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E-Newsletter April 24, 2014
Issue 17
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Featured Practice
An Important Trend in Recovery-Oriented Practice, by Larry Davidson, Ph.D. Self-management in the use of medication for mental health conditions and addiction is an important topic that has been addressed by RTP in several venues and formats, and for which we have received positive feedback over the past few years. Although medications can be very effective tools in promoting recovery, they alone are insufficient for many persons with prolonged conditions. For these individuals, the medications we currently use do not "cure" mental illnesses or addictions. When effective, they may reduce symptoms and a person's likelihood of relapse, or improve his or her quality of life. In mental illnesses, for example, medications may reduce some of the more flagrant symptoms such as hallucinations and acute mania, but do not address the negative symptoms and neurocognitive impairments that are often the more disabling aspects of these disorders. Even in the case of affective disorders, in which medications can stabilize a person's mood and offer protection against relapse, medications cannot repair relationships or help the person identify and plan ahead for managing his or her triggers, such as losses or setbacks.

In the treatment of addictions, medications may render certain substances less reinforcing or reduce cravings, but make no impact on a person's ability to develop new, sober social networks that will support his or her recovery. In this respect, we should avoid conveying the message that all people need to do is take the medications prescribed for them and everything will be all right. Recovery requires hard work on the part of both persons in recovery and practitioners, and with current healthcare reforms under way, practitioners will need to play an increasingly important part in educating people about their own role in their recovery and in supporting their efforts to manage their conditions and recover as fully as possible.

This is because, in the shift to person-centered care, our responsibilities as practitioners change from reducing symptoms, cravings, and relapses through a patient's compliance with prescribed medications to promoting and supporting people and families in their active efforts to self-manage long-term conditions. Because current medications do not cure many of the illnesses we treat, it is up to people in recovery and their families to learn how best to manage these conditions, with our assistance and support, between their appointments. Medication becomes one potential tool they may use in doing so, rather than being the primary focus of care. But for people in recovery and families to take on active roles in using self-management tools, practitioners need to do more than provide education, information, and encouragement.

Research has consistently demonstrated, for instance, that people are much more likely to follow through with treatments they have chosen, and less likely to follow through with treatments chosen for them. To assume responsibility for self-management, people in recovery and families need to feel confident in their knowledge of what they are managing, and in their ability to decide (among relevant options) how best to go about doing so. Thus, part of our responsibility as practitioners becomes laying out the relevant options from which people may then make personal decisions, and respecting those decisions as we would want others to respect our own.

In addition to collaborating in the decision-making process, practitioners can be guided by the following evidence-based principles for promoting self-management:
  1. Elicit the person's and family's perspectives on the issues that brought them to care.
  2. Assess the person's and family's perceived needs and priorities, including cultural preferences (e.g., ethnic, sexual, spiritual).
  3. Identify the person's short and long-term goals.
  4. Identify medication targets that indicate people are overcoming barriers to life goals or increasing their quality of life (over and above symptom reduction).
  5. When needed, prescribe medication as one component of an overall self-management plan that builds on personal and family strengths.
  6. Identify and address barriers to self-care, including the need for additional supports (e.g., transportation, child care, reminders, environmental modifications).
It may be evident from this list that the promotion of self-management is far from an easy or straightforward affair. On a more positive note, these principles create ample room for interdisciplinary teams to divvy up the labor involved according to the person's and family's needs and preferences and the respective expertise of each discipline.

Physicians: 1) Assess, evaluate, and diagnose health conditions and identify personal and family strengths; 2) Collaborate in decision making and prescribe chosen treatments; 3) Monitor treatment response and make adjustments as needed; 4) Educate the person and family about conditions involved, available services and supports, and expected short- and long-term outcomes.

Nurses: 1) Assess and monitor mental and physical health and identify personal and family strengths; 2) Collaborate in decision making and provide selected treatments; 3) Teach and support people to self-administer medications and engage in other self-care activities; 4) Promote exercise, nutrition, and overall wellness.

Social Workers: 1) Assess and evaluate the person's and family's life context and available and needed resources; 2) Collaborate in decision making and provide selected treatments; 3) Advocate for and increase the person's access to needed resources, services, and supports; 4) Assess family situation and offer education, intervention, or support as needed.

Psychologists: 1) Assess and evaluate personal strengths and functional impairments; 2) Collaborate in decision making and, when possible, remediate impairments through selected interventions (e.g., cognitive remediation); 3) When needed, develop and implement environmental modifications to enable the person to compensate for residual impairments.

Rehabilitation Staff: 1) Assess and evaluate personal strengths and interests; 2) Collaborate in decision making and, when possible, offer skills training exercises and/or in vivo support; 3) When needed, implement environmental modifications to enable the person to compensate for residual impairments; 4) Liaise with community organizations to create or expand access to naturally occurring activities.

Substance Use Counselors: 1) Assess and evaluate the person's use of alcohol and other drugs and the degree to which substance use is distressing and disruptive in the person's life; 2) Collaborate in decision making and, when needed, provide motivational interviewing and counseling, including identifying triggers, teaching coping skills, and preventing relapses; 3) Connect the person and family to community-based self-help/mutual support resources.

Peer Staff: 1) Engage people into care who are reluctant or skeptical that it can help them; 2) Instill hope for recovery through tangible role modeling; 3) Collaborate in decision making and, when needed, advocate for care to include the person's and family's life concerns and goals in addition to medical and psychiatric issues; 4) Increase the degree to which people become "activated" to take care of themselves, and reinforce their use of self-management tools and skills.

Because this is a very preliminary and oversimplified list, we welcome feedback and input from RTP readers to better define the respective roles of these and other disciplines.

Dr. Davidson is the RTP Project Director.
Training and Technical Assistance
Training and TA Training. RTP Webinars support practitioners implementing recovery-oriented practice throughout the country. Recordings and slides are available to download.

2014
April: The Role of Self-Management in Using Medications
November: Peer Practice and Context: Developing Quality Standards

2013
August: Peer Support in Behavioral Health and Its Emerging Practice Standards
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. 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
Five years ago, the professional disciplines that were awarded RTP subcontracts initiated their research and assessment by exploring the extent to which recovery existed in their respective fields of practice. Among the awardees in psychiatry, psychiatric nursing, psychology, social work, peer support, and later, addiction counseling, project leaders designed and conducted an array of data collection activities. They led listening sessions and dialogues between practitioners and consumers, completed literature reviews, searched organizational policies and training manuals, examined board and committee documentation, and reviewed staffing structures and job descriptions. Many received early testimonials from professionals about how they were "already doing recovery."

But the Situational Analyses proved otherwise. Psychiatric nurses and social workers in particular were the most surprised to learn that, although their colleagues had attested to being schooled in recovery concepts and principles, their practices were quite different. At the same time, the professionals learned that the systems within which their colleagues worked reinforced quite different—and often very contrary—messages and protocols for the care of people with mental health and substance use issues.

During those early months, SAMHSA's requirement that consumers be part of each step of the disciplines' project development was a foreign idea, one that (aside from the peer specialist group) was met with uncertainty and a bit of unease. Soon after, the awardees formed advisory boards and steering committees with consumer members who provided guidance on outreach and engagement strategies. Starting in 2011, the disciplines were asked to invite one or more of their advisory board consumers to the annual in-person meeting. Needless to say, the meetings have been some of the most productive forums for tackling the core issues of recovery implementation. As one peer described it, the yearly event has "changed the practice of meetings by including people with lived experience. It changes the mindset of practitioners to listen to their consumers."

The process and content for developing RTP curricula evolved uniquely compared with previous training development efforts. Thorny issues and questions were discussed early on by the grantees and RTP project management. For example, the disciplines wanted to know how to handle self-disclosure, not at all sure about how professional practitioners would respond to such an invitation, and how to incorporate experiences of those who might be eager to disclose. Earlier this week, the RTP disciplines met to discuss project updates, impacts, accomplishments, and plans for collaboration. Self-disclosure was part of nearly every group's presentation.

Facilitators and participants in the respective training programs have expressed gratitude for the opportunity to disclose, and most have described how much more meaningful their practices have become since they've been encouraged to do so. Over the course of the project, RTP staff have supplemented experiences in the field with communication products that address self-disclosure from a number of perspectives. It is truly rewarding to know RTP has helped advance recovery-oriented practice in this way.

Throughout the project's 5 years, the complementary components of RTP have effected several noteworthy changes. As the final RTP curricula are just now being launched around the country in various settings and with audiences that extend way beyond original expectations, the disciplines are reporting institutional changes, as well as changes in infrastructure, policy, standards and competencies, and culture. It appears RTP has inspired systems change merely by setting in motion important conversations, activating people and organizations, and supplying tools for implementation.

We know the external environment has undergone great turbulence over the past 5 years, which has cast a synchronistic influence on public health. The Affordable Care Act has spurned dramatic shifts in the way we think about and consume healthcare services. In the same vein, the call for primary and behavioral health parity and integration demands new ways of delivering health care, and the voice of the person receiving services is becoming increasingly important. A person's satisfaction with his or her healthcare providers is becoming part of the metric for reimbursements, incentives, and consequences in public health. There has been no better time for person-centered care and shared decision making—concepts all practitioners should fully understand. Thankfully, RTP will offer training to providers who need it.

Please visit RTP's Web site to access the more than 1,200 resources in our library, including articles, personal stories, videos (see photo of representatives from professional organizations participating in multidisciplinary practice role play above), training programs and tools, and links to other valuable information. Learn about calendar events and explore archived editions of our publications and products. Remind your colleagues, family members, and friends how easy it is to join our listserv.

As always, we value your feedback and appreciate your suggestions. Our Webinars, newsletters, and RTP Highlights are based on your input and contributions. Please send us your stories and continue to inspire the people who are making recovery a reality every day.
Resource Spotlight
For the past 5 years, Recovery to Practice has devoted part of its mission to developing a repository of resources that are diverse, reliable, and—most important—symbolic of the issues practitioners and consumers in the behavioral health sector face every day. Building a database of this nature requires many hands, especially those of our contributors, who have made the Recovery Resources Library what it is: a robust collection of stories, essays, videos, tools, and curricula supporting people in recovery and those helping to facilitate the process.

The Resources Library began with a handful of articles and today contains more than 1,200 items. It is one of RTP's proudest accomplishments and continues to be widely accessed on a daily basis.

The impact of the RTP project may be immeasurable, but below we illustrate what 5 years of collaboration, vision, and growth can do.
Submissions by Year
Submissions by Year
Web Trends
Web Trends
Available Resources by Type
Available Resources by Type
Listserv Growth
2010–13 RTP Subscribers
Listserv Growth
Guest Columnist
RTP Accomplishments and Impacts, by Deidra Dain
Deidra Dain Since its inception in 2009, the Recovery to Practice (RTP) project has upheld its core mission to advance implementation of recovery-oriented practice among practitioners. Along with our Steering Committee of national leaders of mental health and substance use recovery, teams from the six professional disciplines, and subcontractor partners (the New York Association of Psychiatric Rehabilitation Services, National Alliance on Mental Illness, Mental Health America, and National Development and Research Institutes), RTP staff have worked diligently through a variety of interconnected activities and tasks to achieve the project's mission. But what about RTP's impact? Has professional practice really changed?

To answer these important questions about RTP—part of SAMHSA's Recovery Support strategic initiative—we must look at the evidence of early change, which is apparent in many ways among and between the professional disciplines, from the project's data analytics, and from reported incidence of transformation.

The American Psychiatric Association and its partner, the American Association of Community Psychiatrists, have developed a one-of-a-kind model for training facilitators and delivering training using pairs of psychiatrists and people with lived experience. Their approach breaks down barriers and relies on strengths from both participants to fully and equally contribute to presenting recovery concepts like shared decision making, person-centered care, goal setting, and collaborative medication management. In this spirit of working together, the training creates an atmosphere where people feel safe and comfortable. Role play vignettes demonstrate real-life examples of effective (and ineffective) relationships between the psychiatrist and patient, consumer, or peer, making the learning tangibly valuable. A second facilitator training with select modules will be presented at the APA Annual Meeting in May, and the entire course will be delivered at the Institute on Psychiatric Services in October. For more information, email recovery@psych.org.

The American Psychiatric Nurses Association (APNA) has conducted two large facilitator trainings—one for its target audience of inpatient psychiatric nurses and one for its 43 chapter presidents. According to APNA RTP staff, enthusiasm to deliver the training is "growing exponentially." They are working with facilitators from select states to set up training delivery within their own systems. Hospital systems in Wisconsin and Nebraska are two examples. In Nebraska, leadership will first complete the training, then all behavioral health staff will follow, according to a mandate described in the newly developed strategic plan. Recently in Texas, a psychiatric nurse completed her doctoral dissertation on the RTP curriculum and is expanding the training throughout her workplace—a major healthcare management company. Next month, the University of Colorado's School of Nursing will host facilitator training, followed by a day of training delivery with newly trained facilitators. The goal is to make training available to psychiatric nurses statewide. Contact Deborah Hobbs with questions.
RTP In-Person Meeting
RTP In-Person Meeting, April 21–22, 2014
NAMI
"Recovery-Oriented Practice Is a Multidisciplinary Practice" role play at the National Alliance on Mental Illness Convention, June 2012

As many behavioral health professionals know, early writing and research on recovery-oriented practice have been conducted by psychologists. Ironically, the field of psychology as a whole lacks consensus on recovery concepts and principles, leaving gaps in active recovery practice. With assistance from their RTP Recovery Advisory Committee and Committee for Assessment and Training in Recovery, the American Psychological Association's (APA's) RTP staff have successfully facilitated advancement and adoption of recovery in numerous ways. For example, they have earned endorsements of their curriculum from the internal longstanding, well-respected Task Force on Serious Mental Illness. Similarly, plans exist to publish articles on recovery-oriented practice and the RTP curriculum in APA's flagship journals, American Psychologist and APA Monitor on Psychology. Please contact Urmi Chakrabarti for more information.

Following the research and assessment phase, RTP staff from the Association of Addiction Counselors (NAADAC) learned that while their audience largely understands SAMHSA's 10 components of recovery, the majority incorporate only some of the principles into professional practice. A Situational Analysis revealed training in these important concepts is indeed lacking, which may explain the enthusiastic response to NAADAC's monthly RTP Webinars. In total, 3,338 participants have attended the nine live events and 2,403 have viewed the archived versions. All Webinars are free and members receive continuing education credit. Contact Cynthia Moreno Tuohy or Misti Storie for further details.

The International Association of Peer Supporters (iNAPS) has seen an enormous surge in membership and interest in the RTP curriculum since the beginning of the project. Their curriculum has been developed, and delivery is being arranged for working peer supporters as an advanced training opportunity. The demand and interest from the early assessment to the training design and now to delivery led iNAPS to develop practice guidelines for the emerging profession—a year-long process that included participation from thousands of peer specialists. These guidelines lay the groundwork for future core competencies and practice standards to be formed at the national level and used in state certification programs. The iNAPS RTP team, which includes the Depression and Bipolar Support Alliance, has conducted several in-person facilitator trainings over the past 6 months. They are now arranging training deliveries with trained facilitators around the country. For more information, contact Training@DBSAlliance.org.

RTP staff and Steering Committee members at the Council on Social Work Education (CSWE), the accrediting organization for social work baccalaureate and masters' programs, drafted a set of competencies for recovery-oriented social work practice. The 2008 Educational Policy and Accreditation Standards (EPAS)—competency-based standards that social work programs follow to obtain and maintain accreditation—were used as the foundation for the recovery-oriented competencies developed by CSWE. The goal of using the EPAS in this way was for programs and field instructors to be more inclined to consider integrating recovery-oriented competencies into their teaching and field education methods. Additionally, to address inconsistent use of recovery-oriented syllabi, RTP staff identified models and obtained permission to include them in the Social Work Education Programs curriculum packages. For the first time, field instructors (CSWE's target audience) will be encouraged to administer a student field assessment instrument discerning the extent to which the student has knowledge and skills in recovery-oriented practice. This tool will help lessen the gap between theoretical knowledge and operational practice. In another step to achieve systems change, CSWE's RTP staff and Steering Committee made a concerted effort to generate recommendations for recovery language to be incorporated into the EPAS, which will be revised in 2015. The curriculum will be delivered in three Webinars in May, June, and July; asynchronous versions of the training will also be posted this summer. For more information, contact recovery@cswe.org.

Change in practice among the six behavioral health professions will be more fully realized and measured once trainings are delivered regularly and over time. Until then, the systems changes occurring are nothing short of inspiring.

In other aspects of the RTP project, efforts to increase awareness and provide tools for implementing recovery-oriented practice among practitioners have made significant progress. In just over 4 years, the RTP listserv has gained 8,500 subscribers and continues to grow. Biweekly RTP Highlights feature empirical and instructional articles, personal stories, and practitioner experiences in adopting recovery-oriented care. Hundreds of people routinely participate in RTP Webinars, where personal and professional perspectives on topics our stakeholders have identified as priorities are shared. Finally, the RTP Web site continues to build a rich and robust library of resources, an expansive calendar of events, and a link among the various behavioral health professions.

Deidra is the RTP Deputy Project Director.
Testimonials
To ensure the stories we publish resonate with practitioners, consumers, advocates, educators, and family members, RTP has always looked to its readers. The feedback we receive is invaluable—not only because it speaks so highly of our authors and their personal experiences, but also because your letters tell us how timely, poignant, and wide-reaching the mission of RTP really is. Below are just a few of the kind words our readers have shared. Please keep the comments coming! Email us at recoverytopractice@dsgonline.org.

"I want to thank you again for publishing my article in the Recovery to Practice Highlights ... I have received very positive feedback from both peers and professionals. This included a request from one statewide administrator who hopes I may be able to aid her efforts to make crisis services more trauma informed and recovery oriented in her state. —Jim Probert, Ph.D., licensed psychologist, "Toward a More Trauma- and Recovery-Informed Practice of Lethality Assessment and Suicide Prevention"

"The best response I have read. Bravo, excellent and as it should be. You captured everything I have been thinking and stated it beautifully. Thank you. Sharing far and wide." —Laura Minnick, in response to "It's Time to Wake Up and Stop the Violence"

"Loved your piece in Recovery to Practice. It's so important that the so-called 'normal' people hear and read transformative stories—that someone can come back from such a dark place. Good for you and thanks for sharing your story." —Howard Josepher, in response to "A Life With Purpose"

"Thank you for publishing my story in Recovery to Practice! It was a journey from writing, having colleagues assist with editing, and finally sending it. Then, after it was edited and published, I was validated with emails from people [who] could relate to the message. I was even invited to speak in Iowa. It was the first time I had weaved trauma into my recovery story and it was an important experience in my life." —Carol Coussons de Reyes, "When Your Childhood Home Isn't Safe: Finding Sanctuary"

"Carol's article was so well done and such an inspiring read. I will pass it along. Please let her know that to read her story was a gift." —Marguerite Gayle, in response to "When Your Childhood Home Isn't Safe"

"Hallelujah for you, Amy. This discussion should be required reading for every MH professional working in the world today. Hallelujah for the loud and clear voice of the consumer. It makes my day and does my heart good to read something like this. Thanks to you both for the guts and intention of putting this out into the world!" —Jason A. Seidel, Psy.D., in response to "Dear Amy and Larry"

"Thank you so much for the interview. Frankly, it is the best article I've read to date on delusions, and I've been reading such articles for 47 years." —Charlie McCarthy, in response to "Dear Amy and Larry"

"Just wanted to say I appreciate this perspective with the statistics to back up what I have been 'preaching' to my colleagues, friends, [and] associates during the last weeks of demonizing people with a mental health diagnosis. I feel the efforts put forth lately to place blame and rein in violence have fostered a considerable regression in cultural attitudes, undermining whatever progress had been made toward a more enlightened and humane understanding of mental illness. Thank you again and please know there are some of us out here working with people who are trying hard to counter this appalling trend." —Renee MacKenzie, in response to "One Response to One Reaction to the Newtown Tragedy
by Larry Davidson, Ph.D.
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This project was supported under Development Services Group, Inc. contract #HHSS2832 0070 00371 from the Substance Abuse and Mental Health Services Administration (SAMHSA). The opinions and points of view expressed are those of the author(s) and do not necessarily reflect those of SAMHSA or DSG.