Transitioning to Recovery Based
Treatment
Mark M. Lowis, LMSW
Member: International Motivational Interviewing Network of Trainers
Ray Rais, LMSW
Quality Improvement Coordinator – Macomb County Community Mental Health
 Tolstoy:
“I know that most men, including those at ease with
problems of the greatest complexity, can seldom
accept even the simplest and most obvious truth if it
be such as would oblige them to admit the falsity of
conclusions which they have delighted in explaining
to colleagues, which they have proudly taught to
others and which they have woven, thread by thread,
into the fabrics of their lives.”
Give me
5 Minutes
to learn Names
Transition?
From What?
 Institutional Memory
 Goal is to Maintain Stability
in within the System
 What the Agency Offers
 Prescribing/telling
 Compliance Based
 Monitoring compliance
 Mandating Behavior
 Deficit Based
To What?
 Targeted Treatment
 Goal is to Exit the System
through Amelioration
 Individualized Issues
 Assistive Interventions
 Collaborative
 Guiding Incremental change
 Manageable
 Recovery based
Exercise
 Work in groups at table
 Select a scribe for your table
 Select a speaker to represent you table
 Together brainstorm a list of deficit based terms
 Start by saying; “I see you as….” and finish
with the deficit based term/label. (IE: I see
you as lazy.)
 Facilitator gathers list from speaker
Exercise
 Work in groups at table
 Select a scribe for your table
 Select a speaker to represent you table
 Together brainstorm a list of strength based terms
 Start by saying; “I see you as….” and finish with
the deficit based term/label. (IE: I see you as
protecting yourself.)
 Facilitator gathers list from speaker
“Strength Based” means “Making
Sense” out of Resistance!
Some Kinds of Plans
 Behavioral –
 Uses Behavioral Modification
 Awards Points
 Privileges
 Incentives
 Consequences
Some Kinds of Plans
 Institutional –
 Uses levels of functioning to determine privileges
within the institution
 Deficit based –
 Professional determines a person’s needs based on
inability
 takes over decisions
 struggles to control or manage
 contest between system and free will of client.
Some Kinds of Plans
 Agency –
 Converts a person’s desire (what they want from
treatment) to what the agency offers
 says what the client can and can’t have
 Staged –
 Work is collaborative and assistive
 Step-by-step process toward recovery
 Steps are manageable for the person being served
 The pace of recovery is determined by readiness
 Throughout the process the focus is on transition
Institutional Memory
• Historical Approach to Treatment in which the need
•
•
•
•
•
is to protect the public
Identify Persons with Mental Illness based upon
dangerous, aberrant or abhorrent behavior
Remove from Mainstream
Place in institution
Stabilize Symptoms
Maintained forever
– State Facility
– Forensic Center
– Jail
Institutional
•Take Possession
•Remove
•Place
•Depersonalize
•Stabilize
•Maintain
•Ineffective
•Costly
Deinstitutionalize
Home Setting
Smaller Institutions
Less Confining
More personal
Placement
Stabilize
Maintain
Costly
•Community Based
•Group Homes
•Same Approach
•Smaller Institutions
•Resistance from Community
Seeking full citizenship
Person Centered Planning
•Institutional
• Assess
• Diagnose
• Prescribe
•Person Centered
• Facilitate
• Collaborate
• Assist
Goals and Objectives are still Maintenance and
Institutional
Strength Based
Its not looking for their
strengths.
Its knowing that they are there
•Honors autonomy
•Emphasizes choice and control
•What assistance are they seeking
•What do they already understand
•How do they see us working with them
Strength Based
The individual has the right to dignity
and respect from the practitioner(s) and
every person whom they encounter at
the agency
(Mutuality)
Push Back
Examples
 A job is not a service
 We aren’t an employment agency
 We don’t do housing
 We don’t do that
 The CMH has cut our funding so we can’t
 They don’t know what they want
 Some of them just want us to tell them
 The just want medication
 They’re just trying to get…
Maintenance Approach (Institutional Memory)
• Prescribed Goals and Objectives
• Encounters are cumulative and general
• Time frames are subjective
• Consumer must accept expert advise
• Consumer must match expectations of system
• Confront Resistance
– Guardianship
– Consequences
– More Restrictive
– Seclusion and Restraint
– Behavior Management Committee
Recovery Approach
 Good agreement on Goals, Objectives and
Interventions
 Consumer has total choice and control
 Professional is assistive and collaborative partner
 Encounters are specific
 Resistance is understood from consumer perspective
 Professional has interventions for any level of
readiness
 Goal is to achieve amelioration and discharge
 Consumer is welcome back if necessary
 Time frames are realistic
Maintenance Plan
• Problem #2 – The consumer lacks coping skills
• Goal #2 – The consumer will Develop Coping Skills
• Objective #1 – The consumer will attend all therapy sessions
•
•
•
•
•
AEB therapist documentation
Intervention #1 – Therapy 1x/week
Objective #2 – The Consumer will make 3 positive selfstatements per week AEB therapist documentation
Intervention #2 – Therapy 1x/week
Objective #3 – The consumer will identify 3 coping skills AEB
therapist documentation
Intervention #3 – Therapy 1x/week
Now What?
What would the Problem Statement Become?
What would an Objective Look Like?
What would an Intervention look like?
Recovery Plan
• Targeted issue – Symptoms interfere with keeping job
• Goal – Stop symptoms from interfering with ability to keep
job
• Objective 1 – Meet with psychiatrist to discuss and
describe symptoms and the way in which they interfere with
ability to keep a job
• Objective 2 – Be able describe medication including
dosage, how taken, possible side effects, how it will help
with Goal
• Objective 3 – Develop agreement with psychiatrist on
medication
Recovery Interventions (Us)
 Intervention – Psychiatric Evaluation to
determine medication to support goal for sustaining
employment
 Intervention – Demonstrate way in which
medication will assist with goal
 Intervention – Periodic medication review to
determine how used, effects/side effects, reaffirm
usefulness toward goal and adjust if necessary.
 Intervention - Assist with any concerns or barriers
Intervention
What we do
that is
assistive and collaborative
in helping the person with objectives
for achieving the goal
Dean Fixen
The
Therapist
Is
The
Intervention!
Sufficiency Standards and
Authorization
 Amount – number of units needed to provide the
service
 Scope - How the service will meet the need
addressed (Think of Medical Necessity)
 Duration – How long the service will be provided
based on attaining the objective
 Service – Psychiatric Evaluation, Medication Review,
Group/Individual/Family Therapy, Case
Management, etc.
Deficit Based Transition Goals
• Maintain reduction in symptoms for
12/months
• Maintain medication compliance for
12/months
• Comply with treatment
• Stay at Par for 12/months!!
• Intervention – Monitor for compliance
Transition Goals
Recovery
 Find a home that provides more independence.
 Person’s description of the goal: “I want my own place”
 Assist Primary Health Care Provider in transfer of
medication
 Person’s description of the goal: “I don’t need help to
take my medication”
 Intervention – Assist in connecting, scheduling,
attending and adjusting to a resource
(Warm Transfer)
Recovery Based Supports and Services
EXAMPLES:
 Psycho-Education
 Health Education
 Individual, Family, Group Treatment
 Pharmacological
 Case Management
 Primary Health Care Physician-Community Clinic
 Community Resources
 Referral to Human Service Agencies
 Community Living Supports
 Discharge by Warm Transfer
 Collaborative
 Welcome back
Recovery Based Discharge Queues
• “Person's” treatment goals are attained “to their satisfaction”
• On-going care is achievable through Primary Health Care
•
•
•
•
Physician-Community Clinic
On-going issues are able to be provided through other human
service agencies (MRS, Work First, DHS, etc) or support network
Consumer is not attending “for a reason”
Consumer attends only to protect SSI/D
Consumer cannot be contacted
– Leaves area
– Refuses services
– Receiving services elsewhere
Planning Process
1st Identify the “Person’s” Targeted Issues
 Symptoms of Mental Illness (specific) Impact on…
 Co-occurring Substance Use (specific) Interferes with…
 Co-occurring Health Issues (specific) affect…
 Safe and Affordable Housing impacted by one or more life
conditions (specific).
 Employment-Income-Resources impacted by one or more life
conditions (specific).
 Social (specific) and Community Participation (specific) affected
by…
 Self Care (specific) interrupted by…
 Issues compounded by 2 or more conditions
Planning Process
2nd Identify Goals for Amelioration of each of the
Person's Targeted Issues
3rd Identify the Person's Stage of Readiness for working
on each Goal
4th Design Objectives based on the Person's Readiness
5th Design interventions in collaboration with the client to
achieve Objectives
6th Establish accurate, sensible time frames for
achieving Objectives
7th Be willing to adjust Plan when necessary
8th Discharge Goal is always part of plan
Process for Strength Based – Recovery Oriented
Stage Matched
Treatment Planning
Presenting Problem
ID Item to be
addressed
Assessment Domain
Effect on Presenting
Problem
New Item to be
addressed
No
Identified Strength
Goal
Level of Readiness
Objectives
Interventions
Goal
Level of Readiness
Objectives
Interventions
An identified need that will not be addressed by the service agency must be
documented in the interpretive summary and indicate where it will be
addressed. IE: under care of primary health care physician and currently stable.
Process continues through each assessment domain. Each domain is assessed to determine if/how it impacts the presenting problem for any new item that will
need to be addressed. If any assessment domain identifies a need that must be addressed, the assessor must determine if it will be address by the agency in the
plan or by an outside resource/agency. If the need will be addressed b y the agency it must be included in the Individual Plan of Service (IPOS). If the need will
be addressed by an outside resource it must be documented in the comprehensive summary at the end of the assessment. Each item in the IPOS must include
the level of readiness of the individual to work on that item, and must have stage matched interventions. Goals and objectives are the person receiving
services. Interventions are the serving agency.
Staging – Block II
Refer to “Stage to Intervention” Power Point