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Recovery in Acute Care by Maggie Bennington–Davis, M.D., MMM. There is an old medical school adage that says "first, do no harm." In acute hospital settings, people describe all-too-frequent experiences of fear and panic, loss of control, loss of self-determination, seclusion, restraint, and unwanted medications. Inpatient units can seem downright dangerous, not only to those hospitalized, but to staff as well. Before healing can occur, people must feel safe.

During my tenure as the medical director of psychiatry at Oregon's Salem Hospital, I was part of the miraculous transition to a trauma-informed environment. Seclusion and restraint were eliminated, and there was a substantial decline in the administration of involuntary medications (as well as a 30 percent decline in the use of routine medication). People became more involved in psychoeducational groups and therapeutic exchanges with staff. Injuries sustained by staff and those hospitalized dropped dramatically, lengths of stay decreased, and financial performance improved. It was a wonderful example of parallel process—recovery for those coming into the hospital and for the hospital itself.

Recently, I had a phone call from a psychiatrist who specialized in organizational consultation. He asked me, "After you quit doing restraint, what did you do when someone was really upset and out of control?"

I had to pause before I answered, because there wasn't a simple way to respond. Staff in the program were never told not to use seclusion, restraint, medication, or other means of control. Restraint went away because it was no longer necessary, not because it was "banned." If a situation required restraint or seclusion to prevent serious harm, appropriate measures would be taken. But the environment had drastically changed, and those situations didn't occur very often.

We included the people we served as we began our transformation and philosophical shift. We immersed ourselves in understanding the neurobiology of trauma, fear, fight-or-flight response, and the realization that traumatized people perceived our clumsy attempts at "safety" as predatory and controlling. We were astonished to learn virtually everyone who came (or was brought) to us had suffered through difficult childhood experiences. It humbled us to think about our past reactions to these folks and the pejorative language we had used to explain what suddenly seemed like perfectly rational behavior (manipulative, aggressive, help-seeking, belligerent, difficult, etc.). Suddenly, power struggles made a lot of sense, disengagement seemed self-preserving, and the minor events that precipitated catastrophic reactions didn't seem so minor after all. When we changed the lens to one that was trauma informed and started asking "What happened to you?" instead of "What is wrong with you?", everything else changed too.

In essence, when we changed ourselves and the hospital to be really, truly "safe," the people we were serving also felt safe. Independent of diagnosis, symptoms, age, sex, or history, we were by far the most significant variable.

Then the fun really began. We started using our environment to regulate certain physiological responses of people at the hospital. We used drumming techniques to normalize heart rates, music to soothe, colors to evoke calm, and artwork to inspire (instead of posted rules forbidding balloons and knives). We asked ourselves and those we were serving, "What helps us feel safe?" The answers were friendly greetings, calm voices, beauty in our surroundings, constant information, sharing meals, and talking openly about upsetting events. We changed our language, our assumptions about recovery, and our expectations, and made a point of including families and friends. We educated ourselves about customer service. Putting people's fears to rest as soon as possible became our business.

We also realized that staff interactions completely set the tone for everyone else, so we became mindful about communicating and working with one another.

Dr. Sandra Bloom, creator of the Sanctuary Model, taught us how to hold daily community meetings to discuss safety with those we were serving as well as staff (doctors, administrators, janitors, cooks, security, etc.). The twice-daily meetings became the anchors of our serenity. If something happened that shook our sanctuary, we spent the next community meeting determining how to return to safety. We knew when something frightening happened to one person in the community, everyone was affected.

Every now and then, we still experienced an upsetting event. I will never forget the woman who repeatedly banged her head against the hospital wall. She had been restrained many times before, always to keep her from harming herself. We mulled over how we could help her in our new environment. In a community meeting, another hospitalized woman told the newcomer, "Honey, when you bang your head like that, it hurts my head." The group suggested we move the bed to the center of the room, away from the walls that facilitated her head banging. Finally, the banging stopped and the woman began to heal.

There was the man who paced the unit's perimeter, talking frenetically to himself and occasionally banging his fist on the wall. During a community meeting, folks who had been in the hospital for a few days kindly told him they were frightened of him. He looked shocked and apologized, saying he would never hurt anyone. His pacing stopped, his fear and anger seemed to subside, and he began to pursue the opportunities we offered to support his healing process.

We learned to have a different threshold for upsetting behavior. Staff were constantly encouraged by managers to do what was necessary to keep things safe, but the word "safe" became much more inclusively defined. Our staff created an environment where everyone really did feel safe, and the outbursts, anger, and violence mostly melted away.

All of these changes created completely different roles for staff—jobs that focused less on maintaining order and policing the unit, and much more on healing and partnering with people to initiate and support their recovery journeys. The transformation exemplified recovery more than any treatment plan I have ever witnessed. It was truly a highlight of my career.

Dr. Bennington–Davis is the Chief Medical and Operating Officer at Cascadia BHC in Portland, Oregon.

Training and Technical Assistance

Training. RTP is featuring a four-part Webinar series in 2012 on key dimensions of recovery-oriented practice. Each Webinar begins by describing a tool or an approach for assessing an important component of a person's life and addressing that component through interventions and support. The final speaker in each Webinar is a person in recovery with lived experience on the topic.

The first Webinar in the 2012 series, "Assessing for and Addressing Trauma in Recovery-Oriented Practice," was held January 25. Three presenters demonstrated how a trauma-informed system differs from other systems of care. One example was adopting universal precautions and practices in assessment to avoid conflict and violence, meet consumers' needs, and prevent traumatic events that could harm the client or staff. Practitioner Kevin Ann Huckshorn, R.N., MSN, CADC, talked about assessing trauma in an outpatient setting. Paula Panzer, M.D., presented on trauma-informed care interventions. And Eric Arauz, MLER, a member of APNA's RTP Steering and Curriculum Committees, discussed interventions and supports that helped facilitate his recovery. You can download the Webinar presentation and listen to the recording at www.dsgonline.com/rtp/resources.html.

The second Webinar, "Understanding and Building on Culture and Spirituality in Recovery-Oriented Practice," was broadcast April 4. This session focused on three aspects of culture and spirituality in recovery-oriented care: cultural and spiritual assessments, culturally appropriate interventions, and ways spirituality and culture can shape an individual's recovery journey. Presenters introduced a range of strategies in which care is responsive to a person's cultural identity, and discussed approaches for fostering cultural strengths and spirituality in care planning and recovery practices. Reverend Laura Mancuso, M.S., CRC/CPRP, described practical tools for making assessment culturally and spiritually oriented. Dee BigFoot, Ph.D., Assistant Professor of Pediatrics at the University of Oklahoma Health Sciences Center, discussed recovery-oriented interventions with spiritual and cultural components. The last presenter, National Association of Peer Specialists President Gladys Christian, explained how spirituality and culture have affected her recovery journey. The presentation and recording are available at www.dsgonline.com/rtp/resources.html.

We will conduct our third Webinar, "Identifying and Integrating Strengths in Recovery-Oriented Practice," this summer. The session will describe tools that identify personal strengths and strategies for integrating and building on those strengths in care planning and recovery-oriented practice.

The fourth Webinar of the fiscal year, "Evaluating for and Using Medications in Recovery-Oriented Practice," will present approaches for ensuring the appropriate use of psychiatric medications based on evaluations of an individual's situation and condition. Presenters will provide guidelines for the safe and effective use of such medicine when prescribed and selected as part of a recovery plan.

More information on 2012 Webinars will follow in the coming months. Please check your email for registration details and other logistics.

Technical Assistance. RTP Technical Assistance (TA) offers valuable resources that support strategies for implementing recovery-oriented care in practical and sustainable ways. We have an extensive library of recovery articles, personal stories, curricula, videos, and links to relevant publications and professional sources. To access TA, contact RTP staff Monday through Friday from 9 a.m. to 5:30 p.m. at 877.584.8535, or email requests to recoverytopractice@dsgonline.com. We will respond to each request within 48 hours. Arrangements for longer consultations can be made on a case-by-case basis. Although behavioral health practitioners are RTP's primary audience, anyone interested in promoting recovery transformation is welcome to access RTP training and TA.

Project Update

Spring is upon us and it's a time for renewal and growth. RTP sends its sincere appreciation to everyone who has shared personal stories and real-life examples of recovery in practice. It is inspiring to be part of this incredible transformation, which is slowly but surely changing traditional health care paradigms. Recovery principles are rooted in partnership, collaboration, and mutual respect between consumers and practitioners. We are heartened to hear from service providers and consumers who value and are personally experiencing equality in participation, decision making, and goal setting.

A central part of our mission is to identify and disseminate concrete tools and strategies professionals can use to translate recovery-oriented concepts into practice. Practitioners from psychiatry, psychology, social work, psychiatric nursing, peer support, addiction counseling, occupational therapy, and psychiatric rehabilitation are sharing expertise on implementing person-centered practices in their fields.

On April 17–18, the RTP professional disciplines met at SAMHSA's headquarters in Rockville, Maryland. The purpose of the meeting was to share their progress in curriculum development and broaden RTP's reach by including alcohol and substance use recovery perspectives in the conversation. Amid the stimulating dialogue on trauma-informed care, culture, language, and systems change, the word "collaboration" echoed again and again. As each discipline progresses through curriculum development, active partnership between the professions will be a litmus test for bringing recovery-oriented supports and services to fruition. In June, RTP disciplines will jointly present on the importance of collaboration at the National Alliance on Mental Illness Annual Convention workshop, "Recovery-Oriented Practice Is a Multidisciplinary Practice."

RTP will hold its semiannual steering committee meeting in June. The third quarterly Webinar and e-newsletter are scheduled for July. And every Thursday, we will continue to send you Weekly Highlights featuring your personal stories, triumphs, and wellness tips.

Guest Columnist

Healing Heart and Soul by Mary Ann Beall. I've been around long enough to remember the days before trauma-informed care was a buzzword. Back then, few people understood the importance of trauma in the etiology of psychiatric disability. Few knew how to heal it, how to recover from it, and how common it was, particularly among consumers and survivors.

Many consumers have survived not only trauma and abuse, but also the failure of the very public systems designed to protect and help heal them. Their stories and mine are part of a profound revolution in understanding what it is to be fully human and what can transform and heal.

I was very compliant when I first sought help. I followed professional advice and took my meds religiously. But my symptoms continued and I experienced very troubling side effects. One spring in the early 1980s, I gave up psychiatry for Lent.

My healing began when the neurologist my daughter was seeing said he thought I had been misdiagnosed, which was surprising considering my many past diagnoses. He recommended a doctor, the first who treated me as an equal. We traveled the road together, celebrating each victory. His faith in me helped restore my belief in myself. But before we could complete our work together, he died unexpectedly.

Later, I helped found the VA Mental Health Consumers Association, the first Virginia statewide consumer/survivor organization. It was our time for justice, to assert ourselves as fully human and equal to everyone. Ours was a civil rights movement, but more importantly, a human rights movement. We became a committed, beloved community. We saw courage, goodness, and strength in our group and recognized each other's extraordinary talents and gifts, the things we so often couldn't see in ourselves. Most of all, we left behind our internalized stigmas, particularly the grief and shame we'd been socialized to feel about ourselves. We felt safe with each other and wanted people with lived experience to be valued—to serve as the very core of the system. We believed consumer-directed-and-run programs had great power to humanize the entire mental health system.

Our first statewide conference convened a group of more than 400 attendees. We came alone, scared and not knowing what to expect. Hesitantly, we shared our experiences of violence in the treatment system—how the absolute terror of seclusion and restraint triggered retraumatization for many of us. Treatment that used bed restraints was intolerable for sexual abuse survivors. Coercion and force triggered terror or panic, the imperative of fight or flight.

Trauma had so many faces at that conference. People spoke of the abuse they experienced when they had sought help from hospitals, residential programs, relatives, or trusted family doctors. The combination of poverty, helplessness, too many losses, and too much pain had become overwhelming. No matter how hard we tried to hang on, our lives would eventually shatter.

Slowly, pain and grief transformed into determination. We all had the right to safety, to treatment that did no harm and only healed. Ensuring this kind of care for everyone became our goal. But we knew we couldn't do it alone. Somehow, we had to determine where, how, and with whom we could effectively leverage the permanent changes our communities so desperately needed.

We decided two things were essential. First, we wanted to end the harmful use of force and coercion in acute care settings. To do this, we needed to impact every aspect of the treatment system: policy formation, regulation writing, program development, budget setting, and the design of outcome measures. The second and most difficult problem we faced was how to open the hearts and minds of practitioners, many of whom were trained to disbelieve and discount us—to see force and coercion as effective forms of treatment. To change this culture, we had to encourage staff to connect with us as equal human beings and help them see us as partners working towards a common good. We had to show them that force and coercion prevented healing and recovery.

Over the next year, two consumers and I visited every public hospital and psychosocial program in Virginia. As we drove the highways and byways, we designed a workshop, Partners in Healing, to encourage hospital professionals to reconsider common coercive practices. We weren't just opening hearts and minds; we wanted to identify allies who were willing to partner with us in changing the culture of treatment.

We decided to share our personal stories, trauma histories, and psychiatric misdiagnoses, as well as the effective treatment we had received. We would explain how damaging seclusion and restraint had been—how they had set back our recovery and kept many people from seeking help at all. We presented at all eight State hospitals and were met with challenging questions. In the end, however, we found real allies and even friends.

Years later, Lynn DeLacy, Director of Nursing at the Northern Virginia Institute, told me how she had reacted to Partners in Healing. "Most people seek [out] health care careers because of a strong desire to help others," she said. "Yet we often experience moral distress because our work is subject to the limits of our art and science. Seclusion and restraint use occurred in the context of what was thought to be, albeit erroneously, good care, even though for most of the staff the experience was as dreadful as [it was] for the consumers involved. When you spoke to us and with us in a way that invited dialogue, it enabled us to explore ideas and experiences without the need to defend. This was the key ingredient."

Our active allies grew to include academics, newspaper reporters, disability groups, advocates, mental health organizations, legislators, family groups, the Mental Health Planning Council, and many others. Over time, seclusion rooms became comfort rooms, and restraint hours at the Northern Virginia Institute plummeted. In Northern Virginia, a State grant now trains professionals, families, and consumers on trauma-informed care. Consumers/survivors are included by law on bodies with decision-making power over their lives.

We have come a long way. Learning to speak up and out as an advocate for critically needed changes in the public system helped my healing process, building confidence and strength in my heart and soul.

Mary Ann Beall is a member of the RTP Steering Committee and past Chair of the Fairfax–Falls Church Community Services Board. She brings her lived experience of psychiatric disability and traumatic brain injury to her passionate pursuit of equity for consumer survivors. You can reach Mary Ann at 703-533-2144.

Professional Discipline Training Awards

In March, RTP officially welcomed the Association for Addiction Professionals, previously the National Association of Alcohol and Drug Abuse Counselors (NAADAC), as the sixth professional discipline to develop a training curriculum and join SAMHSA's Recovery Support initiative for people in recovery from mental and substance use disorders. With direction from a newly formed advisory committee, NAADAC's RTP project team is assessing how recovery is practiced in substance use and addiction treatment. They will analyze data collected from listening sessions, individual dialogues, and literature and materials review, and develop a Situational Analysis to form the basis for training. Findings from the first phase will also help NAADAC refine the target audience for their training. They will complete the Situational Analysis and first draft of their training outline in September 2012.

Over the last few months, RTP's professional disciplines have forged ahead in the design and development of their curricula. The disciplines are developing training manuals with full participation from their advisory groups and steering committees—teams that consist of people in recovery, leaders from their professions, and other stakeholders. Each organization is shaping its program structure and pilot testing process while adhering to the Framework for RTP Curriculum Development that Development Services Group (DSG) designed to ensure consistency.

The American Psychiatric Association (ApA) and American Association of Community Psychiatrists (AACP) have created learning objectives for eight training modules. At their annual Winter Meeting in early March, AACP board members led individual sessions with participants (each group had several people in recovery) and fleshed out the content for modules to correspond with learning objectives. Sessions were videotaped for potential use in the final curriculum. The ApA/AACP team will revise, edit, and submit modules to DSG and SAMHSA for review. Pilot testing with their target audience, direct service providers and trainers/supervisors, which began at the AACP meeting, will continue in May 2012. Also in May, interviews on implementing recovery in psychiatry practice will be conducted at ApA's Annual Meeting. Video clips of these interviews will be incorporated into the curriculum. Learn more.

The American Psychiatric Nurses Association (APNA) has submitted the first draft of its training manual and reviewed comments from RTP consultants, DSG, and SAMHSA. Following revisions to the manual, APNA will pilot test the curriculum with its target audience: inpatient psychiatric nurses and nurses who work in the psychiatric emergency department. Testing will be conducted in person at urban, rural, and university-based hospitals throughout the country starting in May. Private and public organizations will participate. The project team plans to revise the curriculum in time for APNA's Annual Conference in November, where it will conduct and record the final pilot. APNA's training program will ultimately be offered as online Webinars in two modules. Visit their RTP resources page for more information.

The American Psychological Association (APA) has completed drafts for nine training modules. APA will create 13 modules—two fewer than it had originally planned, as a result of closely matching the content with the module design. Training directors and students in clinical and counseling psychology at APA-accredited doctoral programs are the target audience, and part of APA's outline includes a "training of trainers" for qualified and adjunct faculty. Training directors will help decide how modules can be incorporated into existing courses for doctoral and postdoctoral students. APA also has a longer-term goal to adapt curricula for online delivery. Their pilot tests will begin August 2012. Click here for more information.

The National Association of Peer Specialists (NAPS) has developed eight of nine modules for review and is planning pilot tests for certified peer specialists beginning this June. Given the need for individual reflection and group dialogue, NAPS determined their original 2-hour session would not be sufficient. Each module will now span 4 hours, and the entire curriculum will be delivered during a 5-day workweek. Instead of piloting at local, regional, and national meetings, several organizations throughout the U.S. that employ peer specialists will hold pilot tests on-site. Read the NAPS Situational Analysis and training outline to learn about plans for summer pilot testing.

Finally, the Council on Social Work Education (CSWE) has submitted the first complete draft of its training manual. The curriculum was developed with guidance from CSWE's steering committee, Director of Accreditation, Webinar presenters, and feedback from conferences participants, including CSWE's Annual Program Meeting, Alternatives Conference, and ApA Institute on Psychiatric Services. The training package consists of three 90-minute Webinar presentations, scripted guidance for field instructors and faculty and field directors, pre-Webinar reading, plans for learning collaboratives following the Webinar, and a comprehensive document that links recovery-oriented competencies for social workers with accreditation standards for the profession. The target audience for their training is field instructors—social work practitioners who supervise students in the field. Instructors will teach course material in the classroom and in the field through field assessment. Learn more.

Talking About Trauma. In a breakout session on trauma-informed care at the RTP Professional Discipline Awardee Meeting, April 17–18, 2012, behavioral health specialists, consumers with lived experience, and professionals from social work, addiction treatment, and psychiatry gathered together to share their experiences. The small group discussion exemplified how diverse organizations in the field are collaborating to address critical issues in recovery-oriented care.

Trauma is a sensitive issue among practitioners but it's becoming less obscure to consumers, most of whom have been affected at some point by a traumatic event or experience. Around the table, there was consensus about developing consistent and relatable language to define trauma-informed care, ensuring a safe space and building trusting relationships for open, honest dialogue, and creating self-assessment tools to gauge progress in the healing process. Everyone agreed service providers could prevent further trauma by forgoing forceful and coercive measures and working in partnership with consumers.

The six RTP professional disciplines also shared insight about the importance of person-centeredness, collaboration, organizational change, and culture and ethnicity within their profession.

Personal Story

Mental Illness and Trauma by Eric C. Arauz, MLER. I have experienced a great deal of trauma associated with mental illness—from the trauma of my initial diagnosis, to the trauma of having my liberty taken away during treatment, to the trauma of being held in restraints.

My recovery from tri-occurring disorders has been nonlinear, with many setbacks. I was diagnosed with bipolar I disorder, addiction, and post-traumatic stress disorder (PTSD). My PTSD was recognized 7 years after a long-term hospitalization in a maximum security Veterans Administration psychiatric hospital, where I was restrained more than 20 times and for more than 24 hours in a locked ward. Up until that diagnosis, I was unaware how the symptoms of extensive trauma were controlling my life.

Every day during those 7 years, I experienced the three cardinal symptoms of PTSD: hyperarousal, intrusion, and constriction.

The constant survival mode of hyperarousal made me feel stuck in an endless present—I simply could not look ahead. Constriction prevented me from believing I could build a real life. I had to fight a constant pull to give up.

The problems I experienced with intrusion were frightening, to say the least. That nameless terror would kidnap me from my daily life. For years, anything could trigger flashbacks of my days held in restraint and the paralyzing fear that people were trying to kill me. I could walk into a public restroom, where the smell of industrial strength cleaner would seize me from my surroundings. I seemed to "awaken" moments later with tears in my eyes, trying to calm down and return to the reality of the day. When intrusion trapped me in this wordless landscape, the fear in my stomach sent me back to that psychiatric ward, held down and screaming through the night.

Intrusion is marked by wordlessness—its inability to be initially narrated and the visceral, physical grip it has on the individual with PTSD. In addiction communities (I am sober 15 years), an essential part of recovery focuses on storytelling. People will say they heard "their story" told by a speaker and so they learn to narrate their personal trauma. The safety of the meeting allows the healing process to continue, and the story and remembrance stage in trauma recovery organically flows.

In my recovery from serious mental illness, chronic addiction, and severe childhood abuse and trauma, I never found someone who could tell my story. I was lost without the ability to translate my life experiences, traumas, and heartbreaks.

Eventually, I turned to the numerous works written about people with mental illness. I gravitated toward texts from other cultures that elucidated tremendous suffering and portrayed how people overcame such pain to live full and meaningful lives. In the slave narratives of the 19th century, I found a vein of works that alluded to being "chained" and "imprisoned," and I began to speak to myself in the language of disconnection and eventual freedom.

Although I could not equate my suffering to the anguish of these people, I related to feelings they described of being held down and terrorized by an outside master. In my case, the "master" was buried in the disease that lived in my blood and the trauma sewn into my life's narrative and biases.

The language of enslavement and vernacular of freedom became lexicons for narrating my previously wordless terrors. With these tools, I discovered a verbal roadmap off the plantations of my mind—the confines I had been shackled to since childhood, when my father, who was suffering from his own serious mental illness, tried to end my life.

I have been able to expand this language of redemption in my 15-year recovery journey with books on mindfulness by Thich Nhat Hahn, and the collective works of W.E.B. Du Bois and Frederick Douglass, who have taught me how to cope with my scars and remain free.

I will live the rest of my life with PTSD, but I work daily to monitor my physical triggers and reactions to hyperarousal. I share my pain and fear with others, never hiding from the world due to constriction.

Each day, I read about suffering and redemption so I can continue to narrate my life and never again become lost in the wordless realm of intrusion. My life is not dictated by the horrors of yesterday. I live unrestrained, and that is the miracle of my life.

Eric C. Arauz, MLER, is the President of Arauz Inspirational Enterprises, www.mylifemylimits.com, and Adjunct Instructor in the Robert Wood Johnson Medical School Department of Psychiatry.

Resource Spotlight

Tonier "Neen" Cain is a survivor. But for years she was a victim of sexual, physical, and verbal abuse. Neen's childhood traumas followed her to the streets, where she stumbled into a life of drugs and crime. Over the next 19 years, she was jailed more than 66 times and convinced herself there was no way out.

In 2004, Neen participated in the trauma and addictions program that saved her life. It was the start of a dramatic transformation that revealed her true strength and potential. Once she had turned her life around, she set about helping others, and hasn't stopped since. Neen's tireless work to spread the word about trauma and criminal behavior has taken her from hospitals to maximum security prisons. Today, she is a team leader for SAMHSA's National Center for Trauma-Informed Care.

Healing Neen is an award-winning documentary that uncovers the anguish of childhood abuse and neglect. But the film—much like Neen herself—feels remarkably hopeful, helpful, and sincere. Tonier advocates for trauma-informed care in a call to arms from the National Council for Community Behavioral Healthcare. The organization has backed national policies serving more than 6 million adults and children with mental illnesses and addiction disorders. They develop training programs for behavioral health care staff and produce National Council Magazine, an online publication devoted to mental health and addictions treatment, best practices, and stories from the field.