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Recovery Model: Mental Health Recovery Model Applied to Severely Mentally Ill; JH Rick Massimino MD

Teaching Pages

Teaching Pages begins to expose readers to the psycho-educational component of the John Henry Model(c)

Teaching pages are therapeutic concepts which are generally introduced in group therapy settings (lasting 30-45 minutes) and address specific goals/objectives of individual treatment plans. Though each patient is unique, patients share many developmental and behavioral deficits which can be identified in a group setting and processed for solutions. At a later time these teaching page concepts can be used in one to one dialogue to either reinforce learning or apply the reward/consequence results of individual decision making.

A brief sample of the more than 100 existing teaching pages/DVD's will be provided. Before a specific teaching page is described, let’s discuss the philosophy, technique and general content of a teaching page. How should or can seriously mentally ill people learn and retain critical information for life success? This important question arises out of the reality that a huge percentage of these patients do not believe they have a problem (Anosognosia). They also are often consumed by powerful residual symptoms even when properly treated which interfere with attention, concentration, learning, retention of information, and abstract reasoning. Gradually, after years in and out of public health care treatment settings, they embrace a core set of beliefs (to be described at a later time) which are untrue, counterproductive, and counter therapeutic. And finally, each patient is at a different level of ability and motivation which makes teaching to a group a more challenging and frustrating (for both teacher and listener) experience.

As a side bar topic, to assume that every seriously mentally ill patient receives the proper and best medication for effective symptom control is an error in thinking. The truth is that most of the seriously mentally ill are not provided the needed aggressive medication management for best symptom control. One need only look at the CATIE study to see that Clozapine is the drug of choice for treatment resistant psychosis, yet Public Heath Care Psychiatry (where most of the seriously mentally ill reside) is reluctant or refuses to use Clozapine. This fact is addressed in The John Henry Model by making aggressive medication management including Clozapine a key component of care.

Returning to the challenge of teaching, metaphor is often and repeatedly used to construct easily retainable concepts through images and story. In fact, the entire teaching process is called “Learning How to Succeed in the Game of Life”. The game of life has certain rules which must be understood, demonstrated, practiced, applied, and then retained for continuous use when needed. It is only through a complete mastery (errorless learning) of each critical rule, can an individual hope for and seek greater independence and responsibility. One huge mistake made by treatment environments is to prematurely discharge an individual to greater independence (financial decision or poor treatment plan) only to see regression and likely re-hospitalization because the patient skill sets are deficient.

Metaphor is repeatedly used but not as an esoteric concept. Each metaphor and therefore each teaching page are always linked to real life situations, real life deficiencies and real life success. An early prerequisite teaching page is the Green-Yellow-Red stoplight metaphor. Each word (green, yellow or red) is defined, described, given meaning, illustrated through example, and lastly applied to specific behavior being demonstrated by patients. Are you green (good to go) out of the house in the morning if you have not showered and smell? At the door when you are about to depart you are red (stop, not good to go). Earlier in the morning when you were reminded by a caregiver that you needed to shower, you were yellow (caution, potential problem). Much earlier when the patient chose to shower they were green and had demonstrated (at least regarding this one specific responsibility) that they were good to go.

As we can see, a teaching page has elements or characteristics:
1) It has a theme
2) It utilizes metaphor as a technique
3) It links metaphor concept to a specific and real life difficulty
4) It describes the specific Rules of the Game of Life relating to the real life difficulty
5) It clarifies the rewards and consequences of success and failure to properly learn and apply the needed task.
6) It repeats itself as often as is needed until mastery occurs. This mastery is deemed complete only when success is independently motivated, does not require any prompting, and endures a requisite length of time.
7) It attempts to address the needs of “the many” by addressing the “need of the one.”

Some additional examples of teaching page topics include:
1) The Plane Has Taken Off (attention to time and responsibility to be punctual)
2) Prepared To Launch? (will your skill sets let you fly or will you crash and burn)
3) Getting Out of the Quicksand (learning how to accept, use, and trust guidance)
4) What You Want Isn’t Always What You Need (best interest vs expressed interest)
5) Are You Better Than or Better Off?
6) Why We Behave the Way We Do (we are seeking something)
7) What are ADL’s (not just morning hygiene but all of each days individual responsibilities)
8) ADL Complexity (simple, moderately complex and complex)
9) Is Budgeting an ADL? YES.
10) Is Kindness an ADL? YES. What else should we call an Activity of Daily Living (ADL), and why have we limited the term to just basic hygiene?
11) Sow (plant) and Reap (grow) (how to build habits and character)
12) The Meaning of Life? SMOKING!
13) Climbing Mount Everest (learning to prepare for and deal with change)
14) Your Problem is Not My Emergency (learning to accept personal accountability)
15) The Faces of Entitlement "The Entitlement Syndrome": my money, my cigarettes, my right, my wants)
16)  I Feel, I Act, but Did I Think? (learning how to introduce thought into action)
17) Premack Principle: First/Then (first responsible attention to your illness needs/then you receive your entitlement check
18) What is Normal? Ability to adjust and deal with your life challenges/problems with proper insight and skill which allows for effective functioning and peace of mind
19) Excessive Anything: Addictions of all kinds- Drugs legal or illegal, food, smokes, spending, caffeine etc.
20) Anger is like Barf: You need to get it out but you are not supposed to get it on anyone
21) Smooth Sailing: Even, Uneventful, and Peaceful equals BORING-Dealing with the boredom of stability and symptom control which is called "Maintenance"
22) Being a DUD: To misfire, to be unsuccessful, to fail
23) Faith: Is not an excuse for unclear thinking
24) F.A.C.T.S.: Families Achieving Clear Thinking Solutions- the critical importance of caregiver influence and guidance
25) Russian Roulette: When you stop taking your medications you are playing Russian Roulette with you life
26) Expunging the term "High Functioning": One is high functioning when one effectively applies their specific skill sets, not when one is endowed with better skill sets which they refuse to apply
27) How do I get out?: Graduate, be dislodged, or be expunged
28) The relationship between Counterintuitive and Maturity: Knowing when being counterintuitive will be in the best interest of yourself, your child or your family 
29) The Stages of Rehabilitation: Stage 1- Diagnostic
                                                               Stage 2- Medical stabalization with best symptom control 
                                                               Stage 3- Inventory (Assessment of strengths and deficits)
                                                               Stage 4- Growth Stage (obvious and rapid growth
                                                                               dependent on individual skill sets)
                                                               Stage 5- Maintenance Stage (emphasis on retention of
                                                                               realized gains and possible slower growth)
                                                                DO NOT REGRESS!      ERRORLESS LEARNING!
Two specific teaching pages have proven to be the most important for the John Henry Model and will be offered in more detail. The first is: What is the difference between a right and a privilege? Click here to view this page outline. The second is: What is the difference between a consequence and punishment? Click here to view this page outline.