Wellness and Recovery – The Vision and the Pledge
“60–70 percent of premature deaths among people with psychiatric disabilities are avoidable.”
— National Association of State Mental Health Directors, 2006
The life span of people with psychiatric disabilities is decreasing at a staggering rate. At present, people with psychiatric disabilities have a life expectancy that is 25 years shorter than that of the general public. This unacceptable disparity is a challenge to providers, consumers, family members, administrators, and members of the community.
Mental health systems have a significant responsibility to ensure that their consumers have access to preventive health education as well as health care that is integrated into and managed as part of overall recovery services. Administrators, consumers, family members, and the community also need to participate in realizing a change towards wellness.
In direct response to the current health crisis facing people with mental illnesses, the Substance Abuse and Mental Health Services Administration (SAMHSA) sponsored the 2007 National Wellness Summit for People with Mental Illness where researchers, consumers, providers, policymakers, and families formulated a national vision for “a future in which people with mental illnesses pursue optimal health, happiness, recovery, and a full and satisfying life in the community through access to a range of effective services, supports, and resources.” The action outcome of the summit was the National Wellness Pledge “to promote wellness for people with mental illnesses by taking action to prevent and reduce early mortality by 10 years over the next 10-year time period.” This pledge serves as our field’s call to action.
This newsletter offers information, resources, and ideas for mental health services providers, consumers and families, administrators, practitioners, mental health associations, governmental agencies, funders, and the community at large to begin actualizing the vision and the pledge, and to implement changes promoting wellness for mental health services consumers.
Wellness and Disparities
The health crisis facing people with mental illnesses is in fact a magnification of the public health challenges documented in the general population: high rates of obesity, diabetes, and other health conditions plus the effects of poverty, racism, homophobia, disability and accessibility. The successes of public health efforts to educate the general public about wellness and to develop strategies for improving wellness overall have not, however, been as successfully implemented in services for people with psychiatric disabilities.
According to the National Association of State Mental Health Program Directors’ 2007 report, “Morbidity and Mortality in People with Serious Mental Illness,” only 30–40 percent of premature deaths of people with serious mental illness can be attributed to suicide; 60–70 percent are from avoidable physical diseases and accidents. Obesity, diabetes, metabolic syndrome, osteoporosis, oral health issues, substance abuse, HIV/AIDS, and others are among the conditions commonly affecting people with serious mental illnesses. Most of the conditions that contribute to high rates of premature death can be controlled or prevented with quality health care that emphasizes early detection, healthy eating, exercise, smoke-free living, and other behaviors identified as the basis for wellness (Manderscheid, Druss, & Freeman, 2007). Yet, this population is still less likely to receive preventive health education and health care, and more likely to use expensive emergency and critical care services than the general population (Davidson et al., 2001; Folsom, et al., 2002; Hahm & Segal, 2005; Klinkenberg et al., 2003; McKinnon, Cournos, Herman, 2003; Razzano, 2003).
Traditionally, mental health systems have been designed to focus only on mental illness. Now, systems and providers are faced with the challenge of providing services that reduce illness and improve overall health. Health and wellness promotion needs to be the framework for all mental health services. This is a multifaceted challenge that requires us to change our infrastructure, our practices, our settings, and our financing. “An effective approach to health promotion for people with psychiatric disabilities must involve a dynamic change of ideas, values, and expertise.” (Hutchinson et al., 2006).
Barriers to Wellness
What are the barriers to wellness faced by consumers of mental health services? There are many complex factors that create barriers at every level: individual, provider, programmatic, within the system, and at community and societal levels. Among the barriers and determinants are:
- inadequate health insurance coverage
- access to quality health care
- membership in a diverse community (racial and ethnic minority communities; disability communities; Gay, Bisexual, Lesbian, Transgendered communities, immigrant communities, and others)
- side effects of many psychiatric medications
- negative health care experiences that keep people with psychiatric disabilities from seeking medical care
- lack of health information that addresses the diverse needs of people with psychiatric disabilities
- negative attitudes and prejudice among health care providers
- resistance to change in mental health service delivery models, infrastructure, and settings
- lack of synergy between medical and mental health services
- lack of financing streams that support health promotion interventions
Research supports the connection between mental and physical health—the link between the mind and the body—for people with psychiatric disabilities (Faulkner & Sparkes, 1999). Consumers of mental health services have long sought, used, and advocated for services and resources to address physical illness along with mental illness (Hutchinson, et al., 2006). There is an urgent need for a more holistic framework of health integrating physical and mental care; a framework developed in collaboration with all stakeholders that can serve as the beginning of efforts to improve the health outcomes of people with serious mental illness in our systems, programs, and practices.
Incorporating Wellness into Mental Health Systems
The model for health promotion is a holistic, multidimensional, future-oriented approach to health that focuses not on diseases or conditions, but on helping people move toward attaining and maintaining good mental and physical health as a personal resource for recovery. This encompasses not only individuals but also groups, communities, and systems (Steinberg, 2006; Hutchinson, et al., 2006).
Lifestyle change that supports the recovery of people with psychiatric disabilities can be facilitated by a combination of efforts to enhance awareness, change behavior, and create environments that support good health practices. Prevention education, intervention, and follow-up are also key components of an interrelated, multidimensional approach to physical and mental health and wellness.
Bringing wellness into the mental health system requires change, which can be introduced in small steps. Health education, access to health care, support for follow-up care, and environmental changes can be integrated simply and easily to create immediate improvements in the health of people in recovery. Tools and resources are available from Boston University’s Center for Psychiatric Rehabilitation to help programs introduce inexpensive changes in their practices and environments to support and promote wellness.
Taking Steps Toward Wellness in Recovery
In response to the growing health crisis, initiatives that address health disparities for people with psychiatric disabilities through service, research, and resource development for integrating wellness into mental health services are being introduced around the country. The following are innovative services that will help us achieve the goal of reducing the current disparity to 10 years over the next 10 years.
Integrated Illness Management and Recovery (I-IMR) is an intervention that aims to address the health crisis by adapting an evidenced-based practice for teaching illness management skills to older persons with serious mental illnesses and for integrating their primary mental health care services. I-IMR offers an integrated approach to improving self-management of psychiatric symptoms and medical problems and working towards individual wellness and recovery goals. I-IMR is designed to a) improve consumer illness self-management skills for both psychiatric and medical disorders and b) integrate care management provider services for middle-aged and older adults. An I-IMR specialist and an I-IMR nurse health case manager work together to enhance the quality of health care as well as support the recovery goals of the individual. The ten-month program is currently funded by the National Institute of Mental Health and Substance Abuse and Mental Health Services Administration under the leadership of Dr. Kim Mueser with sites in Chicago, Illinois and Manchester, New Hampshire.
The Institute for Wellness and Recovery Initiatives is a consumer-run program of the Collaborative Support Programs of New Jersey, Inc. (CSP-NJ). The Institute integrates wellness, recovery and economic self-sufficiency for people with psychiatric disabilities under the leadership of Dr. Peggy Swarbrick. The programs available from the Institute include the Recovery Network Project curriculum, a peer-delivered wellness and recovery education program; newsletters; and training and technical assistance. The Recovery Network Project is currently being offered at five state hospitals in New Jersey and has recently expanded to partial-care programs. The Institute also offers workshops entitled Mindfulness, WRAP (the Wellness Recovery Action Plan), Wellness 101, Coaching for Wellness, Time Management, and Self-Esteem.
CHOICES is a New Jersey-based, peer-delivered curriculum aimed at helping people reduce or eliminate tobacco use. The goal is to increase awareness, address tobacco use, and create a strong peer support network for consumers to support their health and wellness. CHOICES provides consumers with information about the consequences of smoking, issues regarding smoking and mental illness, and options and resources available to facilitate quitting.
Optimizing Chronic Illness Self-Management for Individuals with Schizophrenia is a curriculum designed for adults living with schizophrenia that is currently under development by Richard W. Goldberg at the University of Maryland. Based on a modified version of the Chronic Disease Self-Management Program created at the Stanford Patient Education Research Center, the new program’s reliance on peer facilitation and mutual support will make it a welcome addition to the range of recovery-oriented approaches available to consumers. Enhanced delivery methods will specifically address the variety of cognitive, behavioral, and social challenges associated with schizophrenia.
Recovering Energy Using Nutrition and Exercise for Weight Loss (RENEW) is an evidenced-based weight loss program based on the principles of rehabilitation and recovery for people with psychiatric disabilities that has been implemented in Kansas under the leadership of Dr. Catana Brown. The program emphasizes lifestyle change with skills development and social support systems and provides low-cost materials—such as pedometers, measuring cups, and cooking supplies—for participants, who identify group and individual goals for weekly progress.
Hearts and Minds is an educational program developed by the National Alliance on Mental Illness (NAMI) to raise awareness about diabetes, diet, exercise, and smoking. The program includes a 13-minute, inspirational video and a 26-page companion booklet. Hearts and Minds also provides basic information on addictions, recovery, stigma, treatment, diabetes, and sleep apnea, and provides tips for exercise, diet, shopping, and cooking (including recipes) as well as instruction in keeping a food diary.
The Recovery Education Program was founded in 1999 at the Center for Psychiatric Rehabilitation at Boston University as an educational intervention to help adults in recovery develop readiness for healthy changes; the program emphasizes developing functional health as a foundation for role recovery. Students choose up to four classes a semester from a variety of courses at different levels of readiness-to-change that support skills and development for healthy lifestyles. Courses include evidenced-based interventions, such as illness management and recovery, supported physical activity, food education, and education about healthy living and tobacco. In addition, students have the opportunity to learn tai chi, yoga, laughter yoga, meditation, mindful eating, chi gung, walking for fitness, wellness recovery action planning, stress hardiness, and reiki, and also attend healthy lifestyle seminars. Courses are co-taught by trained instructors in recovery and providers who do not have a psychiatric diagnosis. Currently, 150 people in recovery participate in 25 courses a semester.
Hope and Health was a recent Center for Psychiatric Rehabilitation initiative designed as a pilot health promotion day-treatment program for people in recovery who are at risk for or have been diagnosed with the metabolic syndrome. Using the traditional structure of a day-treatment program, the program enhanced health promotion skills in four domains: physical activity, nutrition, illness management, and health literacy. Hope and Health offered four evidenced-based protocols, bundled as a collective intervention, to 33 participants for 16 weeks. At the end of the 16-week health promotion day-treatment program, participants worked with a health coach for an additional 16 weeks who helped them use their new lifestyle skills at home and in the community. Program evaluation results were very positive, with statistically significant changes seen in levels of physical activity and nutritional practices. Participants also made significant changes from the role of patient to worker, student, and engaged community member, suggesting the promise of health promotion interventions in increasing the functional health of individuals in their communities.
Ongoing research is a central part of the Center for Psychiatric Rehabilitation. By focusing on wellness and recovery, and in partnership with a large mental health provider, the Center is studying the effects of a model of integrated health care delivery that uses a nurse practitioner trained in mental health care to provide services in a mental health clinic. The study, funded by the National Institute on Disability and Rehabilitation Research and the Substance Abuse and Mental Health Services Administration, Center for Mental Health Services, is examining the impact on well-being, perceived health status, and the psychiatric status of consumers of mental health services. It will also examine whether providing integrated, accessible health care through a nurse practitioner reduces the use and associated costs of emergency room visits and acute hospitalizations. As part of the study, consumers provide information about barriers they experience in accessing adequate health care. Also, administrators and service delivery personnel at the mental health clinics are providing input on the benefits of this wellness model for delivering holistic medical care to their clients.
There are ways we can immediately begin to reverse trends of co-morbidity to create wellness through small but effective changes. Implementing small environmental and cultural changes in mental health programs, including gaining organizational commitment to the National Wellness Pledge, physical activity on treatment plans and providing healthy food, offering tobacco treatment and support groups to help people quit smoking, changing vending machine contents to include healthier options, and introducing wellness education, have already proven effective in public health and in mental health systems. For consumers and providers of mental health services, empowerment and self-advocacy are key to introducing change at the group, community, and—especially—individual levels. For mental health services to help improve the life expectancy of people in recovery, we must begin to offer a holistic approach to treatment and rehabilitation oriented to improving overall wellness that ensures consumers the opportunity to work, learn, love, and live long, healthy lives.
For More Information
Information on integrating wellness in recovery is available at the SAMHSA Wellness Summit website (www.bu.edu/resources/wellness summit). Other helpful sites include www.smallstep.gov and www.nhlbi.nih.gov. For help getting started integrating wellness changes, and for additional information about services and curricula, how to start using available resources to incorporate wellness in recovery, and consultation and training, contact Dori Hutchinson, Director of Services (firstname.lastname@example.org) at Boston University’s Center for Psychiatric Rehabilitation and visit the website, www.bu.edu/cpr.
Find out more about specific initiatives highlighted in this newsletter.
- Integrated Illness Management and Recovery—Kim Mueser, PhD, email@example.com
- Institute for Wellness and Recovery Initiatives—Peggy Swarbrick, PhD, firstname.lastname@example.org
- Optimizing Illness Self-Management for Individuals with Schizophrenia—Richard W. Goldberg, PhD, email@example.com
- Hearts and Minds—www.nami.org/template.cfm?section=Hearts_and_Minds
- RENEW—Catana Brown, PhD, firstname.lastname@example.org
- Recovery Education Program—Dori Hutchinson, ScD, email@example.com
- Hope and Health—Dori Hutchinson, ScD, firstname.lastname@example.org
- Ongoing Research at the Center for Psychiatric Rehabilitation—E. Sally Rogers, ScD, email@example.com
“An effective approach to health promotion for people with psychiatric disabilities must involve a dynamic change of ideas, values, and expertise.”
—Hutchinson, et al., 2006
Berren, M., Hill, K., Merikile, E., Gonzalez, N., & Santiago, J. (1994). Serious mental illness & mortality rates. Hospital & Community Psychiatry, 45(6), 604–605.
Brown, M., Inskip, H., & Barraclough, B. (2000). Causes of the excess mortality of schizophrenia. British Journal of Psychiatry, 177, 212–217.
Davidson, S., Judd, F., Jolley, D., Hocking, B., Thompson, S., Hyland, B., et al. (2001). Cardiovascular risk factors for people with mental illness. Australian and New Zealand Journal of Psychiatry, 35(2), 196–202.
Folsom, D. P., McCahill, M. J., Bartels, S. J., Lindamer, L. A., Ganiats, T. G., & Jeste, D. V. (2002). Medical comorbidity and receipt of medical care by older homeless people with schizophrenia and depression. Psychiatric Services, 53(11), 1456–1460.
Faulkner, G., & Sparkes, A. (1999). Exercise as therapy for schizophrenia: An ethnographic study. Journal of Sport and Exercise Psychology, 21, 25–69.
Hahm, H., & Segal, S. (2005). Failure to seek health care among the mentally ill. American Journal of Orthopsychiatry, 75(1), 54–62.
Hutchinson, D. S., Gagne, C., Bowers, A., Russinova, Z., Skrinar, & G. S., Anthony, W. A. (2006). A framework for health promotion services for people with psychiatric disabilities. Psychiatric Rehabilitation Journal, 29(4), 237.
Klinkenberg, W. D., Caslyn, R. J., Morse, G. A., Yonker, R. D., McCudden, S., Ketema, F., et al. (2003). Prevalence of human immunodeficiency virus, hepatitis B, and hepatitis C among homeless persons with co-occurring severe mental illness and substance use disorders. Comprehensive Psychiatry, 44 (4), 293–302.
Manderscheid, R., Druss, B., & Freeman, E. (2007). Data to Manage the Mortality Crisis, Retrieved May 24, 2008, from the Wellness Summit website: www.bu.edu/cpr/resources/wellness-summit/
McKinnon, K., Cournos, F., & Herman, R. (2002). HIV among people with chronic mental illness. Psychiatric Quarterly, 73(1), 17–31.
Parks, J. (n.d.). Morbidity and mortality in people with serious mental illness. [PowerPoint slides]. Retrieved May 24, 2008, from the Wellness Summit website: www.bu.edu/cpr/resources/
Razzano, L. (2003). Issues in comorbidity and HIV/AIDS. In H. I. Graham, A. Copello, M. J. Birchwood, & Mueser, K. T. (Eds.), Substance misuse in psychosis: Approaches to treatment and service delivery (pp. 333–346). West Sussex, England: John Wiley & Sons, Ltd.
Steinberg, K. (2007). Wellness in Every Stage of Life: A New Paradigm for Public Health Programs, Preventing Chronic Disease. 2007 January; 4(1): A02. www.cdc.gov/PCD/issues/2007/jan/
The National Wellness Summit for People with Mental Illness website, hosted by the Center for Psychiatric Rehabilitation, includes extensive resources and a list of those who have signed The Pledge for Wellness.
The website is located at www.bu.edu/cpr/resources/wellness-summit/.
Food Education and Mindful Eating is part of the curriculum for the Recovery Education Program at the Center for Psychiatric Rehabilitation at Boston University.
In one of the Center classrooms, the instructor leads a yoga class, attentive to supporting, adapting, and responding to each student’s abilities and individual needs.