An Important Trend in Recovery-Oriented Practice
SAMHSA Recovery to Practice Highlights; Larry Davidson, Ph.D., 4/24/2014
Self-management in the use of medication for mental health conditions and addiction is an important topic that has been addressed by RTP in several venues and formats, and for which we have received positive feedback over the past few years. Although medications can be very effective tools in promoting recovery, they alone are insufficient for many persons with prolonged conditions. For these individuals, the medications we currently use do not “cure” mental illnesses or addictions. When effective, they may reduce symptoms and a person’s likelihood of relapse, or improve his or her quality of life. In mental illnesses, for example, medications may reduce some of the more flagrant symptoms such as hallucinations and acute mania, but do not address the negative symptoms and neurocognitive impairments that are often the more disabling aspects of these disorders. Even in the case of affective disorders, in which medications can stabilize a person’s mood and offer protection against relapse, medications cannot repair relationships or help the person identify and plan ahead for managing his or her triggers, such as losses or setbacks.
In the treatment of addictions, medications may render certain substances less reinforcing or reduce cravings, but make no impact on a person’s ability to develop new, sober social networks that will support his or her recovery. In this respect, we should avoid conveying the message that all people need to do is take the medications prescribed for them and everything will be all right. Recovery requires hard work on the part of both persons in recovery and practitioners, and with current healthcare reforms under way, practitioners will need to play an increasingly important part in educating people about their own role in their recovery and in supporting their efforts to manage their conditions and recover as fully as possible.
This is because, in the shift to person-centered care, our responsibilities as practitioners change from reducing symptoms, cravings, and relapses through a patient’s compliance with prescribed medications to promoting and supporting people and families in their active efforts to self-manage long-term conditions. Because current medications do not cure many of the illnesses we treat, it is up to people in recovery and their families to learn how best to manage these conditions, with our assistance and support, between their appointments. Medication becomes one potential tool they may use in doing so, rather than being the primary focus of care. But for people in recovery and families to take on active roles in using self-management tools, practitioners need to do more than provide education, information, and encouragement.
Research has consistently demonstrated, for instance, that people are much more likely to follow through with treatments they have chosen, and less likely to follow through with treatments chosen for them. To assume responsibility for self-management, people in recovery and families need to feel confident in their knowledge of what they are managing, and in their ability to decide (among relevant options) how best to go about doing so. Thus, part of our responsibility as practitioners becomes laying out the relevant options from which people may then make personal decisions, and respecting those decisions as we would want others to respect our own.
In addition to collaborating in the decision-making process, practitioners can be guided by the following evidence-based principles for promoting self-management:
- Elicit the person’s and family’s perspectives on the issues that brought them to care.
- Assess the person’s and family’s perceived needs and priorities, including cultural preferences (e.g., ethnic, sexual, spiritual).
- Identify the person’s short and long-term goals.
- Identify medication targets that indicate people are overcoming barriers to life goals or increasing their quality of life (over and above symptom reduction).
- When needed, prescribe medication as one component of an overall self-management plan that builds on personal and family strengths.
- Identify and address barriers to self-care, including the need for additional supports (e.g., transportation, child care, reminders, environmental modifications).
It may be evident from this list that the promotion of self-management is far from an easy or straightforward affair. On a more positive note, these principles create ample room for interdisciplinary teams to divvy up the labor involved according to the person’s and family’s needs and preferences and the respective expertise of each discipline.
Physicians: 1) Assess, evaluate, and diagnose health conditions and identify personal and family strengths; 2) Collaborate in decision making and prescribe chosen treatments; 3) Monitor treatment response and make adjustments as needed; 4) Educate the person and family about conditions involved, available services and supports, and expected short- and long-term outcomes.
Nurses: 1) Assess and monitor mental and physical health and identify personal and family strengths; 2) Collaborate in decision making and provide selected treatments; 3) Teach and support people to self-administer medications and engage in other self-care activities; 4) Promote exercise, nutrition, and overall wellness.
Social Workers: 1) Assess and evaluate the person’s and family’s life context and available and needed resources; 2) Collaborate in decision making and provide selected treatments; 3) Advocate for and increase the person’s access to needed resources, services, and supports; 4) Assess family situation and offer education, intervention, or support as needed.
Psychologists: 1) Assess and evaluate personal strengths and functional impairments; 2) Collaborate in decision making and, when possible, remediate impairments through selected interventions (e.g., cognitive remediation); 3) When needed, develop and implement environmental modifications to enable the person to compensate for residual impairments.
Rehabilitation Staff: 1) Assess and evaluate personal strengths and interests; 2) Collaborate in decision making and, when possible, offer skills training exercises and/or in vivo support; 3) When needed, implement environmental modifications to enable the person to compensate for residual impairments; 4) Liaise with community organizations to create or expand access to naturally occurring activities.
Substance Use Counselors: 1) Assess and evaluate the person’s use of alcohol and other drugs and the degree to which substance use is distressing and disruptive in the person’s life; 2) Collaborate in decision making and, when needed, provide motivational interviewing and counseling, including identifying triggers, teaching coping skills, and preventing relapses; 3) Connect the person and family to community-based self-help/mutual support resources.
Peer Staff: 1) Engage people into care who are reluctant or skeptical that it can help them; 2) Instill hope for recovery through tangible role modeling; 3) Collaborate in decision making and, when needed, advocate for care to include the person’s and family’s life concerns and goals in addition to medical and psychiatric issues; 4) Increase the degree to which people become “activated” to take care of themselves, and reinforce their use of self-management tools and skills.
Because this is a very preliminary and oversimplified list, we welcome feedback and input from RTP readers to better define the respective roles of these and other disciplines.
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