H.C. Appendix C

PEER PROGRAMS

Consumer-Operated Self-Help Centers

Margaret Swarbrick

University of Medicine and Dentistry–NJ

Psychiatric Rehabilitation Journal

2007, Volume 31, No. 1, 76–79

DOI: 10.2975/31.1.2007.76.79

Consumer-operated services (COS) are viewed as a legitimate alternative for mental health consumers living in the community. This article provides an overview of, outlines a consumer-operated self-help center model that has evolved in New Jersey, and illustrates how it has become a viable component of the mental health system. The goal is to inspire psychiatric rehabilitation practitioners to create COS alternatives as part of their state-run services transformation efforts.

Keywords: self-help centers, consumer-operated services, and peer support model

Introduction

The President’s New Freedom Commission of Mental Health Final Report (2003) suggests that in order to create a recovery-focused mental health system, consumer-operated services should be promoted. Consumer-operated services (COS) are planned, managed, and evaluated by consumers themselves (SAMHSA,1998; Van Tosh & del Vecchio, 2000). COS (a.k.a. peer-operated, peer-delivered, or consumer-delivered services) are funded through state legislatures and private foundations, and considered both a complement of and an alternative to traditional mental health services (Clay, 2005; Davidson, Chinman, Kloos, Weingarten, Stayner & Tebes, 1999; Segal, Hardiman, & Hodges, 2002; Van Tosh & del Vecchio, 2000). Some services are entirely consumer-managed, while others incorporate the use of non-consumer professionals in certain areas (Solomon, 2004). In the COS model, the extent of non-consumer or professional involvement is within the control

of the consumer-operators (Solomon & Draine, 2001). COS attracts individuals who may access both traditional and non-traditional services (Segal & Silverman, 2002). Consumer-operated services were developed as a result of the mental health consumer movement, which identified that consumers had limited options, choices, and involvement in their individual services and in the system as a whole. Typically, consumers were not empowered by the traditional mental health [care] system, which relied on the doctrine of parens patrae and acted as a surrogate decisionmaker for the person(s) diagnosed with mental illness (Goffman, 1961). Members of this movement viewed the traditional service system as paternalistic and lacking in options and opportunities that could have meaningful impact on planning and decision-making regarding policy and personal treatment (Chamberlin & Rogers, 1990). Their dissatisfaction was the impetus for the creation of COS (Segal & Silverman, 2002). Reacting to their experiences of the inadequacies of the mental health system and the indignities it engendered, consumers aimed to empower themselves by producing their own consumer-operated self-help alternatives (Chamberlin, 1978, 1984). A growing body of literature provides information on participant and program characteristics (Clay, 2005; Solomon, 2004) and program fidelity (Clay, 2005; Holter, Mowbray, Bellamy, MacFarlane, & Dukarski,, 2004; Mowbray, Robinson, & Holter, 2002).

Initially, most research was focused on descriptive reports of program characteristics and service usage (Chamberlin, Rogers, & Ellison, 1996; Davidson et al., 1999; Kaufmann, Ward- Colasante, & Farmer, 1993; Salzer, 2001; Segal & Silverman, 2002). The Community Support Programs demonstration program resulted in a range of COS services including: housing programs; consumer businesses (Van Tosh & del Vecchio, 2000); mutual aid/selfhelp groups and peer support programs (Mead, Hilton, & Curtis, 2001); case management; and drop-in centers (Bond, 1994; Chamberlin et al., 1996; Meek, 1994; Mowbray & Tan, 1992, 1993; White, 1994).

Drop-in centers are the most common type of COS, and consist of a supportive environment where consumers can connect with a peer network, gain practical assistance from peers, relax, and experience freedom in a family-like environment that has no imposed structure. There is evidence that COS offer a more tolerant, flexible, and supportive environment (Davidson, et al., 1999; Mowbray & Tan, 1992, 1993). Other researchers (e.g., Silverman, Blank, & Taylor, 1997) have examined the social environment of consumer-run drop-in centers and found that members perceived their centers as highly supportive and oriented toward mutual learning, independence, and self-understanding.

The Center for Mental Health Services (CMHS) allocated $19.6 million for a multi-site research study designed to examine the extent to which COS programs, when used as an adjunct to traditional mental health services, effectively improve outcomes of adults who have serious and persistent mental illness (The Cooperative Agreement for Evaluating Consumer Operated Services [COSP] 1998). The COSP Initiative investigated the extent to which COS are effective in improving self-empowerment, employment, housing, social inclusion, and satisfaction with services (Clay, 2005). More than

1,827 consumers participated in the study and participation in peer support was found to be positively associated with participant recovery and empowerment (Corrigan, 2006).

Self-Help Centers in New Jersey

The New Jersey Department of Human Services has incrementally shifted service delivery from institutional to community settings, adding a consumer- operated self-help center service model in all counties. This allows consumers of mental health services to improve themselves and provide mutual support. The expansion of consumer operated services in New Jersey was a slow and deliberate process that involved close collaboration between the New Jersey Division of Mental Health Services (DMHS) staff and consumer leaders. The DMHS initially funded a consumer-operated agency,

Collaborative Support Programs of New Jersey (CSP-NJ), and opened three drop-in centers in 1985. By the mid- 1990s, there were 11 centers. The DMHS decided to increase the funding and accountability for COS and worked with consumer leaders in New Jersey to expand the scope of (the renamed) self-help centers to develop a Self-Help Center Policy and Procedure Guideline (2006). The Guideline has become the manual for maintaining a safe, accessible, empowering social environment

(Swarbrick & Duffy, 2000). The DMHS currently funds 27 self-help centers and CSP-NJ operates 21 self-help centers. Self-help centers are freestanding sites, located in the community, and are accessible to individuals 18 years of age and over who are diagnosed with a mental illness and have received/ are receiving mental health services (Swarbrick, 2005, 2006).

Centers are designed to offer a conducive environment where consumers can socialize with peers, meet new people, learn new skills, join self-help and advocacy groups, and enjoy recreational activities (Swarbrick & Duffy,2000). Centers provide a place where separate self-help groups can join together and become a more powerful advocacy voice in the mental health system and the community. An important aspect of these centers is that they provide not only a support network for consumers who feel lonely and lack emotional support, but also access to resources and support that will help them deal with day-to-day problems and life stressors (Swarbrick, 2005, 2006). Centers provide a welcoming environment where mental health consumers feel respected and understood. Consumers can be accepted for who they are by people who are personally familiar with many of the problems they face. The centers offer a non-judgmental atmosphere of acceptance, trust, and empathy from people who have “been there.” Members work out problematic and personal issues and learn to become increasingly interdependent. Involvement in self-help centers empowers consumers to gain control of their lives, revive their sense of purpose, and promote a sense of self that extends beyond their identity as consumers of mental health care (Swarbrick, 2005). Centers are generally open 5 to 7 days per week, including evenings, weekends, and holidays (Swarbrick, 2005).

Centers are based on the principle of mutual aid—the notion that past and present recipients of mental health services (consumers) provide a unique perspective and have the expertise to design and implement services to improve the quality of life of their peers. Peers can offer empathy in the guise of having “been there.” Centers offer a system of mutual support and access to resources that promote recovery. The peer support found at the centers is based on respect for one another’s needs, contributions, limitations, and strengths. Peers help one another by using their own life experiences as their tools. This approach is distinctly different from the traditional mental health system, which often emphasizes medicalization of human feeling and views consumers by their “diagnosis” rather than their abilities (Swarbrick, 2005).

Centers are also different from traditional mental health psychosocial programs because they are non-clinical in nature and structured to meet needs often not addressed in traditional programs. Consumers have opportunities to assume leadership roles (and receive requisite training), which is also different from traditional programs (Swarbrick, 2005). The locus of control is within the peer group of consumers rather than a professional domain. Day-to-day operations are managed by peer groups of consumer-leaders who have opted to take on roles that they find interesting and/or challenging (Swarbrick, 2005, 2006). In traditional mental health programs, consumers have limited control over and choice in their services.

Research on Self-Help Centers

An exploratory, descriptive study was conducted in 2004 to examine the relationships between social environment factors and empowerment and satisfaction (Swarbrick, 2005). Participants (N = 144) involved in self-help centers completed a survey designed to capture perceptions of satisfaction, empowerment, and social environment factors (see Moos, 1974, 1996, 2002), as well as demographic data and other characteristics. Participants were generally unmarried, middle-aged, poor but living in a stable housing situation, and scored high on an empowerment scale (Swarbrick, 2005). Significant, positive relationships between participant satisfaction and two of the three social environment factors studied (relationship and system maintenance and change) were found (Swarbrick, 2005). The amount of support and sense of order and organization offered by the center’s environment predicted satisfaction. No significant relationships between participant empowerment and the three social environment factors studied were found, although associations were found between participant empowerment and self-help center involvement (Swarbrick, 2005). Participants who attended frequently and for a longer period of time scored higher on the empowerment scale (Swarbrick, 2005

Summary

In New Jersey, mental health consumers assume leadership roles and operate self-help centers that provide viable services for their long-term social and emotional needs of peers. The centers are a consumer-operated service that is proving to be a positive resource for mental health consumers living in the community, and supports the idea of recovery and wellness. This article highlights a self-help center model that has evolved through the collaborative efforts of consumer-leaders and the New Jersey mental health authority. The goal is to inspire psychiatric rehabilitation practitioners to collaborate with consumers to create consumer-operated service alternatives as part of their state’s transformation efforts.

References

Bond, G. (1994). The role of drop-in centers in mental health services. Innovations and Research, 3(1), 46–47.

Chamberlin, J. (1978). On our own: Patient controlled alternatives to the mental health system. New York: McGraw-Hill.

Chamberlin, J. (1984). Speaking for ourselves: An overview of the ex-psychiatric inmates’ movement. Psychiatric Rehabilitation Journal, 8(2), 56–63.

Chamberlin, J., & Rogers, J. (1990). Planning a community-based mental health system: Perspectives of service recipients. American Psychologist, 45(11), 241–1244.

Chamberlin, J., Rogers, S.E, & Ellison, M. L. (1996). Self-help programs: A description of their characteristics and their members. Psychiatric Rehabilitation Journal, 19(3), 33–42.

Clay, S. (2005). On Our Own Together: Peer programs for people with mental illness. Vanderbilt Press.

Corrigan, P. (2006). Impact of consumer-operated services in empowerment and recovery of people with psychiatric disabilities, Psychiatric Services, 57(10), 1493–1496.

Davidson, L., Chinman, M., Kloos, B., Weingarten, R., Stayner, D., & Tebes, J. (1999). Peer support among individuals with severe mental illness: A review of evi dence. Clinical Psychology: Science and Practice, 6, 165–187.

Goffman, E. (1961). Asylums: Essays on the social situation of mental patients and other inmates. New York: Anchor Books.

Holter, M., Mowbray, C., Bellamy, C.,MacFarlane, P., & Dukarski, J. (2004). Critical ingredients of a consumer run services: Results of a national survey. Community Mental Health Journal, 40(1), 47–63.

Kaufmann, C., Ward-Colasante, C., & Farmer, J. (1993). Development and evaluation of drop-in centers operated by mental health consumers. Hospital and Community Psychiatry, 44(7), 675–678.

Mead, S., Hilton, D., & Curtis, L. (2001). Peersupport: A theoretical perspective. Psychiatric Rehabilitation Journal, 25(2), 134–141.

Meek, C. (1994). Consumer-run drop-in centers as alternatives to mental health services. Innovations and Research, 3(1), 49–51.

Moos, R. (1974). Evaluating treatment environments: A social ecological approach. New York: John Wiley.

Moos, R. (1996). Community oriented programs environment scale manual: Third edition. Palo Alto, CA: Consulting Psychologists Press.

Moos, R. (2002). Group Environment Scale Manual. (3rd Ed.). Palo Alto, CA: Consulting Psychologists Press.

Mowbray, C., Robinson, E., & Holter, M. (2002). Consumer drop-in centers: Operations, services and consumer involvement. Health Social Work, 27(4), 248–261.

Mowbray, C., & Tan, C. (1992). Evaluation of an innovative consumer run service model: The drop in center. Innovation and Research, 1(2), 33–42.

Mowbray, C., & Tan, C. (1993). Consumer-operated drop-in centers: Evaluation of operations and impact. Journal of Mental Health Administration, 20(1), 8–19.

Salzer, M. (2001). Best practice guidelines for consumer-delivered services. Unpublished Manuscript, Behavioral Health Recovery Management Project.

Segal, S., Hardiman, E., & Hodges, J. (2002).Characteristics of new clients at self-help and community mental health agencies in geographic proximity. Psychiatric Services, 53(9), 1145–1152.

Segal, S., & Silverman, C. (2002). Determinants of client outcomes in selfhelp agencies. Psychiatric Services, 53(3), 304–309.

Silverman, S., Blank, M., & Taylor, L. (1997). On our own: Preliminary findings from a consumer run service model. Psychiatric Rehabilitation Journal, 21(2), 151–159.

Solomon, P., & Draine, J. (2001). The state of knowledge of the effectiveness of consumer provided services. Psychiatric

Rehabilitation Journal, 25(1), 20–27.

Solomon, P. (2004). Peer support/peer provided services: Underlying processes, benefits, and critical ingredients. Psychiatric Rehabilitation Journal, 27(4), 392–402.

Substance Abuse and Mental Health Services Administration [SAMHSA]. (1998). GFA No. SM 98-004. Cooperative agreements to evaluate consumer-operated human service programs for persons with serious mental illness. Rockville, MD:

Author.

Swarbrick, M. (2006). Consumer-operated selfhelp services. Journal of Psychosocial Nursing, 44(12), 26–35.

Swarbrick, M. (2005). Consumer-operated selfhelp centers: The relationship between the social environment and its association with empowerment and satisfaction. Unpublished dissertation.

Swarbrick, M., & Duffy, M. (2000, March). Consumer-operated organizations and programs: A role for occupational therapists. Mental Health Special Interest Quarterly, 23, 1–4.

Van Tosh, L., & del Vecchio, P. (2000). Consumer-operated self-help programs: Atechnical report. Rockville, MD: U.S.

Center for Mental Health Services.

White, M. (1994). Consumer-run drop-in centers as alternatives to mental health services. Innovations and Research, 3, 44–46.

Margaret (Peggy) Swarbrick, PhD, OTR, CPRP, is a Post-Doctoral Fellow, at the University of Medicine and Dentistry-NJ, Department of Psychiatric Rehabilitation, National Institute on Disability and Rehabilitation Research (H133P05006); and is Director, at the Institute for Wellness and Recovery Training Initiatives, Collaborative Support Programs of New Jersey.

Contact the author at: 8 Spring Street Freehold, NJ 07728 Ph 732-625-9516 ext. 113 pswarbrick@cspnj.org

PEER MENTORING

Peer mentors are known by various names, Consumer providers, Peer specialists, Consumer Service Assistants, as well as others.

The idea of “recovery”—in which providers and individuals with mental illness work collaboratively toward the individual’s pursuit of a meaningful and enriched life in the community—is the focus of mental health treatment today.

One important strategy for making mental health care more recovery-oriented is to have mental health consumers serve as providers in mental health clinics and other mental health organizations. CPs offer many advantages:

serve as role models to consumers
voice and broker the needs of consumers
are an important sources of information
serve as a powerful source of motivation
help others while helping themselves
serve as mentors to others, helping them to better understand paths to recovery.

For the systems in which they work, CPs assist clients in navigating often-fragmented service systems are often more willing than nonconsumer staff to perform needed client support activities, such as transportation and life skills development serve as a unofficial liaisons with nonconsumer staff, interpreting and in some cases mediating between staff and clients challenge unacknowledged stigma and bias toward clients augment the services of overburdened mental health systems, thereby increasing access to services.

Given the benefits listed above, it is hard to imagine that any mental health clinic would not want to have CPs as part of its staff. However, employing CPs in this way is new, meaning that most of today’s mental health workforce may be only minimally familiar with CPs and may have no experience in setting up CP programs.

(Source: Mental Health Consumer Providers A Guide for Clinical Staff by

Matthew Chinman, Alison Hamilton, Brittany Butler, Ed Knight, Shannon Murray, Alexander Young, Published 2008 by the RAND Corporation)

Recovery 101

Recovery 101 has 3 main parts. Part A contains the 10 Fundamental Components of Recovery; Part B describes the six stages of grief, which often hinders recovery, while Part C outlines the L.E.A.P. program, which has considerable success in helping people achieve Recovery.

The 10 Fundamental Components of Recovery

Hope

Recovery provides the essential and motivating message of a better future- that people can and do overcome the barriers and obstacles that confront them. Hope is internalized; but can be fostered by peers, families, friends, providers, and others. Hope is the catalyst of the recovery process.

At the beginning of the 20th Century, approximately 6% of those diagnosed with a serious mental illness ever recovered. By the beginning of the 21st century recovery began to exceed 50%. Recovery rates are expected to grow.

Self direction

Consumers lead, control, exercise choice over, and determine their own path of recovery by optimizing autonomy, independence, and control of resources to achieve a self-determined life. By definition, the recovery process must be self-directed by the individual, who defines his or her own life goals and designs a unique path towards those goals.

Individualized and Person Centered

There are multiple pathways to recovery based on an individual's unique strengths and resilience as well as his or her needs, preferences, experiences (including past trauma), and cultural background in all of its diverse representations. Individuals also identify recovery as being an ongoing journey and an end result as well as an overall paradigm for achieving wellness and optimal mental health.

Empowerment

Consumers have the authority to choose from a range of options and to participate in all decisions-including the allocation of resources-that will affect their lives, and are educated and supported in so doing. They have the ability to join with other consumers to collectively and effectively speak for themselves about their needs, wants, desires, and aspirations. Through empowerment, an individual gains control of his or her own destiny and influences the organizational and societal structures in his or her life.

Holistic

Recovery encompasses an individual's whole life, including mind, body, spirit, and community. Recovery embraces all aspects of life, including housing, employment, education, mental health and healthcare treatment , complementary and naturalistic services (such as recreational libraries, museums, etc.), addictions treatment, spirituality, creativity, social networks, community participation, and family supports as determined by the person. Families, providers, organizations, systems, communities, and society play crucial roles in creating and maintaining meaningful opportunities for consumer access to these supports.

Non-Linear

Recovery is not a step-by step process but one based on continual growth, occasional setbacks, and learning from experience. Recovery begins with an initial stage of awareness in which a person recognizes that positive change is possible. This awareness enables the consumer to move on to fully engage in the work of recovery.

Strengths Based

Recovery focuses on valuing and building on the multiple capacities, resiliencies, talents, coping abilities, and inherent worth of individuals. By building on these strengths, consumers leave stymied life roles behind and engage in new life roles (e.g., partner, caregiver, friend, student, and employee). The process of recovery moves forward through interaction with others in supportive, trust-based based relationships.

Peer Support

Mutual support-including the sharing of experiential knowledge, skills and social learning-plays an invaluable role in recovery. Consumers encourage and engage other consumers in recovery and provide each other with a sense of belonging, supportive relationships, valued roles, and community.

Respect

Community, systems, and societal acceptance and appreciation of consumers, including protecting their rights and eliminating discrimination and stigma-are crucial in achieving recovery. Self-acceptance and regaining belief in one's self are particularly vital. Respect ensures the inclusion and full participation of consumers in all aspects of their lives.

Responsibility

Consumers have a personal responsibility for their own self-care and journeys of recovery. Taking steps towards their goals may require great courage. Consumers must strive to understand and give meaning to their experiences and identify coping strategies and healing processes to promote their own wellness.

The National Consensus Statement on Mental Health Recovery is available at SAMHSA's National Mental Health Information Center at www.mentalhealth.samhsa.gov

GRIEF

Grief experienced by consumers of mental health services, whether due to the stigmas associated with mental illness, a perceived loss of any worthwhile future, or with any loss in their lives can help trigger relapse.

Family members can also experience grief at the time of diagnosis, and re-grieve when their family member experiences a relapse or fails to develop age related skills.

(SOURCE: The Journal Vol. 5 No. 3 1994; Recovery: Parental Grief, The Journal Vol. 5 No. 3 1994. Recovery, Parental Grief Regrieving by Diane Welch Vines, R.N. Ph.D.)

Six Stages of Grief

Shock, Denial, Bargaining, Anger, Guilt, Acceptance

The journey from shock to acceptance is, perhaps, the greatest obstacle on the road to recovery.

Shock

Total disbelief: Your world is thrown upside down. You feel out of control. Rarely is anyone prepared. At best you go through the motions. Memory lapses are common. Shock is a defense mechanism which helps you through the first few days of a devastating event so you don’t feel the full impact of the changed circumstances.

Denial

A buffer to the reality of the situation. Denial prevents us from dealing with the feelings the new circumstances brings with it. The longer we are in denial, the longer we avoid facing our grief. Many who stay in denial begin to find other ways of numbing their pain, often with drugs or alcohol.

We pretend if we don’t think about think about something, it will go away and normalcy will return. However, we must feel the pain in order to begin to heal. . When we refuse to feel the pain, we also prevent ourselves from feeling love, joy and other positive emotions.

Bargaining

I will give up smoking. I'll go to church every Sunday. I’ll check the locks three times before going out. If only....

But time cannot be turned back. While bargaining provides temporary comfort, if carried on too long, it can prevent healing and the ability to get on with life.

Anger

The sense of being powerless. The sense of being powerless,… and out of control. Anger at those you believe responsible for placing you in the situation. Blaming God; temper tantrums, outbursts, or turning anger inward; depression. The longer we keep anger in; the longer it stays in our bodies.

It will show up in our relationships with others. It will show up as disease, disability or symptoms. It can abolish the ability to work efficiently. The more a person bottles up their feelings of anger, the more likely that person will explode. Unless anger is properly addressed, it can turn to rage.

Guilt

Guilt is a genuine phase of grieving. People will feel as if they have failed or done something wrong. Guilt is more profound when a person is part of a tragedy; survivor guilt. . Blaming ourselves for a dreadful situation is common. We curse our shortcomings and repeat our should haves.

Guilt will hamper progress in healing. Ask yourself; What lesson am I learning from this? How will this change my life? Will I become a more compassionate and loving person because of it? Is there some way that the new knowledge I have gained can help someone else?

Acceptance

As we acknowledge the situation for what it is, our wounds begin healing and we can move on with our lives. This may not mean that the new circumstances are agreeable, or or that grieving is completed. At times we may fall back into guilt or depression. With acceptance we can reinvent ourselves and create a new future.

We may carve out a new sense of values. We can find new opportunities borne out of our loss. While we cannot return to the way it was, we can still discover meaningful things for us to do. A new set of realities has been thrust upon the person diagnosed with a mental illness. Realities which the individual may not be fully aware of. These new circumstances need to be dealt with. Once an individual accepts the fact that he or she actually has a mental illness, only then does the recovery journey begin.

The journey from shock to acceptance is, perhaps, the greatest obstacle on the road to recovery.

(Sources on Grief • Healing Grief by James Van Praagh • The Journal Vol. 5 No. 3 Recovery 1994, , Parental Grief and Parental Grief and Regreiving , by Diane Welch Vines. R.N. Ph.D.)

L.E.A.P.

                                  Listen  Empathize Agree Partnership

Communication skills that can work to aid an individual in recovery develop a recovery plan… and get back on it should they on it should they relapse.

Guidelines for listening: Set aside the time; Agree on an agenda; Listen for beliefs about mental illness; Don’t react; Let chaos be; Echo what you’ve heard; Write it down

Listen

to attitudes about medication

to concepts about what he can or cannot do

for cognitive deficits caused by the illness

Don’t try to correct the person’s beliefs, scowl, express disappointment, be judgmental; or get angry. The purpose of listening is to understand. The realities of those with a mental illness can be markedly different than for someone without it. Each person with a mental illness is unique, as we all are.

You need to be willing to understand his or her reality in order to build or rebuild trust; and to arrive at consensus on how things should be handled. Ask questions, but leave out the sarcastic comments and trap questions. Ask only questions which are designed to elicit information.

Let chaos be

At times the mentally ill person may not make any sense at all to you.

Empathize

When empathy is conveyed, the person will very likely feel understood and respected. Frustrations about pressures to take the medications. Goals that have not been met; Fears, about medications, about being stigmatized, failing. Discomforts due to medications, weight gain, feeling groggy, slowed down, stiff, being less creative. Desires: to get married, to get out of the hospital, to work, to live on their own, to have children, to go to school. Any feeling that is revealed.

Agree

This does not mean Agreeing that aliens from another planet are controlling every thought. Whenever you see a window of opportunity to convey your observations and opinions, , always begin with something your client/ loved one already acknowledges and believes. The more common ground that is found, the better.

Agree - Being in the hospital makes it impossible to find work.

Agree - It’s hard to do the things you’d like to when you don’t have much money.

Agree - It’s hard to do the things you’d like when the medication makes you so tired.

Agree - Normalize the experience (I would feel the same in your shoes.) Discuss perceived problems (I can’t sleep at night because I’m on guard that they are going to hurt me.) Review perceived advantages and disadvantages (Whether rational or not.) Correct misconceptions - Check that your beliefs are correct. Information, once thought to be accurate has, at times been shown to be incorrect.

Agree - Reflect back and highlight perceived benefits (When you are on medications you sleep better and fight less with your family).

Agree - to disagree (The time sequence of events may be remembered differently, problems started before medication was stopped, or after it was stopped.)
Acknowledge that reasonable people can disagree.

Partnership

Try to agree on goals that are reachable whenever possible. Preferably goals should be agreed upon prior to any crisis situation. At times crisis can be avoided by reviewing a prior agreement, which should be in writing.

Ideally, meetings to discuss the ill person’s feelings and beliefs should be ongoing in a non confrontational, non- threatening, supportive manner. Ask permission to write down anything you think might be important. Keep it in a file/ notebook, along with the date.

(Sources on L.E.A.P. Sources on L.E.A.P. • I Am Not Sick, I Don’t Need Help, by Xavier Amador; Peer Counseling, a course by John Hayes of Disability Resources Center, Long Beach CA )

RECOVERY: A PATH FOR DIFFICULT PEOPLE

This is a sixteen session group that meets for one hour, either once or twice a week.

Suggested Group size is 6– 10

This course uses vol. 1 & 2 of the How to Deal with Difficult People video series by Drs. Brinkman and Kirschner as its primary text. It also uses material from The Dalai Lama’s book, The Art of Happiness, and Emotional Alchemy: How the mind can heal the heart by Tara Bennett-Goleman. The material from the last two can also be found in Mental Illness A Guide to Recovery, by Bob Bennett. It is recommended that the video series be made available for independent viewing as well as during group.

Session 1

Introductions: What would you like to receive from this class?

Overview – Taking responsibility for words, actions, thoughts, emotions, as well as your reactions to stress. Expelling Anger Exercise, Video series: How to Deal With Difficult People (as well as learning to recognize your own difficult behaviors) Transforming anger, meditation.

Session 2

Check in (Did you get angry since last group? What happened? How could you have handled it differently? Expelling anger Exercise.) Taking responsibility for your words, actions, thoughts, Emotions, and reactions to stress. Give homework assignment for course. The goal is to have each group member complete the assignment by the end of the 16 session group. For some, this will be an extremely difficult task. Be gentle. Meditation.

Session 3

Check in. Begin video series from start of first vol. to 28 min 50 sec. Review main portions of video; Meditation.

Session 4

Check in. Continue video: to 59 min 0 sec. Review Meditation.

Session 5

Check in. Video: to end vol. 1, Review Communication skills. Meditation.

Session 6

Check in Discussion of triggers/schemas: What sets you off and why? Abandonment & Deprivation. Meditation

Session 7

Check in. Video: start of vol. 2 to end of sniper segment. Review. Meditation

Session 8

Check in. Discussion of triggers/schemas: Subjugation & Mistrust

Session 9

Check in. Video: Know It All segment, review. Meditation.

Session 10

Check in. Discussion of triggers/schemas: Unloveability & Exclusion

Meditation

Session 11

Check in. Video: Think they know it all /Maybe People, Review, Meditation

Session 12

Check in. Discussion of triggers/schemas: Vulnerability/ Failure Meditation

Session 13

Check in. Video: Yes People/ Nothing People, Review, Meditation

Session 14

Check in. Discussion of triggers/schemas: Perfectionism/ Entitlement

Meditation

Session 15

Check in. Expelling anger exercise. Video: Chronic complainers,/ No People (end of vol.2) review, Meditation

Session 16

Check in. Feedback / Celebration - Hand out certificates of attendance/completion. (Certificate of completion requires completing homework assignment.)

Homework assignment

Step one

The first step is to write down what is making you angry. Take your time with this. If you have a lot of things making you angry, pick the one making you the angriest. If you find yourself getting angry as you write, take a break. Go out for a walk or do something you feel calming. Tell yourself, I’m addressing my anger, I’m working to resolve my anger Take the time you need. Then go back and continue writing. Write down all the details about it. When you think you’re done, ask yourself, Anything else? Write it down.

Step two

The second step is to ask yourself: Did I contribute anything to this situation? Write down all the contributions you made. It may be eighty percent of the situation, or it may be one percent. Write it down. When you think you are done, ask yourself, “Anything else?” If you think of anything else, write it down.

Step three

The third step is to ask yourself, What was the other person’s perspective? Write it down. “What was the other person view of what happened?” Did that other person see some danger to themselves or one of their loved ones? What was the other person’s perspective? Was the other person doing the best he or she could? Write it down. Was the other person in over their head? Was the other person dealing with a new situation? Sometimes it isn’t a person you may be angry with. If you’re angry with God, ask yourself “What was God’s perspective?” Were you being given a challenge to overcome? Are you being requested to improve your life or the lives of others? If the answer feels right to you, it is the right answer.

Step four

Anger is a perceived injustice. If you have gotten this far and still feel anger, either you hid something from yourself along the way, or an injustice was done. Anger is energy stored in the body. It will seek action. It is up to individuals to find ways to release this energy in a way that will benefit themselves and society. MOTHERS AGAINST DRUNK DRIVING (MADD) was formed by parents angry over the death or injury to a child, or other loved one. NAMI was formed by parents and family members who were angry over the lack of knowledge, treatments and care available to those of us with a mental illness. They have changed things. But, more work needs to be done.

Write down what you can do to make things better for someone else who may be in a similar situation, and then do it.

PEER TO PEER

Major topics for the fist week are:

*     Commonality of experience irrespective of diagnosis
*      Trauma as an integral part of the experience of mental illness
*       Impact of social/cultural contexts and resulting discrimination
*       Relapse prevention as a tool for understanding what has happened
*       Awareness as a skill that can be developed

The tone and pace of this week are quite relaxed by design because, underneath the material being presented and group interactions, are the building blocks for the group cohesion that will occur in the next few weeks.

The week attempts to strike a balance between disseminating information, allowing participants maximum “space” and choice, and imposing upon the group the kind of structures necessary to foster the kind of group framework that will be required in future weeks.

Week Two

Schizophrenia, Bipolar Disorder, Depression
Thoughts, Feelings, Sleep
Continue Relapse Prevention Planning

The second week of the course is designed to:

*    Expand upon the idea of commonality of experience by introducing factual information on the biological bases of three mental illnesses and examining their intersections

*     Engage participants in thinking seriously about sleep as:

·        A factor in relapse
·        An important area of personal investigation
·        A universal problem with potential practical solutions

*     Assist participants in discerning how mental illness effects their thoughts and feelings    and using that information to begin to understand their own illnesses with more clarity

*    Introduce the idea of “and” thinking as an alternative to “either/or”

Major topics for the week are:

*       Schizophrenia, Manic Depression, and Depression

*       Sleep

*      Dialectic Thinking

*   Awareness

Certain classroom techniques are employed in order to maximize personal and group development. For example: the technique of letting participants choose how to follow along with the lecture material (attending to hand outs, attending to lecture, both) is designed not only to accommodate individual learning styles, but to emphasize in a very real way that participants have actual choices. The technique of engaging the group in reading course material aloud is designed to both accustom participants to hearing their own voices and to enhance interactivity.

Week Three

Panic Disorder, Obsessive Compulsive Disorder
Senses, Behavior
Continue Relapse Prevention Planning

The third week of the course is designed to:

*     Continue to reinforce the idea of commonality by introducing factual information on the biological bases of two additional mental illnesses and examining their intersections

*     Raise consciousness among participants regarding taking what control they can, with regard to preventing future relapse

*     Assist participants in discerning how mental illness effects their senses and behavior and using that information to begin to understand their own illnesses with more clarity

*    Challenge participants to examine their own experiences retrospectively, from a safe and supported distance mediated by the group process thus far, and prepare participants to tell their story to the whole group in the next week

Major topics for the week are:

*   Depression, Obsessive Compulsive Disorder, and Panic Disorder

* Relapse prevention

*   Awareness

Even though it looks like fewer major topics are being dealt with during this week, the pace of this week is just as fast as last week’s. More time is taken up with interactive exercise material this week, since one of the goals of this week is to prepare participants for next week’s story telling class.

In the first three weeks, participants gather a lot of information about themselves and the other participants in the course. In addition to the structural elements highlighted in earlier weeks, this gathering of information also serves to build group cohesion. In this week particularly, the group and dyad exercises are certainly useful for the information they contain, but they are also serving the purpose of allowing participants to “pre-voice” their stories which will be told next week.

In this week we finish the sections of the course that are primarily devoted to science, and begin to pave the way for the more psychosocial dimensions of the course.

Week Four

Storytelling

The fourth week of the course is designed to:

*     Afford an opportunity for participants to be “listened into voice”
*      Offer participants an opportunity to incorporate new information gained through course participation into their existing stories; and to reframe their experiences if desired

*      Pave the way for more emotionally challenging material in the weeks ahead by reducing the emotional load of the past

*    Serve as a divider in the course: separating the “what happened” from the “what next” of the course material

*    Coalesce the group

In addition to serving the important function of debriefing participants, this week is also a major transition in the course. It is the close of the first section, through which participants have gained a sense of belonging in the course -- in addition to a great deal of information.

The major topics are going to be whatever each group member brings to this week’s class. Mentors play a key role in demonstrating the sorts of validating responses that are appropriate to the occasion, as well as supportively looking for the dialectics in the stories told, but should gradually -- as the class progresses -- be taking a back seat to the group-as-a-whole.

Week Five

Language
Emotions
Continue Relapse Prevention Planning

The fifth week of the course is designed to:

* Assist participants in making the connection between language used to describe mental illness and internalized messages of stigma, or discrimination

* Provide basic and comprehensive information on emotions, and increase participants’ array of coping skills

*    Shift the focus of relapse prevention planning from understanding what has happened to assessing the impact of what has happened

*     Demystify the group experience somewhat by helping participants to place the process of the course in the context of emotional recovery from trauma, reinforcing the shift in power that began last week

Major topics for the week are:

*     Language

*      Emotions

*      Awareness

This week has a medium pace by design, anticipating that the group will use more talk time in the exercises for the week. The topics of language and emotions are brought up deliberately and recursively in a variety of ways, in order that participants have maximum opportunities to engage with the material.

There is a lot of time devoted to relapse prevention planning in this week, since the plan comes together next week and the material of this week consists of those elements necessary to the production of a meaningful plan. The exercises in this week build upon the sense of control evoked last week in the story telling process.

Week Six

Addictions
Spirituality
Medication
Complete Relapse Prevention Plans

The sixth week of the course is designed to:

*      Provide information about addictions
*      Alert participants to risk factors
*      Provide information about addictions:
*      Familiarize participants with how 12 step recovery programs work
*      Introduce the idea of spirituality as a possible aspect of recovery with mental illness


*      Assist participants in deciding what are the most important things they must do or must not do in order to maintain wellness, and to assign levels of risk to their main activities in life in order to complete a comprehensive relapse prevention plan

*      Encourage participants to medicate those features of mental illness that have caused the most distress or are the most troublesome in their lives

*        Assist participants in deciding what are the most important things they must do or must not do in order to maintain wellness, and to assign levels of risk to their main activities in life in order to complete a comprehensive relapse prevention plan

In the first hour, addictions recovery is used as the opportunity for introduction of the idea of a healthy spirituality as a viable component of recovery with mental illness.

*   The second hour uses the topic of medication as the introduction to finalizing relapse prevention plans.

Participants in the first three weeks of the course were looking inside, and have gradually been led to look outside themselves in the last three weeks. In addition to having the kind of comprehensive information they need in order to complete a workable relapse prevention plan, this orientation towards outside is serving to begin the transition out of the program that they will be experiencing in the final three weeks.

  Week Seven

Coping Strategies
Decision Making
The seventh week of the course is designed to:

*    Build on a number of skills introduced earlier in the program; particularly dialectic thinking and setting priorities

*   Confirm that the focus of the program has shifted to “outside” by focusing on strategies for managing in the real world

*   Impart information that may be used to keep people safe in the event of hospitalization

*   Empower participants by elucidating some of the power dynamics behind the scenes in provider-controlled environments

Major topics for the week are:

*        Isolation
*        Coming Out
*        Staying Safe
*        Awareness

This week we focus on the kinds of things -- tips, techniques, ideas -- that are generally only available as a result of long term participation in mutual support. “Collective wisdom” describes the material of today’s course.

This wisdom is also the material of empowerment, which begins the transition into stage three of the model of emotional response to trauma. Participants find value in these highly pragmatic tips for dealing in the real world as much for their informational worth as for their use as the starting point for self-advocacy.

Week Eight

The eighth week of the course is designed to:

*       Promote the idea of family members as potential allies in maintaining wellness and helping participants to identify some of their most common difficulties in relationships

*     Assist participants in thinking realistically about what they need to maintain wellness and during times of distress, and offering suggestions for getting what they need from others in their lives

*    Begin the final tangible work of the course: an advance directive for psychiatric health care decision making

Major topics for the week are:

*                   Relationships
                             with family
                              with providers

*                   Volition
                           exercising personal power
                           choosing to delegate

Many themes from previous weeks converge in this week.

This, almost final, week is focused primarily on self-in-relationship. What is not made explicit in the week’s material but exists in the exercise portions is that this week is very much about repairing what may need repair with respect to personal relationships.

The devising of an advance directive is the final product in this course, and the transition to the final task at hand is designed to keep the focus on personal power in relationships.

Week Nine

The final week of the program is designed to remain structurally consistent with the rest of the course. There is lecture, product, interactive exercise and awareness, but it is all done with an attitude of ritual; of knowing that we are doing these things together for the last time. The pace is medium, except for the closing awareness exercise -- which also serves as a closing ritual -- which should be done slowly to allow participants maximum time to experience the moment and formulate words.

The final week includes a group evaluation process during which participants are invited to report what worked and what didn’t, what stood out, what they loved and what they absolutely hated about the course.

The final product of the course -- an advance directive for psychiatric health care decision making -- can not be completed inside the class room due to the signatures required. This is by design. The advance directive that they take away from the course and that they must complete in the real world is the symbolic blanket of our continued caring about them -- and their continued caring about themselves -- that they must make work outside of the classroom.

The last part of class is reserved for an informal, wrap-up celebration

PEER TO PEER