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E-Newsletter July 25, 2013
Issue 14
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Featured Practice
Intersection of Treatment and Prevention: Prevention and Recovery-Informed Care, by Ted N. Strader, Christopher Kokoski, and Stephen R. Shamblen, Ph.D. Professional practitioners across diverse, yet interrelated, fields (i.e., substance abuse prevention, addiction treatment, psychiatry, psychology, psychiatric nursing, social work) are beginning to realize their intersection, leading to synergistic impacts when coordinating substance abuse prevention and addiction treatment activities. This intersection can be nurtured to be quite broad to serve as a central hub of hope, recovery, and wellness for individuals, families, and entire communities.

Since the early 1980s, we have been involved in the discussion, development, and promotion of both substance abuse treatment and prevention certification. As early advocates serving on the original Kentucky certification boards for treatment and prevention, we had unsuccessfully argued that prevention and treatment were so deeply interconnected that they should share one common certification body. However, in Kentucky and throughout the nation, the two fields have evolved independently.

Treatment began largely as a short-term, client-centered service conducted in controlled environments (i.e., hospitals, treatment centers, etc.). Consistent with the medical paradigm that largely treats acute disease, a short-term approach emerged. Unfortunately, that approach often produced relatively short-term positive outcomes. When clients left this controlled environment and returned to the community, relapse into substance abuse and other unhealthy behavior patterns was commonplace. As a result of these undesirable long-term outcomes, the recovery movement of 12-step meetings (e.g., Alcoholics Anonymous, Narcotics Anonymous), sponsors and other peer support activities were combined with treatment regimens to help addicts transition more successfully following treatment. More support and longer-term support resulted in greater success.

Continue reading.
Training and Technical Assistance
Training and TA Training. With an overarching goal to help people recover from mental health and substance use disorders, the significance and availability of peer support have been central to RTP since its inception, and there is enormous potential for the development of national practice standards to benefit the behavioral health field. In its third quarterly Webinar, "Peer Support in Behavioral Health and Its Emerging Practice Standards," RTP will delve into the promise and practice of peer support as provisions of the Affordable Care Act for people living with mental health challenges and/or substance use disorders near implementation.

An initiative to develop standards by peer practitioners that are rooted in peer support values has been under way for more than a year. In December 2012, a first-ever meeting among peer-run organizations in both mental health and substance use met at SAMHSA. They set forth a process for gathering data from public stakeholders, analyzing the data, and drafting standards by mid-summer 2013. Practice guidelines were recently released (July 8, 2013), and will be available as a Webinar handout.

The goals of national practice standards include
  • The identification of guidelines for developing appropriate and meaningful job descriptions
  • Providing a foundation upon which peer support core competencies can be identified
  • Creating a basis for peer ethical guidelines
  • Creating a foundation for a national credential
  • Facilitating reciprocity policies (recognized in multiple states)
  • Providing information that could be used to examine peer supporter training curricula
Register today for this important event on August 1, 2013, where field experts will discuss how national peer support standards can maximize opportunities and overcome challenges facing the practice.

Recordings and slides are available to download for each of RTP's previous 10 Webinars, which support practitioners implementing recovery-oriented practice throughout the country.

2013
May: The Affordable Care Act and Implications for Recovery-Oriented Practice
January: The Use of Medication in Recovery-Oriented Practice

2012
January: Assessing for and Addressing Trauma in Recovery-Oriented Practice
April: Understanding and Building on Culture and Spirituality in Recovery-Oriented Practice

2011
April: Person-Centered Care Planning
July: Promoting Recovery Through Psychological and Social Means
October: Graduation

2010
June: Emerging Trends in Program and Workforce Development
September: What Recovery Means in Acute Care
December: Outreach and Engagement

Technical Assistance. RTP Technical Assistance (TA) provides valuable resources that support strategies for implementing recovery-oriented care in practical and sustainable ways.

TA inquiries over the last few months have spanned the recovery spectrum, with requests for information on peer support specialist training, establishing recovery-oriented treatment approaches at behavioral health centers, preparing recovery-oriented conference presentations, and incorporating recovery principles in drug court guidelines.

Although behavioral health practitioners are RTP's primary audience, anyone interested in promoting recovery transformation is welcome to access RTP training and TA. 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 staff Monday through Friday from 9 a.m. to 5:30 p.m. at 877.584.8535, or email requests to recoverytopractice@dsgonline.com. We will respond to each request within 48 hours and make arrangements for longer consultations on a case-by-case basis. You can also access most of these resources on our Web site.
Project Update
The RTP Steering Committee met via teleconference on July 8, and participated in an engaging dialogue with the RTP professional disciplines about their curricula. Several Steering Committee members have participated in the review of various disciplines' curriculum modules, which has provided helpful guidance along the way. Questions and further offers to review and participate in the pilots confirmed the widespread commitment to RTP from multidisciplinary practitioners, consumers, and researchers.

The six professional disciplines—psychiatry, psychiatric nursing, psychology, social work, addiction counseling, and peer support—represented by national organizations, are finalizing their curricula following a year of piloting both in-person and online, and are preparing to disseminate and market their trainings this fall. If you are looking for a particular discipline and want to learn more about their curriculum, read the column "Professional Discipline Training Awards" in this issue.

Nearly 7,900 subscribers receive RTP communications. Please feel free to pass along the link to join the listserv to colleagues, friends, and others interested in implementing recovery-oriented practice.

Our Resources Library contains nearly 1,000 multimedia items, including research articles, personal stories, videos, training programs and tools, and links to valuable Web sites. Visit often, as we continually post new additions.

If you have a resource that could benefit RTP's readers, please complete our brief Contribution Form. Our focus is on mental health, addictions and substance use, and co-occurring disorders, and our primary target audience is professional practitioners.

You can access our resources, including archived editions of RTP Highlights, Webinars, and eNewsletters on our Web site: http://samhsa.gov/recoverytopractice.

As always, we value your feedback and appreciate your recommendations and suggestions. We design our Webinars, eNewsletters, and RTP Highlights based on your input. Contact us at recoverytopractice@dsgonline.org.
Professional Discipline Training Awards
Curricula that orient and train professional practitioners on implementing recovery-oriented care in their practice will soon be available for the six RTP behavioral health disciplines. The professional associations are reviewing evaluations from their pilots, making revisions to their curricula, and preparing their marketing and dissemination strategies and schedules to launch the final training programs this fall. Each national organization—the American Psychiatric Association (ApA) and American Association of Community Psychiatrists, American Psychological Association (APA), American Psychiatric Nurses Association (APNA), International Association of Peer Supporters (iNAPS), Council on Social Work Education (CSWE), and Association for Addiction Professionals (NAADAC)—has carefully designed a curriculum that reflects findings from the Situational Analysis developed at the start of the project. All disciplines have involved consumers and peers in every step of the research, development, and training delivery process. This is a first-of-its-kind curriculum that practitioners can use to advance the transformation of people with mental health and substance use conditions.

Equally noteworthy at this juncture of the RTP project are the systems changes occurring in each RTP professional discipline as well as across disciplines.

Recovery-oriented practice is a multidisciplinary practice. Last year, following the RTP disciplines' presentation at the National Alliance for Mental Illness National Convention, and a second, special performance at SAMHSA, the RTP Role Play was filmed and produced. The video demonstrates how recovery-oriented practice can be an integrative principle among multidisciplinary teams in the field and how multidisciplinary collaboration translates to sustainable recovery practice across practice settings. SAMHSA's 10 recovery components and four dimensions that support a life in recovery are highlighted in action throughout the video. Recently, Annelle Primm, M.D., MPH, who leads the RTP project for the ApA, was contacted by the Hogg Foundation to explore ways for medical students, psychiatry residents, and other behavioral health professional trainees in Texas to participate in RTP. Additionally, as a representative of RTP, Annelle was asked to invite the RTP professional disciplines to present as a group at this year's Alternatives Conference. Discussions are under way to plan a session.

The definition of nursing describes recovery. The May/June 2013 Recovery Focus issue of the Journal of the American Psychiatric Nurses Association contains a wide range of accounts describing how recovery-oriented interventions are central to the nursing profession. Several authors are active leaders of the RTP project. More evidence of the dynamic evidence of recovery-oriented concepts and philosophy in nursing is the soon-to-be released updated edition of the Scope and Standards of Practice for Psychiatric-Mental Health Nursing, which designates psychiatric mental health as a nursing specialty within the American Nurses Association. Equally exciting is a recent communication that Deborah Hobbs, Ph.D., RN, Nursing Practice and Education Specialist and staff on the APNA RTP project, received about nursing staff who are integrating hospital-wide training based on their participation in a program on recovery language.

The Task Force on Serious Mental Illness and Severe Emotional Disturbance (TFSMI/SED) fully supports the RTP initiative. The TFSMI/SED has been the driving force behind most of the APA's endeavors to promote mental health recovery within psychology since 1994. Several members of APA's RTP Advisory Committee (RAC) members will present on recovery and the RTP curriculum at this summer's Annual Convention. Along with the RAC, the Committee for Assessment and Training has discussed the potential of supporting a recovery-oriented fellowship for a doctoral student, and a recovery-focused conference that could expose more psychologists to the RTP curriculum.

CSWE plans for dissemination at the fall conference. Recovery-oriented events are scheduled for the Annual Program Meeting this year, including a launch of the RTP curriculum and the conference film festival. The full program hasn't been released yet, but anyone can participate in the virtual student film festival, which is taking place now. The Council on Conferences and Faculty Development is developing study guides to accompany the selected films (all will be available on YouTube), so the behavioral health–related videos may make a nice additional classroom resource for their curriculum.

NAADAC will disseminate its RTP curriculum through state affiliates. On October 12, NAADAC RTP staff will present and discuss the RTP curriculum with its estimated 54 state affiliates and executive committee members at its annual conference. The purpose will be to demonstrate how members throughout the country can participate in the training. Another dissemination strategy is through NAADAC Magazine, a quarterly publication offered to NAADAC members. The spring 2013 issue featured Bill White's commentary, "Is It Time We Become Recovery Professionals?" The recently published summer 2013 issue features Bill White and Cynthia Moreno–Tuohy, NCAC II, CCDC III, SAP, Executive Director and RTP Project Director in "Recovery-Oriented Practice and the Addictions Profession: A Systems Perspective." And the fall 2013 issue will feature a consumer's point of view of recovery.

The National Practice Guidelines for Peer Supporters provide values-based understanding of the roles and functions of peer supporters. Following responses from 1,000 peer supporters involved in focus groups and respondents to surveys, a diverse advisory group with representatives from mental health and substance addictions fields (as well as family support and cultural organizations) led by iNAPS, completed the document. The iNAPS RTP curriculum reflects the guidelines, and as core competencies and standards are developed, the field can expect much more clarity when developing peer roles. According to Steve Harrington, iNAPS Executive Director, the RTP curriculum is useful for support groups as well as for workplaces. During the NAPS 2012 annual conference, a very compelling interview about the closing of Harrisburg Psychiatric Hospital, the Certified Peer Specialist Story—Gina Calhoun and Scott Heller, was filmed and later produced by RTP.

ApA—Deborah Cohen
APNA—Deborah Hobbs
APA—Urmi Chakrabarti
CSWE—Erin Bascug
NAADAC—Cynthia Moreno–Tuohy
iNAPS—Steve Harrington
Guest Columnist
Michael Flaherty, Ph.D. Building a Dialogue and Vision for Prevention, Recovery, and Resilient Communities, by Michael T. Flaherty, Ph.D. Understanding how an illness originates, advances, and damages a healthy person or community is one way of defining how to intervene and treat the illness. However, using that knowledge to strengthen the science behind preventing the illness or successfully sustaining its remission and wellness over time makes science even more practical while strengthening everything else. These are not the same kinds of knowledge. One type explains and addresses an illness while the other further empowers people to build resiliency, wellness, and recovery from it.

Last September, SAMHSA and the Center for Substance Abuse Prevention (CSAP) supported a National Prevention Network (NPN) conference in Pittsburgh, Pennsylvania (www.ireta.org). Those in attendance focused on the shared strengths of prevention and recovery—the cornerstones of health reform—and their powerful transformative potential when joined with treatment to build individual and community wellness and resiliency. With addiction becoming increasingly viewed as a chronic illness, our approaches to addressing it are transforming into more dynamic continua of care and integrated models of individual and community health and wellness. A diverse national panel of field experts saw an early framework for this common vision in addictions in their 2006 consensus paper, "Special Report: A Unified Vision for the Prevention and Management of Substance Use Disorders: Building Resiliency, Wellness and Recovery—A Shift from an Acute Care to a Sustained Care Recovery Management Model," published by the Institute for Research, Education and Training in Addictions (download the paper at www.ireta.org). The NPN conference and subsequent SAMHSA/Great Lakes Addiction Technology Transfer Center (GLATTC) Webinars (www.glattc.org) that followed have begun to set the stage for further discussions and emerging examples of science and practice that includes this practical and more informed use of prevention and recovery. This person- and community-centered dialogue grounded in lived experience applied with best practices, makes science more relevant, adoptable, evidence-based, accountable, and effective as an evolving medical model. De facto, science sticks and knowledge is adopted.

In April of this year, SAMHSA and the Center for Mental Health Services (CMHS) began what will be a series of dialogues to further define a common ground and vision for prevention, recovery, and resilience today. The overall aim of these grassroots and service dialogues is to promote a united behavioral health field including substance use prevention, mental health promotion, mental health services, substance use disorders treatment, mental health recovery, and substance use disorders recovery. Other partners are developing measures and outcomes.

This "unified field" would be actively involved in the development, implementation, and evaluation of efforts to improve community health and well-being in the context of health reform. The dialogue is co-chaired by leaders from SAMHSA, the Centers for Medicare & Medicaid Services, CSAP, and the Center for Substance Abuse Treatment, and led by Cathy Nugent, LCPC, CMHS Senior Public Health Analyst (Cathy.Nugent@samhsa.hhs.gov). In their April meeting, initial progress was made in sketching a collective vision from broad and diverse perspectives. They are now calling for a conceptual alignment group to further refine that collective vision and its relevance for
  • Individual, family, and community wellness
  • Recovery-Oriented Systems of Care (ROSC)
  • Resilience- and recovery-oriented systems and communities
  • Public health
Along the way, providers have been self-identifying as using this more unified and integrated approach in their work. An example was featured in the April 13 RTP eNewsletter: the Philadelphia Department of Behavioral Health and Intellectual disAbility Services Partnership for Community Wellness. GLATTC Webinars have been sharing extensive data from the Council on Prevention Education: Substances (www.copes.org) in Louisville, Kentucky, where entire communities have formed partnerships with providers and people in recovery to identify community "risk factors" with criminal justice, youth, families, and men, reporting on and measuring prevention and recovery. At the current SAMHSA–CMHS dialogue meetings, emerging programs in Vermont (Marcia.LaPlante@state.vt.us) and Detroit (tjohn@mlkcsi.org) presented models on similar community initiatives, while budding initiatives in New Jersey (www.welltacc.org), Pennsylvania, and Ohio were noted.

At the national level, guiding documents have been published, e.g., Recovery-Oriented Systems of Care Resource Guide Book (September 2010), Operationalizing Recovery-Oriented Systems of Care, and Approaches to Recovery-Oriented Systems of Care at State and Local Levels, to name a few. To facilitate further implementation of state and local ROSCs, SAMHSA is funding 33 discretionary grant programs (mostly access to recovery) in this area, including major grants such as the RTP initiative and Bringing Recovery Supports to Scale–Technical Assistance Center Strategy, while also supporting a national family dialogue for youth with substance abuse disorders (sharon@momstell.org). The intended dialogue of integrating lived experience with applied science is evident as the common denominator for all.

If one were to make a cursory study of these founding initiatives, certain "common ground" themes begin to emerge:
  1. By assertively building healthy environments at work, school, and in the community at large, prevention and recovery can improve the quality of life in communities, neighborhoods, and families free of alcohol, tobacco, and other drug use and crime.
  2. Effective prevention of mental illness and substance use requires consistent action from multiple stakeholders, particularly those in recovery.
  3. Prevention and recovery bring power to the community and its families and members by working from within their institutions and with the supports needed to build resiliency and sustain recovery over time.
  4. Prevention, informed by individual, family and community recovery, creates a comprehensive plan in which everyone can have a stake and own at indicated, selected, or universal levels of application.
  5. Systems will change as the community experiences the outcomes of its learning and investments.
  6. Applied prevention and recovery hold community institutions responsible for reflecting best practices and community values.
  7. Prevention and treatment access community "subsystems" that can support attaining and sustaining recovery, e.g., recovery supports and peers.
  8. Prevention becomes a set of steps along a continuum that promotes individual, family, and community health; reduces mental health and substance use disorders; and builds resilience, wellness, and recovery.
  9. Good prevention focuses on reducing individual and community risk factors while building protective factors, i.e., resilience, wellness, and recovery.
  10. Prevention is grounded in evidence-based research and real-world experience informed by qualitative and quantitative adoption and outcome data.
  11. Prevention and recovery provide outcomes at the community level, not just at the program level.
  12. Rather than addressing a single problem or condition, prevention and recovery simultaneously consider a potential wide-ranging set of problems that may be related to the disorder, i.e., anticipatory practice.
  13. Rather than focusing only on the individual at risk, prevention uses all risk and protective factors learned from individual interventions to then alter the social, cultural, economic, and physical environment of a community to promote continual shifts away from what's causing the illness in the first place, i.e., builds individual and community recovery capital.
More will become visible as this evolution and dialogue proceed. The Affordable Care Act has established the Patient-Centered Outcomes Research Institute and major funding to broadly document our understanding of how people get well and remain well within emerging models of care. One can only hope mental health and substance use will be included early on for their potentially substantial role in health reform and understanding and improving health care as a whole. In this way, prevention, recovery, and fortified resilience based on applications of best science with lived experience make our work more relevant, adoptable, scientific, accountable, and effective.

With a clearer unified vision and transformational science of recovery and prevention in all we do, we are better armed to successfully address the problems we seek to eliminate among people, families, and communities. There is no one or universal path to wellness and recovery. People and communities must use best science, practice, and what works for them, and determine how they wish to apply their shared resources, values, and will. That is informed evolution. Defining our common ground with a shared vision around measures of attained and progressing individual, family, and community wellness is a great compass and our greatest strength. It is our evolution.

Dr. Flaherty is a Clinical/Consulting Psychologist and Founder of the Institute for Research, Education and Training in Addictions in Pittsburgh, Pennsylvania. He serves in an advisory capacity for many agencies and projects, including RTP, and has been a provider for more than 30 years. Dr. Flaherty can be reached at flahertymt@gmail.com.
Personal Story
Prevention and Recovery: How Do They Align? by Steven Fry, M.S. We now know recovery from behavioral health problems is not only possible—it's common, with the right individualized supports, help, and effort from the person affected by these conditions. In the field of prevention, efforts are taken to reduce or eliminate conditions of poor health from occurring in the first place. Is there a role for recovery support services in the world of prevention and how do these two objectives align?

A short time after I was asked to write this article, I was in my physician's waiting room glancing through one of his magazines when I chanced upon an article addressing this very topic. What a nice coincidence, I thought. It had to do with a study involving mothers with anxiety disorders. One of the study's findings was that some moms with a lot of anxiety say and do things that, in a sense, "teach" their kids to be anxious. If they are hypervigilant about risk and frequently talk about their fears and the terrible things that can happen in the world, a child will naturally pick up on these signals and may begin to see the world as a scary place, too. While the researchers helped the mothers recover, they also worked with the kids on looking at the world more objectively and challenging the messages they were getting, teaching them different ways to see things. They found that many kids who received this therapy (treatment) were less likely to develop anxiety disorders later in life (prevention).

When I ran a small peer support service in Southeastern Connecticut, we had different kinds of groups in which people in recovery could get together and share their strengths, accomplishments, and encouragement. Many times we practiced exercises in relaxation skills, like deep breathing and muscle techniques. Sometimes we would practice exercises in positive self-talk. Every once in a while a member would bring his or her children along, and the kids seemed to like the activities too. It made me wonder if we weren't inoculating them a bit for accumulated emotional and psychological challenges potentially snowballing into something bigger and "diagnosable." It made me wonder if we couldn't implement emotional education—similar to physical education—in grade school.

On April 15, SAMHSA hosted a Dialogue on Recovery and Prevention, where we sought to determine how the fields of prevention and treatment could learn from each other and better work together to promote healthier communities that foster resilience and wellness. We talked about conceptualizing mental health problems that occur along a continuum of universally experienced feelings, differentiated only by degree. To reduce or prevent behavioral health disorders, we need to have healthy communities where everyone's gifts can be exercised, where everyone can feel safe and respected, where everyone is supported to overcome challenges and achieve their potential. These are the values that underlie recovery. As one of the participants at this conference noted, the fields of prevention and recovery have much in common—they both seek to nourish human capacity.

One of the outcomes of the event was to carry the discussion further. Small groups of participants were interested in how to improve individual, family, and community wellness. Some ideas we wanted to pursue considered how the system of care (the treatment/recovery side) could do a better job of health promotion—health check-ups of an emotional nature more or less. Others were thinking on the community level about how to map naturally existing assets and resources to create environments that foster resilience and health, reclaiming Brownfields use toward the common good. There will be a conversation at the end of this month (we're calling it the conceptual alignment group) on how we can weave theses terrific ideas into action steps that carry community health to a new level with the involvement of the behavioral health system and people in recovery. I expect it will be a very stimulating discussion as everyone from their respective fields seeks a common center to amplify the capacity of all human potential.

Steven is the Associate Director for Consumer Affairs at SAMHSA's Center for Mental Health Services and a member of the RTP project. He is a person in recovery and has provided leadership and education in recovery-oriented behavioral health services in Connecticut for more than 13 years.
Resource Spotlight
Resource Spotlight Prevention, intervention, and treatment are gaining ground in the United States as efforts to address health disparities take precedence. Just as important is a focus on prevention—taking action before injury, illness, or even death occur. The newly revised THRIVE: Toolkit for Health and Resilience in Vulnerable Environments is a system designed by Prevention Institute to help people understand and prioritize factors within their community that can improve health and safety. The tool answers important questions like "How can I identify key factors in my community and rate their importance?" "How are these factors related to health outcomes?" "What can I do to address each factor?" It includes training materials and preliminary guidelines to translate THRIVE results into concrete changes in local policies, programs, and priorities.
Related Links
Related Links Prevention and Early Intervention in Behavioral Health: Promising Practices
This Webcast looks at screening techniques in behavioral health care, emphasizing prevention practices and intervention as constructive elements of health reform. Given the consensus that prevention and early intervention are part of a highly effective public health strategy, defined screening techniques are on the rise. When integrated into primary health care systems, school settings, and community-based programs, screening can inform early interventions, helping people before problems surface.

Behavioral Health—Prevention, Early Identification, and Intervention
Effective prevention calls for widespread support of early intervention and its potential. In a policy brief produced for the Pathways initiative, the American Public Human Services Association suggests prioritizing resources to institutionalize prevention among private systems of care, administrators, and policymakers.

Behavioral Health Prevention
The Behavioral Health Prevention Program for the Saginaw Chippewa Indian Tribe defines prevention as a proactive process that empowers community members, families, and systems to meet life challenges by creating and reinforcing conditions that promote healthy behaviors and lifestyles. A variety of activities, from Bingo with Friends to the Summer Youth Job Corp, summon cultural tradition and community bonds to build on education, personal strengths and skills, and good health.

The Facts on Mental Illness Prevention
A fact sheet produced by the University of Washington School of Social Work outlines four truths about prevention: reducing biological and psychosocial risk factors can prevent mental disorders; exemplary programs exist to prevent biological and psychosocial risk factors; well-implemented programs can achieve significantly more benefits than costs to taxpayers; and an interaction between genetic and environmental factors influences mental health. Supporting reports and evidence accompany each point.
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The views, opinions, and content of this E-Newsletter are those of the authors, and do not necessarily reflect the views, opinions, or policies of SAMHSA or the U.S. Department of Health and Human Services.