[Silence] >> Good afternoon.
We would like to welcome you to SAMSHA's webinar.
This is part of Recovery to Practice series on clinical support.
In our presentation today we will be welcoming and culturally
appropriating engagement for individuals with co-occurring mental health and substance use
conditions.
Our presenters today will be Dr. Ken Minkoff, Dr. Chris Gordon,
and myself, Jackie Pettis, Our learning objectives today, we have two
learning objectives: The first one is to describe specific techniques and strategies for welcoming,
engaging, and inspiring individuals with co-occurring conditions, in pharmacologic practice as well
as other treatment settings.
Our second objective is to describe strategies to successfully engage individuals with co-
occurring conditions where differences in culture, values, beliefs,
and experiences exist between the individual and the provider.
Now I'll hand it off to Dr. Minkoff.
>> Thank you very much Jackie for the introduction.
It may seem odd that we are starting a series of webinars that have a focus on
psychopharmacologic practice with a presentation on welcoming and engagement.
But nonetheless, the success of being able to provide any
kind of service to individuals with co-occurring mental health and substance conditions, including
psychopharm, involves creating an opportunity to develop the most successful relationship
up front that you possibly can.
In order to create an understanding of how that relationship is important, we wanted
to begin by introducing the concept of how necessary it is to prioritize attention to
people who have co-occurring mental health and substance use issues and other complexities.
We call this the complexity challenge.
Individuals with co-occurring mental health and substance issues
are folks who are prevalent everywhere in our service delivery system.
They have issues not just in mental health and substance use, but in multiple domains
including health issues, legal issues, parenting issues, trauma issues, housing issues and
so on.
They are folks who are associated with having the poorest outcomes in multiple domains and
the highest costs, including people who are at highest risk of premature death.
For all of these reasons, it would be important to think across our entire delivery system
wherever we encounter people who have co-occurring mental health and substance issues that we
would want them to be identified and engaged as a priority for care.
So one of the starting places for how to be successful with working with these individuals
is to think purposefully.
How do I as an individual, how does my program, my organization, make a deliberate effort
to welcome these individuals exactly as they are into any service setting, including into
a setting where the purpose is to prescribe medication?
In addition to the challenge of welcoming people with complexity, what's also important
right at the beginning to remember that it's necessary for us to inspire people with hope.
Hope is the driver that keeps people engaged when things get difficult.
It's the energy that the people we work with bring into our conversation that allows
them to do the hard work of engaging with us and doing things including taking medication.
And taking medication properly, that may be very challenging to do while addressing multiple
issues in your life.
So that if we think systemically, everything we do needs to be designed to welcome, engage
and provide integrated services including psychopharmacology services and an integrative
perspective to people with co-occurring issues and other complex needs.
So within the framework of thinking about this, we want all of you who are watching
to enter into this with a very interesting mindset,
which is, every program needs to be thinking of itself as a co-occurring program, because
you already have people with co-occurring issues in your doors.
And you want to organize
yourself to help them as much as you can.
Similarly, every person and every practice needs to be able to be designed to be appropriately
matched for people with co-occurring issues who are being seen, including psychopharmacologic
practice.
We can call this approach a program of recovery for systems, so we all
move together in a direction to help people who need us the most.
Is this your vision?
If it is, how would you get there?
That's one of the things this webinar and the other webinars in this series are designed
to help you move in the context of the larger approach that's called recovery to practice.
What we're going to do today is start by digging into detail on the first principle and a little
bit of the second principle.
Here's the first principle.
When you walk in your office to prescribe medicine or meet anybody who is likely to
be seen in the context of mental health service or substance service, particularly if you're
working at a public sector setting, you're going to find a complexity is an expectation.
And the principle is: we want to build that expectation
in a welcoming manner into absolutely everything we do.
And remove access barriers that make it hard for people to be welcomed, even though they
may seem to have been established since the beginning of time.
And welcome the opportunity to welcome the person as they are and to make it easy for
them to share all of their issues inside their work with us.
Now in this webinar, all of you have had the chance to review the story of Nick M, who
is a man who is coming in for an evaluation, a psychopharmologic assessment, with concerns
about both alcohol dependence, alcohol addiction, and major depression.
What you want to be saying to him is, "Welcome.
Nick, or Mr. M., you are in the right place.
I'm glad you're here.
I know you have a lot of challenges in your life; you had a lot of ups and downs.
It must have been very difficult for you to have made the decision to come to see me.
I want to let you know I'm very, very glad you're here.
You're a person who has lots of things going on.
You're exactly the kind of person I personally enjoy helping.
My goal in meeting you is not to try to fit you into some box, but I want to get to know
you.
I want to inspire you with hope.
I want to help work with you and any other members of our treatment team that we can
find help you, with all of your issues: your mental health issues, your substance issues,
but your life as a whole, so we can work together to help you make progress over time.
To achieve a happy, hopeful, beautiful, and successful life."
Now there's nothing in that speech that is rocket science.
The thing I'm saying to you always is to be thinking about how you practice your own speeches.
So that you can say them not just reading off an index card or a piece of paper, but
looking people in the eye, speaking from the heart, expressing the care and concern that
you already had in a way that helps that person who is probably scared to death to feel like
they have made a good choice coming in.
The final thing I want to say is: What are we welcoming people into?
We're not just welcoming in in the first moment, we're welcoming them into an ongoing relationship
within which we do the assessment and we do ongoing intervention over time.
This relationship has to be conceived of as a partnership.
This is what we've learned is what helps people.
This partnership includes things like shared decision-making, which we will be talking
about other webinars.
It's a partnership that's empathic and hopeful.
It's integrated.
And it's built on strength and to work with people in small steps over time to help them
with their issues, because the best practice care for people with co-occurring issues takes
time to help people move in small steps to achieve their goals.
Now I'm going to transition to Dr. Chris Gordon who will dig further into some of the strategies
that he uses as a psychiatrist to welcome and engage people
who have complex and co-occurring needs.
>> Thank you very much Ken.
That was a superb introduction.
As you mentioned I want to offer a few ideas from my actual practice about how we
can make engagement warm and welcoming and hopefully very effective.
And we can begin with a sort of a commonplace idea that, of course, good outcomes, especially
for people who are facing complex challenges, are whole lot more likely if that person experiences
a durable, solid, good, and warm relationship with their healthcare provider.
And that those relationships are an awful lot more likely to occur if we get off on
the right foot.
And that the process of engagement goes well.
Probably the most important ingredient in that kind of engagement from my point of view
is time.
Working at a pace where there's enough space and time to get to know the person as a person.
Not just as a problem list.
For those of us who work in clinics, we can appreciate this is an enormously challenging
problem because time is in terribly short supply.
This kind of unhurried welcome is what's necessary for us to lead
with the person's strength and be able to meet the person with an open mind and an open
heart.
And what Ken was also emphasizing, the tone of what we do and say is probably at least
as important as the substance of what we do and say.
That is a tone of friendliness, warmth, optimism, and what I like to think of as neighborliness
are really very, very important.
For us, physicians, it's important I believe as we look over the person's history to pay
as much attention to spot and highlight the person's strengths, accomplishments, and just
good qualities as we do to their symptoms, problems, and
possible diagnoses.
Mr. M's history is filled with such strengths and accomplishments.
He immigrated to this country when he was 18, he has achieved full citizenship, is a
bilingual person, a devoted father, a person of deep religious faith, and a member of the
faith community.
All of these are important attributes.
For us as physicians it's particularly important for us to be aware of clinical histories or
symptom list that would tend push us into a particular predetermined direction about
treatment before we took the time to get to know what Mr. M's perspective is; himself
on what his problems are and are not and what
the best approach would be toward their management.
It's also important for us to take stock and notice the adaptive coping side of whatever
the person has been doing to deal with their difficulties.
One thing that leaps out from Mr. M's history, for example, is
he has been trying hard to find work to provide for his children; that he prioritized that
over his own care.
That's a different way of looking at what happened than he just didn't do the work to
come to treatment in the past.
It's also very important to include an inventory of the person's culture and other aspects
of their identity.
Their faith system, the racial, gender, and sexual identification, their country of origin
and any other group with which they identify can be really important clues toward strengths,
resources, and open ideas for pathways to recovery.
It's also really important particularly for those of us who are physicians to take note
of the power asymmetry that exists between us and the people who come to us for care.
We really need to take note of this in order to make room for collaboration and mutuality.
This is even more important for people who have had lousy painful experiences
with the mental health system in the past.
Unfortunately, that describes an awful lot of people.
We're not starting from neutral.
As Ken said, very often people approach is with great wariness, great fear.
We have to do things actively to reassure them that we're not going to be harmful to
them.
One thing that seems to be helpful in my own practice, which I would like to share with
you, is that I often early on in the conversation offer to
share what I know, or think I know, and invite correction right off the bat.
This permits me to show my cards first, to show I'm open to correction and input and
it also gives me an opportunity to share the information I have in a strength-based and
non-pathologizing way.
For example, I could ask Mr. M if he would like me to share the information that came
to me from the hospital, and I could say, "I can share what's on this paper and if
this information is wrong, you could straighten me out right away."
By the way, it's almost invariably wrong.
That gives the
person the ability to make a contribution right at the beginning of the conversation.
If it were okay with Mr. M, I could go on to say, "I see you came to the US when you
were only 18, you've accomplished the task of becoming a citizen, which is awesome.
I see you are a dad, you have a daughter and a son, that you've been working very hard
to provide for them and see them.
But I also see here that things have been very hard recently and your family, your marriage,
has recently ended and it's been very hard for you to find work to provide for your kids.
I can imagine this may have been very discouraging and maybe that contributed to the difficulties
with the depression and drinking."
It's our hope of course that presenting this information in what I hope is coming across
as a friendly, warm, and strength-based way makes a space for mutual conversation and
collaboration and lets us move smoothly into looking back over what has helped and what
hasn't.
I could ask, "As you look back over the last couple years, do things jump out that
been particularly helpful that we could build on, or have there been things that have been
really awful that we would want to avoid?"
That can lead to a discussion about the person's perspectives about what would be best to do
and not do.
I can share with him, "I see you've had really bad experiences with anti-depressants.
Was your experience so bad that your mind would be just closed to anti- depressants
in the future, or would your mind be open to exploring other options?"
That way of acknowledging right off the get go, the resistance to antidepressants is completely
understandable when you've had terrible side effects is a good way of beginning a
more open conversation?
It would also enable me to begin to ask questions about how much of a problem does he really
see his drinking as being.
It can be a terrible mistake for me to make assumptions that he identifies this as a bigger
problem than he himself does, and that can lead to this very poor misalliance.
It can help me open up some discussion about what his hopes and
dreams are for the next
couple weeks or months, or years.
As Ken said, good engagement also really flourishes when we have things to offer people.
Often this is best when these options are culturally familiar and comfortable to the
person.
In Mr. M's case, resources that are connected to the Brazilian American community or connected
to his Catholic faith may be much more congenial to him than resources that are not, and of
course peer specialist, people who have been there done that and can speak with authority
greater than any of us professionals are great way of legitimizing options we have to offer.
think I like to turn to my colleague Jackie Pettis who can do a much deeper dive into
the issues of cultural competence.
>> Thank you.
One of the things I want to say, in terms of listening to what Dr. Minkoff and Dr. Gordon
said, I feel very welcomed and would feel easily engaged in your practice.
I think some of what I'm going to talk about as relates to culture has been mentioned here
before and it pulls it all together so there's a connectedness here.
This definition of culture, we know there are many definitions of culture with it being
very layered and complex, but this definition here is: "the integrated pattern of human
behavior that includes language, thoughts, communications, actions, customs, beliefs,
etc." comes from the federal office of minority health.
So this is one of many I'm sure you have all seen.
Culture is very personal and important aspect of patient care to understand because it's
an essential component of person- centered care and shared decision-making.
I think as we've heard throughout this presentation, it's very important to see the person as an
individual and recognize there are many components of culture, and it's important to see that
person sitting in front of you; what they present, how they identify themselves.
People can identify with more than one culture.
Looking at our case study, we know when it comes to culture, personal and cultural beliefs
will influence how the client has a perception of his illness, as well as the healing process.
We have to understand how a person
explains their illness; some of the origins of where these explanations come from and
that will help people engage in treatment and allow them permission to speak in terms
the person understands.
That all helps in developing a relationship that's so important from the very beginning
and throughout treatment.
Looking at the case studies, some of the things that came up I think were challenges when
there's a difference in cultural beliefs between the person seeking treatment and the clinician.
One thing here in our case Mr. M feels lonely, even though he lists his church community
as important social support.
With the consent of his ex-wife that she may also be important to provide a sense of cultural
history and belief and information about community resources that they, or he is connected to
that can be used to help throughout his plans or improving his life.
He is also a first-generation immigrant whose parents and siblings still live in Brazil.
There may be unmet cultural expectations and family obligations that are causing additional
stress and contributed to his heavy drinking and depression.
This is a man who values his family and is very connected to his children and he's been
working and shown he's resilient and intentional about being successful in his life.
This may be very stressful to him that he may not be able to do the things he values.
Good news, as you've heard before, and talking about strategy to address some of these things
that can be seen as challenges, the good news is he has many strengths and we
heard Dr Gordon and Dr Minkoff talk about these strengths, and it takes a lot of determination
to learning the second language when he came here at a young age and became educated and
a naturalized citizen.
He managed in spite of these challenges to secure housing
and has a very strong faith and relationships in the community, as well as relationships
with his children that he sees as a priority.
In spite of his low resources he made an effort to spend time with them.
Cultural identity is meant to be individualized.
Because of that and interacting with Mr. M and anyone who's coming for
treatment, it's important to ask them about their cultural beliefs and their values and
experiences, because just because there's people from a certain group we don't want
to see them as that group as monolithic and begin to stereotype people.
I think it begins with what the person thinks individually.
As has already been mentioned, you are not going through a list and putting people in
a box.
Each person should be looked at individually as a person and what they value.
Again, from a strength-based perspective, we mentioned earlier, it's like looking at
and asking what's going well in his life?
Focusing on what he wants to do, focusing not just on his symptoms
but where does he want to go.
We've seen he has several hopes and dreams that he has accomplished.
And now he's just a little down on his luck.
This is very important to direct care instead of going down the list, for this particular
diagnosis perhaps, these are things that are recommended.
Those things that may be true, but also from a personal
perspective this person may have specific ideas of what will help them get better.
It's also important to find out if there are specific customs and beliefs he feels are
important that can be integrated into his care.
He's also been in care before, he's been in detox treatment before, it's important
to ask him, what, if anything, did he find helpful in the past?
What are his expectations currently in treatment and looking at how they're going to develop
goals, and the clinician is also going to share their expectation and come
to an agreement on where to begin?
I think also from a culture perspective; his faith is a strong component in his life.
It may be important in asking him to look more deeply at those relationships that he
has with his church family as a place of support that they may offer—many faith communities
offer Celebrate Recovery or other 12 step fellowships that are based on the particular
person's religious person's belief.
Also, with his permission, we might want to reach out or have someone reach out to his
supports, because again he mentioned they were of importance in his life,
but yet he still felt isolated.
Lastly, I think and pulling it all together from a cultural perspective and looking at
the complete person, treatment goals are developed together.
That shared decision-making, person-centered planning will focus on what the person identifies
is most important, what type of support that person needs.
Thank you.
>> Thank you Jackie and Chris.
Those were exceptional presentations.
I just want to take a minute to summarize some of the things I got from listening
to these presentations that might be takeaways.
The three words I'm thinking about that struck me are: neighborliness, taking time to be
a team, and understanding the person and their context.
Let's just summarize how important this is.
The most important overriding message of this webinar is that before you get--dive into
making/focusing on diagnosis and prescribing medication, the most important contributor
to success is the degree to which you establish a relationship.
No matter how much or how little time you have in the encounter, you need to purposefully
plan time to establish that relationship.
You won't find out a person's entire life story in 10 minutes, but you can make a relationship,
however.
It starts with the idea of being a neighborly.
Finally, understanding people is not understanding just their illness.
This is not "a depressive", and "an alcoholic."
This is a person who among many other things struggles with depression and alcoholism.
Understanding his context, culture and beliefs, that he has a family, both in Brazil and here
that are very important to him, be neighborly enough to ask about it and then ask: "Where
does anything I can do to help you fit into what you are trying to do in your life and
in relationship to the people you love?"
Thank you very much.
[Silence] >> Thank you for joining us.
We will be discussing stage-based interventions including peer support for individuals with
co-occurring mental health and
substance abuse conditions.
Your presenters are Dr. Minkoff.
Dr. Minkoff is the Senior System Consultant at Zia Partners Incorporated and a Clinical
Assistant Professor of Psychiatry at Harvard Medical School.
And myself, Melody Riefer.
a senior program manager with Advocates for Human Potential.
We will be presenting and facilitating the discussion.
The learning objectives for this module are: (1) to detail the application of stages of
change and stage base interventions and recovery oriented treatment
including psychopharmacology for people with co-occurring
mental and substance use orders disorders and
(2) to describe the value of peer supporters in working with persons in various stages
of change.
I will now turn the module over to Dr. Minkoff.
>>Thank you, Melody.
In the previous modules in this series we reviewed the principles of recovery-oriented
integrated treatment for individuals with co-occurring mental health substance use conditions.
We gave a general overview of how those principles related to the procedures within psychopharmacology
practice in particular, although it could be applied in other settings.
What we're going to be doing in this particular module is going into more detail on what stage
of change means, what stage matching means—stage matched interventions and stage matched outcomes—and
looking at how to apply different types of stage match
interventions in the situation of Nick M. walking into a psychopharmacologic initial
visit.
We are going to use Nick's stories but we're also going to illustrate different possibilities
of Nick's story based on what he might say when you ask him questions that are designed
to elicit his stage of change for various issues.
In this principle one of the first things to recognize is that when someone asks you
or you think about what stage of change is a person
in, the correct answer is: for which issue or condition?
Even though people have many issues, it is not uncommon for the people we work with,
as well as for ourselves, that we are in different stages of change for each one.
In general, people may say they are interested in working on getting help for "my mental
health issues" including medications, but that "I am not interested in a variety of
ways or partly interested in addressing my substance use."
Conversely, they may say they are interested in working on sobriety because, "I think
I have a real serious problem with substance use issues.
But I do not think I have a mental illness.
I may have painful feelings, but I hope they will clear up when I get sober."
Some may say they don't want to work on either issue.
"The only thing I have is a judge problem or a relationship, job, or housing problem."
One thing we have learned as a best practice is that it is important to meet people in
a partnership exactly where they are and not to struggle.
Then to identify where they are in their approach to each issue and provide an interaction or
intervention that is matched to where the person is in relationship to his or her most
important goals, and then design what we are doing to help them make progress with us,
through the stages.
So the intervention is staged matched and we know the outcome will be staged matched
again as we are moving in small steps.
What we call that is integrated staged matched intervention for each condition.
What are some simple ways in a busy psychopharmacologic office practice that you begin to think about
what stage of change someone is in?
One thing I recommend is using these simple prompts for each issue.
Ask yourself the question in relationship to this person's goals and in relationship
to me, what sentence best approximates their current position on this issue.
There are six stages of change we can use.
Those are just approximations.
A way of helping you guide your thinking.
So you can be more effectively matched to the individual for each issue.
The challenge for us, particularly those of us who prescribe medication, is that we are
doers.
We tend to always be in the action phase.
We get frustrated when the people we are working with are not in the same place we are.
This is a way of thinking as a piece of discipline that allows you to calm down and feel it is
really legitimate to be with the person and helping them make progress through the stages
is actually a measure of success.
So here's the first one, pre-contemplation: "You may think this is an issue, but I don't,
and even if I do, I don't want to deal with it so don't bug me."
So in Nick's case this may be in either direction.
He may come in and say, "Doc, I really, really want help with my depression, I've
heard that antidepressants are great.
That's the thing I need, and until I...
I know they say I have a substance problem, but I don't, and don't talk to me about drinking.
That is none of your business.
It's not an issue.
I just want help for my depression."
Now in this scenario, Nick is not saying that, but he could.
And conversely he could come at it the other way, you know: "I want help with my sobriety.
I heard there are medications that can help with sobriety.
They are saying I am crazy and I have a mental illness.
I do not think I do.
I do not want to see a psychiatrist for mental illness because of my culture being crazy
is very, very bad, but it is okay for me to have a drinking problem."
The next stage is contemplation.
"I'm willing to talk with you about this issue and think about whether I want to change
but I have no interest in changing.
At least not right now."
Contemplation is about talking, thinking, and considering.
One thing to keep in mind in the concept of stage matching is that if people are
in precontemplation when you meet them, your job is to use what we called motivational
interviewing or motivational enhancement strategies.
The outcome you are looking for is not to get people to go from precontemplation to
action or maintenance but to have them go from precontemplation to contemplation.
If someone says, "Do not bug me," your job is to say, "Look, I am not here to bug
you.
I am here to be a great partner and help you figure out the right decision for all of your
issues with
me, with the team, so we can make progress toward your goals.
I want you to figure out the right amount of drinking for you to achieve your goals.
I want to help you figure out the right way to help you deal with your depressed moods
in order for you to achieve your goals.
If you and I can just talk together and think together then we can figure out what is going
to be right for you."
If the person is able to go with you into the area, then you have successfully helped
them move from precontemplation to contemplation.
The more you push on people the more likely they are to go the wrong way.
Once people are in contemplation, you are talking and thinking with them.
Your goal is not to move from contemplation to perfection, it is to move from contemplation
to preparation.
Preparation looks like: "I am ready to start changing, but I have not started.
I need some help to know how to begin."
Preparation sometimes means: "Okay, I now understand I have a major mental health condition
called major depression, and I want to make a full lifelong commitment to being on
antidepressants for the rest of my life."
On the other hand, it is not as likely to mean that.
It's more likely to mean: "Maybe antidepressants might help me.
Maybe there's some aspect of my depression that is more than my situation.
Maybe I am willing to give it a try knowing that there are all kinds of challenges attached
to it: side effects, it doesn't work well --well you know, perfectly right away—it
takes time.
And I still need to deal with my life, but maybe this will be a helpful tool."
And similarly, "I have always heard that I can get sober just by going AA meetings,
but I've never heard of medication-assisted treatment before, and maybe I am willing to
give it a try."
Preparation might mean you saying: "Let's go small and try it for a week and see how
it goes.
You are not making any more commitment than that.
We will see if it feels comfortable, if we have to adjust if you have unpleasant side
effects.
We are working as partners here to see how things work."
From preparation, people might begin to move into early action: "I've
begun to make some changes and need some help to continue, but I am not committed to maintenance
as you would define it or following all of your recommendations."
Now, as a prescriber, we often get upset when people are not committed to following all
of our recommendations.
A long time ago when I was a junior baby newbie doctor I used to think the reason people would
not follow my recommendations is because I was not saying them properly.
Now that I have more experience, I realize: I am an official national expert on co-occurring
disorders.
People pay a lot of money to hear my opinions, and they still don't follow them.
It is just the way it is.
So when you are working with people and they
start to make change remember this is a shared decision-making process at every step.
People are going to explore all of our recommendations and decide whether or not they are right for
them.
And truthfully, we may have great ideas, but we do not necessarily know what is best for
people.
Our job is to join with them and help them figure it out.
So when people are in the early action phase as
Nick might be in the sense that he is just getting started and coming for
help.
And if we try too hard to sell him on something too perfect too soon he is probably not going
to want to come back and work with us.
We're going to work with him in an exploration.
"Try antidepressants for a while and see if they work.
See if they are helpful tool for you along with the all other things you are doing to
try to help your mood.
Maybe medication-assisted treatment would be a great tool.
If you are not interested in it right, now that is fine.
Let's do other things to see how your sobriety goes knowing that we have some tools that
could help you if you begin to feel along the way like you're having a struggle.
And as a prescriber I am sitting here as your partner ready to work with you as we go."
As people move along with us, they are likely to get more toward a late action phase.
Somebody like Nick might say: "In order for me to achieve my goals…"—and his
goals have to do with getting a job that he feels proud of, being a great dad to his kids,
being connected with other people that he can relate to, feeling proud and successful
as a man as well as a parent.
He may say, "As difficult as it may be, in a variety of ways, starting to take care
of myself and getting the help I need to address these issues I have, which are not my fault
but get in my way, is going to help me towards my goals.
I really need to work hard at this.
I need to do everything I can to get to the point that I can manage these things for myself
successfully."
At that point he may say he is working towards maintenance but have not gotten there.
He needs help to get there.
What is important to realize is once people decide they want to do everything they can,
they generally do not know how to do everything they can.
It is not simply us telling them what to do.
It is partnering with them to help them to learn.
If Nick were to say, "I want to make a commitment now to taking antidepressants and doing everything
I can, therapy,"—and he wouldn't use these words 'cognitive behavioral treatment'—"to
manage my depression, as well as trying to get my life in order."
He would not know how to do all of those things.
Our job is to say: "As you are working with antidepressants, realize an important part
of success for anybody taking an antidepressant medication is working closely with your prescriber
and team, talking about side effects and as openly as possible because we know it is unusual
that the first thing we try works perfectly."
People almost always need constant adjustment.
They need help thinking about how to take it and when to take it.
They have questions about potential side effects.
"What should I do with the medication if I slip and start drinking?
Should I keep taking it?"
Which for Nick, the recommendation would be yes, but you know, we would also advise him
to have the skills to call us at any time if he had any question about what had happened
and what was safe.
So all of this is a way of helping people in this stage work towards the partnership,
and the same conversation could happen if we were talking to him in late action for
his medication-assisted treatment.
And then finally, once people are stable, the
conversation is: "How do I help you stay that way?"
It is not inappropriate all.
When people are stable, one question they ask is, "How do I know I need to keep taking
my medication?"
Engaging in that partnership with people is important.
And for some people, let's say for somebody like Nick, who's never really had a successful
trial of medication, the question of whether he needs to stay on it is an open question.
If he achieves a full remission of his depression—he's had several prior
episodes you could say, and the risk of having a reoccurrence is high if he goes off medication,
but it is not guaranteed, particularly if other things in his life have shifted.
The thing important is helping him realize the risk is his, and if he is going to take
that risk you want to work with him as closely as possible.
So if things start to go awry, he and you together can catch it as soon as possible
and reinstitute medication if that is what he wants in order to help him not go backwards.
The same thing if he is working with medication for his addiction.
One thing that is important to realize is as I'm going through this, I'm talking about
stage matched interventions for each issue within the stage, but it is highly likely
that when you meet an actual Nick that he will be in one stage of… different stages
of change for different things.
And as you're working in this partnership with him, the art of doing this is to identify
things that are most important to him, which are probably not going to be either mental
illness or alcohol use disorder.
It will be things that have to do with his actual life, like getting a job, parenting,
and so on.
And then with those things that are most important, making that partnership for:
"How we are working holistically or in totality to help you towards your goal?
And where is it we can meet you where you are at about how to best address
your depression or substance use?"
And then assuming that he may be in different places around his mental illness or substance
addiction, you work with the one he most wants to work, and then you engage him the best
you can in a conversation and finding small steps towards the other.
So I'm going to turn
it back to Melody, who is going to talk about how helpful and important it is to engage
people who provide peer support in the staged matched intervention process.
>> Thank you, Dr. Minkoff.
I want to step back for a moment to review for our audience some definitions and specifically
looking at definitions for recovery and I am including in that framework
of resiliency, because it is such a critical component to serve as a backdrop for all of
these stages of change.
SAMSHA has done some incredible work around developing consensus for their definitions
and the information I'm sharing is available on the SAMSHA website.
Their approach for defining recovery begins with defining four dimensions of personhood
that are relevant for recovery.
Those being overall health, stable home, purpose in one's life, and membership in one's community.
These four dimensions of overall personhood are part of what drives identifying the goal
that would motivate someone like Nick, in identifying the stage of change he is experiencing
and becomes foundational.
Health looks at overcoming or managing one's diseases or symptoms; so that could be inclusive
of learning to abstain from alcohol or illicit drugs or non-prescribed medications.
It could also include managing one's physical illness such as diabetes, heart disease, respiratory
illnesses.
But addressing one's health is a key priority.
Having a roof over your head and a safe stable place to live in the community of your choosing
is also critical for recovery.
Having meaningful daily activities—some people that automatically means work or employment.
For other people it will mean being a stay-at-home parent, volunteering, or attending school.
Even activities that look more like being an artist, being creative—but if the activity
is what creates meaning and purpose in your life, then it becomes vital to your recovery.
And finally feeling membership or relationship with your community.
This might be in broad terms through social networks,
or it might be more intimate terms—relationships with family, friendships,
memberships in one's faith and spiritual practice.
But those four dimensions make up and contribute to overall wellness, recovery, and resiliency.
The definition for recovery at SAMSHA's website also identifies some core principles
that I will not outline for you now, but I hope you will have a chance to review it.
Please note that information is available on the SAMSHA website.
Now in relationship to how peer support and the employment of those people with the lived
experience of recovery can interact with stages of change.
I think there is an important element to consider.
Hiring people as peer specialists or recovery coaches brings in
strength-based services that benefit from having the authentic voice of the peer perspective
integrated at all levels of care.
And that peer specialist or recovery coach can be the prescriber's best ally in helping
identify the stage of change the person is experiencing and the indicators of what the
bridges to increasing stages of change may be.
Seeing that recovery is real is the most effective way of conveying that reality.
My existence as a person in recovery, I am strengthened by looking at my colleagues who
are also in recovery and people who are entering services can hopefully look at my
life and see that regardless of what the barriers were or obstacles were it is possible to overcome
them and have a life worth living.
Having those insights achieved through the lived experience aids both the person being
served and the team members who may not have experienced recovery firsthand.
It brings an authenticity and a truth to what is being said about
the hope for recovery.
Peer support in it of itself is often naturally occurring.
If you have spent any time in a support group or a 12-step group or a group therapy setting
in inpatient or outpatient programs, you see that the relationships between the members
are what bring the most defining and sometimes awesome moments of clarity and insight.
Group facilitators, of course, try to nurture those exchanges, but what people experience
while they are hanging out outside the door or making contact in between
meetings—that is peer support.
The value of peer support as a more formal process through which people receive additional
training and when they operate from a code of ethics is bridging that natural support
with the other professional disciplines that participate in providing services and support
to those people seeking recovery.
The skill set, however, for the person functioning as a peer supporter or a recovery coach draws
most distinctly from the lived experience of recovery as the unique expertise.
So a prescriber goes through a number of years of learning and education to become experts
in medication, experts in dosing, evaluation, and assessment.
Peer supporters and recovery coaches go through years of experiencing illness, displacement,
the cost of having a diagnosis and then working through that with various supporters and changes
in their life to be able to then offer their recovery lessons as a gift to others.
So the peer supporters will sometimes be able to offer a unique insight to help establish
the appropriate assessment of the stage of change a person may be or when those stages
are at conflict with each other.
I might be highly motivated to manage my diabetes, but less motivated to manage my drinking.
It might be a peer provider who learns of this tension
and can help bring the conversation to a more conscious
level of communication.
[Silence] >> Thank you for joining us today.
We will be looking at recovery and support strategies for individuals with
co-occurring mental health and substance use conditions.
Our presenters are Dr. Minkoff, Senior System Consultant at ZiaPartners, Inc. and a Clinical
Assistant Professor of Psychiatry at Harvard Medical School.
We also have Dr. Wayne Centrone, who is a Senior Health Advisor at the Center for Social
Innovation, and the Executive Director of Health Bridges International.
My name is Melody Riefer and I am a program manager at Advocates for
Human Potential and will be facilitating this discussion.
The learning objectives for this module include: demonstrating how to develop a recovery support
plan including natural support networks; and to identify three potential interventions
to support the sample client recovery that can be used in psychopharmacological
practice settings.
Dr. Minkoff, please start us off today.
>> Thank you, Melody.
In this module in our series, our focus is on helping the individual to get into the
specifics of developing a recovery support plan, a plan that the person can ... that
usually has two components: things that the person does by him or herself to address various
issues going forward; and things that person will be doing in relationship to his or her
support system.
When we start working with people on solidifying a recovery support plan, we are usually working
with people at that point to develop a recovery support plan around the issue or issues for
which they are in the later stages of change.
In this slide, we show not all of the stages, but the
last two, which are called late action and maintenance.
In a certain sense— and this certainly applies to Nick—he may say in relationship to his
substance use, that: "I am working towards sobriety.
This is something that is important to me, but clearly I have not gotten there and I
need some help to get there."
For Nick, in this instance, the recovery support plan would incorporate the details of how
to help him to get there.
The same thing may apply to depression.
Or someone—not Nick in this instance but maybe Nick a few months from now—may say:
"I've achieved some stability, but I'm worried that I'm going to go backwards."
For example, he may say that he has achieved some sobriety for a few months and "I have
a job, but at my job everyone is using drugs and drinking and I have some more money in
my pocket, and I'm worried that it's going to be easy for me to go backwards.
So I need a recovery support plan that helps me to stay where I am."
Again, the same thing may apply by saying, "I have been taking these
antidepressants that I do not like, they may have helped me but I'm thinking now that I
have a job I don't need medication anymore.
I am worried that I may go backwards and I don't want to.
What should I do to keep myself on track?"
So in this next principle we talk about a way of framing what we're doing so it focuses
on helping people stay on track.
The emphasis here is that the process of developing a recovery support plan involves not only
adding in content and knowledge recommendations, education, and support, but it involves helping
people develop the skills they need to do what is going to be helpful.
We call this skill-based learning.
We put it in a context of adequately supported, adequately rewarded skill-based learning for
each condition.
The first thing is the intention to shift our emphasis from what we know, say, teach
and recommend, and our ability to work as a partner with an individual to help a person
to learn.
The next piece is that these steps are small and practical.
The way that any of us learn is not just by reading, talking, or attending a course.
We need to learn by doing.
It's important to break those steps down into smaller and smaller steps so that people can
learn and be successful in practicing making change.
Practice, rehearsal, repetition—are critical elements of adult learning.
Within this there are two kinds of skills.
Self-management skills and asking-for-help skills.
So in the self-management skills we're looking at what are the things I do when I'm by myself
to help myself with getting through periods where my symptoms may be exacerbated.
So Nick, even with antidepressants, should you choose to take them, you're gonna have
times where you feel very depressed sometimes, because things in your life have not gone
well or because the medication rarely works perfectly right off the bat.
How do you get through those times in a way that is successful for you and without feeling
like you need to pick up a drink?
As a physician, one of the things you might be doing with Nick is to help develop
some very practical skills in a very short period of time: "It may help you to keep
a mood chart and track
how you are doing.
Write down some of the things you're trying so you can develop a repertoire of things
that work.
Or make a list of 10 or 15 things that you can do even if they only last a few minutes—
this helps you to address the depression.
Have that list available to you so you can get through the periods of time that are difficult."
When this is elaborated, people develop wellness recovery action plans or similar plans, maybe
not following that particular approach, just so that they actually have that structure.
It's the same thing if you say: "You're in a position where you're craving a drink
and you're by yourself.
What do you do to get through that period so that it settles down and then you can regroup?"
The next set of skills are "asking for help" skills.
In the language of AA, people say it's a simple program—don't drink, go to meetings, and
ask for help—but none of those things are that simple.
It's hard to know how to not drink and drug when all of the people around you are using.
You are a nice person and don't want to upset people by saying no, but you need to learn
how to do that.
Do that in small steps—go to meetings; what do you do there?
What do you say there?
Are you required to tell people what medication you're on?
The answer is no.
You are not going to meetings to get medication advice, you're going to get support and
make connections with people who will help you to not drink or not use drugs.
Asking for help when you're in trouble—What does it mean?
"I need a job.
I need a loan."
No, it means, "I'm having a hard time, I need to reach out to somebody in that moment."
Most people learn how to ask for help when you ask them what they're going to do.
It doesn't mean they know how to do it, though.
It's important to help people practice the skill of asking for
help.
So one of the things that I frequently do is to say, look, if you're having a hard
time what are you going to do?
They usually say, "I will ask for help."
"But who are you going to call, who are you going to ask?
This is important, because if you're having a hard time, even over the next few days,
it would be nice to know that you could
call someone.
Who would you call?
And he says, "I don't know.
"I don't think I should call my ex-wife."
And I say, probably not.
But maybe you can call the office ...leave a message?
So we practice how you would do that.
Here is a crisis line that you can call.
Can we practice, reverse role play, right here right now, how you would call them up
and say "Hey, I'm having a hard time.
I need to talk to someone for a few minutes so I can get through the hard time and not
pick up a drink and not do something to hurt myself.
That is practicing skill development.
And if Nick does that—I may ask him to practice it when he gets home: Look, when you get home,
call the office right away, leave a message on machine that shows me you're practicing
asking for help.
And what do you get?
You will get a round of applause – positive reward for small steps of progress.
Very basic.
Just like when people go to an AA meeting and you get a round of applause from the room
for being sober for one day.
Remember in our partnership with people that we are helping, learning these skills takes
a lifetime.
We're never done.
We are always working to improve.
Is easy to lay out all of the things the world thinks we should do.
But it is hard to actually practice doing them and making change.
It's helpful to have teammates to give you rounds of encouragement every time you make
the next small and most difficult step.
It is our job as physicians, and everyone else on the team, to be in the round of applause
business to help that learning take place.
I will turn the call over to Dr. Centrone and Melody.
>> Thank you, Dr. Minkoff.
Recovery as a process, recovery as a model for working with individuals with substance
use disorders and mental health conditions is a powerful tool.
But it is not the only tool.
So how do we use this recovery philosophy to further understand the extension of our
evidence-based practices, the core skills, the efficacious, evidence driven medical service
delivery.
Well, I think it's important to understand that recovery is about working with people.
William Anthony, a major supporter
of the recovery model, describes recovery as a deeply personal, unique process of changing
one's attitudes, values, feelings, goals, skills, and/or roles.
There is a way of living a satisfying, hopeful, and contributing life even with limitations
caused by illness or diagnosis or condition.
So how do we engage Nick—the complexity of Nick, the totality of Nick—in a way that
offers recovery, and supports recovery, and aligns with his needs in his life?
First we recognize that Nick has strengths.
Nick as a gestalt; Nick as the total person, has many different aspects to his life, some
of which are related to what happened on that day—the reason he came to the clinic in
the first place.
Many of which are more complex even than just the simple world of diagnosis.
They involve culture, social circumstance, the desire for a place
in life.
We need to understand Nick from a totality.
Recognizing that he is an immigrant coming to this country seeking hope; he's 18 years
old and he came here looking for more education.
Recognize that he is a father who is deeply in love with his children and wishes to support
his family and recognizing that he is a member of a bigger social support group —his church
and the community that he derives from his church.
Recognizing that he has a strong interest in personal
advocacy.
He describes the desire to find gainful employment, to find a job; that gets him to recognize
that he's already demonstrating self-advocacy in seeking treatment.
He tells you that he has previously been on psychotropic medication, taken an anti- depressant,
although he stopped taking it because of the side effects.
Can we draw from this, can we work with Nick to find a new way to engage medication management
to help him find the life that he deserves and so desires?
And then, how do we work with Nick from the perspective of the demonstration of the strengths?
One of the key demonstrations is the fact that he is in our office today.
He has carried through on the follow-up that was required when he left the hospital.
He made the referral.
He took the steps to come into our office.
How do we draw on that.
Well, I think critical
is understanding that is some respects Maslow was right.
There is a hierarchy of needs, although it doesn't necessarily occur with that hierarchal
place, we do have a foundation that's very critical to our life-support.
I come from a background of working in homeless health service organizations.
My core view is through serving people who are experiencing homelessness.
And what I found in working with people experiencing homelessness is this: seeking to understand
the totality of the needs by asking questions about housing and housing stabilities as though
it's a vital sign.
That housing is a foundation, right?
Maslow said, if you don't have a firm foundation it's really hard to build anything from.
Housing is critical.
The support that comes from a foundation of housing is critical to finding success in
our lives and gaining stability.
So one of the first questions you want to ask Nick about is: "How is your housing
situation?
Where are you currently living?"
And when we ask this, we find out he is moving into a single room occupancy hotel, a stable
housing environment per his definition.
But what Nick would then tell us is, "But I want more.
I want a place that I can invite my children to come back to; I want a place to build a
home."
Not just housing.
So how do we work with that?
How do we call forward the recovery of opportunities?
Well I think the philosophical precept to do that is recognizing trauma is pervasive
in people's lives.
That Nick has been through trauma—early hospitalizations, early experience with substance
abuse while in his country of origin, the process of moving from your country of origin
and repatriating into life that's very different.
It can be traumatizing.
Can we understand that trauma, and the totality of that trauma, to really work in a recovery-oriented
way.
Calling for the strengths that Nick demonstrates by coming into our office; by demonstrating
a commitment to find the tools and resources to establish wellness in his life.
By focusing on the continuum of recovery and not the event of recovery.
It's a process; it happens over a long period of time for many people and it has its ups
and downs.
Supporting him to make
decisions that are in his best interest—this is one of the things I learned that is critical
to the work that I did.
People are people and they have the right to their own decisions, and in many circumstances
their decisions, at that time, are the best decisions for them and
their needs.
So how do we support them to move to move into a place where they can make decisions
that move to a better place of recovery that uses a decision built into a continuum that
seeks and sources wellness.
With Nick we're focusing on the person.
Barbara Starfield wrote eloquently about the concept of person- focused care and not patient-focused
care.
Person-focused care is based on the accumulated knowledge of people, which provides for the
basis of better recognition of health problems and needs over time.
That the person we see in the clinical encounter at this visit
is more than just clinical encounter in the visit, that they're a person that has a
long continuum, and that our goal should be to contextualize the visit for the content
of the role.
That we can work on person-centered focus in everything that we do.
Warwick, in his classic way of taking complexity and making it tangible, wrote in a 2009 article
that we need to understand that there are some seminal maxims of person-focused recovery
orientation.
Those are the needs of the person come first and...
We must seek to understand the persons needs and call for them.
Recognizing that recovery has a number of different principles; these are defined as
health, home, purpose, and community.
And that ultimately recognizing that sometimes just normalizing fears, anxiety, frustrations
and calling forward joy is one way to individualize care.
The data tells us that stable housing is the key to finding wellness in one's life.
That you can't, when working with someone with complex challenges, really create an
opportunity for embedded change without addressing solid social support.
Also, that the solid support needs are a platform to seek better care delivery.
We need to work in understanding that the foundation is critical.
That recovery support and strategies occur and continue.
William White wrote
that there should be no wrong door, that in a purely recovery-oriented system every door
should be an access to care.
I think it's critical— recognizing we can draw from a variety of different literatures
and understand the recovery process.
There is a rich level of literature in the adolescent world about resiliency.
About strength based approaches that engages an assessment, we can work with people by
inviting them into the collaboration.
We can offer opportunities to help them have new levels of knowledge and insight.
It prepares them to be partners in sharing decision making.
We can provide them with the information and do the due diligence of helping them to understand
risks and the benefits, as well as see alternatives and opportunities.
Yet, ultimately, treatment is their decision.
Now I'm going to turn the presentation over to Ms. Riefer.
Thank you for this opportunity to speak with you.
>> Thank you very much.
One thing that's very important to me when I think about recovery and support is that
this is not a one-off option or a side dish to services.
But rather, recovery and support is a light that should illuminate all services that are
being provided.
One way to ensure that recovery and adequate support is being provided to people who are
entering into the services that we offer is that they integrate peer support workers.
This is a way to ensure that peer support becomes a part of the care team; that a peer
support worker is an equal member on the care team; that peer support helps us move beyond
the walls of the facility, whether it be an inpatient or outpatient program that people
actually live their lives outside of our offices.
It's important that the support be available to people where they are physically located
as well as where they are emotionally.
And the importance of making room and to always remember the power of informal peer support
as people work to extend their lives in their communities.
Let's look at each of these points a little more deeply.
Peer-support is a part of the care team.
One of the emerging practices that is happening in our field
currently is placing peer workers within the medication clinic and having peer specialists
or recovery coaches be a part of the medical team.
So while there may be a nurse and a prescriber, and sometimes even a case manager that is
embedded in the medical team, the introduction of a peer worker into that milieu helps to
ensure that the principles that have been spoken to are carried through.
It's really difficult for prescriber or a nurse to know or have the time to do those
elements of the warm handoffs, or inquiring about the safety and appropriateness of one's
home, to explore options around medication by reviewing medication fact sheets.
An example where this successful integration has happened is with an approach called CommonGround
developed by Dr. Patricia Deegan.
I worked with this program and I worked with Pat.
What we are able to observe is that by building out an opportunity for people to prepare to
participate in their medication consultation with their prescriber, they were much more
likely to advocate for what their needs and values are.
That the peers were able to supply support post-appointment by utilizing vetted educational
and decision support materials.
Essentially this is an extension of the medication clinic appointment.
And it helps the agency provide an enhanced experience when in this day and age the time
limitations created by demand really sometimes serve to circumvent our capacity to provide
the quality service that we want.
Using peer support to move beyond the walls.
The goal of recovery is to live life to the fullest, and that's different for each person.
Nick wants to be more of a hands-on father with his children.
He wants that exchange and membership in his faith community.
He wants to work.
Those are values and activities that equal his living life to the fullest.
I want to have deep and meaningful relationships with my family members.
I don't want psychiatric meds to get in the way of my connection to the people that I
love and respect.
So, every person is going to be motivated and pulled into their recovery based on strong
personal values.
Recovery
must be rooted in the person's community and not limited to just those 50 minutes with
a therapist or 15-20 minute med consultations.
But that their recovery is happening as they are walking down the street, as they are preparing
for bed, as they are shopping for their groceries that week.
That all of those things are what add up to recovery.
Peer support can be a natural connection between the formal services at an agency or provider,
to the life in the person's community.
Sometimes people need the modeling of what recovery can look like with boots
on the ground.
Or perhaps the person has lost contact with their family, or they burned bridges with
friends and they need to go about setting up a new community.
This peer supporter can be invaluable in helping to create those connections.
Helping people understand that recovery is a 24/7 commitment and it's not just something
you do at certain times.
It's important to understand that recovery is ongoing; that it is not a linear process.
It is a dance that we dance for the rest of our lives.
Which leads to making room for informal peer support.
As prescribers use that position of authority
to prescribe activities that someone can do.
Activation is one of the most key elements to begin one's recovery.
So, having a prescription of doing something like going to a dance or getting a membership
at the YMCA and swimming twice a week.
Those prescriptions can lead to open doors to recovery as dramatically and as concretely
as a prescription for specific medication.
As mentioned, we cannot really focus enough on inquiring about the natural strength and
support that this person does have in their life.
Help them see that there are options and that they are already taking important significant
steps towards their wellness and recovery.
That they, in fact, are resilient; Nick is a resilient person who is surviving against
all odds.
The more we focus on resiliency and people's capacity to make it through both literal and
figurative storms in their life, the more they're going to be able to embrace and not
be afraid of claiming their natural strength and support.
So be it in other people, in how
they view themselves through the cultural lens, what they are doing besides medicine
or in addition to medicine, or identifying who can be supportive during those storms
- these are really key and important for helping people see and acknowledge the informal peer
support that exists in their lives.
for helping people see and acknowledge the informal peer support that exists in their
lives.
We thank you for participating on this module.
To my colleagues - Drs Minkoff and Centrone thank you for the information that you shared.
For more information on this topic please see the supplemental resources attached to
this webinar.
We invite you to sign up to receive a quarterly newsletter issued by the Recovery to Practice
team.
If you're not receiving this newsletter, please send us an email to RTP@AHPnet.com and we
will be happy to provide you with this newsletter on a regular basis.
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