In January and February of 2019, 12 regional in-person training sessions were delivered. These sessions encouraged participants to consider both large and small scale changes (systems, communities, organizations, individual practice.) Participants reflected on small things they could do, learn, ask, or try that would move some of these changes along. In the training these were called "nudges". These nudges were collected for each region. You can click on the files below to view these.
Background and Purpose
Professional practices in mental health and substance use in Minnesota offer many good options for people with mental health and co-occurring conditions. However, as noted in the recent report from the Governor’s Task Force on Mental Health (Governor's Task Force on Mental Health Final Report, November 15th, 2016) there are still gaps in services and fragmentation in service delivery. As a result, the overall picture is that engaging the system is not always easy and does not always lead to coordination of supports, services, and treatments that make sense to the person receiving them or their family. As a result they do not always lead to recovery and the five effects of person-centered practices that are listed in the Minnesota Department of Human Services’ (DHS) Person-Centered Informed Choice and Transition Protocol (PCICTP) January 2017. These five valued effects (page 9) include:
1. Growing in relationships
2. Contributing to community
3. Making meaningful choices
4. Being treated with dignity and respect and having valued social roles
5. Sharing ordinary places and activities.
These concerns in the coordination and focus of treatments and services have long been recognized as a problem. They are the core of many national and Minnesota-based policy changes in all areas of services and supports for successful community living. Federally there have been many changes to policy and regulations across the spectrum of health and human services to help ensure a holistic view of recovery and that people’s voices and views are central to any service or support they receive. The value of family and other natural supporters in the process of recovery and community living is also being recognized. Both locally and nationally, these approaches are often being pulled under the umbrella of “person-centered and family-centered” practices. While that terminology and those approaches are gaining traction, they are not always familiar in mental health and behavioral health communities. More importantly for practitioners, there is a lack of clarity and good training specific to the mental health community to understand what these terms mean in practice.
Minnesota’s Olmstead Plan, which is the source of the PCICTP, is founded on an individual’s right to have sufficient services and supports to maintain a life in the community. Person-centered and family-centered practices are at the heart of the plan. They speak to concerns regarding fragmentation and coordination issues as a barrier to recovery-based community living. The PCICTP were developed by DHS to help key professionals, including Mental Health Targeted Case Managers (MH-TCM) understand the context of person-centered practice in their work. However, the concrete tie between the protocols and their specific roles has still not fully taken shape.
The University of Minnesota’s Research and Training Center on Community Living (RTC-CL) at the Institute on Community Integration (ICI) and the Department of Human Services’ Mental Health Division will co-create training with the community suited to the unique needs and strengths of the mental health and behavioral health fields. The goal of this work is to provide global, mental health and behavioral health principles to community members and providers and more specifically to MH-TCM through clearly defined practice guidelines. The training and materials are being developed to help people apply person and family-centered practices in their roles and fulfill the expectations of PCICTP in a way that makes sense to the mental health and behavioral health communities.
The project will do this by:
- Identifying the training and resources in person or family-centered practices that are currently available to MH-TCM in Minnesota that are likely to be helpful in implementing the PCICTP in the context of mental health best practices and TCM roles and responsibilities.
- Working in conjunction with stakeholders to co-create:
- Refined definitions and context for person and family-centered practices that have meaning in the mental and behavioral health community.
- Identify gaps between current training and resources available to MH-TCM on person and family-centered practices and expectations.
- Develop additional training and resources meant to fill those gaps.
- Delivering in-person training to support individual, organizational, and system level transformation toward more person and family-centered approaches in mental and behavioral health services.
Person and Family-Centered Practices in Mental Health and Substance Use
The terms person-centered and family-centered are not currently universally adopted or accepted in mental or behavioral health services. However, there are many ways that these communities have been moving in a direction that aligns well with adopting person-centered and family-centered practices. For example, recovery-orientation, community living, self-direction and similar movements have goals that are highly aligned with person-centered practices. The practices of family education and support have been used for decades to increase the ability of family members to support their family member in recovery, while maintaining their own health and wellness in the process.
The following are a set of some Frequently Asked Questions (FAQs) regarding person-centered and family-centered practices as they apply to the mental and behavioral health communities.
Questions answered below:
- Why should we care about person-centered and family-centered practices in mental health and substance use?
- What are core components of person and family-centered practices?
- How do family-centered practices intersect with person-centered practices? Isn’t that a conflict? Are you only talking about children and their families or people who have guardians?
- I understand that relationships are important. But I work with people who have no family contact. What then?
- Many of the people I work with don’t want person-centered services or are satisfied with the way things are. Do we have to force them to take person-centered services?
- Can abstinence-based practices in treatment of co-occurring substance misuse be considered “person-centered”?
- If approaches such as commitments, court orders, and the like are not person-centered, how can I work with people who have these requirements put on them in a person-centered way?
- Are person-centered services and person-directed (or self-directed) services the same thing?
- What is person-centered discovery and how does it differ from assessment?
- How can I accomplish person-centered discovery and practices with the time I have?
Why should we care about person-centered and family-centered practice in mental health and substance use?
To live well, a portion of people in our communities will benefit from assistance with life activities. People who actively engage in recovery-oriented treatments and support have the best chance of success. When the most important people in their lives (often family) are also engaged in helpful ways, positive outcomes of their recovery work are more likely to happen and more likely to endure. Across the social service and health care systems, the focus on person-centered and family-centered practices is growing. (https://www.samhsa.gov/section-223/care-coordination/person-family-centered). There are many reasons for this, including changing requirements by federal funding and policy makers. In Minnesota, the Olmstead Plan is requiring that person-centered practices be used to help push the system to be responsive to individuals and their families and ensure people’s rights to be supported in the community are upheld.
Regulations and policy will continue to drive person-centered practices both nationally and locally. However, funding and organization of services will also continue to be volatile in the current climate. Adoption of a person-centered framework can help to keep important aspects of recovery, inclusion, and self-determination in the forefront of professional practice through these ups and downs. Expecting that people receive treatment and support in the context of holistic health and meaningful participation in community living can make clearer the effects of system limits and fragmentation and why managing them is important.
People's natural supports and the practitioners, professionals, and providers benefit from sharing the work with people seeking services. Compassion fatigue is a reality in our field and a result of feeling disillusioned and overburdened by bureaucracy, documentation standards and expectations of our performance. When we empower people to take ownership of their lives and health we share and shift knowledge, skills, and abilities and help people to reach their highest potential. Many find this approach to be energizing rather than depleting in nature.
Taking the time to define person and family-centered practice in ways that make sense to specifically in the mental health community as part of this process is important. It can help the mental health community avoid having approaches that are thrust upon them without consideration of the match to the actual experience of people with mental health conditions and their families.
What are core components of person and family-centered practices?
There are not consistent definitions for person-centered or family-centered practices that are universally adopted. We are in the middle of figuring that out together. At the same time, there is no doubt this terminology will continue to take hold and define practices for a variety of reasons. We have a list of terms and definitions from the Minnesota Olmstead Plan that we’ll use as a guide and starting place. We also have a core set of resources we use to frame up our approach. (You can click on those tabs to learn more.)
That said, it’s important to remember that person and family-centered practices are about processes, product, and outcomes. To be truly person or family-centered, the people engaging the system need to feel welcomed and valued by professionals. They need to feel heard and actively involved in developing approaches that will work for them. Treatments and support need to be delivered in the context of helping people live full lives in ways that are meaningful to them. The strengths, goals and preferences of each person, including their culture and values, need to be the basis for organizing treatments and supports. Finally those services and supports need to actually help people achieve more of what matters to them. Preferred relationships and success in community living (jobs, school, and inclusion) are central to this definition.
How do family-centered practices intersect with person-centered practices? Isn’t that a conflict? Are you only talking about children and their families or people who have guardians?
Family-centered practices apply across the life span. Part of being person-centered is understanding the person in the context of their most important relationships. Even as adults, family is often a cornerstone of that social network. Recovery is defined in part by the person’s capacity to maintain and develop relationships that are important to them and in ways that make sense to them. This means people having reciprocal and voluntary relationships in which both people are equally valued. It also means having an opportunity to stay connected to people that matter to them and to develop new relationships as they desire.
When practitioners ignore or do not integrate family into recovery proactively, they may inadvertently reinforce difficulties in family systems that could be minimized. This may create unnecessary dependencies on paid supports and the “system.” Active families do better if their needs in the situation are considered and supported and they have a clear understanding of the needs of their loved one. This does not mean professionals should disclose information or engage family members against a person’s will. It does not mean that family members have to be involved in ways they do not find comfortable. What it means is that practitioners always consider this aspect of health and wellness and that they recognize that families may be an essential and important part of a person’s recovery. It means exploring that with the person and their families as appropriate and ensuring that family supporters have information and help to be effective allies in the person’s recovery while maintaining their own health and wellness. If a child or youth is the focus of treatment, it means considering the needs of the whole family context when supporting recovery of the individual child.
I understand that relationships are important. But I work with people who have no family contact. What then?
Sometimes family members can be a strong ally in supporting people through mental health recovery; other times they will struggle with this. The onset of many mental health conditions and especially when they co-occur with substance misuse can put a strain on relationships. Because of the ongoing prejudice against people with these disorders and their families many of these conditions are hidden, ignored, or self-managed for a prolonged period of time. Sometimes the strains of this are too much for families or individuals. Other times, the family who could support the person may struggle with many of their own issues. They may be unable to actively help and support their family member in positive ways. Relationships can change to the point that they are no longer mutual, life-enhancing, or voluntary. Unfortunately, family members may become estranged or lose contact with each other. For some, a separation from family members may even be the only way they know how to reclaim their mental health recovery.
Respectful exploration with people about their views on family participation and family relationships is important in person-centered practices. Practitioners should make no assumptions or judgments about how the person feels or what they think of this. However, it is often assumed that isolation from family is a permanent situation. Sometime, the person may feel their family wants nothing to do with them, meanwhile members of their family may wish for reconciliation. The reality is there are many stories of desired reunions and reconnections between people and their families after even decades of separation. People change and circumstances change. When working with people who have lost contact with family, are not welcome by family, or do not see family as an ally, it is important to explore this respectfully with the person and to keep the door open to change. If the person wishes to try for reconciliation, that can be an important part of their person-centered plan. If they wish to maintain a distance for now, that can also be part of the plan.
People have their biological or adoptive (legal) families. Keep in mind, they may also have people who they consider family or who fulfill those roles but who do not meet legal definitions. They may or may not call people in these roles “family.” For the purposes of person and family-centered practices, these people are critical to the person’s recovery. Professionals should consider these relationships in support. In some family cultures, people such as aunts, uncles, godparents, grandparents or community leaders have equal or greater authority in the family than parents. In some family cultures an oldest sibling may make decisions for younger siblings. It is important to understand the way in which the person defines family and who should be engaged and in what way, rather than applying your own understanding. Finally, if it appears a person has lost many or all relationships, person-centered practices ask professionals to consider how supports can be organized to help people re-establish their connections to others in ways that are meaningful to them or create new relationships.
Many of the people I work with don’t want person-centered services or are satisfied with the way things are. Do we have to force them to take on person-centered services?
Person-centered practices are a professional approach to organizing services and supports that is focused on a holistic and strength-based view of the person and support recovery in the context of community inclusion, relationships, and self-determination. For that reason, they are not something that should be considered optional. However, these practices were initially driven from the community of people who developed person-centered plans. Formal person-centered planning is a specific type of support that should be entirely optional and self-directed.
It’s difficult to believe that many people really don’t want practitioners that consider them through a holistic, strength-based lens that has a focus on personally defined goals in treatment and support. It’s more likely that their understanding of what person-centered practices is not accurate. The practice of “person-centeredness” has had false starts as practitioners try apply these new approaches.
A real and common challenge for practitioners can be when they work with people who have difficulty describing or sharing their goals, aspirations, or preferences. This can be because the person is truly in a difficult time, is very young, or has other reasons why they are struggling to directly share their views. It can also be because they have learned over time that people are not really interested in what they think and have dismissed their strengths. Cultural or linguistic barriers may make this a challenge. In these situations it can take time, patience, and skill to get to know the person better. Simple steps toward choice, direction, and control can help. Goals and choices do not have to be dramatic to be meaningful. Once the basics in life are met (food, clothing, shelter, medical care), it’s often the smallest things that can enhance or deplete our quality of life.
Another real difficulty is when people want to do things that seem risky or dangerous to practitioners or family. Skill at supporting informed choice in the context of dignity of risk is needed in professional roles. Good coordination and communication is needed. It’s important to know that person-centered supports include due diligence in this area. Person-centered does not mean reckless or uncaring. It does mean the time is taken to understand the person, support them in their goals, and ensure they understand and are ready for the responsibilities that come with risks they chose. It also means having tolerance for people to make mistakes and a belief that they can learn from them.
Can abstinence-based practices in treatment of co-occurring substance misuse be considered “person-centered”?
Any treatment approach can be considered person-centered if the person agrees to the treatment and feels it will help them meet their goals. Many people who struggle to manage their use of substances find that a firm line between what is acceptable behavior (not using) and unacceptable behavior (using at all) is helpful in recovery. On the other hand, some people feel they would rather learn how to manage their substance use more appropriately rather than simply quit altogether. Still others who may fit criteria for substance misuse disorders and have behaviors with substances that concern others, may not want to focus on that at all. Requiring people to attend and participate in abstinence-based approaches as part of court orders, commitments, or participation in other services (such as housing, sheltering, employment, etc.) is not a person-centered practice. This does not mean it is necessarily inappropriate to a given situation but it should be considered a last resort.
It’s important to be very transparent and open with people about what options will or will not include requirements such as abstinence. It’s also important to fully, honestly, and without judgment explore where people are as far as their hopes for themselves and how their substance use affects those goals. Motivational interviewing approaches can help. Whenever a person is forced into a treatment options, it does deplete their trust of the system and their trust of others. Sometimes people are grateful in the long term that they received helpful treatment. Sometimes they begin to opt out of treatment completely when they can.
Any forced treatment should be seen as the very last choice and only in the most difficult and dangerous of situations and with many checks and balances. On the other hand, ignoring difficult or potentially dangerous situation is not “person-centered” either. If a person is losing or straining relationships, losing their ability to participate meaningfully in valued roles, at risk for incarceration or homelessness, we should be working with them actively to help them move toward recovery. We should do so vigorously through person-centered practices and shared decision-making. Even people with very significant mental health and substance misuse concerns can start toward wellness and recovery. However, they must feel safe, respected, and heard in the process.
If approaches such as commitments, court orders, and the like are not person-centered, how can I work in a person-centered way with people who have these requirements put on them?
Person-centered practices are not about neglecting or ignoring people’s real needs and real situations. It’s not about professionals working on a person’s goals for them rather than with them. When a person is under commitment or on parole, they will certainly have limits put on them. However, the five effects of person-centered practices from the PCICTP can be supported even if there are some limits. (1. Growing in relationships; 2. Contributing to community; 3. Making meaningful choices; 4. Being treated with dignity and respect and having valued social roles; 5. Sharing ordinary places and activities.)
Effective and early use of person-centered practices, in particular things like motivational interviewing and shared decision-making can be very helpful to preventing these situations. It can help people articulate their goals and preferences. It can help people develop the skills and strategies that support them in achieving what is important to them in ways that are safer and more acceptable. It supports people in learning from their own mistakes and choices, without neglecting our responsibly to support them in informed choice.
Person-centered practices are balanced approaches to learning about people and supporting them in a way that ensures the person’s voice and views are included, recognized, and guide service and supports. The process of really hearing a person and their hopes and dreams for themselves is a powerful hook to doing the hard work of change. In fact, people are unlikely to work hard at anything that does not lead them to something they find valuable. When working with people who are already under commitment listen to them without judgment. (No one really wants to be under a commitment or a court order or told they can never use a substance that has helped them cope in the past even if there are reasons for those things.) Be honest about what you can and cannot do for them. Don’t ignore their desires or diminish the person’s hopes. Build them into your plan and help the person understand what skills and strategies they could gain that can help them achieve their goals. Keep in mind also, that “moving toward” goals are always more powerful than “moving away” goals. For example: “Getting off commitment” or “out of this facility” are not as meaningful or useful as “Being able to see my kids every day” or "Getting back to work.”
Are person-centered services and person-directed (or self-directed) services the same thing?
No. They are inter-related concepts but not the same.
Formal self-directed services means that the person receiving services has taken on some or all aspects of selecting, managing, organizing services for themselves (with or without help of others they have designated to help them, such as family members). In self-directed services, professionals serve as conduits or guides to the procedures of accessing benefits or staying in compliance with rules. (For example, they may show people when and how to fill out paperwork to maintain benefits.) Formal self-direction is something that may or may not be of interest to people. Some will not want the responsibilities and effort that go with it. However, even when a person does not embrace a formal role in self-directing services, professional responsibilities still include ensuring that people direct their own services to the maximum extent possible and preferred. In addition, even when a person chooses self-directed service options, they still benefit when professionals approach their work in a person-centered way.
Person-centered services are those in which professionals and systems approach services in a person-centered way. They seek to understand what really matters to the individuals they work with beyond seeking a specific treatment, service, or support. Person-centered services include a balanced and unique understanding of each individual’s goals, strengths, resources, and preferences. They are organized in ways that support people to achieve personal goals in a context of what is meaningful to them. True person-centered services must also be person-directed in the sense that they seek to ensure the focus is to help people move toward achieving things that matter to them in ways that make sense to them.
Are person-centered plans, person-centered service plans, person-centered planning, person-centered practices, and person-centered thinking all different words for the same thing?
No. These concepts are related but not the same.
Traditional person-centered plans (called “formal person-centered plans” in the PCICTP) are the product of processes that are guided by a facilitator. They help the person elicit and organize a positive vision of themselves and their life in the broader community (roles, relationships, accomplishments, preferences, contributions, goals, etc.). They identify the next steps and responsibilities in moving toward that vision or maintaining that vision. These plans are initiated by the person. They are only shared with people with whom the person wants to share. There are many types of traditional person-centered planning processes that can be valuable. They are particularly helpful for people who have been part of the service system for a long time and/or who have barriers to recognizing and communicating their positive vision of their lives to others. In mental health a well-known and evidence-based form of person-centered planning is the Wellness Recovery Action Plan (WRAP). (Copeland Center for Wellness and Recovery https://copelandcenter.com/).
Person-centered service plans are similar to traditional person-centered plans. However, they are initiated by the service professionals for a specific purpose. A person-centered service plan is meant to provide a meaningful framework for professionals and others in working with the person that aligns with the person’s positive vision for themselves. If a person has their own person-centered plans and is willing to share aspects of it, this can help services align with their understanding of what works and what matters.
Person-centered planning process must work for the person regardless of who initiates the process. This may be a direct consent to specific type of person-centered planning. It may be a less direct process of simply maintaining control over what is shared with others and in what way. Facilitators of any type of person-centered planning are sensitive to ensuring conversations and processes are working well for the person and are not about pushing forward the agendas of others. Formal person-centered planning processes only include people the person wants to include. The person must have a lead role in directing the process and selecting desired outcomes. They only participate in ways that make sense and are comfortable for them. This does not mean that difficult or concerning things are not discussed as part of a person-centered planning processes. It does mean that they are discussed, explored, and supported in ways that make sense to the person.
Person-centered practices are grounded in the same concepts as person-centered planning. They are universal practices that seek to understand each person holistically. They validate and presume a person’s ability to know themselves and what will and will not work well for them. They seek also to help the person explore life broadly and engage fully in areas where they may not have experience or may have lost hope. In mental health communities they align well with self-direction and recovery-based, trauma-informed, and shared decision-making practices. Informally, professionals of all types are being encouraged to implement and embed person-centered practices at every point of contact, including ensuring that service plan processes and outcomes are person-centered.
Person-centered thinking is a set of concepts, tools and skills that have been organized by The Learning Community on Person-Centered Practices. Training in these concepts encourages professionals to consider what is important to each person as well as what is important for them. In Minnesota, training on these skills and attitudes has taken place around the state and there are many person-centered thinking trainers and opportunities to participate in this training. A particular form of person-centered planning that expands on these skills (the picture of a life) has been used as a way to train many professionals on person-centered planning. These skills and tools have also been embedded in an online training available to people in Minnesota through the DirectCourse Person-Centered Counseling (PCC) training. They have also been embedded into regional training and technical assistance for lead agencies and providers in organizational practices and positive supports.
What is person-centered discovery and how does it differ from assessment?
Assessment is something that is done to see if someone is eligible for a specific service or treatment option, or meets criteria for formal diagnosis. These may be important activities in order to access specific types of services for which a person is eligible. However, they do not tell you much about the person outside of their ability to function in a certain way or areas where they struggle. Person-centered discovery is a process of getting to know people in the context of what matters to them. It starts by seeking to understand what is important to the person. This includes preferences and expectations around goals, relationships, activities, status, opportunity, material items, and routines. It uses these unique views and preferences as the launching point for understanding the person’s preferences for support, including which services will be used and how they will be organized. Person-centered discovery can often provide the details needed for some assessments. It can make clearer if the assessment is necessary at all. (By clarifying if the service offered even aligns with anything the person would find valuable.)
How can I accomplish person-centered discovery and practices with the time I have?
Good time management is important to all professionals in this day and age. There is so much to do and very little time. There is no doubt that learning new practices always take time and effort. However, once they are embedded most practitioners find that person-centered practices take a similar amount of time as traditional processes or less and they produce better results overall. By focusing on the person and what’s important to them, you immediately build rapport. People are more likely to be honest with you and forthcoming if they believe you are interested in providing information and support that they think is meaningful. When they are active participants in all aspects of services and supports they are more likely to fully and effectively utilize what is offered to them. Well- done, purposeful person-centered conversations and interactions typically lead to a rich amount of useful information in a relatively short amount of time.
To be truly effective, person-centered practices should be universally applied in organizations. Tools, training, evaluations and overall organizational processes should support this approach. Often by thinking creatively, individual practitioners can work within systems to make this happen. However, individual practitioners can only do so much. It’s important to invest in person-centered practices at an individual level but also work systematically to ensure ongoing changes to policies, practices, and procedures at all levels are supportive of person-centered practices. By creating and supporting organizational and system-level change, practitioners ensure person-centered practices will be easier to apply. They can be more consistently delivered. The needs of practitioners to do this work should be part of this systematic change.