All right. So this is being recorded for posterity. So that's the reason that I'm on the recording. But we can break with that at times. So let me tell you what I was planning. And we can see what you guys would like to do, since there's two of you. So we have a little bit more prerogative, I think, in terms of how this is going to roll out. So yes, this talk was actually written by myself and two other psychologists, Dr. Shelby Arnold and Dr. Francesca Lewis-Hathaway. They were not able to come. And so I'm presenting the work for all three of us. But we all work at the center. This is what I'm hoping to do. I just want to kind of get you knowing who it is that we are, give you a little sort of sense for what CTR is, and then show you the tool, which I've given you, the recovery map. Because my idea was to give it a little bit of a practice. So I'll give it a test drive to see sort of what it does for teams. And then basically, I'll introduce it. We'll try it out together, because I have a case example, which I've given you, and the map, and just see what you think. Welcome. It's a very intimate session today. So I have materials for you, if you wouldn't mind coming up and getting them. There you go. OK. All right. So this is our plan. This is our agenda. This is our plan. OK. So who are we? So we're the Beck Institute. We're located in the Philadelphia area. It was actually founded by Aaron Beck and his daughter, Judy Beck. And we specialize in CBT and recovery-oriented cognitive therapy. I am the director of the Center for Recovery-Oriented Cognitive Therapy. I do have a couple of books I've written, so I have a disclosure. Shelby also has written a book. Interestingly enough, all the talks I've been to, almost nobody had disclosures. It was kind of interesting. So I kind of wonder if I'm overdoing it here. But this is our team. Just to show you that some of the people who wrote this talk are here. But it's quite a diverse team in terms of the background. We have an educational specialist, a couple of forensic specialists. We also have a research team. We have a research team. a registered nurse, so we are in some sense a team. Is it okay? Oh, yeah, the security system, I understand. Thank you, sorry to interrupt. It's okay. We like intrusive thoughts, so it's all good. Makes us better. Anyway, just letting you know. This is our spiritual guide and mentor and friend, and sadly, he's not with us anymore. Next, no, sorry, in July, so in about six weeks, it would have been his 102nd birthday. He did make it halfway to 101, so it's been about, I would say, a year and a half since we lost him, and he did a lot of things, but he was very deeply involved in this work, and the original reason that I ever came to this conference is because of him, and I wanted to just tell you that he said he saved the best for last, so that's this, so you'll see a lot of him in what it is that we're doing here, and I just wanted to give you this quote of his because he did a kind of Henry V thing. We work in some major systems, which I'll show you in a second, and we gathered everyone together to kind of recognize people's successes and things like that, and he wanted to say something inspirational, and this is what he said. There's nobody in the world that doesn't have aspirations, that doesn't like to think of making their life better. People come in discouraged, demoralized, and apathetic, and they are offered a new life, and they're able to go on and live the lives they've always wanted to, and that's what we have to offer. So some of what we're gonna be doing with the recovery map is trying to map that out, starting with somebody like this gentleman, Michael, that we're gonna work on, who is definitely in that earlier phase of things, and trying to move him to the lower phase. Anyway, Aaron Beck, he's a very special person. So this is the kind of work we've done over the last 15 or so years. Just wanna emphasize that we've done training in many of the major state systems across, a few of them are missing, but sort of kind of a smattering of states. And I just wanna emphasize that the CTR happens to fit a lot of settings, so we certainly have done a lot of work with community teams, both fidelity and non-fidelity, specialty care teams. We've also worked in institutions, so state hospitals, forensic state hospitals, residences of all sorts, programmatic, not programmatic. Some of the programs that support independent living. And we even have been quite successful working with sex offenders, interestingly enough. Also, it's a multidisciplinary approach. It fits most, if not all, the scopes of practice that people have that you find working with individuals with serious mental health conditions. So you can see we have quite a list there. And one of the things I wanted to focus on with the recovery map is just that when you have a team composed of some of these people, people can approach it differently based on the formulation that you come up with. And one of the reasons that this recovery map that I've given you is one page is because we discovered in practice that's what worked. That was what, people are like, give me one page, and we'll put it together, and then we'll put it into practice. Eight, 10, 12 pages, things will get missed. Okay. So this is sort of what we've been trying to do now for a bit of time, just to kind of introduce you to it. The first thing for the individuals is completely what Beck said in the quote. So really just helping them find their best self, be able to live that more often, develop their resiliency, or discover it. I think a lot of times they have it, they just don't discover it and apply it in the context that they need it in. And ultimately, have as independent a life as they can. And in many instances, it's pretty impressive what they can do. For the staff, I think it's really about enhancing what they can do. Everyone comes to the table with a lot of stuff. I think that CTR can help people put together some stuff, figure out why some stuff works, generalize it to other things that work. And this extends to paraprofessionals, direct care staff, peer specialists, et cetera. All of these people can utilize the principles. At the organizational level, I think sometimes what you can find is that the organizations can be in crisis a lot of times. They're constantly focusing on putting the fires out. And I think the CTR sometimes gives a different perspective. Let me give you an example of that one. We worked in a residence. It had about 16 people in it. It's a special to Pennsylvania where we're from. It's called a long-term structured residence. Some jurisdictions have it, some don't. But typically, it's the first place that you would land in the community after being in a state hospital. I remember when we went in there, they had 16 residents, and at least eight of them never got up. And they said, give us a magic wand so we can get them up in the morning. And when you interviewed the nurse in particular, she would say, I'm worried about these people. I think they will need to live here forever because I'm afraid if they go outside, they'll get run over by a truck with a big street right outside. Fast forward to about, it was about 12 months later. The same woman was saying, you just can't believe what people are capable of. It's really amazing, and the house is very different. So that's kind of what we're shooting for. If we can get people to try it and do it, it can really change. So the people weren't in bed. There was a lot of social stuff occurring. And then at the systems level, a lot of what we've done, say in Philadelphia, places like that, is create a sort of network of continuity of care so that when the individual comes out of the hospital or when they move from the residence to less, shall we say, just restrictive, sorry, restrictive level of care, it's seamless in some sense. So it's like this recovery map follows them. And so the people at the next place pick it up with a warm handshake. So it just helps sort of some of that kind of stuff. So in Philadelphia, we set up a network of care linking the state hospital to independent living. And so the person can pass through all those stages. Okay. So that's kind of what we've been doing. So I told you who we were and talked a little bit about what we've been doing. But now what is the focus of it? What is CTR? Because that's what this session is really about. So this is what we're looking to do. We find that it's an enhancement for people. And so it allows people to find out why some of the people that they haven't been able to reach, some of the people that aren't interested in treatment, don't think they need treatment, et cetera, how can you reach those people and find what they're really interested in, establish a trusting relationship with them, and then help them build whatever life they want to build. So that's at the, and it's very practical kind of stuff, as you might see. We found that it has to apply broadly. So it's not like prolonged exposure or something like that, where it's about a very specific problem. This has to apply much more broadly because when you're working in the community, you run into a variety of things with people. And at the end of the day, someone said this to me, everybody, oh, so it's Bex said, everybody can have the dreams for the life they want. That's a human thing. And then figuring out if we have specific ways of understanding how it is that people get stuck, and then ways, things we can do about that and really engage with them, then we can help them get the life they want. So that's what we're gonna talk about is how we do that. And it's a practical and it's one way to do things like strengths-based and recovery-oriented, resiliency-focused, and ultimately empowerment, I think is the end of the day, is the game here. We do really start with people who don't think they have a life. And we try to sort of help them find that. But it's very active. It's not a, it's funny, all these things are called psychotherapies, but I really think it's a misnomer because you do stuff. You don't just talk, you do stuff. And really it's gonna be action, conclusion, action, conclusion, meaning is gonna be the kind of thing that we're gonna really focus on. We've got a really terrific theory. And it's gonna be a little surprising. This part maybe isn't because I told you Beck is the part of the creation with me. And he developed the cognitive model in 1963. Kennedy was president when the thing was published. It was published just before the assassination. It's been around a while. And that could sound like that if it was a car, you'd say it's a classic. But I think in terms of this, what's happened is it's developed and been applied to so many different problems that it's very useful in the community because there pretty much isn't anybody who you see who you don't have a template for thinking about what the challenge might be. And no two people are the same. And so it's very, very useful in that way. And there's a lot of know-how and evidence-based that's associated with it. But there's something else. We've got the cognitive model. It's very, very helpful to us. But we're not a problem-focused approach. We're really a whole person approach. I wanna introduce you to how that concept works. So these are the kinds of beliefs that, again, he developed in 1963. It's very useful, I think, for families. It's very useful for people. It's got a very straightforward interface with it. But this is the part you might not know. This is another one of his theories. And we put these two things together. And this is what gets us really going with the work that we're gonna do. So this is a theory of modes. And this is really about how it is the individual fits into their environment. And we're different in different environments. I have some of the sort of casual ways that people talk about that. But if you're in some place outside, and all of a sudden there's a really, really loud sound, and I've experienced a couple of those since I've been here, all of a sudden, you're in a different state of mind than right before that. Beck would call that a mode. Similarly, we actually have a colleague who's, it's kinda cool, he's a hockey player, pianist, concert pianist, and cognitive therapist. And so you gotta imagine that when he's a hockey player, he's actually very good at the checking and that kind of stuff. Very different behaviors and thoughts are in his mind than when he's a pianist. And so the idea is you can describe those kinds of relationships to the situations you're in as a mode. And we're gonna use that because that's gonna help us find the best self of the people that we're working with. Because a lot of times you'll find that staff will say, so-and-so is always like this. Nobody is always like anything. And so being able to find the other stuff. But they're often, what you see is they're dominated by what you could call symptoms, by the challenges. And so what we wanna do is use the theory of modes as a way to find the person's best self and grow it, and then understand how they get stuck. So we're gonna put the two together. This is the take-home chart for how CTR works. It puts the two together. So we're gonna gather together a lot of what you see with individual serious mental health conditions into what we're gonna call a disconnected mode. It's probably really a set of different modes. But this is really when you're gonna, I think a lot of times when you see, so somebody who has a propensity to aggressive behavior is gonna be somebody who's really disconnected from everyone around them. People give them space. Disconnected mode. Somebody who's really paranoid, really, really worried about other people, very disconnected, can't trust other people, et cetera. I think when someone's really focused on voices, they're disconnected. So that's why we're calling it the disconnected mode. And it's dominated by the negative beliefs that Beck has studied for a long time, and a lot of other people have. And it leads to a lot of negative expectations about what's gonna go on in the environment. And really, I think the two kinds of things that we tend to see is that people are either just withdraw, kind of the negative symptom side of things, demoralized, or they act, they push it back against it. So you've got the aggressive behavior, you've got the self-injury, and things of that sort. Substance use, that kind of thing. So action or withdrawal, I think are the two ends of that. But I think the new concept is this concept of the adaptive mode. And this is the concept that is central to CTR. And this is, if we go through the exercise together that I've set up for you, this is what we're gonna be trying to find and develop in somebody. And I've had a lot of people describe experiences like I've had, which is what got us started on some of this. But you can have people that you're in a residence or on a psych unit, and they're all disconnected from each other, they're together, alone, that kind of stuff. And then you go on a picnic, say, and there's the opportunity to play some sports. And all of a sudden, all these people are wildly different. Hmm, how do you understand that, right? Everyone, I've had so many people, if you've seen One Flew Over the Cuckoo's Nest, they have the whole scene where they go fishing. That shit's real. Oh, sorry, there's only three of us, so. Oh, I'm recorded, oops. That stuff's real, that's what happens. But it can be more micro than that, right? So there's the woman who sleeps all week, but once a week, there's music group. And in music group, all of a sudden, she looks like staff, she is just together, excited, she gets there, she could lead the thing, okay? So we think, we all have this, it's the adaptive mode. And you can switch from whatever the more symptom-dominated mode is to the adaptive mode, like that. I have a video that I sometimes show where there's this woman, she's in a nursing home, and she's really sort of complaining that she's gonna fall and not get up and all that kind of stuff. Then you put on some really lovely salsa music, and all of a sudden, she's different. And she pulls the therapist over and she begins dancing with him, she pushes her walker away. That's the adaptive mode, everybody has it. And what this does for us in terms of, in the community and on teams is, since everybody's got this, how do we find it? And what we've got in there is, and this is what's different. We discovered that the cognitive model isn't just useful for understanding problems, it isn't just useful for, shall we say, some of the unpleasant things that happen to people. They can help us understand how people actually flourish, how they actually thrive, how they actually get better, and have the life they want. So that's the adaptive mode. So it's these positive beliefs that become much more active to people. So that's what we have, those are active. The negative beliefs are further away, it's all about inaccessibility. And it leads to a very different set of expectations and much more of an engagement. So in CTR, we're gonna be looking for the adaptive mode and we're gonna try to make it the focal point. So that's what makes it different than, shall we say, your grandfather's CBT. He invented both of them. So this is a way of looking at in terms of the beliefs. So the negative beliefs up there, that's from a review paper that we put out a couple years ago. But those are pretty intense. When those are really active for people, they often, it really gets in the way of a lot of different things or it leads to a lot of challenges. But look at the difference with the adaptive mode. Same person, snap of a finger and you can be there, right? Quite a bit different, right? In terms of good person, it's good doing things with other people. And the huge thing I think is being able to make a difference. I think that's a really big thing, be able to contribute in some way. I think that is one of the most repetitive things that I've seen in all these years doing this work. So this is CTR on a slide with an arrow, with some boxes. And what I wanna show you is that this is sort of the process. We're gonna look at it when we think about the recovery map. We're gonna look a little bit at how this works. So we're gonna start from the start. We're gonna imagine that, like with the gentleman here, that you don't actually have a relationship to begin with. So where do you get started? We're gonna be looking for how do you access the best self? How do you find the person's adaptive mode? And it's just like the examples that I gave you. There's times when people are different. Sometimes you can observe it. Sometimes the staff knows. Sometimes the family knows. Sometimes you just gotta try things. The great thing about this is that it doesn't cost you anything to try things. Once you find out what it is, and I would say if you know exposure-based therapies or things of that sort, you know when they're working because you can see the person relaxing as the exposure goes on. With this, it's the opposite. What you can see is that they become activated. You know you've got the right thing because you can see it in terms of their posture, in terms of their facial expression, et cetera. Even for people who are historically flat. Once we know how the person, and usually it's gonna be through their interests, their passions, their knowledge, that kind of thing. Once we know what that is, then we wanna make it more systematic. We wanna make it so it's the kind of thing that happens more because at this point in time, it's random. It happens randomly. Oh, March Madness happened. Okay, I was really excited when March. Someone has written a really nice paper. Greg Strauss has written a really nice paper about how oftentimes for people with serious mental health conditions, their environment does not have a lot of opportunities and it's very impoverished. So some of what we think CTR does is you're changing the environment. You bring the change to the person. The team brings the change to the person. And that starts to change things. But one of the things that we know is that that can't sustain itself. So it's great. So we start changing the environment. It becomes more systematic. The person's getting into the adaptive mode. They're experiencing their best self. They're starting to be connected to other people, notice other people, just be more what they feel like themselves. But how can they sustain it themselves? How can this be the way they live? That's the middle step there. We call it developing the adaptive mode. And what that's about is really getting the person to dream about what they want their life to be like. And a lot of times people have had no shot at this. They've had arrested development. So what is the life that you want? And you have to have trust. That's why I have these, shall we say, wellness and recovery dimensions that I have for each of the steps. This is one way to get trust and to get hope. But you start to think about what is it you really want to be doing? What's the life that you want to be having? And then we have some pretty cool techniques we use to really help the person get the most out of that. Because motivation is often a real problem, people having access to motivation. This is one of the places that we get that. We dip into that. And it might very well be, I was at a community mental health center in Philadelphia last week. People are always worried, well, what if they can't get to it? We need the motivation. We'll figure the rest of it out. Without the motivation, they can't go anywhere. And it's not that they don't have it. They don't know how to get to it. And we can collaborate with them to help them get it. It's there. That's the cool thing. As someone said to me, it's in them, right? It's in them. It's just a matter of helping them find it, find it together. So we're gonna use a word for this. We call it aspirations. And we did this on purpose because we found the goals are sometimes a smaller scope. And a lot of times, some of the people feel that goals are what other people want them to do. What are your goals, right? And so aspirations isn't as utilized. And so that's theirs. And so we just wanna really make that kind of, sometimes, I've been about three, four talks here where people said, language matters. And I think in this instance, it really does. So once we have a sense for what the person is really going for, and we develop it, we have some beautiful ways of developing it, this is not sort of just change the color of your lenses, and then we're awesome, kind of therapy, we gotta do it. We gotta do it. So the actualizing, and this is where everything comes together in that fourth step there, the actualizing. Because at that step, what you're doing is you're pursuing the aspiration in two ways. One is, there's a step between, let's say you wanna be a nurse. A lot of people wanna be helping professionals, even if they're in their 60s. They wanna do something helping. So there might be, they wanna be maybe a personal care person, or they wanna be a peer specialist. There's a number of things they wanna be. But they're a long way from it, they have just gotten started. So you're making steps to move it forward, you have a link to that. But every single thing that's an aspiration that people want also has what's good about it, what's the best part about it, what's the most important part about it. And whatever that is, usually it's helping people, it's being a good family member, you can do that all the time. So you can get the meaning, your values, that's the way you bring your values into your daily life. So actualizing, we get two different ways we go at it. And the great thing is that's, of course, when challenges are gonna come up, you're gonna be taking risks. Maybe you wanna try to get a job, maybe you wanna start volunteering somewhere, maybe you wanna date, there's all kinds of things people wanna do. And it might not always go right, but that's when you can bring your skills to bear. And if it doesn't look like you have the ones you want, you can get more of them. But not at the start, when we're trying to live the life that we're trying to live, when it's relevant. I don't know if you've all run into this, but oftentimes there are people who just kick the heck out of DBT skills and things like that. In the actual class, they go right into the hallway and somebody says something and they do the opposite. So one of the things that we've really worked on is, when you got those skills, when can you use them? And it's when the rubber meets the road. The final part of CTR is what we call strengthening. And that's really Beck's guided discovery, or it's really about helping the people notice. Because I think there's pretty good evidence that a lot of the individuals who would be given a diagnosis of schizophrenia or schizoaffective disorder, they don't naturally, I think we all kind of don't naturally learn, but they especially don't naturally learn from positive social experiences. So we can just help make sure that they do. There's some handouts here up front, if you'd like to. I'm unfortunately tethered to this table. And because I'm supposed to record what I'm doing. Thank you. Yeah. So I would say action and meaning. And the meaning is really what helps the person develop their sense of agency and ability to really realize they're stronger than they expect to be and to live the life they want to live. But that's the key thing, because I think it's pretty good evidence, and also just interpersonally, clinically, it's very easy for people to dismiss positive social experiences given the way that life has gone for them. So this is how we make sure that they really develop the way of seeing things that fits their situation and treats them the best. Okay. So, each of the steps really has, shall we say, a mission. So sort of accessing and energizing, it's really about trying to find out where the best person, the person's best self is, and then really helping them experience that predictably. So it happens more and more often. It becomes more a natural way of being. It leads to the development of trust with the team. It also helps them see that it's not just because the team is there, it's they're doing it. The meanings are coming from them. We have meanings related to, you have more energy when you do things, that you can connect with people, and capability is a huge one, helping people realize they're more capable. A lot of times, the reason people don't follow along with some of the things they need to do to go forward is they don't think that they can, so they don't pay attention to their medical problems, they don't take care of some of their other challenges, and then that leads to some of the early mortality we see with our people. When we talk about aspirations, really the focus there is trying to get the person's life that they want to be having, and really developing it with them, because that's where we're gonna get the motivation. I can think of a young lady we worked with when it finally came out, she did want to be a personal care helper. The team got really excited, she was working with an ag team, and they started to help her plan it, and she got scared. She got really scared, and so backed up a step and said, no, no, tell me what would be good about being a personal care. Well, I would be really good at it. I think I would really be compassionate, and I would show that I can take care of people, and that I've come a long way, that kind of stuff. So that kind of thing, slowing it down, trying to get what's good about it. Someone said to me, a couple of the people who work for me have said that if they knew all the work they had to do to get their degree, they would have, they wouldn't have done it. But it was that excitement at the start that got them going. Okay. So for actualizing, it's what I told you, for actualizing, what we're really trying to do at that phase is really try to help the person achieve the life they want, and see that they can do it, and develop beliefs around success, and also around their sense of resilience when they're able to handle challenges that come up. All right. And then finally for strengthening it, this is, I really do think this is one of the stronger medical interventions that we have, because you can help people live a better life, and get all of their needs met, and see that they can do that. And it's all a matter of being able to ask the right questions, and think about the right meanings that people need to have, and anybody can do that. We often say, everyone knows how to give a compliment, everyone knows how to ask a question, you can put those two together, and it's super powerful for people. And that's pretty amazing, considering some of the high tech stuff we've seen at this conference, that it's sometimes the basic clinical stuff. Okay. So I'm gonna stop for a second, because this is when I was gonna transition into the tool we're gonna talk about. But since it's just us, how are we doing? I think I know the answer, but I'm gonna let you answer it. When you think about the stages of change, and pre-contemplation and contemplation, and so on, how do you see this model fitting? I would say, we developed this precisely for people who didn't want treatment, didn't think they needed treatment, and certainly didn't think that they wanted to change, or were gonna change. So, right at the beginning. That's what I would say. And as you work, a lot of people do relate this to motivational interviewing, although we developed it separately, partially because we have a broader thing. We could focus on substance use, but we can focus on anything else in somebody's life with it. So I would say, as you start to move along, the person starts to see the possibilities. And then we can work on what they're doing. So then you move your way through those steps. Something resonated with me with something that you said that reminds me of our own Community Mental Health Center. So, how much of this, excuse me, how much of this is really related, so I'm setting a little bit of a straw man, how much of this is really related to the modality, as much as it is related to the own change process of the staff, and their belief that recovery is possible. Because, like you said with the nurse, if the nurse believes all they can't, if they step outside, they're gonna get, I'm very familiar with that, they're gonna get hit by a bus. They're too fragile. But then if you work with staff to believe that recovery is possible, and that everybody has the potential for motivation and for recovery, it goes into the common factors debate. What is the most important aspect of the therapeutic relationship? I'm just wondering your thoughts on that. I'm not in any way saying that the cognitive therapy part is not important, but getting the staff buy-in in their own change process is imperative in making this work. Yeah, so the question is about really the role of the staff as opposed to the individuals, right? And, yeah. And I would say I have a, this wasn't on implementation, so I don't have that slide in there, but I have a slide that essentially talks about you do the training, and the mediating variable is the staff, right? And, but I think it's there, definitely their attitude, but it's also knowing what to do. So how do you think about it when the person isn't getting out of bed, and day after day after day after day? So how can you understand why that's happening, and then what can you do? So I think it's that. I think it's you've got to believe that you have some efficacy, and then you can see the success. So we often feel that we go backwards. We get success, and then the staff feels like they can do it. It's an interesting thing. I think that's the way it works. I definitely think the staff is critical in these concrete care settings, and the team settings. Absolutely. Yeah. It's not an individual therapy often. It's team-based, yeah. So, in some ways, this session was misadvertised as collaborative care. It's collaborative care, and you can aid health in a medical context. I'm teasing, but have you put this in a medical context? Yes, we have. Yes, we have. I have a whole other presentation where we talk about people's medical needs, and how you collaborate with them to address those. Yeah, yeah. Well, I can send you the slides. I can send you the stuff. Maybe we can talk about it. Okay, cool. Welcome. I'm using the microphone because they are recording the session, so I apologize if it's off-putting. I have some materials here you might want to see. We're getting to the action section. Sorry for my little dragon. All good, all good. It is eight o'clock in the morning on the final day. So, okay. But let's keep this going. It's a small session, so we can definitely tailor it to what you're interested in. Okay. So, you know, that there's many articles that talk about how teams that sort of think about the individuals together and have a way to sort of put their ideas together, they feel more supported. They feel like they can be more effective. And that's, in fact, what we've seen with this as well. And we can talk in some of the ways about how we use it. But the recovery map is this one. I'll have it on the... This is the tool that we have that the teams can use. And really, I have the three concepts here. We often don't, when we're in the community, we often don't hit hard on the word formulation. Because for some people on the team, that concept sounds like it's just for psychologists or psychiatrists. But if we think more in terms of planning, and you think more in terms of strategies and interventions and targets, everybody can get on board that they do that kind of stuff. So we tend to describe it that way. And so some of what I wanted to try to do with you all today is to just go through the motions of how we would do it and how we would do that planning. And I think that we can think about the different roles that the different staff members have in the treatment and what would be appropriate for them to do or how they think. So they bring different information to the table, but they also could then do different things with the individual, depending on what we come up with. So it's a way of gathering information together and then coming up with a plan. And I think I said at the start, as somebody moves through levels of care, as a peer specialist said to me, it should be you're stepping to higher and higher levels as you're stepping out of more restrictive levels of care. This can follow along to help everyone pick it up at the right spot. So promoting continuity of care. This is it. This is the tool I wanted to use, give you all a chance to work with. And it's set up in this way to really kind of follow that arrow that I had for you earlier. Really, we wanna start with how do you access the person's adaptive mode? How do we find their best self? So what are ways? So we have interests or ways to engage because that's usually the way that it's done. I have some materials down here if you'd like to come grab them. And the way it's gonna be really sort of tacked onto the theory that we're talking about is we're always thinking about positive beliefs. And so that's the right-hand side of the top row. So what engages the person? Well, they like basketball, that they're really interested in ballroom dancing, they're very good at chess, that kind of stuff. And then we think about, so when they're doing those activities, what kinds of beliefs might come up? Are they feeling capable? Are they feeling connected to other people? Are they feeling like they can do something that helps other people? Whatever it might be. So those are the positive beliefs we're looking for. That is gonna be our Royal Road. We have some pretty good evidence that those are the things that really promote change for people. That's the top row. We're gonna try that out in a bit. The middle row is really what I was talking about. It's where the agency comes in. It's where the person really develops their sense of what their life will be. What do they want? What do they want? At the end of the day, what do they really want? And most importantly is what does that mean? What are the meanings that come out of that? What's the best part about that? Because those are the meanings we wanna help the person get into their life more and more. And again, this is really a place where people can access their motivation. It's often a real challenge for some of the people we work with to do that. And that's what this middle part is about. The third row is what usually you find in people's treatment plans. That's what could be called symptoms, problems, et cetera. So they might have a problem that they focus on voices a lot, not other things. They might really be focused on some of their suspicious thoughts. They might really have low energy, they might really not be doing a lot. I have these materials here I'd like to hand to you. Just so you have them. There we go. And we'll try a little bit because the example I've got for you, there's definitely some challenges and thinking about what beliefs are underneath that because our target's gonna go to the beliefs, not necessarily to the behaviors. That's really where the team puts together its plan. So that's really where you get your strategies, your interventions and your targets and also where the team often uses to write their notes and to document the work they do. That can all sort of fall out of that bottom section. And this is something that we update as we go. As we learn more about a person, we can update it. What I have for you, I have a fully filled out recovery map for the person we're gonna consider at two time points, just to sort of show you how that might look. Okay so far? Okay, so that's, we're now moving into the, let's give this a try mode. So I have for you this sheet here is the description of the case. And since there's just five of us, I was gonna have you break into groups but I think we might just do it call and response and then think about how we would do it if that sounds okay to you. All right, so this is a summary. I actually would encourage you just to read the vignette. You didn't? Did I not give you the materials? Was I holding back on you? No, I got the case map and the instructions. Yeah, here we go. So, I mean, I could read it to you but I've, you know, I think you can pull out the relevant information. I've just sort of tagged it. Here we got a 27 year old man and he's got a community team. He's somebody who's been in and out of the hospital quite a lot and he lives with his family but he often is physically and verbally aggressive towards them. He has some of the classic symptoms you see with a serious mental health condition. I wouldn't put it the way it is in the slide. That's not the way I would write it. I don't think the challenge is that you experience hallucinations, it's that you focus on them. It's the focus on them, I think that's the key thing. And why I would support that is there's a lot of people that hear voices and it doesn't get in their way. So it's a focus on the voices. It's a focus on the worry that people are going to harm you. And then the sort of prominent negative symptoms, having low energy, being sort of challenging to get out of bed and do things. The bottom paragraph talks about what the gentleman was doing when he was feeling a little bit better. So he was in vocational school, he has some interesting hobbies and things of that sort. Okay? So. So let's think about the top part of the recovery map for a second. This is how we would do it with a team. And so we're just trying to get you there. So. So just based on the case vignette, we have some information that we could use. Now if we didn't have this case vignette, we could ask the family, right? We might be able to observe him when we go see him, see if he's ever doing things that are different. But if you look at the final paragraph, it gives us a real sense as to what things we might try with him, what things that the team might try with him. And I'll just go ahead and show that to you. So here, this is just sort of our how-to guide, sort of what we're looking for. What are the kinds of things that really bring him out? We happen to find, for example, that when people have things they're interested in, if they can teach the team members about it, they open up. They really open up. I think that's largely because they don't get that experience. And then what does it say about you that you taught your ACT team member a chess move? Or you showed them how to play a video game or something like that? There's a bunch of things you can do there. It changes the relationship, it equalizes, that kind of thing. And you can see sort of the person coming out. So I'm gonna just give you this part of it, because these are right there in the case vignette I gave you. He seemed like the things that we would wanna try. He seemed to be interested in food. Definitely video games is a big thing, and especially for people in this age range, I think it's a really great way to engage them. Oftentimes, the team members don't know anything about video games, and that's the perfect situation. It's the perfect situation. I had somebody who was working with me from Australia, and she said, how can I talk to him about baseball? I don't know anything about baseball. I said, that is perfect. Because you don't know anything that can teach you all kinds of stuff, and you're gonna be able to draw their attention to how knowledgeable they are, how they've helped you understand things of that sort. So that's sports and movies. Okay, so that's a pretty good start. Sometimes we have nothing. Sometimes we don't know. And if we don't have anything like this, we might start with just trying things out. And that's actually what we do. We have act teams try things out, show videos and things of that sort. And I tell you, sometimes something hits. Maybe it's cars. Maybe it's a Rachel Ray video. You just don't know what it is. Or maybe it's a college basketball vignette. You don't know what it is, but that's how you get started. But what I wanna focus you in on is what we would call the formulation part of it, which is the other side. So we're looking for positive beliefs that we would think might be coming up for people when they're doing those activities, right? So I've got some examples here for you. Capable, energized, in control, helpful. These are all the kinds of beliefs that can be useful for people. Yes? Just a quick question. Does that also include any exploration of values? We'll get to values. Okay, that's not in this section. Not in this section. We'll get to values. And the reason for this, there are some people that jump right to that. That's true. And you can just go there, because that stuff's even deeper. But for some people, they're not sure if they should trust you. Yeah, a young woman who said, I don't know what you're gonna do with my dreams. I don't know what, so that's why we have it where we have it. Everyone wants to get to the goals and the values, but we wanna make sure that we have a good relationship. And there was a young woman, so in a specialty care team, so she was at high risk for developing a psychotic disorder. And she was so shocked that her CTR therapist remembered her name, remembered what music she liked, had listened to it between sessions, and had questions. The bar's low. The bar is low, and there's basic things sometimes I think you need to do for trust. And so that's why we have it this way. It's a great, great question, but that's why we did this first. You say, well, this isn't therapy. It is. And that's what I want you to think about. So we'll just do a call and response. So what kinds of beliefs might be active for Michael when he's doing these things? We can pick one in particular if you want. That he can do something. We can maybe refine that even, that I'm capable. No, no, don't take it wrong. That I'm capable, right? I'm capable. I can enjoy myself more. Yeah, I can connect with other people. I think connection is broad, yeah. I can connect with other people. Maybe it's better to do things with other people. Other ideas. Just trying to think about, this is how we're starting to think about what the person's best self is, and how we can help them notice that. Well, cooking is about taking care of our people. Yeah, could be. That's right, right. So I can contribute. We had a guy we were working with in a residential setting who liked to cook, but he had really severe negative symptoms. And I remember this one morning, they wanted him to help. Hey, hey, we're gonna go, Can you help us make the pancakes right and so? He's laying in bed. You've got the blanket over his head Okay, we're going to go do it without you, and then they said they shouted up to him. They're burning They're burning and so that that worked he said oh you could you losers and so he went down and he cooked the pancakes So that's why I'm really glad you brought this up for everybody then what happened right everyone sat down. These are really great What kind of beliefs could we think about that he would experience at that point? He knows how to make pancakes He can make other people's lives good, and they said you know you should show us how to do that That would be useful for us right so it's contribution all that kind of stuff Something as basic as cooking so yeah, so I think it's really important, but it's person-Centered not everybody likes cooking one size does not fit all other other thoughts that you have I Can have fun that is huge for people like him to have negative symptoms. I can have fun because they often Don't expect to have fun, and they don't try and they stay to themselves This is great. I thought that we're going to We could do call-and-response, so here's the ones we came up came with came up with right I belong and feel safe around others Others enjoy spending time with me. I'm talented and capable right Control is an interesting one because because you might think that that some when we get to his challenges that some of them might be related to feeling like he doesn't have any control and so one of the reasons that you would withdraw from people and not Participate in things is that you don't feel like you have any control of where your life's going Seem okay We're trying to focus on the positive beliefs Again, these are ones that we come up with oh, I should say I meant to say this earlier We do guessing at this point guessing is fine We're guessing right and as we do things with him will find out which ones are the ones that are for him So but but guessing gets gets us started I'm to figure out what it could be and then as we do it with him We can sort of find out what it actually is but this this is especially I think useful for teams Because they could think they can tend to think that Cooking video games and all that kind of stuff isn't related to treatment It's it's sort of like this sort of fluffy thing But it's actually the core of it and one of the ways to keep that and keep in mind is this okay? What could he be experiencing which gives you some empathy? And then we can find out exactly what he is experiencing We can build that up over time as he does these things more and more The questions about sort of how that works Make sure I'm mindful, okay aspirations Typically especially early we're gonna have no idea what these are. This is my experience We often don't know the sort of big dream that somebody has And they may have given up on it like the Beck quote or they just haven't thought about it in a long time I've worked with people that it took a while to get to this reason that we have this this is the values There's a reason that we have it here So that we're trying to establish a trusting relationship with somebody we really care about what they care about We care about their passions that kind of thing now What is it that their life would they want their life to be like in this case? We do have one we do have one piece So these are some of the questions that the team can ask right if everything were the way you want it to be What would you be doing? Before although this stuff was happening Michael What did you want to do that kind of thing? There's a couple ways to get at it. You can also build it out of what you're doing I notice we've been doing a lot of cooking together Cook is cooking something you might want to do in your future is something related to food so you can get it a couple of ways and and Essentially what we're looking for is something bigger if we get things that aren't bigger We can we can take it there. So let's say the person says I want to I want to get my driver's license. Okay? Let's get a driver's license. Once you've got it. You've got it. So the question would be what would you be able to do with it? That's a cool question actually ask people because I say well, you know, I could take people places I could I could You know other people say I have freedom. I'd be able to do things. I want so some places that can go But there's ways to make it bigger in this instance, we only have one thing Become an electrician was something that he had when we come back around to a later The later version they'll have we'll have a little bit more but so same question I ask you that the meaning part is what I want to have you think about We there's a way that we can elicit what the person is looking for as I said to you earlier I don't think at this point it matters that it's quote-unquote something that they will actually do. It's really where their motivation is It's their dream. That's where they get the access to the motivation. I could start living the life I'm standing here in front of you doing something very different than I imagined I would do when I got started with everything very very different. I think a lot of us that's true of that's perfectly Okay for the people too. So so that's something we have to help teams with we have to help teams like it's okay We'll just we'll meet them where they're at They'll find out what it is and and where we get the real action is in the meaning, right? And that's really what we're going to roll with that's what the values come see so our way of going at the values as we Find out what the person wants to do and then we find out what's the most important part about that Or what's the best part about that and those kinds of things then lead us to what the values are And those are the things they can experience every day. That's kind of how we find it So I think there are other traditions where they try to go for the values and then go to the meaning we can do it Either way, but we find this is a this is a better way, right? So this is our question What would be the best part about it? How would you see yourself if you accomplished it? How would others see you getting to those positive beliefs? That's kind of the key thing there. So If we're thinking about becoming an electrician again, we can guest get started. So what might be the best part about that? I Can develop my skills When when an electrician does something they fix something right so that could be a form of contribution You know, I have a way of contributing and also I think you're right. It's a sense that I'm I'm Talented or I've got a skill or you know, there's there's a ways to think of yourself as somebody who's competent I think there's a sense of competency Probably related to that and then it has a role in making things better and you might just think that damn stuff is neat There's also that so there's there's something like that other things It can go in different direction it There we go. That's I was looking for. Thank you Just sort of that well Well, I would be able to I would be able to be a sort of a collaborative provider For a lot of people that I've worked with They've never had a chance to do that to contribute to some kind of budget where we're making things better for each other That's stuff like that So I'm gonna be related to that right to having money Being able to use the money for the kinds of things people like use them I so there's a few things I think I don't actually have the answers here because the Because because you want to get it from the person But I want you to be thinking about it because I think that's really with it where the heart of the thing is is to Be thinking about it and sometimes people can have some pretty big things that they'll put here I think sometimes because they haven't had a chance to really live life yet And so it needs to be big so they can catch up, but it's okay. It's okay if it's big It's okay, if it's big, you know, I want to be an entrepreneur I want to be that because what's the best part about being an entrepreneur? It's a you know, you know again, you're capable You might get respect. The other thing is respect. We didn't say respect here And I think sometimes there's respect something like that. You do a good job and people respect you. They appreciate you So these are the kind of directions we go with that So we just it's important to get it from them, but we can be thinking about what it would be when we get it Okay, the challenges so most of the the write-up has the challenges in it we started with them even though we don't typically we don't we don't focus that way but But you know sort of what is it that puts the person on a higher level of care? What kind of gets him in and out of the hospital that kind of stuff and I'll just give those to you as well Right, those are all the all the ones that are in there and so he's got that kind of a Kind of presentation we often see in the community, right? He's got a bunch of different things happening. He's got the voices He's got the the focus on not being safe with other people He sometimes gets really impatient and and it gets a bit aggressive He really doesn't isn't participating in anything. He's actually got the the The Specifics in there is he's also got the the idea that he's being controlled So he's got these machines that are trolling him that kind of thing So those those are the those are the those are the kinds of things that we see and this I think is a more classic Formulation if you want to talk about it that way and so how he's getting stuck how we find him Where is why might it be that he's doing these things? So we can we can think of it in the same way as we were thinking about it before Right, right. We start with guesses to figure out. Well, what do we think might be driving that? Why is why is he doing that? Right? So And we can look so why would he do it? Well, what would you believe? This is actually kind of a cool move also with teams is to kind of crack it open because sometimes the people are doing things that it's hard to relate to but if you sort of get your head and say well, What would I need to believe to to feel like? My head is being controlled or how might it be that it's hard for me to get out of bed or that kind of thing? And that's kind of what I want you to think about for a second here Sort of what might be some of the beliefs that are underneath the kinds of things why would he focus on the voice for example? Why why would he not engage with the team? Right. So what thoughts do you have? Yeah, so he's he's not interested in doing those things. So why might he not be interested? So it's more at the belief level Right, it could be what he deserves Right, exactly. So leave totally from his perspective So what do you think? What do you think? The world is dangerous is a big one. I think with with some of the beliefs he's got there. You got to be careful He might might think that He's a failure. Why try I'm just gonna fail. So why would I engage with the team? Why would I try that the activities that I used to like? those kinds of things So so here's here's some of the ones we had right certainly the safety it can be related to A sense of vulnerability. That's a big one. We find when people have persecutory Experiences and just not feeling safe around others. So trying to isolate This is why some of the earlier phases are going to be important that we just talked about sort of Developing some sense of trust because it's really hard to trust people and really this defeatist attitude that I think a lot of people have is just I'm 27 years old and I haven't been able to do what I want yet So, why would I be able to do it now? So maybe you know, it's a kind of demoralization So so for some of this stuff We put it here because it helps us understand where the person is But then we're gonna try to do some of that earlier stuff that I was describing for you to help them actually Counter all of this because typically these beliefs are the opposite of the ones that that are coming out when they're in the adaptive But they're pretty much the opposite and so helping them see that when we're doing some of these activities It's good doing things with other people they don't feel so vulnerable They have some control of where things are going because they just taught me how to play a video game and maybe Kind of sort of little bit might be okay to do things other people something like that So it's using the positive. So this this approach is not so much an approach where we're disconfirming these we're more or less Making the other ones accessible and and having these be less relevant Okay So far so good So far so good Okay, and I might I might say that what I didn't say before is when you have a multidisciplinary team Different members of the team can can fill in that section or think about what they see Especially with the positive stuff. I often find that it's they're they surprise each other as to what they've seen. Well, you know, he's not always Just focused on the voice, you know There's occasionally these moments and that's how that everyone can learn has one of the advantages of doing this with a team I think So this is the part where you plan. So so I thought we think about that for a second, right? So we've in some sense filled out the first three sections of the of the map and now what we want to do is plan interventions Great question, it usually comes up. So I'm glad you asked it you can do it either way I tend to find that this helps the team get their act together So that they can figure out what they want to act together for their acting But but it's not necessarily involving the person but it can Usually what we find is that the individuals like this once they're further along once they're further along but often we're starting with them I think it's a good idea to have a multidisciplinary team Once they're further along once they're further along but often we're starting with them. I don't know for example, let me just back up to this Some of these things they wouldn't agree with And so we don't want to risk the disc discontinuity with them over some of the challenges It's especially true if somebody has grandiose beliefs. Well, I'm not really aggressive with my family all these kinds of things So we tend to not Start with it. Well, we can if you if you want to we've had people do it But this is largely for the team to get their stuff together anything that we're thinking about With this stuff we're gonna do with the person right? So when we did this stuff together boy, this is I really enjoyed this What about you seems like you're got more capable sometimes than you think you are. So we're completely doing this with them We're just not using the form with them when we do it. It's guiding our interactions with them Okay So to the planning page, so really it's trying to think about what where are we in terms of what we're doing And what would be most useful and again a team can Problem-solve this given everything that we know about him and the things that we know he likes. Where should we start? So the strategy could be That we want to establish trust with him and help him feel like it's he's safe when he's with other people That could be our strategy and then you can think about well, what will we do? What specific things could we do to do that with him? So have him teach us about video games have him to tell us about sports, but the local sports team Maybe you know go outside and shoot some hoops Whatever it is he's interested in all of those things are examples of we're doing stuff together. We're establishing Trust with him and then we want to make sure that we have guided discovery questions that are part of it So he notices the benefit of it So so it's strategy what we're doing and then what we're hoping that he's going to get out of it So that's sort of the three parts of it and then I just have Something here just about sort of how to guide you for doing it, right? so Predictable ways to interact with other people is pretty key and then I have the beliefs for you there could be connected It could be injured you came up with them when we thought about it Similarly if there are roles are really cool way for people to have consistent Experiences that activate their best self where they're being able to contribute in some way So being able to find something in their environment that will allow that so that they can contribute So that could be another way to go and again the teaching is really I think Has always been effective and what's great about teaching is it's low tech Someone can teach you we've done this in forensic settings where people had to had to be in shackles Not that we wanted to be there, but we could do this kind of thing in that kind of thing They can still teach you something Okay, so that's a when you're a little bit further along. It's really about finding out what the aspirations are Really trying to develop them with the person so they have a rich rich rich image It's really a little bit like sports psychology I think neuroscience mixed with that because it turns out that Imagery is one of the best ways to experience emotions better than with words And depending on the type of imagery that's the type of emotion so be able to experience the positive emotion you'll experience the Motivation but also to be able to see that you can do it. So it's all that stuff together That's why we that's the kind of stuff that would do with that phase and then ultimately trying to plan out ways that they can be moving forward and also experience their values and Ideally every day. So again, this is this is sort of those are the strategies and then the different beliefs that we will be looking for It's interesting that started with number three, but that's okay looks like I lost something Yeah, that's interesting. Okay, that's all right. I'll live with it Just make sure All right. So it looks like we lost about two or three slides here That's okay Humility I think is the very important in these kinds of situations So So this is this is basically the third step when you have the trust So the first the first step I just wanted to read to you what I have Oh wait, I have it on the recovery map. Hold on All right, cool So what we had for this guy We thought so given everything that we know about him and given how withdrawn he was The first step we thought would be to activate his adaptive mode more frequently get him into that state more frequently And the team could combine different people could do different parts of it So the examples we have which is straighter watch sports clips with him have him teach you about video games Shoot hoops at the nearby park ask for recommendations for meals to cook us, you know that you could cook with family and friends Sometimes the people that really like food that just really brings them alive I've worked with some people who say I want to have my own place. Tell me about that. What what are you gonna do there? Oh, I want to have a TV on the wall. I want to have a kitchen. I'm gonna make pizza I'm gonna have people over we're gonna watch the game that kind of stuff. That's the richness of this Ask for advice about movies to watch so we got a bunch of different things The great thing about this is they have different team members. They're not all doing the same thing We might get a little bit tiresome if everyone comes by say, all right teach me video games teach me video games Okay, so that's what would go on the left and on the right we would have building connection and trust act and activating his positive beliefs So then the next thing so we will we try to help the team do is not jump too far So the first thing is just to get the adaptive mode going a little more often for him because he's really got pretty strong negative Symptoms, I'll hand this out to you in just a minute As you're doing this with him then the next thing is to make sure he's noticing the meeting So we have some guided discovery questions that the team could consider And so some things like you really know a lot about video games, don't you? Right? So it's it's emphasizing his knowledge It's really fun when we shoot hoops together. Should we do this more often, right? So the point of this is how specific that is, right? We're trying to really help the team get really specific They're doing specific activities and they're drawing specific conclusions with him Trying to help him notice that he can connect with be all the things we talked about So we identify what the beliefs were and now we're trying to help Have a strategy so that he can experience that more often and we can strengthen that and then this is the third one Once he starts to trust you a little bit more We might begin exploring what he wants for his future. That'd be the third step that we would do, right? and so since electrician is something that that He said if he says he still wants to do it We can we can ask him so tell me about that paint me a picture of what it would look like be working at an electrician You know, I'd be down in somebody's basement, you know, we'd be pulling that board out and and putting things together They would be impressed at what I could do and then their lights work, you know that kind of thing So that's the way it looks Any questions about this so far? This is just like Initially setting up the plan for the team Trying to make sure that they go through things in this particular order and then also thinking about different different members of the team can Do different parts of this so they're kind of coordinating what they're doing with him To try to really help him Be in the adaptive mode more often which is going to pull him out of his negative symptoms It's going to pull him away from focusing on his voices so much and helping him to feel safer and that kind of thing Any questions about that? Sorry, it wasn't all on the slide, but I will have a fully filled out recovery map for you So what we wanted to do is Maybe fast forward a little bit to show you what it would look like later So initially when we started it's like this we're just getting going We're trying to really sort of help him get more energy help him do more grow his life space But now after a while, we're gonna learn a few more things. Let me show you what we learned, right? Have a family we got a second one a more potentially vulnerable one that he wouldn't share right away So he's interested in having a family. So that concept about money and things like that is pretty important And then we got we actually got the the meanings right purpose He can provide Right, he can help others right big one and it feels successful capable Which is often something that the people we work with don't feel at all that they've almost never experienced that They often never had a had a close relationship and they often haven't had these experiences All right. So this is where we're at with this. So then the question is how do the strategies change? What could we do and maybe we can think about this for a second? If we know these are the meanings that he's going for What kinds of things could could we then the team be doing with him to pursue these things any thoughts Right, so maybe find out sort of what are the next steps in terms of moving towards that so is it some training I Worked with some people who are in a forensic setting so in a hospital Who were actually interested in stuff like this actually more related to computers and things like that And it's surprising what you can find online to start learning about stuff Got some books in start, you know, and really this was actually a gentleman had a real hard time with aggressive behavior But being able to focus on that and see that he could really be in the community and work on computers and things like that Totally changed me. That's great other thoughts you might have so trying to go there And then being able to link that up to what he wants being able to say so every time you know You do one of these YouTube videos. You're getting a little closer to being electrician, aren't you? What you just said I think is pretty critical in a family situation, which is oftentimes I think that the people who are like Michael, they don't have a role at home. Everyone is attending to them or trying to take care of them. So yeah, being able to change the lights for people. We had a young kid who fixed Alexa for his family. He was really demoralized and didn't even have Alexa. Sometimes Alexa goes rogue and starts saying lots of things, playing music when you don't want to. But yeah, exactly. Having a role within the family where you're contributing. And that also could be related to wanting to have your own family. I think that's really great. Other thoughts? So this is kind of how the team would sort of problem solve it and then think about the meanings we would have. So, right, right. You know, it was kind of interesting when those doors were open, for some reason, right out the door, you can see the church. It made me think of the movie, The Graduate, if you've ever seen it. Random. That's why I do what I do, right? So the idea is that trying to figure out the steps he can take, right, to become an electrician, but also thinking about, well, what's the meaning behind that, right? Purpose, control, contribution. Are there other things he can be doing? Your example is beautiful. Maybe he can help people change the lights. You know, maybe he can help them solve a problem that they have around the house. That's all cool stuff. All of that is valuable, and the second part of this is just to help him also notice the impact that he's having, and that's the second part, right? Oh, the empowerment is actually related to when the challenges come up, right? So you're going to pursue the aspiration. When challenges come up, you can see that you're stronger than you expect to be, and when you're doubting yourself, right? So it's worth spending time with your team. It will get you closer to getting back to school to become an electrician, right? Just sort of pointing out that the work they're doing together is helpful. When you're playing basketball, how much are you focusing on the voices? Is it possible we've got a bit more control, right? So just drawing his attention to the fact the stuff he's doing is actually addressing some of the things that are getting in his way, and he can get through things if he puts his mind to it, right? And so it's really about whatever works for the formulation, and then the third part is really about really noticing the meanings, right? What does it say about you that you've started doing, opening up to your team, even if it was hard at first, right? I know being an electrician is really important to you, and you've been taking a lot of steps towards getting back to school. Who's in control? You are the voices. It seems like you've been finding a lot of ways to help other people lately. What does that say about you? That last question turns out to be one of the most powerful ones we have. Once we have enough of a relationship with somebody, what does that say about you, that you're helping people here? I'm a good person, I'm contributing, others appreciate me, all of those kinds of things. This is just an example of how we would move it forward as we knew more about him and changed the focus of what we're doing, right? So this is essentially what we think recovery maps can do. They're a way for teams to pool their knowledge, plan, and then update as they work with the person to essentially help them recover and become empowered relative to things that are often very difficult to work with. And we start with guesses, like I said. I think it's very useful for teams to think that way. Why might it be is a really great question that opens them up to possibilities and also makes it very person-centered, I think. And then ultimately, you're able to help the person, in this instance, step off the team and step into a lower level of care and really have the experiences that they want. So I have the fully filled out recovery map that I want to give you. So, this handout has all of the – this is one way it could work with Michael, just one way of showing you sort of what we have is an initial set of strategies and a later set of strategies, just so you can see how that looks. So we have a little bit of time left. This is just kind of summarizing. We think this can be a pretty useful tool. I realize all of you don't know recovery-oriented cognitive therapy that much, so I tried to kind of just give you enough a sense of it so that we could try to apply it. But we've just found that this way of conceptualizing things can be very helpful in teams. It's one way to really sort of galvanize team-based care and move it beyond. We've worked with a lot of people who are in crisis a lot and, you know, help them get out of crisis and start to move ahead with the life that they want. Question. I was driving from San Jose, so maybe I missed the first portion, not maybe, for sure. Can you tell me who is the team? Will you involve family? Will you see wife, parents as vulnerable? Yeah, that's a very good question. I apologize for that. If you read the case study, it tried to give you an example of what the team could be. So I think it's both. But what we were focusing on is the community team here, sort of. But it could have been a residential team. It could have been an inpatient unit team. But I think the family is extremely important. It would be very important to work with the family. The main work with the family, which we didn't have on here, would be establishing what the family is like at its best. What do we like at our best as a family? And a lot of times when somebody is 27 years old, like Michael is, the family has gotten a long way away from all of that. And sometimes the family is the ACT team, and there are a lot of other things trying to take care of their relative. But we try to have them take a step back. What is your family like at their best? What is your relative like at his best? And then what are things that you haven't done in a while that really bring out this best part of your family? And can you start thinking about maybe doing more of those? Second thing we might do is ultimately have them collaborate on aspirations, because one of the things that happens for young men like this is that they feel like they're always receiving care. And everybody else is great, and they're receiving care. But everybody's working on something. So I've got the aspiration, I want to be a mechanic, I want to have a family. Maybe my father has the aspiration, he wants to retire, he wants to do woodworking or something like that. We can help each other on that. And then the family is working as this kind of unit together. And then being able to understand some of the things up here like the beliefs are tricky to understand for anybody, right? Why would he believe there's machines in his head or things of that sort? But just having a way of understanding that in terms of beliefs. He doesn't feel safe. He feels like he's falling behind. But here's what you can do when you hear that. That means he's really feeling disconnected. What are some things that bring out his best self? And how might we think about you bringing that to the table? I'm writing a book on this. So that's maybe why I just spilled out with all of that. Did that answer your question? No, I think this is great with all the stuff that you're bringing up and in terms of the team dynamic. And some of what I would say, we often ask, what's a good day at work? What are you most proud about in your work? What's a good day at work? What are you most proud about? And then we think about what's going on with that. And the recovery map is an equalizer because everybody has something to say. So case managers and peer specialists often have the most important things to say. And it really can empower them to be a part of the team. So I think some of the stuff you're talking about comes out of that. But we're trying to think about, how do we work best as a team? And then this is a tool that can help us do that, is what I would say. But I definitely agree with you about what's a good day at work? How are we working well together? And how can you have the mutual respect that you're talking about? I think it's really critical. And that's often the surprising thing. Sometimes the direct care staff, because we work with a lot of direct care staff, they have no education at all. Sometimes they don't even have a high school degree. But you're asking me, yeah, yeah, what do you see when you sit with him? I don't know, he kind of likes Minecraft a lot. He likes Minecraft? So it's that kind of stuff. So I think that's the lived thing. But sometimes really just asking about what would make a great day at work and how could we work well together, I think, does some of the stuff you're talking about. Yeah, that's a good answer to the question. I'm going to piggyback on that one. Not that I necessarily believe this, but as a director, this is something I hear a lot about, which is administrative work. Like you've introduced another thing that needs to be done. In our treatment planning process, we do recovery-based treatment planning. But the treatment plan is still influenced by joint commission standards, CMS standards, state standards. So we get as close as we possibly can. A lot of what's being done there is very akin to a treatment plan. Have you been able to successfully, I mean, are there teams that you've worked with where they've been able to take this and be able to integrate it into an improved treatment planning structure? Yes. Unequivocally, yes. Both in inpatient settings, outpatient settings, and residential settings. So all of those. Sometimes they have it freestanding, but other times they put it right into the middle of it. Because I agree with you. Some of this stuff is in the treatment planning. Some of it is required by law, or by, as you say, the joint commission. But there's also stuff that's not in there, especially the focus on the meanings. Those are often not there. One of the things that bottom section gives us is, so OK, let's say we play cards with Michael. How is that treatment? We came up with the meanings. We know what it is. It's going to be addressing his negative symptoms. It's going to be addressing his belief that he can't do things with other people, that he can't trust other people. So that's some of how we get some of that stuff. But yeah, definitely. You can definitely. Yeah, we're working with, I work in the state of New Jersey where they've replaced some of the independent housing with what they call community service teams. So I'm working with those teams. And they have a hard time sometimes with individuals who they can't understand why they won't be interested in housing and stuff like that. So this is what they need. And so there's a way to use this in their work. Because it has a value. That's why they do it. That's why they do it. And there's so many requirements that they have. It's just, sometimes you've got to wonder. I mean, I guess I hope I'm among friends here. But sometimes I know the abuses of the past have led to the rules, but sometimes it seems like the rules get in the way of the care. To make sure that there isn't abuse, then sometimes we can't do the best care. So sometimes I wonder about that. But we have been able to collaborate with, especially if you get some people who really see the value of this, then it doesn't seem like something extra. It seems like part of what you're really trying to do with the person. And it gives you valuable information you don't otherwise have. But if it feels like it's extra, the implementation trainer is not doing his job. Because it shouldn't be extra. That's a great question. And then just one more. So a lot of this reminds me of just talking about mapping and CBT. And I'm wondering, for the cognitive therapy part, especially with working with individuals experiencing schizophrenia, how much do you actually get into maybe the nuts and bolts of cognitive therapy and talking about core beliefs, schemas, automatic thoughts? Because I mean, I think what you're doing there from a practical recovery-oriented point of view definitely works. From the therapist's point of view, how much do you go deeper in having a person thinking about these things? That is a person-centered question. Because I think for some of the people, that's exactly what they want. And so you definitely do that. I think for some people, they don't want that. I just want to get back to my life. I don't want to be, you know, and this voice is getting in the way, so we'll work with that. But we won't go as deep because they're not interested in that. Or, you know, kind of thinking about thinking isn't something that's terrifically motivating for them. Because that's why I say it's an action-oriented therapy. But there are some people, that's what they want. And so then we could do that. I mean, I think that the part that's going to look like cognitive therapy, like you're describing, is mostly trying to understand where the person is getting stuck, or where they're maybe stuck in a high level of care, or they're either distressed, or that kind of thing. That's when it's going to look like that. But it's mostly to identify what's doing that. And then we do things to try to elicit the opposite, as opposed to having them. But we might draw a conclusion. So I see, in a lot of my work, it's a conditional belief, if we're going to talk in terms of the cognitive mapping, the person comes to. So I've got a person with negative symptoms, and they don't feel like getting up in the morning. Why try? I'm just not going to succeed, so I won't. And as they start to do so, then they kind of have this, and you can help them do this. So maybe this is the closest to what you're saying. At first, I feel like I can't do it, but I know if I push through, I'll make it. And then they might have something they've drawn on their wall, or something to remind them, like Superman's shield, or something like that. And that's how they do it. So I think that the original negative beliefs become conditional beliefs that the person can then use as part of their resilience to push forward. At first, I don't feel it. At first, it seems like nobody loves me, but then I remember. People do care about me. They do appreciate me. It's that kind of thing. That's how I think we do it. But we don't get too heavy into the terminology, like core beliefs and things like that, unless the person wants it. And we started kind of really, if you know a little bit about cognitive therapy and schizophrenia, some of its limitations is insisting on some of that stuff. And since I happen to be working with the inventor of the stuff, he was the first one to say, Paul, that's not working. We've got to try something else. And that's why we're doing this, is because there are some people that works for that. That's the effect sizes in all the studies. But there's a big group of people it doesn't work for. And that's what we mean this for. And then we discovered that the people that works for you do it, too. They want to have the life they want to have. One of the limitations of some of the CBTP studies is it doesn't look like the people get their life back. They just don't feel as distressed. So we're trying to make sure the person gets their life. I'm not even going to, I couldn't improve upon that. I couldn't improve upon that. I would approach this from a, well, where I'm coming from is I'm responsible for a committee in the National Day of Collaborative Care program within the end-stage renal disease world, or near-end-stage renal disease, and I sort of think about that similar to the voices. These are these people whose kidneys are failing, and it's starting to affect their function, and there's an element that it's both other and a part, and how do you approach that, and how it fits in the way of what the aspirations are, and how do the voices fit in the way of the aspirations of those where you have them? You could write my talk on the medical conditions. That's exactly how we do it. We do the same thing for forensic involvement, right? Forensic involvement, justice involvement, same thing. Because people don't, what am I going to do about this? It's overwhelming. I'm not going to be successful at this. It's somebody else. You've got the wrong person here. I'm not the person that did it. With medical things, it's exactly that. They feel incapable. They're not going to be able to do it. They're not going to succeed. The aspiration is the thing we have that might make it worth it, and we've seen this work with people who can take care of their diabetes because they want to have more time with their grandkids, and it does work. I think it's right. It's funny. You say the renal stuff. We had the opportunity. It's sort of fallen through at this point. We had the opportunity to do a project based on CTR for people who were coming for dialysis, and what we were going to do for that project was to actually create something like a CTR group where everyone would be doing stuff together while they were getting dialysis, and so it was going to be like a group. For some reason, it was at Staten Island University. For some reason, it's not happening at the moment, but I love that that's what you do, and we had this idea that why can't, because people don't want to come, right? Isn't the issue that they don't want to go for their dialysis, and then they could die, so could we create a situation where they're coming together. They're thinking about their future life. The dialysis is connected to it, but they've got a group that's doing it. We're going to have them doing it as a group. Anyway, I don't know if that's useful to you, but if you ever did anything with that, it would be really gratifying. Do you have a targeting map specifically for bipolar disorder, for major depression disorder? Yeah, yeah. You can make them for those as well. We invented them for this, but we definitely extend. We work in the community, so you can't really not work with depression, bipolar disorder, really anything that gets the label borderline, all of that stuff is stuff that we do. I think it's, you know, back at the end of his life, I can still see him stretched out there on his bed when he couldn't move, he was blind. We were talking about whether you could do this with depression, because he wouldn't be who he is without his depression work. He wasn't sure. Unfortunately, since he has died, I've been a part of a couple of beautiful cases with people who have severe depression, so much so that they're in a state hospital with very, very strong suicidality, and focusing on finding their best self, finding the kinds of things that they do. The guy I'm thinking in particular, he was married, but he thought he was a horrible husband, and he liked to help people, he was really good at detailing cars, but he just thought life wasn't worth living, and he just wanted to, you know. So you know what we did, we just reversed all that. So we didn't so much focus on the core beliefs and things like that, we focused on the kinds of activities that he did that bring that value, and helping him see that value. So he exactly follows along with this, and he really, really improved, and they were able to discharge him a lot quicker than anyone thought. It's really interesting, the key thing was helping him notice all the values that he was discounting, and then figuring out a way for him to maintain that. And then this might seem more like traditional CBT, where he just identifying signs that it might be going the other direction, and then what could he do, and how could his wife help him with that, stuff like that. So yeah, I think very much so. Yeah, we're focusing a little more on meanings on the end of it, right? So, yeah. Yep, totally. Yeah. Yep. Yeah. Yes. Yes. That's great. It always feels good when someone in the audience gets it. That's it. That's right. It's great when you guys get it. We're actually past time. I've never had as intimate a session as this in a lot of conferences, so I want to thank you all for sharing this 90 minutes with me. Your questions show me you are the people, so I appreciate and really respect that you are here. And I hope there was something valuable in this for you in whatever way, and I wish you well, and continue your good work. Thank you.

recovery-oriented cognitive therapy

Beck Institute

serious mental health conditions

adaptive mode

disconnected mode

community settings

institutional settings

recovery map

multidisciplinary teams

trust-building

team-based care

personal aspirations

implementation challenges