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Evidence-Based Practices: Shaping Mental Health Services Toward Recovery

Workbook for Clinical & Practical Supervisors

Important Concepts

Chapter 2

• Objectives
• Complementary Activities
• Important Concepts
• Recovery
• Stress-Vulnerability Model
• Review

Objectives
Introduce the concept of recovery as the goal of mental health treatment.
The concept of recovery is one that may be new to people. Recovery does not mean cure, but it does mean learning ways to live with an illness so that it is not the driving factor in a person’s life.

Provide a framework for understanding the onset and course of mental illness.
This chapter includes an overview of the stress-vulnerability model. This model provides a useful framework for understanding mental illness and factors that influence its onset and course. The stress-vulnerability model also offers a schema for thinking about the objectives of assertive community treatment and the skills that consumers need for their recovery.

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Complementary Activities
Visit the web pages of the National Empowerment Center
The National Empowerment Center operates a website (www.power2u.org) that has stories and articles written by people who have experienced psychiatric disorders. The articles provide a glimpse of what it is like to be on the receiving end of mental health services, as well as, accounts of personal journeys to recovery. You will find articles to share with your team as well as training materials that can help team members better understand the experience of mental illness.

Read more about recovery
Much of the information on recovery in this chapter comes from a report called A Review of Recovery Literature written by Dr. Ruth O. Ralph for the National Technical Assistance Center for State Mental Health Planning (NTAC) and National Association for State Mental Health Program Directors (NASMHPD). You can download this report in its entirety (about 30 pages) from the NASMHPD website – http://www.nasmhpd.org/ntac/reports/ralphrecovweb.pdf.

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Important Concepts

1. The ultimate goal of assertive community treatment services is to support consumers in their recovery processes.
2. In a recovery framework, mental health practitioners are called upon to be a source of hope and support for consumers.
3. Mental illness involves two key factors: (1) biological vulnerability that predisposes individuals to mental illness, and (2) stressors.
4. Objectives of assertive community treatment interventions are to reduce the stressors to which a person is exposed, and to change conditions that affect the person’s susceptibility to stressors

This chapter presents two concepts that are important in understanding the goals and objectives of assertive community treatment. One is the concept of recovery. Recovery in the context of severe and persistent mental illness may be new to some team members. Since the ultimate goal of assertive community treatment services is to support the consumer’s recovery process, this chapter begins with a discussion of this concept.

The second concept addresses the stress-vulnerability model. This model provides a useful framework for understanding mental illness and factors that influence its onset and course. The stress-vulnerability model also offers a schema for thinking about the objectives of the services that assertive community treatment teams provide and skills that consumers need for their recovery.

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Recovery
The idea of ‘recovery’ from severe and persistent mental illness may be new to team members who came of age professionally in an earlier era when the mental health field generally held and communicated low expectation for people with severe and persistent mental illness. ‘Recovery’ embraces a more hopeful vision for people who experience psychiatric disorders.

In a recovery framework, the expectation is that people who experience severe mental illness can live a life in which mental illness is not the driving factor for their existence. Recovery means more than expecting people to simply ‘cope’ with mental illness. It also means more than ‘maintaining’ people with mental illness in the community.

In a recovery framework, mental health practitioners are called upon to be a source of hope, support, and education, and to partner with people on their journey through mental illness and the accompanying social consequences. As Alan McNab describes it, people with mental illness are looking for:

• support and education so they can take responsibility for controlling their symptoms,
• encouragement to set personal goals and work toward them, and
• help getting facts, planning strategies, gathering support, and targeting their efforts.

In a publication prepared for the National Technical Assistance Center for State Mental Health Planning (NTAC) and the National Association for State Mental Health Program Directors (NASMHPD), Dr. Ruth Ralph describes recovery as “a process in which consumers learn to approach daily challenges, overcome disability, learn skills, live independently, and contribute to society.”

Helping consumers in the process of recovery is the ultimate goal of assertive community
treatment teams.

Consumer Comments on Recovery
The dictionary talks about recovery in terms of regaining something or getting something back. In consumers’ comments on recovery, there are themes of regaining:

• hope
• motivation
• self-confidence
• meaning
• independence

It is important for practitioners to convey the belief that consumers can:

• get well and stay well for long periods of time,
• work toward and meet goals, and
• lead happy and productive lives

Consumers who were involved in the development of the Implementing Evidence-Based Practices Project materials described their experience of recovery. These individuals discussed the importance of goals in providing meaning and instilling hope. As one consumer says, “I have to have goals. That’s what gives my life meaning. I’m looking to the future.”

According to another individual, “It’s about motivation.” The idea of motivation and how to use it in helping individuals with recovery is discussed in another Resource Kit (Illness Management).

For another consumer, the issue is self-esteem: “Recovery is about having confidence and self-esteem. There are things I’m good at, and I have something positive to offer the world.”

Independence is also important: “The most important thing in my recovery is to be as independent as possible. I’m working at that all the time.” Team members work with consumers to help them achieve maximum independence in many areas including housing, finances, and medication management. Team members can also help consumers become more independent in their relationship with the mental health system by educating them about mental illness and treatment options and relating to them as partners in the treatment process rather than as the subjects of treatment.

Other Perspectives
We want to be careful to say that we are not suggesting that recovery means that a consumer simply goes back to where he or she was before the onset of illness. For one thing, we are all continuously changing, growing, and learning. Further, being diagnosed with a severe and persistent mental illness is a life-altering experience. For these reasons and others, some consumers prefer to talk about the experience of mental illness in terms other than recovery.

In Dr. Ralph’s publication (mentioned earlier in this chapter) a paper written in 1999 by S. Caras called Reflections on the Recovery Model and another by K. Cohan and S. Caras written in 1998 called Transformations were cited. We include these quotes to give team members a broader view of consumers’ thoughts about the experience of mental illness:

“I am not recovered. There is no repeating, regaining, restoring, recapturing, recuperating, retrieving. There was not a convalescence. I am not complete. What I am is changing and growing and integrating and learning to be myself. What there is, is motion, less pain, and a higher portion of time well-lived.”
S. Caras, 1999

Our lives seem not to follow a traditional linear path; our lives appear to be like advancing spirals. We relapse and recuperate, we decide and rebuild, we awaken to life and recover/discover, and then we spiral again. This spiral journey is one of renewal and integration, the dynamic nature of this process leads to what can only be described as transformation. Recovery and rehabilitation imply that someone was once broken and then was fixed. Transformation implies that proverbial making of lemonade after life hands you lemons. It is the lesson, hard learned, of the opportunity available in the midst of crisis that evokes a substantive change within ourselves.”
K. Cohan & S. Caras, 1998

Recovery as a Process
Recovery does not mean the same thing as cure. When we use the term recovery in this workbook, it is not meant to imply that a person will never experience psychiatric symptoms again. What we are talking about is an ongoing process. Based on a review of the literature on recovery and severe mental illness in the publication by Dr. Ralph this process might be seen as a journey through mental illness to a place where a person has the courage, skills, knowledge, and aspiration to struggle persistently with psychiatric symptoms and the impairments that can limit people from living independent and meaningful lives.

The process of recovery involves consumers’ experiencing and processing their feelings about having a mental illness and the consequences of that illness in their lives. Consumers write and speak of experiencing grief, frustration, loneliness, despair, and anger at God, the mental health system, and at society’s treatment of people with mental illness.1,2

As you work with people, it is important to allow them to express their feelings about having a mental illness. Anger, grief, frustration, hopelessness, and despair are all normal emotions a person diagnosed with a major illness might be expected to experience. Be careful not to write these feelings off as merely symptoms of mental illness, mood swings, or labile affect.

Listen and validate feelings, without discounting or minimizing their experience. You will want to help people refocus on what they are able to do, and ways they can decrease the symptoms they experience, prevent them from recurring, and become involved in meaningful adult activities that interest them.

1 See “The Wounded Prophet” in Recovery: The New Force in Mental Health, published by the Ohio Department of Mental Health.
2 See “How I Perceive and Manage My Illness” by E. Leete in Schizophrenia Bulletin, Volume 8, 1998.

Conveying Hope
It is easy for a person diagnosed with a severe mental illness to lose hope. The symptoms of psychiatric illness can be very difficult to live with. As a society we have historically sent a clear message that people who experience psychiatric illnesses are less valued members of our society. Even the mental health profession has sent the message, until recently, that the best a person might hope for is to “cope.” While progress is slowly being made to change attitudes and eliminate the stigma associated with mental illness, a person diagnosed with a severe mental illness will still receive many negative messages and it is easy for them to be internalized. Your job involves countering those negative messages by showing the people you work with the same respect and consideration you would any adult and by helping them to envision social roles for themselves other than that of a patient or consumer.

Barbara Julius, who directed the Outreach Program in Charleston, South Carolina for more than a decade remembers her struggle coming to believe in the possibilities for people diagnosed with severe mental illnesses:

When the Outreach Program started, I did not have a lot of experience working with people diagnosed with schizophrenia. When it was time for me to review charts to decide if we were going to admit someone to our program and I began to read about the bizarre behavior and incidents that had led to people being in the State Hospital for long periods of time, I found myself thinking, “Oh no! This person could never be in the community. That would be a huge a risk. What about our program’s liability?”

During a consultation with Debbie Allness, a member of the original program for assertive community treatment, I shared these concerns and I remember her saying, “If you think this is impossible, maybe you shouldn’t be doing the work.” Her comment was a turning point for me. I realized that if you cannot, as a team leader or program director, hold the dream of possibility for another person, then you should not be leading an assertive community treatment team. If your thinking is so restricted that you cannot envision people who experience severe and persistent mental illness getting better and you think they will require constant supervision, then why do assertive community treatment?

Your role is not only to help the people who receive your services to see a more hopeful future, but also to help change the attitudes of those around you. Mike Neale, who has helped to develop more than 50 ACT programs for the Veterans Administration talks about the role of assertive community treatment team members in changing attitudes:

[Assertive community treatment] is all about advocacy, all the time. That is the mode you go into when you start doing community-based services. You do not know where, when, and how, but you know you will do it. And you need to. You need to educate everybody; all the stakeholders from yourself, to your client, family members, others out in the community, other providers, providers on your team, providers back in your system, and community members. It is the whole spectrum of education about what you do, what the potential is for people diagnosed with a serious mental illness, and how mental health treatment can work. Essentially, you are trying to change perception and behaviors at every level.

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Stress-Vulnerability Model
The ultimate goal of assertive community treatment is to help individual’s reach a point where having a mental illness is not central in their life. In order to help people reach that point, team members need to understand something about the onset and course of mental illness. The stress-vulnerability model provides a framework for thinking about mental illness and a practical schema for conceptualizing the objectives of services.

According to the stress-vulnerability model, an episode of major mental illness such as schizophrenia, schizoaffective disorder, bipolar disorder, or major depression involves two factors: biological vulnerability and stress.

In order for a person to develop a mental illness, he or she must have the biological vulnerability for that particular illness. The illness may then develop spontaneously or when the person is exposed to stress. The illness, triggered by stress, may reoccur periodically. In some individuals with severe disorder, vulnerability appears to increase with repeated episodes of illness. The criteria for admission to assertive community treatment programs makes it particularly likely that consumers who receive ACT services will have had multiple episodes of illness and experience symptoms that may
not fully remit.

Need graphic link

Figure 2.1 Stress-Vulnerability Model

Researchers are not certain of the exact precursors of biological vulnerability. There is research implicating genetics, biochemical agents, and early biological development.

On the other hand, stressors are something with which everyone is familiar. Look at the list of stressors in Table 2.1. You will see that some stressors are major unpleasant life events. These stressors include experiences like losing a loved one, being fired, losing your home, being arrested, and being hospitalized.

Stressors can also be events and experiences that happen to people that are generally considered positive or desirable. For example, being discharged from the hospital, being released from prison, the birth of a new child, a job promotion, an increase in pay, and starting a new relationship are experiences that would generally be considered changes for the better. The key is that they involve change and change, even for the better, can be stressful.

Stressors do not always have to be major events. Daily hassles such as traffic jams, cranky children, rude people, or deadlines can also be stressful.

There are times when people may be particularly susceptible to stress; when even little things that normally would not bother them are stressful. These may include times when people are hungry, tired, lonely, or not feeling well (Table 2.1).

Table 2.1 Stressors and Susceptibility to Stress

Some conditions and circumstances make it easier for people to cope with stress, for instance, exercise, proper rest, and good nutrition. Social support, that is having people who will listen and support when things are not going well, can also make it easier for people to cope with stress.

Implications for Intervention
Returning to the basic premise of the stress-vulnerability model, when a person is biologically vulnerable to mental illness and encounters stressors such as those listed in Table 2.1, there is a risk of relapse. It stands to reason then that a person’s odds of experiencing psychiatric symptoms (and chances of reaching a point where his or her life does not center around mental illness) can be favorably altered by interventions that:

• change the person’s biochemistry
• change the person’s risk of being exposed to stressors
• change factors that influence the person’s susceptibility to stressors

Change Biochemistry
One way to alter the stress-vulnerability equation is to alter biological processes. Medications can alter the workings of chemicals within the brain to reduce or eliminate psychiatric symptoms. These medications can have substantial side effects and using them effectively requires a close working relationship between the consumer and his or her doctor.

Drugs and alcohol also affect the chemistry in the brain and can make psychiatric symptoms worse. Effectively addressing psychiatric symptoms means also treating co-occurring drug and alcohol abuse disorders.

Change Person’s Risk of Exposure to Stressors
Major negative life experiences such as job loss, arrest, and injury are likely to be common experiences among people in assertive community treatment programs. When people initially enter the program, the team focus will be on helping them through the aftermath of these experiences. To change people’s exposure to stressors, it is important to think ahead about what skills, support, and resources people need to prevent such events from recurring. For instance, future evictions might perhaps be avoided by helping the person devise and carry out a plan to pay his or her rent on time or by coaching the person to keep his or her apartment reasonably clean. Perhaps future arrests can be avoided through coordinated interventions that include helping the person occupy his or her time in activities that provide alternatives to using illegal substances.

The comprehensive assessment and psychosocial history timeline can help the team anticipate antecedents of these negative life events. This information can then be used to inform approaches to prevent these stressful events from recurring.

There are some stressors people may not want to avoid; for example, a move to a new apartment, discharge from the hospital, or a new job. In these instances, the team will want to think about strategies to make the change less stressful. One approach to managing these positive events is to break them into manageable, ‘bite-size’ pieces. For instance, the move to the new apartment might begin with the consumer spending part of a day there with people he/she knows. On the next visit, the person’s supporters might only stay for part of the time. The next step might be for the consumer to spend time in the apartment alone, eventually working up to spending a night alone in the apartment. Starting a new job might be done in a similar fashion; the consumer might spend increasing amounts of time on the job with the amount of immediate support being gradually reduced until the consumer is comfortable in the situation. These types of interventions, and the need for them, will vary from consumer to consumer.

Not all stressors are major events. Life is full of hassles that can be sources of stress, some may be easier to deal with if they can be anticipated, then plans can be made to either avoid the hassles or strategies can be rehearsed for coping with them. For instance, if traveling to a job during rush hour is intolerably stressful for a person, the team might want to help him or her make plans for leaving for work at a different time to miss the rush. Another alternative might be to rehearse with the person a conversation with his or her job supervisor about starting work at a different time. Team members might also work with a person about learning to recognize signs that he or she is experiencing stress and practicing ways to relax. For instance, the person might decide to try listening to quiet music on a headset when he or she recognizes signs of stress.

Change Factors that Influence Susceptibility to Stress
Table 2.1 also listed factors such as health, nutrition, social support, and attitude that affect a person’s susceptibility to stress. One approach to reducing the likelihood of psychiatric symptoms is to focus on assuring that he or she has good physical health, adequate nutrition, and proper rest. Because of the psychiatric symptoms and related cognitive and social impairments people experience, it may be difficult for them to organize and carry out basic activities to care for themselves and their homes. For instance, proper nutrition involves being able to plan what foods to purchase, managing a budget, travel to the store, selecting food, paying for it, bringing it home, and preparing it. Fatigue and disorganized thinking may make it difficult for the person to plan and follow through on the steps involved in purchasing and preparing food. Similarly, good physical health requires, in part, being able to communicate health concerns and follow through on treatments for medical problems. Psychiatric symptoms and associated impairments can make this difficult.

According to Allness & Knoedler, side-by-side help and support are effective in motivating and helping consumers restore activities of adult role functioning. Side-by-side help and support means that team members actively participate with consumers to plan and carry out any or all activities to live independently, work, and socialize.

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Review
1. Review the Comprehensive Assessment in Appendix A. The table below lists stressors and hassles that influence a person’s susceptibility to stress discussed in this chapter. Identify which of theses factors Mr. Jones, the subject of the Comprehensive Assessment in Appendix A, experienced in the year prior to the assessment. Which were present at the time the comprehensive assessment was done?

2. Review the treatment plan in Appendix B that was developed for Mr. Jones. The action steps identified in the plan are listed below. Review each action step and decide which of the following the step addresses (there may be more than one response for a step):

A. change the person’s biochemistry
B. change person’s risk of exposure to stressors
C. change person’s susceptibility to stressors
D. other

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