produced through its programs, councils, federal contracts, or other affiliations.

The Recovery Empowerment Network provides peer-owned and operated services and a unified voice for behavioral health consumers of Maricopa County in Arizona. It also works to change or enhance a service delivery system that meets the needs and desires of the people it is charged to serve.

The Mental Health Association of San Francisco has provided leadership in mental health education, advocacy, research, and service for the diverse communities of San Francisco, Calif., for nearly 60 years. The organization is one of 340 affiliates of the National Mental Health Association throughout the United States.

Focus on Recovery–United, Inc. (FOR-U) is a peer support program staffed entirely by paid and volunteer peers. FOR-U envisions a statewide network of peer-provided recovery education and support opportunities for adults in Connecticut. Dedicated to promoting a culture of wellness by encouraging positive change in the lives of adults, their family members, providers, and the community. FOR–U espouses the values of mutual respect, shared responsibility, honesty, hope, education, self-advocacy, and support.