Last month we introduced you to Paolo del Vecchio, associate director for consumer affairs at SAMHSA's Center for Mental Health Services. Paolo gave us some very interesting information on the endeavors of the 10 by 10 Campaign, which is focused on increasing the life span of people diagnosed with mental illnesses by10 years within the next 10 years. If you missed that column, we suggest you read it as background on what we're sharing with you this month (visit http://behavioral.net/ashcraft0908).
Two astonishing findings that we highlighted in the previous column were that people diagnosed with mental illnesses in the public system have a life span 25 years shorter than the general population's, and the gap actually has been increasing. This increase is due to both the general population living longer and people in the public system diagnosed with mental illness living shorter lives.
This information instilled in us a sense of urgency about including physical health services in behavioral health programs. So we left you last month with a list of ideas that could kick-start program development for the most prevalent causes of premature death.
This month we are giving you more in-depth information that can help you address this urgent issue by developing services that promote physical health. This venture can make a huge improvement in the quality of life of those diagnosed with mental illnesses. To respond to this challenge and reach the best outcomes, and to also avoid some of the mistakes we've made in the past, we need to be prepared to invest a considerable amount of creativity and ingenuity. Why the cautionary note? Why don't we just get busy and make this happen since it's such an urgent situation? Let's take a closer look.
Living a life that reflects a commitment to wellness is a challenge for all of us, whether or not we have a mental illness. Promoting healthy living is not new, and most of us don't have spotless healthy lifestyles. Sorry to bring this up, but we might as well be realistic about what we're up against so we can outwit the inevitable hindrances along the way.
So what are these “hindrances” we're asking you to outwit as you plan and develop recovery wellness programs? Well, think about it! Look at the death rates from preventable diseases such as heart disease, cancer, obesity, and liver disease. If we all stopped smoking, eating junk foods, overconsuming alcohol, and being couch potatoes, we could prevent most of these diseases. This is a no-brainer, right? Wrong! If it were this easy, we wouldn't have the problem in the first place, and we wouldn't need new programs.
The most formidable “hindrance” we're up against is this: These indulgences are habit forming. And, unlike other preventable diseases, such as polio or small pox, no inoculation can prevent or wipe out these habits. Changing them requires a great deal of individual effort and commitment. Furthermore, individuals have to make these changes themselves. If we had realized the importance of individuals' decision making when behavioral health programs were initially implemented all those years ago, the field could have avoided the mistakes that took us down a road that did not lead to recovery.
Mistakes? Did our field make mistakes? Well-meaning as they were, the two actions that hindered recovery the most were, first, not believing it was possible and, second, thinking people diagnosed with mental illness could not make good decisions and therefore needed to be controlled, managed, and taken care of indefinitely. These mistakes prevented people from being self-determining and from developing the motivation that comes from having hopes and dreams.
So here's the deal: We need to add physical health services built on a foundation of recovery to behavioral health programs. This time we need to take responsibility for creating services that inspire people to participate, instead of trying to force them into it. We need to develop interesting and compelling programs so people will want to participate without being coerced. No small task, we know. Furthermore, skills that inspire and compel are very different from the skills used to control and manage. The following three concepts give us a way to grasp and picture the new skill set.
We talk about this all the time because it's really the most important precursor to producing good outcomes. The first order of business is to establish program protocols that call for the development of relationships with those who use the service. Staff need to know who service users are as individuals. Remember, you are interested in the whole person, not just the unwell part. Engage their “well parts” so they can use them to manage the not-so-well parts. Ask staff to share enough about themselves so they can become a “real person” to the people they serve. This often has been a problem for many professionally trained staff, but we promise you that it's quite possible to share enough information to become a real person to the people being served without causing any problems. This can be done without transgressing any boundaries that often have become barriers to relationship building in the past (see http://behavioral.net/ashcraft0408).
Once a good connection has been made with the prospective wellness customer and he has been engaged in the conversation, it's time to create interest in what your program has to offer. At this point, it's too early to count on the person's motivation, so staff need to describe wellness services in ways that are irresistible.
This word is not part of the behavioral health world's usual jargon. We like it because it describes a theme that runs through the new skill set we've mentioned. If services, and service providers, become irresistible, our collective energy can be directed toward a person's goals instead of squandered on coercing and controlling.
One of the tricky things about this concept is that it's different for each person. What's irresistible to one person may not even interest another. Staff need to identify individuals' “threads” of interest and weave them into a plan that can guide the healing process.
The key to irresistibility is to find out what individuals really want and give them a way to make it a reality. Does someone want to live longer so he can see his niece graduate from college? Does someone want to stop having heartburn? Does someone want to lose weight so she can walk without a walker? Once staff know what people want, they've got something to work with. Remember, this needs to be about what the person wants, not what staff think is best for him. The person may not start with the most important goal first. That's OK. Sometimes people need to work up to things that are the hardest for them. So if someone says he wants to start getting some exercise, and staff think he really needs to stop eating junk food, guess what? Work on the exercise.
A way to really lock in irresistibility is to have those who have successfully reached the same goal tell their stories to those who need hope to get started. So if a person is trying to stop smoking, surround them with people who have successfully stopped smoking and have them tell their stories regularly. This is the most reliable booster you can give people who have racked up frequent failures at reaching a specific goal. Success stories are magical because they demonstrate what's possible.
In behavioral health programs we routinely have taken things away from people or asked them to stop a behavior without giving them something positive to fill the void. We ask people to stop drinking, stop doing drugs, stop smoking, stop eating Twinkies and Ding Dongs, but what will they get in return that is important to them? A straightforward approach usually works fairly well: Just ask what else they could do that would bring them the same amount of pleasure.
If the straightforward approach doesn't seem to work, there's always the backdoor approach. This involves asking individuals to consider what they already are giving up when they, say, can't stop eating Twinkies three times a day. Here's an example of how the backdoor approach might play out in your programs.
Janet is extremely overweight. She has trouble standing and is completely out of breath just walking the short block from her front door to the bus stop. She just has been diagnosed with diabetes. She has extreme pain in her joints, especially her knees. She says she'd like to lose some weight, so staff, being their irresistible selves, begin by asking her to describe in detail what she really wants. They have a good conversation, and staff may think they're well on their way to planning for results. However, when it gets down to the nitty-gritty, Janet says, “I want to lose weight, but I just can't give up desserts. They are the one thing in life I look forward to.” She goes on to say that she just can't give up white bread either, nor can she give up the wine she has with dinner every night, and the potato chips she has at bedtime. The last thing staff want to do now is to get into a power struggle, but this often is what happens when we see people refusing to give up things that we know aren't working for them.
Using the backdoor approach, staff would ask Janet to look at the things she already has given up to have what she doesn't want to give up. She's given up her ability to rise from a sitting position without a struggle; she's given up her ability to walk a block without having to stop and rest. She has given up freedom from diabetes; she has given up the joy of being proud of how she looks. And so on.
ConclusionOnce you and your staff implement these three concepts, your agency will be well on its way to creating wellness services that avoid the two main mistakes we've made in the past. In closing, we share with you the sage advice of Lauren Spiro, director of public policy for the National Coalition of Mental Health Consumer/Survivor Organizations. The following excerpt is from a presentation Lauren delivered to last year's National Wellness Summit to Reduce Co-morbidity and Early Mortality of People with Mental Illness. Lauren reminds us to stay focused on the whole person when delivering physical health services:
We die young because we have no hope. We die young because our dreams have been crushed. We die young because our voice is neither heard nor understood. We die young because many of us live in poverty, and some of us live on the streets. We die young because our physical needs are routinely ignored, often because any problems we have are attributed to our mental illnesses…. In order for our needs to be met, the definition of disability needs to focus not on fixing us or telling us to adjust to our deficits but rather on providing services, supports, and treatments designed to assist us to attain or maintain independence and to promote wellness and community integration…. We need a relationship built on alliance, not compliance. We need a collaborative relationship in which we share information and forge a partnership of equals, where we establish consensus on the problem, the goals, and the criteria for success…. Listen to me, love me, respect me, and provide support so I can figure out who I am and find a meaningful place in the community.Lori Ashcraft, PhD, directs the Recovery Opportunity Center at Recovery Innovations, Inc., in Phoenix. She is also a member of Behavioral Healthcare's Editorial Board.
William A. Anthony, PhD, is Director of the Center for Psychiatric Rehabilitation at Boston University.
To contact the authors, e-mail email@example.com.Behavioral Healthcare 2008 October;28(10):8-12