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By Taylor Sisk
It seems obvious: that the objective of treatment for someone living with a mental health issue or addiction disorder would be recovery.
But that’s seldom the case.
More commonly, the objectives are symptom control and medication management. These goals can be essential. But often, recovery, getting back to a productive and fulfilling life, isn’t even on the agenda.
Shouldn’t that be the ultimate objective?
A growing number of people in the mental health field think so.
“The expectation for recovery-oriented care is really the prevailing wind that’s blowing across behavioral care services worldwide,” said Catherine Upchurch, director of risk management at Broughton Hospital.
Broughton, one of North Carolina’s three state-administered psychiatric hospitals, located in Morganton, is now in the second year of a hospital-wide recovery-oriented initiative. The overriding mission is to ask and seek answers to a fundamental question: “How can I help this person recover?”
There’s evidence Broughton’s efforts are beginning to show results: The state Department of Health and Human Services compared data from June 2013, about the time the initiative was launched, to June 2015 and found a 16 percent reduction in the use of all types of restrictive interventions.
‘The right thing to do’
The federal Substance Abuse and Mental Health Services Administration’s definition of “recovery” is, “A process of change through which individuals improve their health and wellness, live a self-directed life, and strive to reach their full potential.”
Broughton’s website states that recovery is the common thread “in all successful programs where restraints have been reduced or eliminated, and is essential in restraint reduction and violence prevention.”
“There just continues to be more and more evidence of how effective recovery-oriented care services are,” Upchurch said. “They reduce recidivism, shorten length of stay, improve outcomes and reduce all kinds of violence and incidents in inpatient units.
“We knew it was the right thing to do.”
But doing things differently required a fundamental cultural shift. When Vivian Streater became Broughton’s CEO in 2012, one of her primary goals was to make that shift.
“Though recovery-oriented care isn’t a new concept, Streater said, “it is new for impatient care, and there are a lot of hurdles.”
The first hurdle was dispelling myths around recovery-oriented care: that it requires getting off your meds, for example.
“I’m not sure exactly where that myth came from,” Upchurch said, “but that was one that we’ve really had to address.”
“Another myth that we’ve addressed successfully is that recovery-oriented care means that patients can do whatever they want with no consequences,” she said.
Another is that recovery-oriented care results in more staff injuries and that units will be less safe.
But Upchurch pointed out that research indicates that recovery-oriented care decreases violence and decreases staff and patient injuries.
Cherene Allen-Caraco, CEO of Promise Resource Network, a peer-run recovery-oriented care organization in Charlotte, agrees. She consulted with Broughton at the outset.
Allen-Caraco, who is herself in recovery, said most people living with mental health issues have experienced trauma, and stressed the importance of acknowledging and addressing it.
“A hospital has extra challenges in creating an environment in which a person doesn’t feel like they’ve done something wrong,” Allen-Caraco said. “A locked environment that removes all of their control and power and dignity and renders them helpless is the type of environment that retraumatizes people.”
She said that people need an opportunity and some space to start the healing process.
“Depending on what you do with people and how you treat them, you could actually be doing the opposite and exacerbating the situation.”
The new approach
Allen-Caraco describes the “three Cs” approach that Broughton embraced: culture shift, competency building and capacity building.
Culture shift, she said, requires “developing processes that don’t criminalize people and make them feel like they’re to be feared.”
It means making available someone “who’s been there before and can help them understand what the hospital is designed to do, what the routine looks like and how to get involved in what’s going on,” Allen-Caraco said.
It means offering care packages: socks, lotions, things that comfort. “Because they’re coming in at one of the lowest points in their life,” she said.
Competency building is about rethinking and reshaping staff roles within the hospital.
“If you see yourself as a bouncer,” Allen-Caraco said, “you’re going to act like a bouncer.” Consider yourself a healer, she said, “and the way you interact changes.”
Capacity building requires asking, “Is this process facilitating recovery?”
For example, Allen-Caraco said, staff and patients need to examine the impact of physical health on the person’s emotional health.
Another challenge, she said, is helping people rethink their identity around wellness versus thinking of oneself as “ill.”
The hospital begins to involve patients in the process. That includes creating events – such as picnics and talents shows, as well as treatment tasks – for patients to help plan.
“That’s a big step for a hospital system to make,” Allen-Caraco said.
‘A different hurdle’
Another big step was bringing on board a peer-support specialist.
“So many times as a patient, all you see is illness,” Allen-Caraco said. Spending time with people who have moved beyond illness and are living a life of recovery is invaluable, she explained.
In addition to hiring a certified peer-support specialist, Broughton is inviting others to come and “tell their stories so that staff and patients can see that persons who have challenges related to mental health can be successful,” said Stacie MacDonald, director of Broughton’s Psychosocial Treatment Center. She said these visits instill hope.
MacDonald said that many of her patients see a psychiatric hospital stay as “almost a life sentence, and they carry this idea that ‘now the life I had expected for myself is over.’”
“When they meet someone who lives quite successfully with mental health issues, who lives quite successfully even after being in a psychiatric hospital, that fosters the belief that ‘I can do this too, it’s just a different hurdle in my life,’” she said. “I think that’s critical.”
All Broughton staff members are receiving ongoing training in recovery-oriented care practices.
The focus in the coming year will be on moving from principle to practice, to provide staff with the tools to be able to form partnerships with patients and help them make informed choices, “to make sure that what I do is respectful and inspires hope in people who need hope,” Upchurch said.
Equally important, she said, is balancing people’s right to make choices and take risks as part of their recovery process with staff’s duty to keep people safe, while providing safe care.
At the same time, staff must make certain that they don’t manage risk so much that they’re avoiding it altogether.
“We’re trying to move that pendulum back to a more moderate position of identifying acceptable risks and managing those risks,” Upchurch said.
“We’ll be asking ourselves multiple times a day, ‘OK, is this an acceptable risk? Does it fulfill the mission envisioned of the hospital?’”
Streater described the process as a journey. “I think we’ll always be working in this direction,” she said.
“It’s not easy to change culture within an organization with around 1,200 to 1,300 employees, and I know that I’ve just had to keep reminding myself that we’re just going to take it step by step, and just keep moving.”
Upchurch said Broughton staff is excited about the direction, one many have wanted to take for a long time.
“Every day, I’m just awed and amazed by the amount of humanity that people will display here in the midst of all this change – patients and staff,” MacDonald said. “You’ll have people step up to do the right thing because it’s the right thing to do.”
Allen-Caraco said that she too is amazed at the investment Broughton’s leaders and staff have made in making the revised approach work. “And they’re figuring it out, they’re sticking to it, and they haven’t wavered off that path.”
“There are some things in a hospital system that are nonnegotiable,” she added, “because of regulations and funding and safety.
“But there are things that can be changed … some simple, some sweeping.”