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Supported Socialization. How exactly does one go about finding a friend? It seems so simple. After all, most of us have friends, so it seems logical that we would be good at demonstrating how to attain this as a treatment goal. In our experience, coupled with the research from the mental health community, however, it seems that this logical assumption is just that: an assumption.

A few years ago, some colleagues and I came across the concept of supported socialization. The research on the concept provided a good set of guiding principles, but we found that we needed a little more direction regarding the “how to” of the approach. The following explains how we applied supported socialization, in both concept and practice, into our organization.

In reviewing the articles on supported socialization, we found six key principles that gave the approach its character and identity:

  • Structured opportunities for socialization are provided.
  • There is increased access to ongoing social and recreational activities.
  • The process is marked by the establishment of reciprocal relationships with peers based on strengths.
  • Supported socialization takes place in normalized and naturally occurring settings, outside of the mental health community.
  • “In vivo” supports are provided to ensure people overcome or accommodate for the disability.
  • Supported socialization creates mediating structures that enable participation in community life.

These principles were then paired with current evidence-based practices to inform how we could then move from an idea to a treatment approach. Our research found that supported socialization should follow in the footsteps of other “supported” approaches. Thus we looked closely at the Individual Placement and Support (IPS) model offered by supported education and employment. This aligned closely with our guiding principles for supported socialization, as they all feature a very clear “place, then train” style. This is a departure from our traditional “prove it before you move it” style of group programming for social and recreational treatment.

With the emphasis on direct placements in the community, we still needed to define just how we would “train” individuals to be successful. For this, we turned to Social Skills Training (SST). It is important to mention that this evidence-based practice still largely occurs in group settings. Although the homework activities do connect people to the community, we found that there may be individuals who respond better to a one-to-one, personalized approach. The important emphasis here, then, is not group over individual programming, but rather ensuring that connection to the community, outlined by the six principles, is not lost in the application of SST.

As we applied the IPS approach and SST, the subject of “socialization coaches” came up as potential providers of service and connectors to the community. For this, we have recruited peer supporters and peer providers of service. Social learning theory stresses the importance of credible role models in learning new skills. Peer supporters/providers have an emerging evidence base for the unique impact they can make in this type of situation.

We been applying the supported socialization approach since 2007 and continue to develop, refine, and evaluate our practice using the outlined framework. And in just these past few years, we have become passionate about the potential and amazing implications of this emerging practice.

—Michael F. Seiferling, BSW, RSW, RTC, Psychosocial Rehab Worker, Phoenix Residential Society/PEARL Manor, Regina, Saskatchewan, Canada

Training and Technical Assistance

Training. In the first Webinar of a series in Year 2 (and the third for the RTP Project) that addresses the continuum of recovery-oriented care, SAMHSA’s Recovery to Practice Initiative focused on the initial stage of engaging a person into care—either for the first time or following a series of disappointing experiences in which the person did not find the services offered to be responsive to his or her needs. The Webinar was presented by three leading authorities on different aspects of the engagement process, which all would agree is made possible through the cultivation of a trusting and respectful relationship between the practitioner and the person in need of care.

White flowers on green backgroundThe first speaker of the   Webinar, King Davis, Ph.D., LCSW, focused on the cultural aspects of engagement and how practitioners can factor a person's cultural background, affinity, and identity into the cultivation of such a relationship. Next, Roger D. Fallot, Ph.D., addressed the role of trauma as a barrier to engagement, and how practitioners need to presume that the people they work with have had previous traumatic experiences, attend to this history, and be aware of its impact on the person's relationships—including and especially their relationships with care providers. Finally, Laura Van Tosh articulated the principles and practices involved in a customer service approach to engagement, tailoring a practitioner's approach to engagement based on the individual’s unique qualities and strengths and promoting a welcoming and validating culture with people who may be reticent to accept help.

You can conveniently download the presentation slides and the complete recorded session from the RTP Resources Web page at: http://www.dsgonline.com/rtp/resources.html/.

The next RTP Webinar will take place in March, on the topic, “Step 2 in the Recovery-Oriented Care Continuum: Person-Centered Care Planning.” Watch your email for the date, time, and details on where and how to register!

Technical Assistance. RTP technical assistance (TA) provides valuable resources that support learning strategies for implementing recovery-oriented care in practical and sustainable ways. We have an extensive library of recovery-oriented articles, personal stories and anecdotes, curricula, videos, and links to relevant publications and professional sources. To access TA, contact RTP TA staff, Monday through Friday, from 9:00 a.m. to 5:30 p.m., at 1.877.584.8535, or email requests to RTP_TA@dsgonline.com. Each request will be responded to within 48 hours of receipt. Arrangements for more lengthy consultation are available on a case-by-case basis.

Although mental health practitioners are the Resource Center's primary audience, anyone interested in promoting the cause of recovery transformation is welcome to access RTP training and TA.

Project Update

We are pleased to hear from participants on our ListServ that the Recovery to Practice initiative is touching people’s lives through our last Webinar, “Step 1 in the Recovery-Oriented Care Continuum: Outreach & Engagement”; the Weekly Highlights every Friday; and our ongoing technical assistance. If you would like to find a resource or request assistance on a particular topic, please email us at: recoverytopractice@dsgonline.com.

Our next Webinar, in March, will follow the continuum of recovery-oriented care to address person- and family-centered care assessment and planning. Please watch for announcements about registering. As always, to view all our resources and review them individually, go to http://www.dsgonline.com/rtp/resources.html/.

We have developed a series of print products—brochures and guidance documents—that are in production and will be distributed through a variety of channels. We’ll announce them along the way. Stay tuned for the launch of the RTP Web site, where you will find all our resources and be able to contribute your personal story and request technical assistance.

The RTP Steering Committee met “virtually” last week to hear about project accomplishments, discuss future plans, and contribute to upcoming events. Awardees reported on their assessment activities, described their approaches to synthesizing their results, proposed target audiences for training, and characterized their draft Situational Analyses. Members from our Steering Committee will help review the awardees’ Situational Analyses. For more information about the awardees’ progress, read our column, “Professional Discipline Training Awards.”

Guest Columnist

Miriam DelphinThe Critical Role of Culture in Recovery-Oriented Care. Attention to culture is critical in recovery-oriented practice. Defined as an integrated pattern of behaviors, learned beliefs, and assumptions about the world, culture includes, but is not limited to, such identity designations as race, ethnicity, gender, sexual orientation, economic status, and spiritual or religious beliefs. A complex and dynamic phenomenon, culture influences all aspects of a person’s life, including his or her experiences of health, illness, help-seeking, and wellness.

The existence of disparities in health and health care based on these designations had already provided a persuasive argument for the inclusion of culture in behavioral health care. The importance of acknowledging and incorporating the role of culture has only been made even more pronounced and pressing by the shift to recovery-oriented practice. If, as studies show, culture mediates the ways in which a person’s body metabolizes medication, think of the even larger role culture plays in a person deciding what kind of life he or she wants to lead in the community.

In addition to shaping each individual’s vision of what recovery will look like, there are many junctures at which culture plays a key role in the paths and strategies people will choose to employ in meeting life’s challenges. For instance, an individual's preferences regarding where and from whom to seek assistance, whom to involve in recovery planning, the possible use of complimentary or alternative therapies, and the ways in which a person envisions connecting and engaging meaningfully with community resources and supports—all are mediated by culture. Providers attuned to these and other cultural beliefs and preferences will be able to foster care that is both person-centered and culturally responsive. In addition, exploring areas of culture that are important to a person can lend to improved cross-cultural understanding, engagement and communication, and enhanced recovery-oriented outcomes.

Along with addressing consumers’ cultural values, a critical aspect of providing care that is both recovery-oriented and culturally responsive is identifying your own (perhaps implicit) cultural beliefs and the ways in which these may impact your work with different people. Practitioners need to ask themselves such questions as: How do I respond when my client’s spiritual, religious, or other beliefs are vastly different from my own? What automatic beliefs or expectations do I have about this person? How might these beliefs impact care planning and my communicating a sense of hope and respect for this individual? Maintaining this asking stance, of both oneself and one's clients, can help to ensure that care is truly consumer driven, in that it is responsive to those cultural beliefs, values, and preferences identified by the person as central in his or her unique recovery journey.

— Miriam Delphin, Ph.D., Assistant Professor and Director of Health Disparities and Cultural Competence, Yale Program for Recovery and Community Health

Professional Discipline Training Awards

The professional discipline awardees ended 2010 with the completion of their assessments of how and where recovery exists in their respective professions. Each organization conducted thorough data collection activities—both qualitative and quantitative—that began last March, and engaged a variety of professionals, consumers, and other stakeholders in both the assessment process and in their recent submission of their draft Situational Analyses. In all cases, the advisory boards for each awardee played a leadership role in reviewing the data gathered, analyzing it, and preparing the Situational Analyses.

In addition, the awardees reached out to new consumer partners to assist with the interpretation of the data, which will play a critical role in the ultimate recovery-oriented curricula. Involving consumers was a fairly new endeavor in a couple of cases, and our project partner, the National Alliance on Mental Illness, assisted in that recruitment process. Additionally, in December, our project partner, New York Association of Psychiatric Rehabilitation Services (NYAPRS), conducted a special group teleconference with all the awardees to review and discuss the importance of including consumers. Following the group call, NYAPRS held individual consultations with the awardees to strengthen their strategies for reaching out, orienting, and involving consumers in their respective fields.

Synthesizing the data from all the assessment activities was an ambitious undertaking. Not only did the awardees compile findings from literature reviews, results from routine organizational surveys and documentation, outcomes from group dialogues, and reviews of professional accreditation standards, they probed into contextual conditions—both internal and external environmental issues—that gave them a more well-rounded understanding of the systems in which their professions practice. In this way, the curriculum that is ultimately developed, disseminated, and implemented will be more assuredly grounded in, and reflective of, the reality of the professions, lending greater probability of acceptance and adoption.

Within their description of contextual conditions, and analysis of assessment data collected, the professional discipline awardees noted the extent to which the following core elements currently exist:

  • SAMHSA’s 10 recovery components
  • Cultural competency
  • Participation of consumers and family members
  • Recognition of the role of trauma and need for trauma-informed care
  • Infusion of recovery throughout the organizational system as compared to appearing as a standalone topic

Next, the awardees—the American Psychiatric Association, the American Psychiatric Nurses Association, the American Psychological Association, the Council on Social Work Education, and the National Association of Peer Specialists—will revise their draft Situational Analyses, following review and comment from an array of consumers and professionals, including SAMHSA. They will finalize the Situational Analyses prior to preparing the draft training outlines in the spring. Much of this year will be spent refining the outlines, including more peer and consumer input, followed by developing several iterations of the curriculum along with pilot testing, marketing, and dissemination. The project continues to arouse curiosity and stimulate provocative conversation among many people, both those seasoned and those new to recovery-oriented practices.

Personal Story

Chuck WeinbergPeople ask, “What is recovery?” There are so many ways to answer this question. We can answer in terms of the process of working toward valued life goals that give meaning and purpose, in spite of symptoms of mental illness. We can answer in terms of outcomes, and research by people such as Dr. Courtenay Harding, to make sure we do not skew or have unrealistically low expectations of those we work with, due to stigma or lack of knowledge. We can answer in terms of the courageous and phenomenal people (such as Dr. Fred Frese, Dr. Daniel Fisher, Dr. Patricia Deegan, and more) who, by being open with their problems, change attitudes, give hope to millions, and push our system to treat those with mental illness fairly.

Veterans and mental health providers both understand the concept of recovery, but both also struggle with it. Veterans appreciate the need to be treated like a person, not an illness, but sometimes struggle with the responsibility involved with shared decision-making and self-directed care. Providers want better outcomes just like veterans do, but sometimes do not include themselves as part of the equation that leads to less-than-optimal treatment results (besides consumer variables, provider variables and system variables also influence outcomes). False assumptions endure. Many still think that symptom stabilization from medication is a prerequisite and necessary condition before psychosocial support toward life goals can be offered. This is not true. The reality of the process is that there exists a bidirectional circle, where symptom stabilization from medication can help in achieving life goals, but co-occurring work and support toward achieving life goals can also lead to symptom stabilization (or coping with and acceptance of ongoing symptoms). Recovery-oriented relationships must be built with both consumers and providers, so we all can learn together.

But I think the following story helps shine more light on what recovery is really about. When we started our Mental Health Intensive Case Management (MHICM) team, one of our first experiences was helping a veteran with schizophrenia. This veteran had been homeless, so the first thing we did was find him good housing. But every few months, the veteran would leave his home; he would check out and walk off or leave town.

Superficially, this behavior appeared only to be a function of his illness: It appeared to be impulsive and a function of his ongoing psychosis. But because, we worked closely with this veteran, we got to know him as a person, as much more than his illness. This individual was lonely and bored. He had few social contacts. He had no purpose, work, or sense of self-worth. And he was not satisfied to simply not be suicidal or homicidal, to sit and smoke cigarettes and drink coffee all day. He wanted something more from his life. So he would leave in search of something more.

Now, this veteran often did not think through where he was going, and how this would meet his goals. If he were regarded only a schizophrenic, a medication adjustment would be all anyone might do. But when we saw him as a person with normal human desires that anyone would have, we were able to engage with him in a way that built trust, engendered respect and cooperation, and helped him cope and move in ways that were meaningful to him. And, if meds needed adjusting—well, we could do that too.

When I talk about recovery, I often ask, “Would any of you be satisfied, in spite of any illness, to sit and smoke cigarettes and drink coffee all day and to not be suicidal or homicidal? Would that be good enough for your loved ones?” Of course it wouldn’t.

While mental health providers sometimes struggle with the notion of recovery, it is really no mystery. Individuals with mental illness want the exact same things anyone would want from their health providers: eye contact, handshakes, encouragement, respect, support, education, and involvement in the process.

And so we move forward together, celebrate successes, identify areas to share and engage with, and cope with the long road ahead.

—Chuck Weinberg, LICSW, BCD, Local Recovery Coordinator, Huntington Veterans Affairs Medical Center, Huntington, W.Va.

Resource Spotlight

James F. GardnerGuide for Person-Centered Services and Supports. The Council on Quality and Leadership (CQL) has published the Guide to Person-Centered Excellence—Application for People With Mental Illness and People With Substance Abuse Disorder. The guide is a product of CQL’s What Really Matters Initiative, launched in 2009 to explore the challenges and solutions in realizing person-centered, recovery-based supports across the full range of mental health and substance abuse systems.

Over a 12-month period, CQL sought innovators across a range of health and human services, commissioning research reports from external experts, conducting an international Delphi Panel survey, convening advisory groups, and holding listening sessions and discussions with key stakeholders in the mental health and substance abuse fields. From this, the Guide to Person-Centered Excellence was developed. The guide features 8 key factors and 34 success indicators that characterize excellence in person-centered, recovery-based supports, which can then be used to facilitate a dialogue among mental health consumers, professionals, and organizational leaders on improving person-centered, recovery-based services within organizations, communities, and health and human service systems.

The guide can be downloaded for free at http://www.thecouncil.org/pceguides.aspx/.

For more information, please contact CQL at 410.583.0060 or info@thecouncil.org.

—James F. Gardner, Ph.D., President and CEO, The Council on Quality and Leadership, Towson, Md.

Related Links

The American Psychiatric Nurses Association, one of the RTP awardee associations, has developed a three-part series of Counseling Points on tobacco dependence, “Breaking Barriers and Implementing Change.” The strength of Counseling Points lies in its ability to deliver the most current and authoritative best practice information directly to care providers of patients with mental health and psychiatric issues.

http://www.apna.org/i4a/pages/index.cfm?pageID=4458

The Center on Adherence and Self-Determination is funded by the National Institute of Mental Health. The Center conducts research aimed at promoting choice and full engagement in services that help people with serious mental illnesses achieve their recovery goals. The Center leads the field in the conceptualization, development, and dissemination of innovative research methods, analytic approaches, and interventions aimed at promoting self-determination and service participation.

http://www.casd1.org

The Council on Quality and Leadership, whose resource is highlighted in the Resource Spotlight, is recognized for person-centered supports and services for people with disabilities, people with mental illness, and older adults. Through their services, publications and public presence, they establish real connections between theory and practice and help organizations and systems take the important step from innovative ideas to everyday action. Their goal is to be partners and mentors to their customers, showing them how they can become even better at ensuring that all people lead lives of dignity and quality.

http://www.thecouncil.org

The Centers for Disease Control and Prevention released a new report, CDC Health Disparities and Inequalities Report — United States, 2011. It highlights the progress and challenges in achieving health equity and also underscores the need for more consistent, nationally representative data on disability status and sexual orientation. The report, the first of a series of consolidated assessments, highlights health disparities by sex, race and ethnicity, income, education, disability status, and other social characteristics. Substantial progress in improving health for most U.S. residents has been made in recent years, yet persistent disparities continue.

http://www.cdc.gov/mmwr

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Contact Us

For more information about RTP, contact us at recoverytopractice@dsgonline.com, or call 877.584.8535.

The views, opinions, and content of this E-News are those of the authors and do not necessarily reflect the views, opinions, or policies of SAMHSA or HHS.