Using the Empowerment Scale In Treatment: an Educational

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

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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

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Learning ObjectivesPart One

• Define Recovery Empowerment
• Describe how Recovery and Empowerment apply to
  all consumers
• Describe the conditions for Empowerment

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Resilience Recovery

• Ideally during youth, people acquire resilience,
  an innate capacity that when facilitated and
  nurtured empowers children, youth, and families
  to successfully meet lifes 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

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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

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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.

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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)

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Another View of Recovery

• Instead of focusing primarily on symptom
  reliefrecovery 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
  curePatricia Deegan, 1997

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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

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THEREFORE

• The goal of treatment here is assisting people
  in gaining greater control of their lives and
  assisting them in regaining valued roles in
  societyDan 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

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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)

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Recovery is for Everyone

• The processes of recovery as described above
  can happen for everyone despite level of
  functioning or types of symptoms

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What is Empowerment?

• The process of investing with power
• Recovery does not occur without Empowerment

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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.z
  a

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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 consumers decision-making
  capacity

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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

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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
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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

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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

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ConditionParticipation Skills

• People must have some level of participation
  skills to meaningfully participate in treatment
• Many systems have access to Climbing into the
  Drivers 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

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ConditionPsychological 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

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ConditionMutual Trust and Respect

• Consumer believes clinician wants whats best and
  respects consumers 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)

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ConditionReciprocal 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

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ConditionAvailability 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
  failurebrought about by not being readymay
  foster powerlessness rather than empowerment
• A decision to defer decision-making is also OKit
  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

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ConditionParticipation Structures and Processes

• Empowerment should be a part of the formal
  processes in a service setting
• Involving families and/or significant othersat
  the consumers discretionis empowering
• Individualized treatment planning implies that
  the consumer is present and participates

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ConditionAccess 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

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ConditionAccess 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

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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

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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

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Empowerment Requires Actual Change

• Increasing consumers 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

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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

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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

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Learning ObjectivesPart 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

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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

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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

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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

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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

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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

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Self-Esteem/Efficacy

• Loss of self-esteem is a major concern for
  virtually all consumers
• Without some sense of self worth, a persons
  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

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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

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Self-Esteem/Efficacy

• Low self-esteem is like driving through life
  with your hand-break on
• -Maxwell Maltz

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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

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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

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Optimism and Control Over the Future
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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

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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

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Community Activism and Autonomy
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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

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Power/Powerlessness Items

• 40. People have no right to get angry just
  because they dont 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 cant 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

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Power/Powerlessness
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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
  DistressMore Anger, More Distress
• HOWEVER, Symptom Distress and Anger are sometimes
  a sign that the consumer is ready to change

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Righteous Anger Items

• 37. Getting angry about something never helps
• 40. People have no right to get angry just
  because they dont like something
• 43. Making waves never gets you anywhere
• 48. Getting angry about something is often the
  first step toward changing it

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Righteous Anger
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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

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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

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Reports

• Several reports are available that give
  information about the Empowerment Subscales and
  items
• StrengthsAssets
• Red FlagsTargets
• Change Over TimeGraphically monitor progress at
  scale level
• ARROWSuggested Activities
• Adult Basic ReportOne-page report monitors
  progress at subscale level and some items

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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 dont find ones you like, ask
  your vendor to add them

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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

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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

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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

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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

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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 consumers scores
  have changed, Reliable Change amount noted
• Invites consumers to consider their progress in
  treatment
• Available in the ODMH Reports Generator

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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

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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

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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

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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

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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

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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

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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

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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

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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

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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

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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

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Supervision

• Check progress on Outcomes, and
• Review consumers who are doing poorly or well in
  supervision
• What worked?
• What didnt?
• 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

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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