Podcast: Why Words Matter in Mental Health Care
Jenn talks to Nathaniel Van Kirk, PhD. Nathaniel explains recovery-oriented practice and why it’s important to add it into psychiatric care. He also explains how language can help patients explore their abilities and strengths, as well as the impact of feeling defined by a diagnosis or symptoms.
Nathaniel Van Kirk, PhD, is the coordinator of inpatient group therapy at McLean Hospital and the coordinator of clinical assessment at McLean’s OCD Institute. His clinical research focuses on the role of motivation across treatment and the impact of trauma on care outcomes. He also works to promote innovative methods to assess and conceptualize recovery.
Jenn: Hey everyone, welcome to Mindful Things.
The Mindful Things podcast is brought to you by the Deconstructing Stigma team at McLean Hospital. You can help us change attitudes about mental health by visiting deconstructingstigma.org. Now on to the show.
So, hi folks. Thank you for joining today. I’m super excited about today’s session as evidenced by the giant grin on my face. And I would like to officially introduce myself. I’m Jenn Kearney, and I am a digital communications manager for McLean Hospital.
And today’s session is all about helping to debunk that old saying that I’m sure most of us have heard, “Sticks and stones may break my bones, but words will never hurt me.” Words and language actually matter a lot because no one wants to be recognized by a diagnosis or defined or limited by symptoms.
So, by choosing our words wisely, we can actually empower patients to explore abilities and strengths and bring resilience and hope back into their care plan.
So today, Nathaniel is going to talk about Recovery Oriented Practice and language, and how by changing the way that we say and describe things, we can actually transform patient lives and even our own lives from being hopeless to hopeful.
And if you are unfamiliar with the wonderful Nathaniel Van Kirk, PhD, I would like to introduce him right now before I turn the mic over to him. He is the coordinator of inpatient group therapy at McLean Hospital. And the coordinator of clinical assessment at McLean’s OCD Institute amongst a whole bunch of other things.
Dr. Van Kirk’s clinical research focuses on the role of motivation across treatment and the impact of trauma on care outcomes. He also works to promote innovative methods to assess and conceptualize recovery. So, Nathaniel, I’m going to pass it over to you. Thank you so much for joining and we will get started.
Nathaniel: Thank you very much, Jenn. Thanks for having me on today and thank you for everyone who’s joining. So, before we get started, just to give a concept of this idea of recovery, it’s a term that tends to get kind of tossed around a good bit or talked about. And everyone may have a little bit of a different conceptualization of what recovery is.
And so, we’re going to talk a little bit about why that is and some of the positives of that. But one of the ways I really like to set the stage actually comes from a quote from the National Institute of Mental Health in England, where they really talk about recovery as not necessarily kind of what services themselves do to or for people, but that recovery is actually what people experience themselves as they become empowered to manage mental health challenges.
The goal here is kind of to help empower people in a way that allows them to achieve a meaningful and positive sense of belonging in their community and within their lives as a whole. And so, with that kind of idea in mind, Recovery Oriented Practice framework is actually this kind of overarching framework is designed to help support and promote an individual’s mental health recovery but it has a very specific focus on certain elements.
And these include enhancing autonomy or feelings of choice, identifying and building on strengths for individuals. This idea of fostering hope and developing resilience through the recovery process.
And one of the things that kind of defines the recovery framework is that it is more of a process based approach to mental health. A lot of times, kind of both in the research and in clinical practice, we talk about recovery as not just an outcome, but both a process and an outcome because it is kind of this ongoing journey of being human in many ways.
And so, when we think about this process, recovery oriented frameworks are really striving to have a more kind of holistic framework where it’s not just looking at a specific set of maybe symptoms or challenges that someone’s struggling with in that moment. But it’s also looking at the impact that they may have on the life as a whole.
And how do we help promote kind of this idea of recovery and hope across all domains of an individual’s life? Linda Flaherty who’s been spearheading the interdisciplinary recovery and practice committee here at McLean, kind of framed it as this framework that provides an additional lens for staff to use in providing care to our patients kind of throughout all the different aspects of what we do here at the hospital.
And so, while for many of you, this may have been one of the first presentations on recovery oriented practice, or maybe you’ve heard many different presentations on this framework. One of the things I always like to put out there is that this framework is actually pretty widely integrated across the world. Within the US, there are a number of hospitals that use this recovery oriented framework.
The Veterans Health Administration is probably one of the examples of having this recovery oriented practice framework integrated into all elements of what they do. Additionally, when you look at places like Australia and England, they’ve taken this framework and actually use it as a foundation for their behavioral health systems for the entire country.
And have actually put out some very detailed processes for doing this and are showing really wonderful outcomes in both behavioral and mental health following this integration.
When I talk about Recovery Oriented Practice, one of the questions I get a lot is this idea of when we’re thinking about recovering oriented framework, is this at odds with the idea of specialized or empirically based clinical care?
And many times, one of the concerns that some of these overarching frameworks is what does this do to empirically based interventions? And almost a concern of, is this a recovery versus empirically-based interventions?
And so, one of the things I wanted to start with is that Recovery Oriented Practice by nature is designed to include empirically-based interventions. The two are actually very synergistic. When we think about recovery oriented frameworks, the goal here is actually to enhance access to empirically based interventions for everyone seeking mental health support.
And the goal is also to enhance overall outcomes such as global quality of life, engagement, and community. And so really this framework is a way to build upon the wonderful empirically-based and specialty interventions that we do have.
And look for what are some other aspects of the recovery process that we can identify, that may actually enhance treatment response and help us evolve these interventions as we go. And so that’s just one of the things I just wanted to put out kind of to start before we start talking about some of the details of covering practice.
Is that this really is a kind of integrative, synergistic framework that allows us just to take a slightly different approach to implementing empirically-based interventions with the goal of enhancing them in the long term. And there’s some a few great examples of this that have been published in probably the last 10 years or so.
One of which is this Integrated Recovery-Oriented Model where essentially they created this recovery-oriented framework for implementing and improving access to empirically-based interventions for individuals with severe mental illness.
And really what they did is they focused on how do we implement these kind of highly researched, highly empirically-based interventions in a way that allows us to focus on promoting feelings of hope for one’s future, allowing for the fact that each person’s idea of recovery is a little bit different because each of us are a little bit different.
And so, kind of going after the subjective idea of recovery and helping individuals strive for their goals not necessarily the ones defined by us as clinicians. And with an enhanced focus on not just the interventions but also promoting community inclusion and a sense of choice or autonomy. Similarly to international classification of functioning programs implemented in Italy in rehabilitation settings.
And what was interesting about both of these, they not only demonstrated kind of a reduction in symptoms that were being targeted through these empirically based interventions, they also demonstrated a really significant increase in overall functioning and increase in social connection.
There is also an increase in feelings of self-efficacy or belief that I can recover. I can do this recovery process from the individuals that were going through these services.
One of the other things that was really great is that we also saw that it had an impact on employment outcomes, which is an outcome that we don’t necessarily always focus on. But as a core element of the recovery process, it’s thinking about helping individuals get back to their day-to-day life. And I think one of the coolest findings around this is actually that there’s some really great research that demonstrated that.
Not only can we see these outcomes and the kind of more typical measures that we might use for treatment outcome research, but that when we kind of pulled individuals who were going through these services in institutions, pre and post recovery-oriented practice trainings, that the individual receiving services were actually able to identify and report on the ways in which their services had changed and the way in which they engaged with their treatments teams had changed.
And actually said that these were highly valued shifts for their ongoing clinical care. Which I think is a really important aspect of this, is that by using this framework, it gives us a way to actually make noticeable shifts in the way we deliver treatment and in a way that is valued by those that we’re working with.
And so ,in order to kind of talk about this framework, I want to kind of take a step back and talk about how do we define recovery correctly? One of the most widely used definitions of recovery comes from the Substance Abuse and Mental Health Services Administration where they did define it as a process of change through which individuals improve their health and wellness, live a self-directed life and strive to reach their full potential.
And they identify four major dimensions of recovery. The first being health, and being able to make informed healthy choices that support physical and emotional well-being. The idea of making sure to have a stable and safe place to live. Developing a sense of meaning or purpose in daily activities and a way to meaningfully participate in society around you.]
And then this idea of building community or building relationships and social networks that specifically provide support, friendship, love. And what I really love about this idea of recovery is that it leaves it open for an individualized process.
The idea that each of us has a slightly different recovery in mind. Everybody’s goals might be slightly different. For those of you that were on earlier, listening to the conversation that Jenn and I had.
You probably might be thinking that if I were your clinician, you probably wouldn’t want me setting the goals for what your life’s going to look like, given that I was someone who’s kind of, I guess, gone down in infamy for eating a sandwich off the bottom of my shoe. I’m probably not the person that you want setting your goals.
And so, the idea here is with recovery is that it’s an individualized collaborative process between individuals and their teams that help promote a kind of more holistic vehicle of what the recovery process is. Not just to focus on symptom dimension.
And so, as part of this concept of recovery, SAMHSA’s identified 10 kind of guiding principles of implementing recovery-oriented care. Today, we don’t quite have time to go through all of them.
So, I’m just going to highlight a few the second half of today’s presentation. Some of the ones that we see pop up the most are this idea of hope or the idea of believing in a better future. Fostering the sense of hope. Feeling of being person-centered and respect for the individual.
Kind of respecting each person’s idea of what they want the recovery to look like and really having the recovery process folks on what is it that the individual themselves is hoping to achieve or work towards. I think one of the other really big ones to highlight is that recovery has many pathways.
Many times, we talk about recovery as if it were this linear kind of process. But what all the research shows is that there’s always ups and downs to recovery. That’s part of the process of learning. And so, the idea that recovery itself is nonlinear and can take many different forms.
It never looks the same for each person because when we look at it more of a holistic fashion, everybody is a little bit different. And we want to have a framework that allows us to implement care that really shows respect for those differences for each person’s strengths and allows them to use that in a way that helps them in this recovery process.
And so, coming from a kind of research background, I always think it’s important to kind of highlight what is the data and what is the research that supports this framework. And what we do know from the research is that things like shared decision-making was really kind of build on that idea of a person-centered care and respect for an individual’s autonomy and choice.
Actually, it’s not to kind of enhance outcomes in a variety of rehabilitation services through numerous studies. Additionally, one of the things that I really like is this idea of hope.
They actually found that an individual’s feeling of hope following completion of treatment was actually moderated the relationship of how people respond into subsequent stressors in their life.
Finding that there’s higher feelings of hope actually demonstrated greater resilience, had more self-efficacy and their ability to kind of roll with all of the challenges that life may present. And overall, had kind of greater outcomes in the long term, somewhere with greater self-esteem.
And so, each of these individual areas has actually been shown to be associated with better outcomes when fostered. Additionally, when you let individuals define their own sense of recovery, we found that when you ask someone, how do you feel like you’re doing on your recovery process based on your kind of goals?
The higher they rate their progress on their recovery, we actually find that, that was correlated with lower levels of psychiatric symptoms across the board, greater self-esteem, greater social support.
And I think the important part about this one is it wasn’t just having relationships but it was actually a greater utilization of those and connection with those social supports. So greater engagement with them due to feelings of empowerment. And we also saw that overall, higher levels of recovery was associated with just an overall higher quality of life beyond just the reduction of psychiatric symptoms.
And so, as we talk about this framework, we always talk about this idea that symptom reduction alone is not necessarily equivalent to recovery. Is a core element of recovery, but there’s so much that goes into living a meaningful life. And that’s what this framework allows us to focus on. It’s one of those other aspects and how do we help foster those aspects to... the treatment process.
And so, with that as background, I want to talk a little bit more about kind of the idea of language and the different elements in how this recovery process might actually take place in a clinical setting, such as here at McLean. And so, the first part of this is that recovery is person-centered as one of those kind of core pillars of the recovery process.
And what this means is that recovery is really focused on a process that respects and responds to an individual’s preferences, needs, and values. We’re trying to essentially acknowledge that each person’s values and goals are going to be a little bit different than their peer that’s next to them, or then from ours.
And that’s important for us to respect those and ask about those to understand how treatment can be most effective in helping people work towards the life that they desire.
And really a core element of this is how do we communicate actively between individuals, their healthcare teams, and in the case of say, inpatient units or residential units, how did the healthcare teams on those units communicate with the individuals, support networks and healthcare teams outside of the units as well?
But it’s not just about whether or not the communication takes place but also how that communication takes place. And so that’s where we come into this idea of person-centered language, which has also been kind of talked about as person first language, recovery language.
All of these kind of, have this general underpinning of, the fact is that the words that we choose tend to reflect our attitudes and they do impact those around us, whether it be the individuals that we’re working with or our colleagues and peers.
And so, by choosing our words carefully, we can actually promote this sense of resilience. We can foster this idea of a renewal of hope for many who may feel like hope is hard to come by in their day-to-day.
Especially if we think about within the context of the ongoing pandemic and just kind of what 2020 and kind of held. Hope can be hard to come by. And so how we choose our language can be really important in how we help individuals feel hope for the future as we move into 2021 and beyond.
It’s also a way to demonstrate dignity and respect, and honestly, decrease stigma about mental health as a whole. And one of the things that we’re really going for is that we want to choose language that focuses on empowerment of an individual and their support networks their families, those that are close to them.
But also allows us as providers and the individual themselves to be able to see past a diagnosis and see themselves as that whole person so that they can continue that recovery process in a more holistic manner.
And so, one of my colleagues always talks about this. Sometimes it’s more honestly about the spirit in which we have these discussions than necessarily each specific word because sometimes we all make mistakes with our language. But the spirit in which you engage in things can be a real important part of that.
And so, when we talk about person-centered language, we’re really talking about a spirit that reflects curiosity and genuineness. Is demonstrating respect and empathy for those that we’re talking to and really has a sense of openness.
There’s my colleague, Jason Krompinger said just kind of being fundamentally human is kind of our goal. And so a couple of ways that we can kind of focus on what to and not to say kind of within this spirit is thinking about things like trying not to be vague in the words that we use whether it’s in discussions or notes that we use.
Not using derogatory words that are really kind of overgeneralized, that don’t really mean a whole lot. So, this idea they are mentally ill versus the individual was recently diagnosed with generalized anxiety disorder and struggles with worry around day-to-day life events.
One of the things that I think is really important here is when we use those more kind of vague, somewhat judgmental words, they actually have a lot of different meanings. And so clinically... they don’t really tell us anything.
And that may not tell the individual anything about what do we do? How do we help? One of the other things is that we want to talk, not just about an individual’s kind of illness itself but also who they are as a person.
So, we can understand the context of the struggles and other challenges. And kind of think about what are different ways that we can help them move through this and the direction that’s important to them?
Another element of kind of recovery in this kind of in this area is that recovery is collaborative. The hope is that each individual takes a sense of ownership in their own recovery. And that as providers, we work together as a team with them collaboratively helping plot the course forward.
And so, one of the key ways in which we do this is through shared decision-making which is a process by which kind of healthcare choices are made jointly between treatment teams, practitioners, and individuals. The core here is having a collaborative discussion.
Using that person-centered language kind of spirit to have a discussion about what is it that the individual is looking for? And then both bringing all of the different kind of knowledge and options that the provider may have to the table so that both parties can discuss what makes sense for that person next while being well-informed.
So, the idea here is to both acknowledge the best scientific evidence available but also acknowledge the person’s values and preferences. And the fact that they are the expert on their life.
And so, we’re bringing these two areas of expertise together to have a collaborative discussion with really the goal is to help an individual have all the information necessary to have and feel supported in making a decision for their future.
And really this is kind of like the center of recovery oriented care and patient centered care and has become an emerging best practice across the world both in behavioral and physical health. And so, this is just a little bit of an overview of what we mean by bringing kind of acknowledging both the individual and the providers, you need expertise and bringing them together.
Of kind of using that knowledge from both sides to have a discussion using decision support tools and truly discussing what the options are, both the pros and the cons, so that an individual can make a supported and informed decision for themselves.
The other piece that’s necessary for Recovery Oriented Practice is that it has to be trauma informed. And so, we talked about trauma informed care as a core element of recovery. One of the reasons this is most important is really when we look at the data, about 90% of individuals seeking mental health services have experienced or exposed to trauma.
There’s actually somewhat recent data coming out that about 83 to 87% of the general community at some point in their life will experience, will be considered a significant traumatic event. So, the experience of trauma is more the norm than the exception.
And so, trauma-informed care is all about recognizing a role in the impact of trauma, both on individuals that you’re working with but also as providers recognizing the impact of trauma on ourselves or on our peers. And so, when we talk about trauma informed care, it has two main elements.
The first is the kind of the clinical element of assessing, discussing, recognizing, and acknowledging the impact that trauma may have on an individual and how that may inform what we do clinically. But also, from an organizational standpoint, it’s important to have kind of a framework that supports things like empowering individuals who’ve experienced trauma.
Providing choice and making sure to provide a collaborative, safe and trustworthy experience, knowing that those are the things that trauma can impact the most. And that we don’t really know whether or not someone’s experienced trauma. Unless we ask.
And so, when we think about trauma informed care, they call it the four Rs of trauma informed care. These are the four main components. The first is realizing just how widespread trauma is and really learning and realizing the impact that trauma can have on an individual.
And the way that we as humans may trust someone. The way we may feel safe, where we feel safe, or whether or not we feel safe. The way we feel whether or not we have a sense of power and control of our own life and our own destiny in that sense.
The next is to recognize the signs and symptoms of trauma both in the individuals who we’re working with. So, looking for them and being able to recognize them, both in individuals that you’re working with and in colleagues and peers. The next is to respond to trauma by incorporating this awareness into all of your clinical and organizational activities.
One kind of core piece of this is asking and assessing for trauma, even if you’re not in a trauma specialized program, but making sure to assess for it ‘cause all of these things are really focused on resisting accidentally re-traumatizing someone.
We never really kind of set out to re-traumatize someone, but sometimes it can happen by accident if we’re not paying attention to the impact that trauma plays and really maintaining an awareness of how pervasive trauma is.
And so I think these are kind of core elements of having discussions with individuals to understand their own history, their own context of what it is other struggling with and how we can best understand what their experience is so that we as clinicians can have a good collaborative relationship in which we’re working together towards the recovery process that the individual is looking for.
And so as we kind of wrap up this part and then open it up for questions, there’s one piece of this recovery model that doesn’t always get talked about quite as much as some of these others but it’s an incredibly important part of the recovery process. And that is the idea of promoting recovery through peer support.
And in this case, this is the idea of allowing individuals to collaborate and work with peers who’ve experienced similar challenges and can provide a sense of hope, a model for learning and can really foster empowerment and essentially help share that recovery is possible.
And so when we think about this concept of peer support, there are certified peer specialists which are individuals who have lived experience, who are trained to share their personal experiences in a way that promotes hope and reduces stigma and enhances feelings of autonomy and empowerment for individuals.
Our peers and as those of you that have been working here may have actually interacted with many peers during your time at McLean Hospital or working in kind of these types of hospital settings, peers are integral to providing both individual and group services, as well as providing didactics and training to hospital staff on what it’s like to live and work through mental health challenges.
What that looks like and to help give an idea of what recovery looks like. Peer specialists and peer mentors, they use their lived experience with mental health struggles to offer hope and connection, support, and ideas for recovery.
And it can be an integral part of the treatment team in those moments. Especially as we’re trying to navigate each person’s individualized recovery process. Peer specialists are also uniquely suited to talk about some very specific topics such as self-blame and what that’s like when you’re struggling with mental health challenges.
How to address things like a fear of failure and kind of empower oneself to embrace the dignity that comes with taking risks and working towards what it is that you value the most. How to address negative self-talk.
And some of the ways in which that can really become a challenge to the recovery process for an individual. And a lot of times, it’s negative self-talk that things that we might be ashamed or scared to share with treatment providers. And peers can provide that bridge and that supportive environment to do so.
It’s also a way to reduce stigma, to normalize the fact that mental health challenges are part of being human. And that unfortunately the stigma that gets in the way, it makes it hard for us to necessarily discuss those or gain support or support networks around it, for fear whether it be a retaliation of misunderstanding or the way in which others may look at us a little bit differently.
And the other pieces that peer specialists really focus on and have been trained to help enhancing feelings of empowerment and help enhance self-advocacy, which is incredibly important, as we talked about to this recovery process, to allow for things like shared decision-making. These discussions about what’s next and what an individualized recovery process might look like.
The other element of kind of peer support is this idea of helping individuals shift from what they might come into a mental health and medical system thinking of as the kind of typical medical values that as an individual seeking treatment or seeking help can be kind of disheartening.
This idea of like once you enter the system, you’re supposed to have low expectations for your life or that your focus shifts just maintaining your symptoms or stabilizing. That everything has to focus around your experience of your mental health symptoms.
But peer support is all about helping transition these kind of ideas of typical values into this idea of recovery oriented values, where an individual can hold a high expectation for their life. They can strive with things that are most important to them. Where the focus doesn’t become so much on just maintenance but this non-linear recovery process as a whole.
And each of these steps as a process of learning as you work towards that kind of self fulfilled life. A focus less on just the illness and the deficits that one’s struggling with. But more emphasis on the strengths and how they can use those to overcome the challenges in front of them. How to reintegrate into the community and how to feel a sense of dignity about that recovery process for oneself as you move through it.
Since 2015, we’ve actually had certified peer specialists from Waverley Place that have been sharing their recovery stories on units here at McLean Hospital. Additionally, since 2014, the Interdisciplinary Recovery and Practice Committee was actually developed here at McLean with the goal of enhancing these principles that we just discussed and the recovery-oriented framework into the culture of McLean.
And part of that has been the development of recovery Oriented Practice toolkit which gives more in-depth training to each of these elements that are kind of reviewed today. As part of this, we’ve collaborated and worked with numerous peer mentors and certified peer specialists who are part of this committee.
And in 2017, became formally integrated into many of the inpatient units and helped us build and facilitate the implementation of a peer mentor pilot where we were actually evaluating the outcomes of having peer mentors on the units and integrated into the staff of these various inpatient units. And I just want to kind of share this as the final piece.
So David Weene, who kind of spearheaded one of these evaluations, actually kind of shared with us many of the, I don’t know if it’s feedback that they were getting from these recovery stories and these recovery lands and groups and individual discussions they were having.
Finding that 89% of individuals felt more hopeful after hearing peer mentors and peer specialists speak and share their stories. Further, the top responses really focused on this idea that these experiences were fostering a sense of hope for individuals who are on the inpatient units. A hope for their future, hope for recovery.
Many of them found it helpful about thinking about their kind of recovery process a little bit differently. And one of the ones that we saw the most was that we need more things like it.
I think really speaks very powerfully to the impact that peer specialists, peer mentors, and this recovery-oriented framework can have on individuals who are going through treatment currently, whether it be on an inpatient or a residential unit as part of a partial program or part of an outpatient program.
This framework really can have a powerful impact on recovery for many and gives us a essentially a guide to help individuals live the life that they’re looking to live. And so, with that, I just like to say a big thank you to the IROP committee and the content leads who really created all of this content. That I got the privilege to kind of give the overview of today.
And so, I just want to say a big thank you to all of them. And for the next, I guess about half hour, we can open up the questions and kind of take the discussion where those of you that are here with us today would like to talk about. So, thank you all very much.
Jenn: Alright. So, we’ve got a bunch of questions already. So first and foremost, how can we help somebody recognize that they need help particularly after experiencing a trauma?
Nathaniel: I think that’s a really good question and a very difficult question because for each person, it’s going to be a little bit different but I think just providing education and resources in a supportive way about trauma and about the kind of impact that trauma has.
So, the Substance Abuse Administration, SAMHSA, that I talked about actually has a lot of great trauma informed care resources. There’s also a number of organizations dedicated specifically to trauma informed care.
So, if you Google trauma-informed care, you’ll see a number of resources, many of them in different areas either the state or the country. That finding one time near you will have a lot of good research about what trauma is and how it impacts us.
And I think one of the important things that goes with that is that in many ways as humans, we’re actually hardwired in a way to recover from trauma. But a lot of times, trauma can become so intense, overwhelming, or prolonged. That something in the environment can get in the way of that naturally hardwired process.
And so really treatment for trauma is all about helping kind of get those things out of the way to allow you as an individual to do what it is that your brain is designed to do, which is find ways to be resilient. And so, I think sometimes framing it in that manner that it makes sense.
The reactions that one might have to a traumatic event. That they make sense and there’s nothing inherently wrong with them. That’s part of how we’re wired to cope with trauma and try to keep ourselves safe.
And so really treatment isn’t about denying or getting rid of it, it’s more about helping you understand what that process is and figuring out what’s getting in the way or making it more difficult to providing support as someone goes through it. And so, I think that can be a really great way to do it.
Also places like NAMI have wonderful support groups for it. The Cole Resource Center has peer mentors and peer specialists. That would be another great way to just talk about the experience of trauma.
Where I worked today in the Veteran Affair Hospital, that was one that we did a lot where we would have veterans come in and talk as peer specialists about what it’s like to experience trauma and the fears about the treatment process and help answer questions. I said, I think all of those are wonderful ways to help kind of normalize the process of seeking help for trauma.
Jenn: Okay. So how do we talk to patients if we’re a provider about the right to fail? I know that there’s a lot of folks who see it as if a treatment doesn’t work for them, it’s a setback and not a step in the different direction. Do you have any advice for how to reframe that?
Nathaniel: That’s a wonderful question and a really great discussion to have with individuals. One of the ways that I like to have it is actually talking, focusing on that nonlinearity of recovery. And I actually think the recovery framework is a really nice way to discuss that because it talks about recovery as essentially like a series of learning events.
There’s a quote from, I believe it was the seeking safety protocol that focuses on PTSD and substance use when they co-occur. And it talks about this idea of an individual walking down the street and falling into a big pothole ‘cause they didn’t know it was there. But then the next day, they’re walking down and they kind of realized I just fell into the same pothole again.
And then the next day, they walk around and like, they see it, they know it’s coming but they still kind of trip and fall into it. But then over time, the more that they kind of walk that path, they get a better sense of I remember right, this is where it is.
So, they’re able to walk around at the time after that. But one of the things that they did get really good at, was getting out of the pothole because of the practice. And is it okay if I share a whiteboard screen real fast?
Jenn: Yeah, by all means.
Nathaniel: So, one of the other ways that I like to kind of talk about it is that when you think about recovery a lot of times, people kind of think about it as, it’s supposed to go like this. And so if you’re thinking of it as this linear kind of gradual process where everything always gets better, it can be really difficult to take a risk and feel like, well, that means that if I fail, then this recovery processes is ruined for me.
And some of our earlier models of motivation tend to talk about this idea like relapse was almost inevitable and then you start over and go around it. But a lot of these models have actually been kind of revamped now to talk about recovery less as this linear process but kind of more as like kind of a looping process. I can’t really draw using my mouse but get the idea where--
Jenn: That’s great.
Nathaniel: Excellent. As you go through it, there are these setbacks, but each of those setbacks is actually an opportunity to learn how to generalize the skills that you’ve learned in one context to another context in your life.
And there’d be no way to learn to generalize this unless you tried them. And so, what you do by actually having a little bit of that setback and then saying, alright, so this is where I kind of struggled or what skills I might need to develop for this type of situation.
It gives you the opportunity to learn those skills and be better prepared for the next one. So even if you have setbacks, you’re still moving in a positive direction, it’s just a little bit bumpier, kind of looks like stock market, lots of ups and downs but it’s the idea that with each of those, you learn something new and it becomes quicker and quicker and quicker to kind of pull yourself out of that pothole and find different ways around it in the future.
Jenn: I think that’s a really great way of looking at it. And it’s even like if you look at somebody’s conceptual Everest, so to speak, even Everest, doesn’t go straight up. It’s got all these peaks and valleys and crevices along the way. Nothing is linear. I mean, unless you’re looking at a legit graph but nothing is ever linear.
Nathaniel, we have received at least half a dozen questions on how do I become a peer specialist? Do you have advice about where to get started, any programs in the area, any online resources? So, people want to know.
Nathaniel: So, there is a place that’s called Transformation Center. I believe it’s called the Kiva Institute here in Massachusetts. And they do certify, they do have a program for becoming a certified peer specialist.
Other places that you can, I really recommend if you’re interested in this, talking to a peer specialist to learn more about the process. There are a couple of great places to do that. One is through Waverley Place.
The other is through the Cole Resource Center here at McLean. So, they have peer specialists who will talk about that process. The peer specialists, both from Waverly Place and Cole Resource Center are a part of the recovery and practice committee and have been wonderful about talking with people about the process.
And so, I’d recommend reaching out to Waverly Place. Some of their certified peer specialists or to the Cole Resource Center or to, I hope I’m getting the name right. I think their new name is the Kiva Center. It used to be a transformation center.
If you Google that, it’ll come up. Within Massachusetts as well. So those are some great places to start for those of you that are here in Massachusetts.
Jenn: So, we had someone ask about, can you give some specific examples of positive language to use with family members to help encourage and give hope for the future?
Nathaniel: So, I think one of the ways that you can think about it and it’s going to be specific to what each person has kind of struggled with. So, I’ll try to come up with good one on the spot.
I think, one of the ways that you can do it is framing it within the context of what the individual is learning. And the other, so one of the things that I’ll say a lot is that, struggling ‘cause I work in anxiety in OCD. So, one of the things that I’ll talk about a lot is this idea that anxiety is kind of an innate hardwired way that we all tend to keep ourselves safe.
And one of the challenges of anxiety is sometimes it comes out of nowhere and we don’t really know why it happens, especially ‘cause we may not know what that danger is but our brains are really good at coming up with all the different possibilities of how things could happen.
And so part of what we do in treatment is help kind of take that natural creativity that your brain has of generating all these alternatives but be able to feel a sense of control over it so that you can use it when it’s helpful and kind of notice it, but not get stuck in it when it isn’t.
And the other ways that we’ll talk about that is that really, it’s just a process of learning and finding something that is kind of important enough to challenge those feelings for you.
And for each person, that’s going to be a little bit different. So, I think kind of, for me, it varies a little bit based on who we’re talking to, but it’s always framing it in the terms of that treatment is possible.
I always try to reframe it also into giving examples of people who’ve gone through treatment or given testimonials or stories or read books about kind of navigating treatment successfully.
And also give a sense of what is it that they’re, I asked for what their values or goals are ahead of time and talk about how treatment will allow them to engage in those specific tasks, values, or goals, and what that would look like.
So, kind of framing the treatment process in terms of where it is that the individual wants to achieve is one way that you can kind of relay that to the family members.
The other is kind of talking about the idea that I think this is actually an important one is that you don’t necessarily have to be at the end of treatment to live a valued life or to regain those valued connections with family members.
I think that’s one of those things that can be challenging, is so do we just have to wait until there’s no anxiety? A lot of times what I’ll say is if you have no anxiety, that’s actually a bigger problem because that’s the only thing that keeps us alive when we compare our ability to survive, to compare to like a bear or a wolf or a honey badger or any other animal, we’re hilariously outclassed.
We need anxiety, we just need to learn how to use it. And that’s what treatment’s about. Is learning how to use it effectively. And so, I think sometimes we bring it in that way as well. It’s like, what is the functional aspects of what someone’s going through? How does it make sense and how do we help kind of harness and utilizing skills to not get stuck in those moments?
Jenn: Could you talk a little bit about using peer support for youths? And the example that was provided was that having a young peer support person for another young patient or client where the person who asked the questions that I see the benefits and also worry about the risk of vulnerable youth peer support specialists becoming triggered or re-traumatized.
Is there any evidence-based treatment to have this type of peer support for somebody who’s a minor?
Nathaniel: That is a good question. To be completely honest, I don’t know. Most of the peer support programs that I’m aware of, are not necessarily for youths. The times that we’ve had, so in the OCD community, we have an annual conference that involves individuals with OCD, family members, friends, loved ones, clinicians, and researchers.
And so, in the context of that, a lot of times, it might be in a context of a larger panel where there’s also like a clinician involved or doing it.
Sometimes I’ve done it where I’ll be working with an individual and someone will come in to share their story, but I’ll kind of co-facilitate with them to almost act as a clinician to act as a shield for them, but also making sure that they have a really clear understanding of what it is that they’re doing and make sure that their kind of legal guardians and parents are on board.
And that they feel like kind of asking them what is the line that you feel comfortable with? So that as staff we can jump in should that line get close, that we can redirect.
I think that’s always important. I would say that I’m not really clear on any certifications or empirically based interventions that focus on kind of like adolescents or otherwise, but peer support.
Most of those are currently are focused more on adults who have gone through this peer training and usually are working under supervision as well by other peers. They approved group supervision, consultation with staff on a unit.
So, it’s a pretty close-knit integrated process but I think that’s a great question. I wish I had a better answer for you but I think it’s definitely something that kind of we as a community should look into, because I know there are many who are excited for the idea to be advocates. But it’s tough to figure out what that path is.
Jenn: Do you have any strategies or advice for inspiring hope and empowerment if you have a client that is struggling with learned helplessness and or self-sabotaging maladaptive behavior?
Nathaniel: I think in those moments, one of the ways we could go about it is actually helping them highlight strengths. I think with the idea of learned helplessness, a lot of times it can be related to this idea of a certain core belief about one’s ability.
And we know kind of from, both clinically and from the research that once those core beliefs take place, it can be really tough not to filter out contrary information or evidence.
And so, a lot of times, I’ll try to focus on helping an individual identify and kind of elevate the things that they did well or their strengths. And even in other domains or what are the things that they’ve done before, that maybe they’re not really giving themselves credit for ‘em.
Where if they’re taking one experience and overgeneralizing it and saying like, I’ve always done this, then we’ll kind of look for some of that alternative evidence of other times when they did things like that, really, really well.
The other would be actually reaching out if you’re in like a group setting, sometimes we’ve asked people to share their experience of each other, if they’re a really close-knit group. And then we talk about the process of how difficult it is to hear somebody tell you, you did something well.
And how like kind of sometimes our innate response is to be like, cool, cool, can we move on? But almost like helping people sit in that moment and talk about the things they did do well, can be one way to challenge learn helplessness.
The next can be just kind of in fostering small accomplishments together that you can kind of support them in. We almost like a therapist assisted exposure, if you will, or behavioral experiment and kind of build on that. The other would be using motivational interviewing to kind of get an idea of like what is it that they do want to change?
And I’ll see what their ideas for change are. Even if they feel like I can’t do this and say, alright, well, let’s find the things that are in the way of being able to do this great idea you just came up with. And where can you use support? And so, we can find those support mechanisms as we go through.
Jenn: So, I know that you had mentioned shared decision-making as one of the recovery principles that has a better outcome. What do you advise if somebody isn’t in a place where shared decision-making is possible? For example, if you’re a minor who’s seeking care or somebody that just has a healthcare proxy that’s making the decisions for them.
Nathaniel: I would recommend trying to have that discussion with all parties, excuse me, with all parties involved. Especially if you’re working with individuals who are minors. Don’t have a healthcare proxy. There may be discussions that occur with them but I think from a clinical standpoint, including them in the discussions can be incredibly important.
And also making sure that any of those decisions that are being made by kind of either the parents or healthcare proxies are articulated to the individual in a way that they understand, that makes sense, and giving them an opportunity to ask questions.
I think that sometimes is a really an overlooked kind of avenue that shared decision making is here’s what we’re thinking. Here’s what maybe your parent, a healthcare proxy is thinking.
Here’s kind of some of the ideas that we came up with. What do you think of these ideas? Any of these that seem more doable to you or concerns that you have about them. Or do you have questions about why some of these.
I think that’s also one of the big ones is saying we’re going to do this but sometimes, when we get busy, we can forget to say why. And so, people start doing it and it’s kind of like, all right, well, I was told to versus actually spending that time to help kind of explain why that is the thought, it can be very beneficial.
Jenn: What do you suggest that we do if we make a mistake with language, whether or not we’re a loved one, we’re a provider? Do you have any tips for ways to apologize and start rewriting that ship?
Nathaniel: I mean, I think, you kind of hit in that question, hit the nail on the head with, I apologize. I think it kind of goes back to that idea of the spirit of it. That it doesn’t necessarily mean you have to have the perfect like language or words to say you’re sorry.
But just to say, hey, I noticed this. Or I noticed that I use these words. How did that make you, like how did that kind of resonate with you? And I’m sorry if it kind of felt defeating or like I was breaking it down. What would be there? And then ask, how would you prefer that I talk about this?
I think that similar question comes up a lot around the idea of being a patient versus client versus individual. And honestly, everybody has their own preference. Some people prefer the term client when they’re being referred to.
Some prefer patient. It gives them a sense of comfort or a medical sense. Some prefer individual. There’s no right or wrong around it. So, I think just apologizing or saying I noticed that I was using this and then asking and then kind of going with that.
Jenn: So, a follow-up question would be, if I’m somebody who’s recognizing that my social circles, whether they’re colleagues, parents, et cetera, they’re not being cognizant of the language that they’re using. Do you have advice for how to introduce these sorts of concepts to them?
Nathaniel: That can be a tough one depending on the type of social circle. If it’s more occupational, I think sometimes just having, using something like what we have on Brainwaves around it’s kind of the recovery language or just posting around, but then also modeling. I think sometimes that’s the best way.
And I especially encourage new trainees or new staff to kind of model what they would like others to see ‘cause the way that they use language will stand out, to others, and can be a way for change and then look for opportunities to do education and do talks on shared decision-making and person-centered language.
When it comes to social circles, I think sometimes, it always comes, for me, it kind of comes back to starting with the modeling piece and trying to make sure not to attack people for because they’ll tend to shut down. But more of say kind of model how you would discuss it within that conversation of what language you would use or you would like them to use.
The other, if it’s kind of directed towards you as an individual would be to just kind of try to, set up a way to have a one-on-one conversation with that person not so much in the group setting and say and kind of explain what the impact of that has.
If you don’t feel comfortable with that kind of disclosure in that area, I think then it becomes down to the modeling component of choosing that different language because it will stand out to those around you and kind of slowly affect change. It may take a little bit of time, but it can be helpful.
Jenn: And that modeling is something that’s so important across all types of identity, whether or not you’re talking about sexual identity and referring to your wife as your partner and something that just introduces the fact that you are more of a safe space through your language.
Jenn: How is a person, can I keep an eye out for what I might be subconsciously implying through the words that I’m using? And if I find myself referring to people as being depressed or anxious, even like focusing on that language a little bit more even when I don’t want to, how do I start disrupting this cycle?
Nathaniel: Honestly, I think in that case, you’ve taken the first step to do it. It’s just actually thinking about the language you’re using and reflecting and noticing when you use it. The next step a lot of times is just to actually reframe it for yourself when you say it.
And if you notice that you may be used in conversation, try to essentially switch it in that conversation. Like notice it and say, I’m sorry, I mean, when someone’s struggling with anxiety or when someone is kind of confronting anxiety or experiencing anxiety or experiencing sadness, or the impact that feelings of depression may have for someone.
And so, it’s kind of taking those moments and just noticing them, and then trying to like, almost the next time you use that in that same conversation, try to switch the wording order a little bit. That over time will kind of take hold and help kind of perpetuate that. But I think the fact that you’re thinking about it and looking for it, already shows a spirit of person-centered language.
And means, you’re going to be a little bit more aware of it when you’re talking about those topics moving forward. And so, then you can kind of use some of like the language guides potentially and there are many of them online about kind of big ways to reframe certain statements into kind of more, kind of person-centered language.
Jenn: Do you have any evidence of the impact it has if somebody is discussing specific symptoms versus labeling it as their mental illness? The example that the person wrote in was I’m really manic as opposed to I’m spending too much money having racing thoughts not sleeping.
Nathaniel: I don’t know. I don’t have a lot of data that I kind of know off hand but what I will kind of say anecdotally and clinically, is I think in some ways, it’s also important to have the discussion. If we’re talking about an individual who is talking about themselves, there are different ways to talk about symptoms that you’re experiencing or experiences that you’re having. That it’s going to be a little bit different for each person.
I know for some individuals, they’ll talk about like I’m feeling or I’m struggling with mania symptoms or kind of I’m being overwhelmed by anxiety my OCD something like that. And for them, that’s helpful.
And for others, it’s more helpful for them to identify the individual and be specific about what it is that they’re experiencing. I think ultimately if we’re thinking about person-centered language and person-centered care, we have to ask the individual what that experience is for them.
And ultimately, it’s their decision on how it makes the most sense for them as they’re talking about their own experiences. I hope I’m interpreting the question right in terms of that idea of like talking about, someone talking about their own experiences.
But as a clinician, you might just ask, what’s the impact of that for you? Like when you say like I’m manic or I’m bipolar and that label, what does that mean to you? And is it helpful or do you feel like that kind of like starts off this kind of series of rumination where you kind of get down on yourself? ‘Cause so, we can talk about different ways to talk about those symptoms that may inspire more hope.
And so, you’re kind of trying to have that discussion with them and then help them find their own language that helps it make sense for themselves and can be more kind of future oriented and a little bit more hope kind of driven. That’s just one personal take on though.
Jenn: Do you have any advice for ways to come up with language if the client is struggling to find the right wording? So, an example that a person wrote and it’s schizoaffective but they’re trying to develop better language around brain disruption but haven’t found that one that sticks.
Nathaniel: I think sometimes just focusing on like the kind of objective behavioral like objective slash behavioral or cognitive experience of that, when it comes to like things like brain sharps and things like that. It can be a little bit more challenging than some of the abstract concepts.
But I think sometimes lately, like trying to help them label the emotions that they’re feeling or the experience without necessarily meaning to have a singular term that encompasses it. But what is it that they’re struggling with at the moment?
So, what is the experience that they’re trying to get to that they’re having a hard time capturing. Kind of talk almost like, certainly like you’re talking around it a little bit.
The other is, there are many kind of mental health dictionaries, if you will, that talk about like, for example, labeling emotions. And even after all these years of practicing, when I look at some those emotion charts, I’m like, I can’t remember the last time I used this word for emotion.
And I think before this, I was still a little fuzzy on what this word meant in terms of like what kind of combination of emotions we’re talking about. And so, I think even using some of those types of charts.
The other piece is just talking more behaviorally on what it is that they’re struggling to do. And kind of using that objective reporting of behavior or objective reporting of emotional or internal experience can be helpful. And it takes a little of the pressure off of having like the right term that they have to use knowing that it may vary each time they have similar experience but it may be slightly different.
Jenn: We’re one minute over the hour but can I get one more question out of you?
Jenn: Amazing. Any specific guides, resources, books that you would recommend to help us with person-centered language?
Nathaniel: I mean, I have to put in a plug for the recovery practice toolkit because that’s where a lot of what I presented today came from. So, if you’re here at McLean on Brainwaves, we do have the recovery oriented tool kit that has an entire section on person-centered language, a number of great guides.
There’s also the kind of, you might see, if I can hop off screen for a second, I can show it. So, for this, this is up around the hospital is I get promoting first person language is you may see signs like this that are also available on Brainwaves and on McLean’s website.
The other place to really, the Substance Abuse Administration and Mental Health Administration, SAMHSA, they have a really wonderful set of resources for all these and they have links to a number of different websites that all focus on each of these aspects of recovery. So, I think they’re a wonderful place to look.
One of the others that comes to mind, I’m trying to recall off the top of my head. I should have these written down ahead of time. But I think those are some of the main ones to look into. Also, looking into the concept of universal design and health care.
They do have a subset and links into a person-centered language as well. Those are the places I would probably start ‘cause they are updating a list of recommended readings, books, handouts, pretty regularly. I have a really wonderful resource kind of library for that.
The other one if you’re looking more from an organizational standpoint, Australia actually published their overview of recovery oriented framework integration for their healthcare system.
And if you kind of look for an overview of recovery oriented process integration for an empirical kind of articles, that will actually come up and it’s actually a really great resource ‘cause they did a wonderful job explaining it. I think those are some of the main places.
NAMI is another good place they do have lot of information on recovery oriented practice. And then I’ll try to come up with some others and maybe something we could send out after I can pull on to my colleagues who are focusing specifically on this piece and get some of their resources to send out.
Jenn: Awesome. That would be fantastic. And I know I’ve stolen a few more minutes of your time and while I knew that language mattered before the session, I’m sorry that I pigeonholed you into being the guy that eats the sandwich off his shoe.
Nathaniel: I’m okay with that.
Jenn: So, so sorry about that. And thank you so, so, so much for all of this information. This has been an incredibly valuable hour. I cannot thank you enough for all of this and I want to thank everybody else for joining.
This actually ends our session. Until next time, be nice to each other, wash your hands, stay safe. Thank you again, Nathaniel. Have a great day, everyone.
Nathaniel: Thank you and thanks for having me.
Jenn: Thanks for tuning in to Mindful Things! Please subscribe to us and rate us on iTunes, Spotify, or wherever you listen to podcasts.
Don’t forget, mental health is everyone’s responsibility. If you or a loved one are in crisis, the Samaritans are available 24 hours a day at 877.870.4673. Again, that’s 877.870.4673.
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The McLean Hospital podcast Mindful Things is intended to provide general information and to help listeners learn about mental health, educational opportunities, and research initiatives. This podcast is not an attempt to practice medicine or to provide specific medical advice.
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