Using the Empowerment Scale In Treatment: an Educational Program for Consumers, Clinicians and Supervisors :1 Using the Empowerment Scale In Treatment: an Educational Program for Consumers, Clinicians and Supervisors


Outline of Entire Presentation :Hope! 2 Outline of Entire Presentation Part One: Setting the stage for personal growth and Recovery through Hope, Empowerment and Preparation: An Overview Part Two: Using the Empowerment Scale to plan and monitor treatment aimed at Empowerment and Recovery


Part One :Hope! 3 Part One Setting the stage for personal growth and Recovery through Hope, Empowerment and Preparation: An Overview Review conditions necessary for Empowerment to take place


Learning Objectives:Part One :Hope! 4 Learning Objectives:Part One Define Recovery & Empowerment Describe how Recovery and Empowerment apply to all consumers Describe the conditions for Empowerment


Resilience & Recovery :Hope! 5 Resilience & Recovery Ideally during youth, people acquire resilience, “an innate capacity that when facilitated and nurtured empowers children, youth, and families to successfully meet life’s challenges with a sense of self-determination, mastery and hope” From: Resiliency Workgroup People can build resilience even as adults If an adult becomes mentally ill, they will use what resilience they have to Recover One goal of treatment may be to build resilience to avoid future mental health problems


Hope :Hope! 6 Hope Hope is a desire accompanied by confident expectation. Having a sense of hope is the foundation for ongoing recovery from mental illness. Even the smallest belief that we can get better, as others have, can fuel the recovery process. Early in the recovery process, it is possible for a treatment provider, friend, and/or family member to carry hope for a consumer.  At some point, however, consumers must develop and internalize their own sense of hope From: MHRecovery.com


Hope and Recovery :Hope! 7 Hope and Recovery Without Hope, why would anyone proceed in mental health treatment? Recovery from Schizophrenia is possible: 55.5% achieved recovery in multiple studies* With many other less serious disorders there are similar or higher improvement rates We should offer hope to consumers! *From Liberman, R.P. & Kopelwicz (2005) Recovery from Schizophrenia: A concept in Search of Research. Psychiatric Services.


Our Hope: Recovery :Hope! 8 Our Hope: Recovery Refers to the process in which individuals are able to live, work, learn and participate fully in their communities Recovery is the ability to live a fulfilling and productive life despite a disability Recovery also implies the reduction or complete remission of symptoms. Science has shown that having hope plays an integral role in an individual's recovery (President's New Freedom Commission on Mental Health)


Another View of Recovery :Hope! 9 Another View of Recovery “Instead of focusing primarily on symptom relief…recovery casts a much wider spotlight on restoration of self-esteem and identity and on attaining meaningful roles in society. The definitions do not, however, imply full recovery, in which full functioning is restored and no medications are needed. Instead they suggest a journey or process, not a destination or cure”Patricia Deegan, 1997


People are Labeled with Mental Illness Due to: :Hope! 10 People are Labeled with Mental Illness Due to: Many reasons including: Severe emotional distress Insufficient social supports/resources/ coping skills to maintain the major social roles expected of them during that phase of their life Those who have adequate resources to cope with their symptoms may not be labeled as mentally ill


THEREFORE: :Hope! 11 THEREFORE: “The goal of treatment here is assisting people in gaining greater control of their lives and assisting them in regaining valued roles in society”Dan Fisher, MD Recovery is made possible through a combination of SUPPORTS needed to re-establish social roles and SELF-MANAGEMENT needed to take control of major decisions


Treatment With Recovery Focus :Hope! 12 Treatment With Recovery Focus Mental illness is not a life-long process Builds assets that can help consumers get on with their lives despite potentially continuing symptoms of mental illness Empowerment is a key asset that can be built in the presence of symptoms Empowerment is negatively correlated with symptom distress (Stewart & Kopache, 2003 IASPRS Conference Presentation)


Recovery is for Everyone :Hope! 13 Recovery is for Everyone The processes of recovery as described above can happen for everyone despite level of functioning or types of symptoms


What is Empowerment? :Hope! 14 What is Empowerment? The process of investing with power Recovery does not occur without Empowerment


Empowerment Process :Hope! 15 Empowerment Process The process of increasing personal, interpersonal and political power to enable individuals or collectives to improve their life situation. It requires the full participation of people in the formulation, implementation and evaluation of decisions determining the functioning and well-being of the society.http://www.polity.org.za


Empowerment Helps Everyone :Hope! 16 Empowerment Helps Everyone The components of empowerment are part of the healing process for everyone, not just those with severe mental illness Empowerment issues (low self-esteem, sense of powerlessness, etc.) are present in almost all cases, regardless of diagnosis For those with mental illness, empowerment can be a tool to enhance a consumer’s decision-making capacity


Each Person Must Become Empowered Themselves :Hope! 17 Each Person Must Become Empowered Themselves Empowerment is not something that can be given to a person or that can be done for a person BUT clinicians can and must aid in establishing the conditions necessary for Empowerment Empowerment in life cannot be gained without empowerment in treatment


Conditions for Empowerment :Hope! 18 Conditions for Empowerment Managed Psychiatric Symptoms Participation Skills Psychological Readiness Mutual Trust and Respect Reciprocal Concrete Incentives Availability of Choices Participation Structures and Processes Access to Resources Supportive Culture David Linhorst, 2006, Empowering People with Severe Mental Illness: A Practical Guide


Conditions for Empowerment :Hope! 19 Conditions for Empowerment Empowerment can begin even with a minimum level of these conditions Clinicians should proceed assuming that empowerment is possible and work to establish the necessary conditions


Condition: Managed Psychiatric Symptoms :Hope! 20 Condition: Managed Psychiatric Symptoms Consumers can participate in treatment planning even with symptoms present Symptoms do not impact all areas of decision-making; assume that persons can participate


Condition:Participation Skills :Hope! 21 Condition:Participation Skills People must have some level of participation skills to meaningfully participate in treatment Many systems have access to Climbing into the Driver’s Seat training that helps prepare consumers to take part in treatment planning Even with symptoms, a person can acquire participation skills needed to take part in treatment planning Give opportunities for decision making; making even small decisions builds skills Honoring consumer choices, sometimes even poor ones, fosters a sense of confidence in their ability to make decisions


Condition:Psychological Readiness :Hope! 22 Condition:Psychological Readiness Hope for change is needed, but hope is fragile Psychological readiness can be inhibited by past failed attempts to change, feelings of powerlessness, lack of hope, and other reasons Motivational interviewing (characterized by active listening, empathy, non-argumentative style, open-ended questioning) can be useful in fostering readiness Small successes build readiness


Condition:Mutual Trust and Respect :Hope! 23 Condition:Mutual Trust and Respect Consumer believes clinician wants what’s best and respects consumer’s abilities, choices and basic worth as a person Clinician believes consumer can make good decisions and is willing to cooperate Mutual trust and respect build the therapeutic alliance, which has been shown to improve treatment outcomes (Crane-Ross, Lutz & Roth, 2005)


Condition:Reciprocal Concrete Incentives :Hope! 24 Condition:Reciprocal Concrete Incentives Both consumer and clinician must have concrete and meaningful incentives to participate in treatment Consumers have incentive of better life as a result of successful treatment Clinicians have the incentive that the consumers they serve will have positive changes in their life Sometimes the incentives have to be pointed out to be recognized, or put in place if not there already


Condition:Availability of Choices :Hope! 25 Condition:Availability of Choices In order for decision-making to be meaningful, valid choices must be available These choices can be in style of treatment modalities, additional services, or goals of treatment Even bad choices can be empowering; however, more failure—brought about by not being ready—may foster powerlessness rather than empowerment A decision to defer decision-making is also OK—it does not indicate a general inability or unwillingness to make decisions People make choices all the time; show consumers that everyday choices are evidence of their power


Condition:Participation Structures and Processes :Hope! 26 Condition:Participation Structures and Processes Empowerment should be a part of the formal processes in a service setting Involving families and/or significant others—at the consumer’s discretion—is empowering Individualized treatment planning implies that the consumer is present and participates


Condition:Access to Resources :Hope! 27 Condition:Access to Resources Ability of consumers to identify and access resources will enhance treatment effectiveness In order to recover, a consumer must be able to learn to identify and access resources, including: Peer Support Mediation Community events as social opportunities Educational materials


Condition:Access to Resources :Hope! 28 Condition:Access to Resources Clinicians also need resources: Training Time to conduct meaningful engagement (it takes longer to write treatment plans with the consumer taking part) Tools such as Outcomes reports Evidence-based practice models


Condition: Supportive Culture :Hope! 29 Condition: Supportive Culture Clinicians do not work in isolation: the culture of the agency either supports or inhibits empowerment A supportive culture: Has empowered clinicians that instill hope and set an example for consumers Minimizes stigma Assumes consumers are self-reliant or can grow into self-reliance Has Mission and Vision statements that support Empowerment and Recovery Has leaders that support Empowerment and Recovery


Conditions Only Set the Stage :Hope! 30 Conditions Only Set the Stage The effectiveness of treatment depends on how much of each condition is present The conditions provide a structure for nurturing consumer empowerment To the extent possible, all conditions should be present


Empowerment Requires Actual Change :Hope! 31 Empowerment Requires Actual Change Increasing consumer’s self-esteem, self-efficacy, and sense of power are necessary but not sufficient conditions for growth These subjective changes must be accompanied by objective or actual changes in order for progress to be sustained


Part One Summary :Hope! 32 Part One Summary Hope is the seed that can start and sustain the recovery process Empowerment is essential to recovery because it enables the consumer to lead their own recovery Empowerment is up to the consumer, but clinicians can set the stage by fulfilling the conditions of Empowerment


Part Two :Hope! 33 Part Two Using the Empowerment Scale to plan and monitor treatment aimed at Empowerment and Recovery Review Reports that Incorporate Empowerment Sub-Scales and Items Review how to use the Reports in the various phases of treatment


Learning Objectives:Part Two :Hope! 34 Learning Objectives:Part Two Explain the components of the Empowerment Scale Know which reports incorporating Empowerment can be used in treatment Give specific suggestions about how to use the Empowerment Scale in treatment


The Empowerment Scale :Hope! 35 The Empowerment Scale The Adult Consumer Survey of the Ohio Outcomes System Includes: The Boston University “Making Decisions” Empowerment Scale has 5 components Self-Esteem Optimism and Control Over the Future Community Activism and Autonomy Power/Powerlessness Righteous Anger


Empowerment Exercise :Hope! 36 Empowerment Exercise Complete and score the Empowerment Scale Special hand-scoring version included--Do not use this version in treatment! Leave about 15 minutes for this task Consider what you would like to work on if it were your treatment plan


Finding the Positive :Hope! 37 Finding the Positive The amount of self-esteem, power, righteous anger, community activism and optimism/control over the future can vary in different areas of life Part of the clinical process must be to find areas of life where empowerment exists These scales and the individual items can help find areas of strength and find areas where improvement is still needed


About Normative Data… :Hope! 38 About Normative Data… Normative data are usually constructed from scores representative of the population we are measuring; norms provide a standard with reference to a population of interest Some norming data are included in subsequent slides to provide a general sense of the Empowerment scale scores


About Normative Data… :Hope! 39 About Normative Data… The primary use of the Empowerment data in treatment is to compare the person to themselves over time Norms are not Targets! These are what exist in a Grade B system (NAMI state ratings, 2006) “If you always do what you always did, you always get what you always got” -Martha Hodge


Self-Esteem/Efficacy :Hope! 40 Self-Esteem/Efficacy Loss of self-esteem is a major concern for virtually all consumers Without some sense of self worth, a person’s reason to live or participate in treatment may be lost “Every new adjustment is a crisis in self-esteem” -Eric Hoffer “If you put a small value on yourself, rest assured that the world will not raise your price” -Unknown


Self-Esteem/Efficacy Items :Hope! 41 Self-Esteem/Efficacy Items 38. I have a positive attitude toward myself 39. I am usually confident about the decisions I make 42. I see myself as a capable person 45. I am often able to overcome barriers 47. When I make plans, I am almost certain to make them work 51. I am able to do things as well as most other people 52. I generally accomplish what I set out to do 57. I feel I am a person of worth, at least on an equal basis with others 59. I feel I have a number of good qualities


Self-Esteem/Efficacy :Hope! 42 Self-Esteem/Efficacy “Low self-esteem is like driving through life with your hand-break on” -Maxwell Maltz


Optimism and Control Over the Future :Hope! 43 Optimism and Control Over the Future Sense of the future is a key component of mental health Without optimism, there is no reason to expect results in treatment “If you think you can, you can. And if you think you can't, you're right” -Mary Kay Ash


Optimism and Control Over the Future Items :Hope! 44 Optimism and Control Over the Future Items 34. I can pretty much determine what will happen in my life 35. People are limited only by what they think is possible 46. I am generally optimistic about the future 60. Very often a problem can be solved by taking action


Optimism and Control Over the Future :Hope! 45 Optimism and Control Over the Future


Community Activism and Autonomy :Hope! 46 Community Activism and Autonomy Fulfilling positive roles gives life meaning, an essential component of Recovery Activism can build safety nets Being part of a community gives consumers a chance to build social assets outside the mental health system “Never doubt that a small group of thoughtful, committed people can change the world: indeed it's the only thing that ever has!” - Margaret Mead


Community Activism and Autonomy Items :Hope! 47 Community Activism and Autonomy Items 36. People have more power if they join together as a group 44. People working together can have an effect on their community 53. People should try to live their lives the way they want to 58. People have a right to make their own decisions, even if they are bad ones 60. Very often a problem can be solved by taking action 61. Working with others in my community can help to change things for the better


Community Activism and Autonomy :Hope! 48 Community Activism and Autonomy


Power/Powerlessness :Hope! 49 Power/Powerlessness Presence or absence of belief that personal efforts will produce meaningful results In order to achieve the outcomes of treatment, the consumer needs to have a sense of personal power Consumer participation in treatment will hinge on the power a consumer has or is given by the clinical team “Power can be taken, but not given. The process of the taking is empowerment in itself” -Gloria Steinem


Power/Powerlessness Items :Hope! 50 Power/Powerlessness Items 40. People have no right to get angry just because they don’t like something 41. Most of the misfortunes in my life were due to bad luck 43. Making waves never gets you anywhere 49. Usually I feel alone 50. Experts are in the best position to decide what people should do or learn 54. You can’t fight city hall (authority) 55. I feel powerless most of the time 56. When I am unsure about something, I usually go along with the rest of the group


Power/Powerlessness :Hope! 51 Power/Powerlessness


Righteous Anger :Hope! 52 Righteous Anger Anger is OK in the face of an inappropriate action Knowing when anger is OK and responding appropriately are what makes righteous anger a tool for recovery Unlike other Empowerment subscales, Righteous Anger positively correlates with Symptom Distress—More Anger, More Distress HOWEVER, Symptom Distress and Anger are sometimes a sign that the consumer is ready to change


Righteous Anger Items :Hope! 53 Righteous Anger Items 37. Getting angry about something never helps 40. People have no right to get angry just because they don’t like something 43. Making waves never gets you anywhere 48. Getting angry about something is often the first step toward changing it


Righteous Anger :Hope! 54 Righteous Anger


Righteous Anger :Hope! 55 Righteous Anger “Don't let justified emotions rob your health and well-being” -Doc Childre and Howard Martin, “There was never an angry man that thought his anger unjust” -St. Francis De Sales “Righteous anger comes easily; Righteous action is carefully planned”


Empowerment Scales :Hope! 56 Empowerment Scales While the Overall Empowerment scale can be used as an indicator of progress in treatment, the individual subscales and individual items are more useful in the treatment planning process


Reports :Hope! 57 Reports Several reports are available that give information about the Empowerment Subscales and items Strengths—Assets Red Flags—Targets Change Over Time—Graphically monitor progress at scale level ARROW—Suggested Activities Adult Basic Report—One-page report monitors progress at subscale level and some items


Reports :Hope! 58 Reports Reports are not essential --you can review the individual items of the Empowerment scale with the consumer Whatever reports you use, give the consumer a copy! Find out which reports are available from your system, and if you don’t find ones you like, ask your vendor to add them


Strengths Report :Hope! 59 Strengths Report Lists the positive and very positive responses Allows consumers and staff to identify strengths that the consumer can use to achieve their treatment goals Invites consumer participation if consumers are allowed to select the strengths they want to use Available in the ODMH Data Entry and Report Template


Slide 60:Hope! 60


Red Flags Report :Hope! 61 Red Flags Report Lists items with a negative or very negative responses Invites consumer participation if consumers are allowed to select the targets of treatment Available in the ODMH Data Entry and Report Template


Slide 62:Hope! 62


Change over Time Report :Hope! 63 Change over Time Report Graphic display of how Outcomes scales change over time Empowerment subscales are included Invites consumers to consider their progress in treatment Available in the ODMH Data Entry and Report Template


Slide 64:Hope! 64


ARROW Report :Hope! 65 ARROW Report Achieving Recovery & Resiliency the Outcomes Way (ARROW) Based on Maslow's hierarchy of needs and consumer's responses to the Adult Consumer instrument ARROW suggests potential activities for a consumer's treatment and/or recovery plan The activities suggested in the report can augment treatment by calling on non-agency resources More at: www.MHRecovery.com Available in the Reports Generator


Slide 66:Hope! 66


Adult Basic Report :Hope! 67 Adult Basic Report One-page report to monitor progress on subscales and selected items Includes Provider Community Functioning scale and summary of victimization items Empowerment subscales are included Useful for looking at how much consumer’s scores have changed, Reliable Change amount noted Invites consumers to consider their progress in treatment Available in the ODMH Reports Generator


Slide 68:Hope! 68


Getting The Reports :Hope! 69 Getting The Reports Reports come out of two Access databases: Reports Generator Data Entry and Reports Template These tools are at: http://www.mh.state.oh.us/oper/outcomes/data.flow.template.html


Using The Empowerment Scale In Treatment :Hope! 70 Using The Empowerment Scale In Treatment The Empowerment Scale is intended to be used the same way as all Outcomes Scales: Complements Initial Clinical Assessment Basis for Treatment Planning Basis to monitor and track progress Basis to modify treatment based on progress


Outcomes & Self-Report :Hope! 71 Outcomes & Self-Report Reviewing Outcomes with consumers gives a starting point for discussion Outcomes are not the final word about how consumers feel Outcomes need to be used collaboratively with the consumer


Initial Clinical Assessment :Hope! 72 Initial Clinical Assessment Each subscale reflects a necessary component of successful treatment; therefore, check where consumers are on each Use these reports: Strengths Red Flags Adult Basic Report - AND - Review the Items


Outcomes Use in Treatment Planning :Hope! 73 Outcomes Use in Treatment Planning The Longitudinal Consumer Outcomes (LCO) Study found that good Outcomes were best predicted by: Consumers’ perceptions that their needs are met! Consumers’ perceptions of service empowerment (e.g., involvement in treatment planning) was most highly correlated with degree to which they felt their needs were met Using Outcomes in a collaborative fashion in Treatment Planning helps empower Consumers --they see that their needs are being attended to


Treatment Planning :Hope! 74 Treatment Planning Use Empowerment Items and Scales as targets of treatment Use Empowerment Items and Scales as strengths in addressing other targets of Treatment Use these reports: Strengths Red Flags ARROW


Monitor and Track Progress :Hope! 75 Monitor and Track Progress Review the reports with the consumer Use the: Change Over Time Report Adult Basic Report And: The ARROW report, if you used in original treatment planning


Modify Treatment Based on Progress :Hope! 76 Modify Treatment Based on Progress Check Empowerment and other Outcomes gains scores against planned goals of treatment If non-responsive, or if deteriorated, seek consumer input into what course corrections are needed in treatment If goals are met, acknowledge success, plan next steps Between formal reviews, take every opportunity to recognize and validate consumer steps toward goals


Documenting Work on Empowerment and Recovery :Hope! 77 Documenting Work on Empowerment and Recovery The Empowerment Scale and reports are appropriate material to be used as sources of information in documenting need for work on Empowerment and Recovery aspects of treatment However, it is outside the scope of this training to explain what constitutes acceptable medical necessity documentation Therefore, a training on medical necessity is included in the Empowerment training package if it is necessary to have guidance on medical necessity


Summary :Hope! 78 Summary The Empowerment scale has 5 parts: Self-Esteem/Efficacy Power/Powerlessness Optimism/Control over the future Community Activism and Autonomy Righteous Anger Various Empowerment reports are available The Empowerment Scale items and subscales can be used during all phases of treatment


Supervision :Hope! 79 Supervision Especially for new clinicians, write comments on Outcomes reports where clinicians need to pay attention Assign the use of the ARROW report especially with clinicians new to Recovery Use Outcomes to identify where clinicians may need further training


Supervision :Hope! 80 Supervision Check progress on Outcomes, and Review consumers who are doing poorly or well in supervision: What worked? What didn’t? Review change over time reports with clinicians to identify when consumers are progressing or deteriorating Review Outcomes to identify what kinds of consumers the clinician effectively serves


Contributors :81 Contributors Joyce Campian Janet Galligan Geoff Grove Lisa Grubbs Dana Harlow James Healy Kraig Knudsen Renee Kopache Michelle Litton-Betts Wilma Lutz Sandi Miller Nancy Nickerson Rick Shepler Dora Sterling Jonas Thom Kathy Trubisky Marsha Zabecki "You have been criticizing yourself for years, and it hasn't worked. Try approving of yourself and see what happens."- Louise L. Hay “Strength does not come from physical capacity. It comes from an indomitable will."- Mahatma Gandhi