July Ask the Expert
07 Recovery Is a Family Affair
Ask the Expert:
Paolo del Vecchio, MSW, is the Director of the Substance Abuse and Mental Health Services Administration (SAMHSA)’s Center for Mental Health Services (CMHS). SAMHSA is the lead Federal agency designed to reduce the impact of substance abuse and mental illness on America’s communities.
Previously, Paolo was the CMHS Associate Director for Consumer Affairs where he managed SAMHSA’s precedent-setting activities in addressing consumer participation and education, issues of discrimination and stigma, consumer rights, wellness, recovery, trauma, and others.
Paolo was the first Consumer Affairs Specialist hired in 1995 by SAMHSA. In this capacity, he promoted consumer participation in all aspects of the Center's policies and operations ranging from public education to developing evidence based practices to address the needs of persons with mental illnesses. Those efforts included initiating historic dialogue meetings between consumers/peers and practitioners, regional peer meetings, social inclusion efforts, training programs, and grant development.
Prior to joining SAMHSA, Paolo worked for the Philadelphia Office of Mental Health in the areas of policy formulation and the planning of a comprehensive system of community-based mental health services addressing homelessness, HIV/AIDS, and many other issues.
A self-identified mental health consumer, trauma survivor, and person in recovery from addictions, Paolo has been involved for over 40 years in behavioral health as a consumer, family member, provider, advocate, and policy maker. He graduated summa cum laude with a master’s degree in social work from Temple University, has published widely and is a highly sought after national and international speaker. Paolo has been a leader in many Federal efforts including the Mental Health Statistics Improvement Project Ad-Hoc Advisory Committee, the Federal Advisory Planning Board for the Surgeon General's Report on Mental Health, the HHS Multiple Chronic Conditions and Community Living Initiatives, and numerous others.
1) Question: You mention non-traditional families. Do you have any thoughts on "family dynamics" when the individual's "family", in a very real sense, consists of his treatment team? This individual is dealing with complex trauma from 14 different foster homes, a divorce, an adult daughter he has not seen in many years, a traumatic brain injury from a DUI accident, chronic depression, and multiple substance use issues- primarily alcohol but also including illicit drugs. At the moment, he is homeless and bouncing back and forth between wet and dry relapse. Through it all, he keeps reaching out to his "family". What is the best way we can help him?
Answer: Recovery from mental illness and addiction is more likely in a caring and supportive environment. Supporters play an important role in recovery by providing hope and demonstrating that they genuinely care about an individual’s health and wellbeing. Any network of support, whether family or providers, is a key element of a recovery plan. However, all roles should be clearly identified for the individual and the supporters, including the treatment team. Support should be consistent with the individual’s identified goals and objectives for recovery.
Providers sometimes move, are promoted, and/or change jobs. Natural supports in the community may be more consistently a part of an individual’s recovery and it is important to help identify individuals who actively participate in this way. Family psychoeducation materials may help encourage family members to be a part of the treatment and recovery process for a loved one. SAMHSA developed an evidence-based practice toolkit on the importance of educating and engaging family members in the recovery process. Please go to http://store.samhsa.gov/product/Family-Psychoeducation-Evidence-Based-Practices-EBP-KIT/SMA09-4423 for more information.
SAMHSA’s Partners for Recovery (PFR) is a partnership with key stakeholders in the substance use disorder treatment field. It was conceived as a way to engage a variety of organizations and systems to improve the field of addiction treatment and the diverse systems and organizations that support individuals in recovery. It addresses issues of national significance and it is driven by the individual, families and communities it serves. The PFR Initiative supports and provides technical resources to those who deliver services for the prevention and treatment of substance use conditions and co-occurring mental health and seeks to build capacity and improve services and systems of care. For more information please go to http://partnersforrecovery.samhsa.gov/index.html.
If therapeutic attempts to reconnect an individual with their family do not work, other individuals in the community may be able to fill that role. Individual supporters can help with recovery and navigating systems of support such as access to housing and employment. Supporters can also help connect individuals to peer groups and encourage connections with others who have similar experiences and circumstances. This reduces isolation and increases hope and motivation for recovery.
2) Question: How can we better access psychiatric services in rural communities? How do we identify psychiatrists who are willing to participate in telemedicine? What are some recovery support practices that are evidence-based for rural communities under 5,000 people?
Answer: There are clearly challenges that exist in rural communities in accessing needed health and community services. Although telemedicine offers great promise to meet this challenge, access to these services can be difficult due to workforce shortages and technical needs.
Workforce development and attracting the participation of psychiatrists and other mental health providers in telemedicine is an essential activity of telemental health. Some technical challenges include access to sufficient internet bandwidth to download and upload the data needed to support real time counseling interactions that may not be consistently available in rural communities. The data collection necessary to support electronic medical records of that service also may not be consistently available.
Few rural and even fewer frontier communities have ready access to individuals trained in telecommunications equipment. Distance maintenance of this equipment remains problematic at this time. However, the need for such technicians offers new employment opportunities in rural communities.
The following links below provide much information on workforce development and technical issues related to accessing services.
Evidence-based recovery support practices for rural communities are growing. SAMHSA’s National Registry of Evidence-based Programs and Practices (NREPP) provides access to more than 290 Evidence-based models that can be replicated in most settings.
One useful source for information is the Rural Policy Research Institute at Iowa State University: http://www.rupri.org. You may also find the following information helpful.
Rural Research Centers:
Rural Health Research Gateway: This site provides access to publications and projects funded through the federal Office of Rural Health Policy (ORHP) as part of the Rural Health Research Centers and Analysis Initiatives grant program. Research Topics: http://www.ruralhealthresearch.org/topics/mental-health/completed-projects/
Sowing the Seeds for Hope: The Sowing the Seeds of Hope program (1999-2010) provided behavioral health services to uninsured, underinsured and other at-risk farm and ranch families and agricultural workers. Seven states (Iowa, Kansas, Minnesota, Nebraska, North Dakota, South Dakota and Wisconsin) formed the regional program in 1999. The Wisconsin Office of Rural Health and Wisconsin Primary Health Care Association designed and initiated the SSoH project. The project was supported by grants from the U.S. Department of Health and Human Services Office of Rural Health Policy, Bureau of Primary Health Care, state and federal appropriations and private contributions. AgriWellness, Inc., a nonprofit organization, provided administrative services. Find more at http://www.agriwellness.org/SSoH.htm
3) Question: Could you please comment on two related issues regarding families and recovery: 1) the length of time real recovery from mental health or substance abuse requires vs. allocation of benefits for that; 2) the segregation of mental health and substance abuse treatment – which, in my opinion, makes effective treatment almost unmanageable for the consumer?
Answer: SAMHSA has a working definition of recovery from mental disorders and/or substance use disorders that states that 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. The definition also identifies several guiding principles of recovery that address the role of families in recovery. An important factor in the recovery process is the presence and involvement of people who believe in the person’s ability to recover; who offer hope, support, and encouragement; and who also suggest strategies and resources for change. Family members, peers, providers, faith groups, community members, and other allies form vital support networks. Through these relationships, people leave unhealthy and/or unfulfilling life roles behind and engage in new roles (e.g., partner, caregiver, friend, student, employee) that lead to a greater sense of belonging, personhood, empowerment, autonomy, social inclusion, and community participation. Individuals, families, and communities have strengths and resources that serve as a foundation for recovery. For more information on the working definition of recovery please go to http://store.samhsa.gov/product/SAMHSA-s-Working-Definition-of-Recovery/PEP12-RECDEF.
Many advances have been made to promote recovery concepts and practices. There are a variety of effective models and practices that States, communities, providers, and others can use to promote recovery. However, much work remains to ensure that recovery-oriented behavioral health services and systems are adopted and implemented in every state and community. Drawing on research, practice, and personal experience of recovering individuals, within the context of health reform, SAMHSA continues to lead efforts to advance the understanding of recovery and ensure that vital recovery supports and services are available and accessible to all who need and want them.
The time it takes for someone to achieve meaningful recovery will vary from person to person and many individuals who are successful in their recovery make a long term commitment to healthy behaviors and wellness. Insurance coverage will vary also, however, the purpose of services and recovery supports are to help a person to identify the actions they can take on their own as well as to engage supports around them that positively impact their recovery. Some supports, like medication and periodic checkups, might have longer periods of coverage. Other things like support groups or spiritual pursuits are free and enduring ways of supporting recovery in the long term.
Leaders in the behavioral health field over the last few decades have recognized the prevalence of co-occurring disorders (mental health and substance use issues at the same time) with the people they encounter. They have addressed this with a range of innovations from developing competencies to treat the conditions simultaneously in one location to improving communication and collaboration between providers in the two specialties. You can learn more about how SAMHSA has been supporting these efforts and resources for consumers and families to help make choices in care at http://www.samhsa.gov/co-occurring/.
4) Question: I am now nearly 61 years of age and have managed my serious mental illness since about 1976. When it interfered with my regular life, both professionally and personally and I finally 'disclosed', my family said absolutely nothing. As a result I felt abandoned –when I know now that if there had been family support I would most likely have recovered and resumed my life sooner than just a few years ago. My question is - at this time, how do I regain some familial relationships with my older sister and younger brother, estranged for years due to stigma and lack of understanding? I have made so many attempts yet not been successful, although I gained understanding and acceptance.
Answer: Personal and family relationships may be strained for many reasons and based on individual circumstances. There are many approaches that may be helpful, but one idea may be to suggest to your siblings some type of safe and brief interaction, where either you or your sibling has the opportunity to leave. You may consider taking a short walk together in a park or something else that is of short duration and that is on neutral terms. If this goes well, you may want to repeat this approach a few times before getting together for a longer interaction, such as lunch or dinner. In other circumstances, you may want to write a letter to your sibling(s) stating how things are going now and what your wishes are regarding getting back together for familial interaction. You may want to ask for certain boundaries in your interactions such as not discussing past negative events or interactions.
5) Question: As a parent of adult addicts who has tried everything possible and know that I am powerless and have no control over the choices my children make, what else can I do? My new approach towards them has been to be clear that they know I love them, stay in connection, and try to create a relationship where they do not stay away from me out of shame. I ask that we still talk on the phone, and they be real with me. I believe this is all I can do as I maintain hope that one day they will choose to stop using. This has been one of the most painful experiences as a parent. Their use started in early adulthood, and I know it's not my fault. For myself, the worst is over as I move forward with my life, but I would like to know any advice you can give me on this matter.
Answer: It sounds like you’ve already come to some great realizations about your abilities and responsibilities in these circumstances. It is important to note that individuals including parents of adult children cannot control the choices that others make however you are able to establish and maintain firm boundaries to protect yourself and your ability to pursue a positive life. One avenue to gain further insight is to consult with others who have or are experiencing similar situations. There are any number of self help resources and support groups you can find in your community. Partnership for a Drug Free America might be one place to find these groups at http://www.drugfree.org/. Another suggestion is to become familiar with getting treatment if one of your children is ready to take that step and you choose to be a part of their recovery. You can also tell them about the treatment locator at http://www.samhsa.gov or encourage them to call the helpline 1-800-662-HELP (4357).
6) Question: Currently are Social workers, LCPC's, Psychologists and other Social Service providers certified in treatment for substance abuse? If not, is it being recommended that it become part of their training prior to graduation?
Answer: Licensed psychologists, licensed clinical social workers, and licensed professional counselors are trained to help people with many different problems and situations, including substance abuse. There is a growing understanding of co-occurring disorders and it is being promoted in the field of behavioral health. Some providers seek additional specialized training and credentials. When choosing a provider, be sure to ask about their interest, training, and experience in the areas that are important to you.
7) Question: Is ADHD considered a mental health disorder and illness? Also, does ADHD come in stages – from mild to severe? Is medication the only treatment? What does research indicate with models of therapy?
Answer: Yes: Attention-Deficit /Hyperactivity Disorder is considered a mental health disorder with varying levels of severity. In SAMHSA’s National Registry of Evidence-based Programs and Practices (NREPP) (http://nrepp.samhsa.gov/SearchResultsNew.aspx?s=b&q=ADHD), there are six treatment models listed for ADHD that include interventions based on behavioral and cognitive theories that help individuals gain and maintain self-control over emotional responses to stressful events and improve communication and decision-making.