A
Call For change:
Toward
A RECOVERY-ORIENTED
Mental
Health Service SYSTEM
for
Adults
A
Publication
Of
The
PENNSYLVANIA
Office
of Mental health
AND
Substance Abuse Services
ACKNOWLEDGEMENTS
Recovery Workgroup
Members
Kim Anglin,
Linda Bakmaz,
Shelley Bishop, Thomasina Bouknight, William
Boyer,
Mary Lyn Cadman, Michael
Chambers, Timothy
Connors, Michele Denk, Mary Jo Dickson,
Virginia Dikeman, Kate
Donegan, Suzanne Elhajj,
John Farmer, Cheryl
Floyd, Hickman Gardner, Jeff Geibel,
Scott Heller, Shirley
Hopper-Schaech, Jim Jordan, Diane Keefer, George
Kimes, Mary Kohut,
Glenn Koons, Gayle Lorenz,
Wendy Luckenbill,
Robert Manrodt, Jim
McCormack,
Edna McCutcheon, Karen Morton,
Nancy Porter, Robert Primrose,
Suzanne Ralph,
Mary Ellen Rehrman, Joseph Rogers, Jean Rush,
Mary Jeanne Serafin, Lewis Silverman, Betty Simmonds, Caroline
Smith, Kenneth Thompson,
Sue Walther, Carol
Ward-Colasante,
Rae Weber, Danny
Wildasin,
Wendy Wood, Dave Wooledge, Linda Zelch
Recovery Steering
Group Members
Linda Bakmaz,
Shelley Bishop, William Boyer,
Mary Lyn Cadman, Michelle
Denk, Cheryl Floyd, Jeff Geibel,
Scott Heller, Diane
Keefer, Mary Kohut, Jim
McCormack,
Betty Simmonds, Caroline Smith,
Kenneth Thompson, Linda
Zelch
Drexel University
College of Medicine/Behavioral Healthcare Education
Taylor Anderson,
Donna McNelis, Brenda
Weaver
Consultant
Laurie Curtis
A
Message from Joan
Erney
It
is with great optimism that I
present A Call for Change:
Toward a Recovery-Oriented Mental Health
Service System for Adults.
As I traveled
around the state recently participating in the Service Area Planning
meetings,
it became clear to me that we are in the midst of an exciting awakening
of
hope, realization, and change. The
meaningful stories, the emerging leadership, and the compelling impact
that a
strong consumer voice is having across this Commonwealth is already in
evidence. This
document is meant to
serve as a further tool to move us toward our statewide vision that
assures
that every person will have an opportunity for growth and recovery.
I
wish to thank the many
individuals who stimulated our thinking and committed to the hard work
of
developing this document, especially the work of the OMHSAS Advisory
Committee
Recovery Workgroup. A Call for Change clearly represents and
honors the voice of
individuals who are experiencing recovery and their undying advocacy to
establish the realization nationally and in Pennsylvania
that recovery from mental illness happens!
Recovery is the goal!
A
Call for Change establishes a firm foundation for the Pennsylvania
transformation to a recovery-oriented mental health system. It offers an understanding
of how we’ve
arrived at this time of recovery transformation, provides a concise
definition
of recovery, and further consideration of what a recovery-oriented
system is
and is not. Indicators
are provided to
serve as critical reference points for services, agencies and county
mental
health programs looking for more specific strategies for transforming
to more recovery-oriented
services. A Call for Change highlights the
challenges we have yet to address
and the need for us to engage in open, honest discussion and debate
about these
issues.
Most
importantly, we are called to
take the steps and risks associated with true transformation. As noted by William A.
Anthony, PhD.,
“Massive system changes must occur if the vision of recovery
is to become a
reality for an ever-increasing number of people with severe mental
illnesses. For this
very different vision to become
reality, brilliant leadership is required.”
A Call for Change
recognizes
and calls upon the brilliant leadership of all who are part of our
system –
consumers, family members, advocates, providers, policy-makers and
administrators – to effect true transformation in Pennsylvania.
OMHSAS
is dedicated to building on
the foundation of A Call for Change,
so that the opportunity of recovery is fully supported for all who are
served
in our public mental health system.
We
look forward to your dedication in working with us to achieve this goal.
Table
of Contents
ACKNOWLEDGEMENTS.. ii
A
Message from Joan Erney.. ii
Table
of Contents.. ii
Why
a Call for Change?. 2
Introduction.. 2
Envisioning a Transformed
System in Pennsylvania.. 2
Role of the OMHSAS
Advisory Committee and the Recovery Workgroup. 2
Scope and Role of A
Call For Change.. 2
The
Roots of Recovery in Mental Health.. 2
Deep Roots and a Legacy of
Reform... 2
Views of Recovery.. 2
Research &
Longitudinal Studies. 2
Civil Rights. 2
Pennsylvania
Consumer/Survivor/Expatient Movement.. 2
Community Support Programs
(CSP) 2
Addictions, 12-Steps, and
Mutual Support.. 2
Growing Recognition and
Interest in Mental Health Recovery.. 2
On the National Scene. 2
What
Does Recovery Look Like?. 2
More than Treatment or
Services. 2
Individual. 2
Programs/Services. 2
System... 2
Resiliency.. 2
But, We Already Do All
That! 2
Indicators
of a Recovery-Oriented Service System... 2
Recovery Is Not a New
“Model”. 2
Basic Domains. 2
Indicators of Recovery
Oriented Systems. 2
Implications
of Shifting Toward a Recovery-Oriented Mental Healthcare System... 2
Challenges and Barriers. 2
Addressing Challenges and
Barriers. 2
Toward
Transformation.. 2
Only a Beginning.. 2
Your Call to Change. 2
Conclusion.. 2
Why
a
Call for Change?
The
goal of a transformed system: Recovery
“Tangata
Whai Ora”: A term chosen by and used for people with
experience of mental
illness or distress in New
Zealand.
Translated it means “people seeking
wellness”.
˜™
Introduction
We have all seen them
– those pictures of people
confined to locked wards of rambling old hospitals, the hopeless look
in their
eyes, abandoned by family and friends, and facing a future that is
bleak and
desolate. It
doesn’t matter how old those
pictures are, the 1880’s, the 1940’s, the
1970’s, the eyes are still the
same. At different
times, there have
been waves of reform to improve conditions, to institute more effective
treatments, to seek new ways to promote and support healing from
psychiatric
disorders. We have
found new, more
helpful medications; we have helped people move from institutions to
settings
in our communities; we have found ways to help people find jobs or go
back to
school. We believe
we have had some
success in this work. And, to some degree we have. But too often, the
eyes are
still the same. People are still disconnected from family and friends,
isolated
within their communities, and often trapped in assumptions about bleak
futures
due to chronicity and disability.
During the past decade,
many voices have risen
to challenge some of the basic assumptions about mental illness and its
impact
on the lives of individuals and their families.
People with serious mental illnesses do, in fact, recover.
Some become
fully symptom-free with time, while others live rich and fulfilling
lives while
still experiencing some psychiatric problems.
The amalgamation of these voices has created what is now
known as the
“recovery movement” in mental health. One of the
basic premises of this
movement is that the role of a mental health service system is not to
“do for”
or to “do to”, but to “do with”
– recognizing a fundamental shift in roles,
power, and responsibility for providers and consumers alike. It is not about units of
care, placement, or
“functioning” or even a cure per se; it is about
building real lives. It is
both a goal or destination and a continual, very human process of
growth,
change, and healing.
The recovery movement is
impacting the mental
health system at all levels by challenging mental health providers,
administrators, policy-makers, funders, workers, as well as people who
experience mental health problems and their families to look at how
negative or
limiting assumptions are driving approaches to services, to funding, to
treatment, to policies, and ultimately to the course of
individual lives. The
federal government has issued a call for
sweeping transformation of the mental health service system throughout
the United States.
In Pennsylvania,
this document, A Call for Change: Toward
a Recovery-Oriented Mental Health Service System, carries
this same mandate
for change into the Commonwealth, building upon our current efforts,
and
providing a foundation for further reflection, discussion, planning and
ultimately our transformation to a more recovery-oriented mental health
service
system for adults in this State.
Drawing from the
experiences and ideas of
Pennsylvanians, as well as contemporary literature and the experience
of other
states in tackling these changes, A Call for
Change presents what is currently known about the elements of
a
recovery-oriented mental health system and presents a set of indicators
by
which the process and outcomes of transformation may be evaluated.
OMSHAS
expects that this document will help to articulate a more detailed
vision of
what a recovery-oriented system will look like in Pennsylvania
at the state and local levels, and introduces the Call
to Action for more strategically defining the necessary steps
of transformation.
In November, 2004 the
Pennsylvania Recovery
Workgroup generated this definition of recovery to guide service system
transformation in this State. It
was
fully endorsed by the Pennsylvania Office of Mental Health Substance
Abuse
Services (OMHSAS) in 2005.
Recovery
is a self-determined and holistic journey that
people undertake to heal and grow.
Recovery is facilitated by relationships and environments
that provide
hope, empowerment, choices and opportunities that promote people
reaching their
full potential as individuals and community members.
Operationalizing this
definition of recovery
throughout the Pennsylvania
public mental health service system for adults is the prime goal and
vision of
this document.
Envisioning
a Transformed System
in Pennsylvania
OMHSAS Vision & Guiding Principles
In 1995 Deputy Secretary
Charles Curie
developed the first OMHSAS mission statement that included an
expectation that
every person served within the system will have the opportunity for
recovery. In 2003
under the leadership
of Deputy Secretary Joan Erney,
the OMHSAS,
with input from representatives of all major stakeholder groups,
developed a
recovery-focused vision statement of a transformed service system in Pennsylvania.
To support this vision,
OMHSAS also identified a
core set of guiding principles that outline primary tenets to be
reflected in
all change initiatives. These
guiding
principles are as follows.
Guiding Principles
The Mental Health and Substance
Abuse Service System will
provide quality services and supports that:
· Facilitate
recovery for adults and resiliency
for children;
· Are
responsive to individuals’ unique strengths
and needs throughout their lives;
· Focus
on prevention and early intervention;
· Recognize,
respect and accommodate differences
as they relate to culture/ ethnicity/race, religion, gender identity
and sexual
orientation;
· Ensure
individual human rights and eliminate
discrimination and stigma;
· Are
provided in a comprehensive array by
unifying programs and funding that build on natural and community
supports
unique to each individual and family;
· Are
developed, monitored and evaluated in
partnership with consumers, families and advocates;
· Represent
collaboration with other agencies and
service systems.
Role
of the OMHSAS Advisory
Committee and the Recovery Workgroup
In May 2004, OMHSAS
redesigned its Advisory
Committee Structure to be more inclusive and more responsive to the
various
stakeholder groups. This re-organized structure took on the
responsibilities of
the previous Mental Health Planning Council, and further identified its
role to
provide guidance to OMHSAS on its broad behavioral healthcare mandate
which
includes mental health, substance abuse, behavioral health disorders,
and
cross-system disability. The OMHSAS Advisory Committee membership is
comprised of
a diverse group of stakeholders including representatives of children,
adolescents, older adults, adult consumers of mental health services
and their
family members, persons in recovery from addictions, persons with
co-occurring
mental illness and substance abuse, providers, advocates, and
government
officials.
Recognizing the emerging
need and growing
interest in Pennsylvania
to make
a shift towards a more recovery-oriented service system, the Advisory
Committee
formed a Recovery Workgroup. The
task of
this workgroup was to explore how to transition the Pennsylvania
mental health system into a more recovery-oriented approach. This task was incorporated
as a Priority
Project of OMHSAS and approved by the Advisory Structure with specific
charge
to develop a blueprint to help frame and guide the transformation.
In November 2004 the
Recovery Workgroup was
brought together by invitation to discuss the process of developing a
blueprint
for building a recovery-oriented service system in Pennsylvania.
The group met over two days to share ideas and develop consensus about
the
definition and indicators of recovery-oriented services in Pennsylvania.
A contractor was engaged to draft a document based on the output of
these
meetings and other relevant materials. A Recovery Workgroup Steering
Committee was
formed to guide development of the draft and to review the document
before
submitting it for broader field review and comment.
Scope
and Role of A Call for Change
A
Call for
Change outlines a destination and provides some guidance on
ways to get
there. Its purpose is to stimulate thinking, generate discussion, and
serve as
a foundation for more targeted strategic planning throughout Pennsylvania.
Some would want this
document to be very
detailed and highly prescriptive, a “how-to” guide
for transforming the Pennsylvania
mental health care system. Others
would
find that level of detail much too overwhelming and stifling. Through
workgroup
dialogue and process, a consensus was formed in regard to the charge of
“creating
a blueprint.” It
was determined that
strategically detailing the work of transformation was going to demand
participation beyond the workgroup members and indeed, beyond OMHSAS.
A
Call for
Change offers a basic framework for transformation, including
guiding
principles and indicators of a recovery-oriented system. And, it discusses some of
the implications of
these changes and recommends some approaches for using the indicators
to
initiate changes in local, county, and state-wide systems. It is to be considered a
“living-breathing”
document and not a “set in stone” plan. It is
anticipated that it will serve as
a foundation for strategic change planning at many levels and over
time, but it
is not a strategic plan in and of itself.
As the first phase of an ongoing process, its purpose is
to stimulate
discussion in all arenas and at all levels. Additional materials will
need to be
developed to help inform and guide the process as we shift toward a
more
recovery-oriented service system in Pennsylvania.
While the initial intent
of this document was to
encompass “recovery” in the broadest context of the
service system, it soon
became clear that there are a number of groups that need focused
attention and
a more refined service and support array than can be presented in this
initial document;
specifically the needs of adolescents/transition-age youth; older
adults;
individuals at first onset of mental illness; persons with co-occurring
disorders and some cultural/ethnic groups. Additionally, active
discussion is
needed in understanding how the concepts of recovery apply for younger
children
and their families.
While mental health
services are relatively new
to understanding how recovery concepts may apply to psychiatric
disorders, Drug
and Alcohol services have long embraced the term
“recovery”, and it has some
specific meanings in that arena. Currently, there are some
philosophical and
practical differences in how substance abuse services and mental health
services individually understand and employ the concepts of recovery.
Considerably more discussion is needed in order for the two fields to
move
toward a unified definition of recovery and more congruency in their
terminology and approaches to recovery.
It is beyond the scope of
this first document to
be fully responsive to the barriers presented by the terminology and
philosophy
of these various groups. Therefore,
the
content of A Call for Change has
been
driven primarily by concepts emerging from the adult mental health
recovery
perspective and focuses only on transforming services for adults using
the
public mental health service system.
The Roots of Recovery in Mental Health
A fundamental question remains: If the purpose of the
mental health system is
not to help people on their path of personal recovery, what is it for?
One of the chief
objectives…is to bring about a
rational attitude toward disorders of the mind.
This means teaching people to recognize early the warning
symptoms of
mental disease. It
means also the
establishment of mental health services to which people will feel
impelled and
be willing to go without delay for advice and treatment.
˜™
Deep
Roots and a Legacy of
Reform
During the past decade,
the concept and
principles of recovery have emerged as a new way to understand mental
health
problems, treatment, and outcomes. Mental health consumers/
survivors/expatients have been a prime force in promoting this
approach, often
drawing from their personal experiences, both positive and negative, to
help
others understand that people can and do recover from serious
psychiatric
problems.
The roots for this
movement toward
recovery-oriented mental health services are both broad and deep. This
chapter
briefly explores some of these roots. They encompass not only our
historical
desire to understand the phenomena we term mental illnesses, but also
the
ongoing drive to find ways to help people who experience these
difficulties.
Some of our historical efforts have worked, some have not, but the
process of
learning is continual and continues today.
Even a cursory review of
the history of mental
health services in Pennsylvania
shows that the contemporary concepts of recovery in mental health had
their
genesis decades, even centuries ago.
Recovery is not really a new idea in mental health, but a
re-emergence
of fundamental values and long-standing knowledge about what it takes
for
people with serious mental illness to re-gain and live meaningful and
productive lives. In
many ways recovery
is a return to basics, enhanced by the phenomenal contributions of
science,
research, and understanding.
Strong leadership,
advocacy and innovation have
established in Pennsylvania
a
legacy of reform that can be traced to the colonial period. Over 200
years ago,
Dr. Benjamin Rush of Philadelphia, now considered to be the
“Father of American
Psychiatry”, recognized that psychiatric illness could be
diagnosed and treated,
emphasizing that considerate treatment of people with mental illness
could be
much more effective than the rough modes then prevalent. Another
innovative and
early Pennsylvania
leader, Thomas
Kirkbride developed an approach to treatment that included not only
medical
services, but therapeutic treatment which included attention to
physical health
and comfort, well being, industry, activity, fresh air, and other
considerate
therapies.
The roots of recovery draw
not only from medical
and biologically driven knowledge; they also reach into sociological
and
psychological research, humanitarian values, civil rights, social
movements,
spiritual elements, and even political and economic arenas. The experiences of
individuals and families
who have lived with mental illness, however, form the bedrock of the
movement
toward more recovery-oriented mental health systems.
Views
of Recovery
For the past two decades,
there has been
increasing interest about the concept of “recovery”
as it applies specifically
to mental health – and increasing confusion about what it
means.
Recovery has
traditionally been a biomedical
term relating to resolution of acute episodes of illness, distress, or
disruption. In this
context it implies
“cure”. In the medical arena, when the term
recovery is applied to long-term or
chronic disorders such as diabetes, asthma or many physical
disabilities it
does not imply cure, but rather a return to full or partial functioning
in most
aspects of one’s life. In
this context,
the process of recovery may also imply acceptance of and adjustment to
limitations and losses. Resiliency is a related concept, relevant to
both adults
and children, which implies the ability to manage and rebound from
stress,
trauma, tragedy, and other life adversities.
The term recovery can also
include the act of
“gaining,” as in recovering something that was lost
– a sunken treasure, a
sense of personal comfort or safety, confidence in speaking out, a new
lease on
life, and so forth. In a broad sense, to be
“in recovery” refers
to the active, uniquely personal process of finding ways of resolving
or
managing physical, emotional, behavioral, spiritual, or interpersonal
issues
that cause problems or pain, and simultaneously learning or creating a
more
positive, constructive, functional, meaningful, and ideally satisfying
way of
being. Regardless
of the definition, the
concept of recovery implies a dynamic, multi-dimensional, often
non-linear and
very individual healing process.
Research
& Longitudinal
Studies
The fact that people can
and do recover from
serious mental illness was first met with suspicion by professional
service
providers who provided example after example of persons with perceived
chronic,
life-long and disabling disorders. The concept continues to be the
focus of
considerable dialogue and debate in both the mental health and the
substance
abuse communities. The anecdotal database of consumer stories was
substantiated
with the findings of research conducted by Courtney Harding and her
colleagues
on the longitudinal course of schizophrenia. This research has been
confirmed and
amplified the findings of other international studies: the majority of
people
diagnosed with schizophrenia can and do recover.
And as the work continues, the evidence grows, our knowledge deepens,
and the
word is getting out.
Civil
Rights
The contemporary
application of “recovery” to the
mental health context evolved in large part from the human rights
movements of
the 1960’s. Here
recovery basically
refers to proactively taking charge of one’s life and mental
health,
challenging stigma and discrimination, and moving beyond perceptions of
chronicity often associated with psychiatric diagnoses. The
idea that
people could –
and did – actually recover from
psychiatric illness grew from the experiences and stories of the people
who
experienced recovery in their own lives.
They were the first to challenge the tautological idea that if a person
recovered from mental illness, then he/she had been initially
misdiagnosed.
Like many other social
movements of the 1960s
and 1970s, the consumers/survivors/ex-patients emerged as a group with
a shared
history of marginalization, the shared experience of ongoing stigma,
discrimination, and systematized suppression of their personal civil
and human
rights. These voices merged to form a consumer movement that has
survived many
decades of derision, fear and struggle and has emerged as a powerful
force. Some of the basic goals of
the movement are
encapsulated in the concept of empowerment and can be understood on
several
different levels:
· Systemically
-- the redistribution of power held by the state and the institution of
psychiatry;
· Collectively
-- the rights of a group to express their “voice”
and to significant and
meaningful participation in issues of importance to them;
· Individually
-- taking control and responsibility for one’s own life,
having and expressing
personal choice.
Stories of recovery through
empowerment are not
limited to more recent times. For example, Clifford Beers penned his
compelling
and powerful autobiography “A Mind that Found
Itself” in 1908. Based on his
experiences as a patient in various psychiatric hospitals and in
community
situations, he understood that a larger voice was needed in order to
challenge
beliefs, change conditions, and create opportunities for persons with
mental
illnesses. To
further his vision, he
created the National Committee for Mental Hygiene, the precursor to the
contemporary National Mental Health Association.
Pennsylvania Consumer/Survivor/Expatient Movement
Self Help and Advocacy
The mental health
consumer/survivor/expatient (C/S/X) self-help
movement began in Pennsylvania
over
20 years ago. In 1984, the Mental Health
Association of
Southeastern Pennsylvania (MHASP) received a grant from the
Philadelphia Office
of Mental Health/Mental Retardation to implement a Patient
Self-Help/Advocacy
Organizing Project.
Joseph Rogers was hired by MHASP to establish the goals of this
project,
bringing experience gained from his work in New
Jersey
and Florida
where he had been
involved in patient self-help movements.
He organized other individuals in Philadelphia
and throughout the state who provided leadership in organizing the Philadelphia
and larger Pennsylvania C/S/X movements.
The Involved Consumer Action Network (ICAN) lead by Mark
Davis, and the
Leadership, Education, Advocacy, Development project (LEAD) lead by
Janet Foner
were formed to establish a statewide network of consumer-run
initiatives, such
as self-help and advocacy groups and drop-in centers.
The success of this work was seen with the
establishment of strong C/S/X advocacy and self-help services not only
in Philadelphia,
but also in Pittsburgh,
Erie,
State College and Lancaster
as well as more rural areas of the state.
Pennsylvania
Mental Health
Consumers’ Association (PMHCA)
In 1986, the need for a statewide
organization to provide
systems advocacy was realized with the founding of the Pennsylvania
Mental
Health Consumers’ Association (PMHCA) the only statewide
membership association
representing current and former recipients of mental health services
that is
governed and run by the same. Organizing
activities of PMHCA have grown throughout the state and the C/S/X
movement
began realizing success in advocating legislatively and systemically
for needed
funding and development of consumer-run initiatives.
Over the last 20 years, this movement has been
successful in building a strong voice for increased community-based,
self-help
and recovery-oriented services.
National Mental Health Consumers’ Self-Help
Clearinghouse
Emerging from the strong local
consumer movement in Pennsylvania,
the National Mental Health Consumers' Self-Help Clearinghouse was
funded by the
National Institute of Mental Health (NIMH) in 1986. It was the nation's
first
national technical assistance center focusing on the needs and
interests of
mental health consumers – and it was consumer run itself. For
the past 20
years, the Clearinghouse has helped individuals, service providers, and
policy-makers nationwide to understand the importance of self-help and
advocacy, and created resources and tools to help other consumers build
services in their areas. It
continues to
tackle issues relevant to mental health consumers as well as to provide
assistance to self-help groups and other peer-run services for mental
health
consumers.
Consumer/Family Satisfaction Teams (C/FST)
Pennsylvania
consumer and family leaders created the innovative Consumer/Family
Satisfaction
Team (C/FST) approach to service evaluation and systems change. This approach, begun in
the 1990’s in Philadelphia,
has spread throughout the state and served as a model for other
consumer and/or
family lead evaluation services in other states and even
internationally. Consumers
and family members work as a formal
team to “determine whether priority population adult
behavioral health service
recipients and children and adolescents with serious emotional
disturbance
and/or substance abuse disorders and their families are satisfied with
services
and to help ensure that problems related to service access, delivery
and
outcome are identified and resolved in a timely manner.” Today C/FSTs are operating
in 62 of the 67 Pennsylvania
counties and are a growing force in county quality management programs.
Community
Support Programs (CSP)
Since the 1970’s
the federal Community Support
Program initiatives of the National Institute of Mental Health (NIMH)
helped to
shape the emergence of community resources and services for persons
with
psychiatric disabilities. While
these
services were typically conceptualized, developed, operated, and
promoted as
necessary life-long supports, they also contributed to the emergence of
recovery in mental health by spotlighting the value of community,
relationships, and work in the lives of persons diagnosed with
psychiatric
disorders, and by demonstrating that a person’s ability and
potential are the
result of interactions between the individual, expectations, and the
environment, rather than diagnosed pathology or intensity of symptoms.
Pennsylvania,
with the assistance of a State Technical Assistance grant from the
National
Institute of Mental Health (NIMH), formed the State Community Support
Program
(CSP) Advisory Committee in 1984 with backing from the Pennsylvania
Department
of Public Welfare, Office of Mental Health. This committee became a key
coalition for consumers, family members, advocates and providers to
collaborate
and provide a unified voice in advocating for statewide systems
changes. The
principles of CSP became integral to shaping Pennsylvania’s
existing and future mental health service system. It was emphasized
that
services must be consumer centered, strengths based, culturally
competent,
accountable, flexible, coordinated, designed to meet the needs of
special
populations and rely on natural supports that promote the full
community
integration of consumers. The original Community Support System (CSS)
model
disseminated by NIMH provided advocates and planners with a guide for
designing
a system of services, supports and opportunities that would allow
adults with
serious mental illness to recover and reach their full potential as
contributing members of their respective communities.
The growth of the CSP
movement in Pennsylvania
in the years that followed extended across the four regions of the
state. Using a
regional committee structure, the
basic values and ideas about community support were integrated into
planning
and service delivery approaches around the state. The committees, along
with
others, have done much to advance the development of community support
services
such as crisis services, supported housing, case management,
psychiatric rehabilitation,
drop-in centers, peer support and consumer run programs. In October, 2001 the CSP
wheel was modified
to include the concept of recovery as central to a community support
program.
Further, the network of regional and state CSP committees evolved so
that the
membership reflected the concerns and goals of the state’s
diverse geographic
and cultural
context. As of
2003, there were 46 mental
health/mental retardation programs in the 67 counties of the
Commonwealth and
CSP committees existed in nearly all of them.
Addictions,
12-Steps, and Mutual
Support
The mid 1900’s
saw the emergence of a variety of
self-help and 12-step programs that provided an opportunity for people
with
addictions and other kinds of personal difficulties to come together as
peers
with shared experiences and to help each other.
Alcoholics Anonymous (AA) was the prototype for most of
these programs
and continues to influence the field of addiction treatments.
While promoting the
understanding of addictions
as diseases rather than weakness of will or deficiency of character, AA
and
other 12-step programs were the first to recognize that the traditional
concepts of medical recovery were not sufficient to address how people
healed
from these disorders. For
example, they
taught that sobriety was more than mere abstinence from use of the
addictive
substance – that
it entailed completely replacing old
ways with new ways, giving up an old life and learning how to create a
healthy
and fulfilling life. With this approach, the concept of recovery was
expanded
to encompass many non-medical aspects of healing: the social,
cognitive,
interpersonal and even spiritual elements of an individual’s
life. For example,
a basic tenet of recovery in
most 12-step programs is to initiate efforts to heal damaged
relationships. Similarly,
symptom
remission or illness management alone is inadequate to define recovery
from
psychiatric disorders.
Recovery in both addictions and mental health means learning to live a
full and
healthy life.
Over the years AA and
other 12-step programs
have demonstrated the effectiveness of people helping each other not as
experts, but as peers: peer
support. It is well
recognized that both
people involved in peer support are positively affected in these
helping relationships,
so much so that AA strongly encourages members to become sponsors
– (personal
supporters and guides) for others as part of their personal recovery. Drawing from personal
experience and actively
helping others are well-known to be powerful tools in the process of
establishing and sustaining one’s own recovery. This idea has
extended the
parameters of peer support and now encompasses the growing belief that
persons
with lived experience of personal recovery are not only valued members
of formal
treatment services, but are often seen as necessary elements of an
addictions
treatment program.
Concepts such as relapse
prevention were well
established in addiction services before they gained traction in mental
health
services or with Wellness Recovery Action Plans (WRAP). Further, the
12-step
approaches have also helped us recognize the importance of spirituality
in the
process of recovery for many people, something that has traditionally
been
outside the consideration of mental health treatment.
So, is recovery in mental
health the same as
recovery from addiction? There
are some
who consider the process of recovery from mental health issues to be
identical
to the process of recovery from addictions.
There are many similarities to be seen, including the
non-linear aspect
of the recovery process – “two steps forward, one
step back”, the
recognition that
the process is not as easy as others may
think it is, the reality that people rarely do it alone successfully,
and
recognition that the presence of supportive others and environments can
make
all the difference.
But there are also some
fundamental differences
between the concepts of substance abuse and mental health recovery as
they are
currently understood. Some
of these
differences may be simply in how language is used within the respective
groups,
but others are more philosophically rooted.
For example, one of the core differences centers around
the issues of
power and powerlessness. One of the primary elements of 12-step
recovery is to
admit powerlessness and turn one’s self and life over to the
power and
direction of a trusted “other” or Higher Power.
In mental health recovery, the focus tends to be more on
empowerment and
self-determination, helping individuals to find their own voice and
self-determination. This
is based on the belief that individuals
need to reclaim their own power as one of the first steps of a recovery
process.
In 12-step programs,
members are encouraged to
label themselves as their addiction or disorder:
I am an alcoholic, an addict, and so
forth. In mental
health recovery there
is emphasis on helping individuals to move beyond the diagnostic labels
that
have been applied to them by service providers and others. Often individuals
internalize these labels,
accepting them as their primary identity and experiencing unnecessary
and
detrimental self-stigma, low self esteem, and self-limitations. In recovery-oriented
mental health care,
individuals are encouraged to NOT identify themselves or be identified
by
others as their diagnosis: I am a schizophrenic, a bipolar, and so
forth. A
person may “have” a disorder such as schizophrenia
or depression, but there is
more to the person than this – it is not their sole defining
characteristic.
Another aspect of the recovery concept in mental health is that an
individual
may be in active recovery and also continue to experience some ongoing
or
periodic symptoms or difficulties.
In
many substance abuse service settings a person ceases to be considered
“in
recovery” if he/she is no longer abstinent.
Growing
Recognition and Interest
in Mental Health Recovery
Gaining Footholds and Support
In the 1990s, some leaders
in mental health
services began to recognize that recovery was not a synonym for
psychiatric
rehabilitation and that recovery would become a significant and guiding
vision
for future mental health services.
Mental health recovery
became a more frequent
topic at professional conferences and other training venues. Some states and regions
began to host
dialogues that brought mental health consumers/survivors/ex-patients
and
professional service providers together on more equal ground to talk
about
recovery related topics. The
National
Empowerment Center hosted several ‘Learning from
Us’ conferences where consumer
leaders were the presenters and the participants were primarily
providers,
curious about or willing to learn about recovery in mental health. More
service
providers attended the national mental health consumer conferences,
“Alternatives” in order to listen to what consumers
were saying about
recovery.
Some states and counties
established Offices of
Consumer Affairs within their mental health services administration
departments. Increasing
numbers of
mental health agencies began hiring C/S/X as employees to provide a
wide range
of services from peer support to case management, evaluation, program
development and management, and staff training.
Consumer/survivors/ex-patients
became increasingly
involved in research as partners as well as independent researchers who
design,
conduct, analyze and publish studies. Their involvement not only
challenged the
established research agendas to include recovery-oriented questions and
to
address the elements, process and outcomes of recovery in mental
health, but
also helped to demonstrate that consumers make significant and
enriching
contributions in all aspects of mental health related research.
Gathering Momentum in Pennsylvania
While there is growing
interest and support on a
national level for promoting recovery –oriented approaches in
mental healthcare
services, there is also evidence that it has been gaining momentum in Pennsylvania.
In November 2004, the first
Recovering
Pennsylvania Conference was sponsored by OMHSAS and coordinated by the
Mental
Health Association of Southeastern Pennsylvania.
The conference brought together by invitation
a broad array of consumers, family members, providers, state and county
mental
health administrators and other stakeholders to explore how to move Pennsylvania’s
mental health system toward one grounded in hope and recovery. One task assigned to
participants was to
identify the recovery-focused initiatives already underway at both a
state
level and in local communities. The
initiatives identified included the following. These current activities
demonstrate some existing understanding and commitment to
recovery-focused
services in each region of the State already and provide a launching
point for
expanding and deepening this knowledge and interest more broadly
throughout the
state. The movement
towards a
recovery-oriented system and growing interest in recovery information
and
training among all stakeholders is evidenced by:
· Increase
in both state-level and local recovery
conferences which bring together diverse stakeholders to address
recovery
issues.
· Formation
of local, regional and statewide
recovery committees and task forces.
· Increased
stakeholder collaboration in planning,
evaluation, and policy development.
· Leadership
training for consumers to participate
in shaping system of recovery.
· Participation
in Real Systems Change federal
grant to expand Certified Peer Specialist training program.
· Pursuing
strategies to secure Medicaid
reimbursement for peer support services.
· Provision
of Cultural
Competency training.
· New
Freedom Initiative Project providing
grant-funded focused technical assistance to six counties for three
years.
· Support
for passage of legislation for
psychiatric advance directives.
· Development
of Pennsylvania Recovery
Organizations Alliance (PRO-A), new addiction support group in Pennsylvania
focused on education, advocacy and public policy.
· Anti-discrimination/anti-stigma
initiatives.
Examples of local recovery
initiatives from around
the state include the following:
· Expanding
Consumer/Family satisfaction initiatives.
· Developing
certified peer specialist programs;
peer mentor programs; warm lines.
· Increasing
appointments of consumers to boards
and committees, including to the Board of Trustees of Allentown State
Hospital.
· Holding
Recovery dialogues and “trialogues” –
organized discussions on recovery.
· Training
individuals in Wellness Recovery Action
Planning (WRAP).
· Using
reinvestment dollars for recovery-oriented
initiatives.
On
the National Scene
Many Calls for Change
Many government studies have stated
the need for the same
changes to be made in the behavioral healthcare service system. In 2003 the federal
Veteran’s Administration
released an Action Agenda stating that recovery should be the core
principle of
system change of services for veterans. In addition a 2000 report
from the National
Council on Disabilities focuses on the critical role that consumers and
people
who are in recovery from mental illness should play in the service
system
development and administration. In addition, the following
two reports from
the federal government mandate significant change – even
total transformation
of the public mental health service system.
Surgeon General’s Report, 1999
In 1999 the U.S. Surgeon General
issued a report on mental
health that for the first time on a national scale, recognized the
importance
recovery in adult mental health, stating “the concept of
recovery is having
substantial impact on consumers and families, mental health research,
and
service delivery.” Recovery should be the
expectation, not the
exception, in mental health care.
President’s New Freedom Commission on Mental Health
In its 2001 Interim
Report to the President, the President’s New
Freedom Commission on Mental
Health (NFC),
described the current system of behavioral care throughout the United
States as fragmented,
complex, and filled
with gaps, unmet needs, and barriers.
For people with serious mental illness, the picture is
even bleaker:
high unemployment and underemployment, co-occurring substance abuse
disorders
are common, and disability continues. The current system is more
focused on
managing symptoms and the disabilities associated with mental illness
than on
promoting and facilitating recovery from these disorders.
In 2003, the final report
of the NFC, Achieving the Promise:
Transforming Mental
Health Care in America
called for recovery to be the “common, recognized outcome of
mental health
services”, stating unambiguously “The goal of
mental health services is
recovery”. In this report recovery was defined as:
The process in which people
are able to
live, work, learn, and participate fully in their communities. For some
individuals recovery is the ability to live a fulfilling and productive
life
despite a disability. For
others, recovery
implies the reduction or complete remission of symptoms.
The NFC Final Report
outlined a vision for “a
future when everyone with a mental illness will recover, a future when
mental
illnesses can be prevented or cured, a future when mental illnesses are
detected early, and a future when everyone with a mental illness at any
stage
of life has access to effective treatment and supports –
essentials for living,
working, learning, and participating fully in the community.”
The NFC acknowledged that
the current mental
health service system is far from reflecting this vision and
recommended
fundamentally transforming how mental health care is delivered. The
term
“transformation” was specifically used by the
Commission to reflect its belief
that mere reforms to the existing mental health system are insufficient. “It is time to
change the very form and
function of the mental health delivery service system to better meets
the needs
of the individuals and families it is designed to serve”.
OMHSAS endorses the NFC
report and calls for all
counties to begin to take action to achieve transformation of their
mental
health services, using this document, A
Call for Change: Toward a Recovery Oriented Mental Health Service
System for
Adults, as an aid to this process.
What Does Recovery Look Like?
Recovery is variously
described as
something that individuals experience, that services promote, and that
systems
facilitate, yet the specifics of exactly what is to be experienced,
promoted,
or facilitated –- and how — are not often well
understood by either the
consumers who are expected to recover or by the professionals and
policy makers
who are expected to help them
All people with mental illness
have
personal power, a valued place in our families and communities, and
services
that support us to lead our own recovery.
˜™
More
than Treatment or Services
Recovery is construed many
ways, including as an
organizing principle for mental health services that is based on
consumer
values of choice, self-determination, acceptance, and healing.
What
distinguishes a recovery approach or “recovery-oriented
services” from what is
in place now? Don’t we already do this?
In essence, not often.
Recovery
is not simply a multiple-domain treatment plan, case management,
tittered
medications, or job placement. Done well, all these services can help
to
stimulate, facilitate, and support recovery for persons with
psychiatric
disorders and help them to break the custodial chain between consumer
and
provider. However,
recovery is more than
treatment and services and for many, it actually happens outside the
traditional
mental health service arena. So, what is it?
There have been recent
efforts to clarify these
ideas and to build consensus around core elements of recovery from
personal,
programmatic, and systemic perspectives. This provides for
increased understanding and
consistency in the meanings of terms for policy, research, evaluation,
and
service development purposes.
In 2005 the
Pennsylvania Recovery Workgroup
developed, and OMHSAS endorsed, the following definition of recovery to
be the
foundation for recovery-oriented activities and initiatives within the
Commonwealth. The following material goes into more depth about
personal,
programmatic, and systemic aspects of recovery, and is drawn from
various
sources and reflects the results of consensus dialogues at the national
level.
Individual
Drawing from many perspectives and
resources, a recent
consensus statement on mental health recovery
generated by the U.S. Department of Health and Human Services and the
Interagency Committee on Disability Research, in partnership with six
other
Federal agencies, states that from an individual perspective,
Mental health recovery is a
journey of
healing and transformation for a person with a mental health disability
to live
a meaningful life in communities of his or her choice while striving to
achieve
full human potential or “personhood”.
Recovery is present when
individuals live well
and fully in the presence or absence of a psychiatric disorder. From a consumer
perspective it embodies all
that is necessary to manage and to overcome the psychological,
physical,
identity, economic, and interpersonal consequences of having a mental
illness. It is also
the individual
person’s responsibility to him/herself, family and others, to
take on the
responsibility of choosing, pursuing and sustaining personal recovery.
This may
include creating a personal crisis plan/advance directive for chosen
agents or
families to follow.
By all accounts, mental
health recovery is a
highly personal and individual process; it occurs over time, and is
rarely
straightforward – often characterized by steps forward and
back. Recovery does
not always mean that a person will live symptom free or regain all the
losses
incurred because of psychiatric problems.
It does mean that people can and do live without feeling
enveloped by
mental health issues or that their potential or opportunity is
curtailed
because of them.
Despite the highly unique
nature of each person’s
journey to recovery, there are remarkable similarities that people
experience
in this process. Some
researchers have
been working to identify specific stages to the process.
Identifying these similarities and stages helps us to better understand
the
complexity of the process itself and the various ways people benefit
from
formal mental health services as well as other avenues for help and
healing.
Some people recover with minimal or even no use of mental health
services. But many,
many people look to mental health
services for help, hope, and pathways for healing from psychiatric
disorders
and the challenges in living they create.
Programs/Services
From a programmatic or
service perspective,
recovery-oriented services are those that are dedicated to and
organized around
actively helping each individual served to achieve full personal
recovery. Individual
recovery always happens in the
context of a person’s real life – not just their
service environment.
For many people needing
mental health treatment,
however, service environments often play a critical role. Service environments and
relationships with
mental health workers can promote, facilitate, and support the process
of
personal recovery, helping persons to develop richer understanding of
themselves,
to take productive risks, rekindle or sustain hope, and to develop
positive
visions of their future. Alternatively they also can impede, hinder or
restrict
opportunities for individuals to explore, to risk, to learn, and hence
to limit
potential growth towards recovery.
Many
aspects of the traditional medical model include attitudes, practices,
and
policies that can cause difficulties and sometimes significant harm to
individuals searching for personal recovery.
There have been a number
of initiatives,
inventories, and consensus meetings in the past few years that have
made great
strides in naming the core attitudes and practices that distinguish
recovery
from more standard service approaches.
The December 2004 Consensus
Conference on Mental Health Recovery, sponsored by the
Center for Mental
Health Services (CMHS) of the national Substance Abuse and Mental
Health
Services Administration (SAMHSA) generated a consensus statement on
mental
health recovery. This
document provides
the following ten fundamental elements and guiding principles of mental
health
recovery that serve well as guideposts for recovery-oriented services.
Self-direction: consumers lead, control, exercise
choice over, and determine their own path of recovery by
maximizing
autonomy, self-agency, and independence.
Individualized
and Person-Centered: there are multiple pathways to recovery
based on the
individual person’s unique consumer needs, preferences,
experiences – including
past trauma, and cultural backgrounds in all of its diverse
representations. Individuals
also
identify recovery as being an on-going journey, an end result as well
as an
overall paradigm for achieving optimal mental health.
Empowerment: consumers have the authority to
exercise choices and make decisions that impact their lives and are
educated
and supported in so doing.
Holistic:
recovery encompasses the varied aspects of an individual’s
life including mind,
body, spirit, and community including such factors as housing,
employment,
education, mental health and healthcare services, complementary and
naturalistic services, addictions treatment, spirituality, creativity,
social
networks, community participation, and family supports as determined by
the
person.
Non-Linear:
recovery is not a step-by-step process but one based on continual
growth, occasional
setbacks, and learning from these experiences.
Strengths-Based:
recovery focuses on valuing and building on the multiple strengths,
resiliency,
coping abilities, inherent worth, and capabilities of individuals.
Peer
Support:
the invaluable role of mutual support wherein consumers encourage other
consumers in recovery while providing a sense of belongingness,
supportive
relationships, valued roles and community is recognized and promoted.
Respect:
community, systems, and societal acceptance and appreciation of
consumers -
including the protection of consumer rights and the elimination of
discrimination and stigma – are crucial in achieving recovery. Self-acceptance and
regaining one’s belief in
one’s self is also vital, as is respect for others.
Responsibility:
consumers have personal responsibility for their own self-care and
journeys of
recovery. This
involves taking steps
towards one’s goals that may require great courage.
Hope: recovery provides the essential
and motivating message that people can and do overcome the barriers and
obstacles that confront them.
There are increasing numbers of
evaluation tools available
that focus on recovery indicators and outcomes in treatment settings
and
services. Regular evaluation of
services provides not
only quality assurance, but also benchmarks for progress in
transformation and
a pool of evidence that demonstrates program effectiveness.
System
Mental health service
systems have the
responsibility to provide the leadership, direction and resources to
support
services and programs that help individuals experience recovery. For service systems, this
responsibility
includes identifying which policies, standards, and funding mechanisms
restrict
or interfere with services operating from a more recovery-oriented
stance. The kinds
of services available are dependent
on what is funded. For example, peer support, crisis prevention and
hospital
alternatives, holistic wellness support, community education and
de-stigmatization
initiatives are dependent on both the systemic policies that promote
them and
also on the funding made available to support them.
Critical policies not
only include regulations,
rules and service standards, but also the role and process of
evaluation and
quality improvement within the system.
The real values and definitions of quality in a service
system are
reflected in what is measured through its quality improvement
activities. A
recovery-oriented system has congruence throughout – not
necessarily on
specific practices or programs, but on value, desired outcomes, and a
willingness to continue to seek out better ways of helping individuals
with
their personal recovery journey. These,
however, present a challenge when it comes to measuring outcomes.
The NFC Final Report
emphasizes that the goal of
a transformed system is recovery.
The
report outlines the following six goals of a transformed and
recovery-oriented
healthcare system.
1. Americans
understand that mental health is essential to
overall health.
2. Mental
health care is consumer and family driven.
3. Disparities
in mental health services are eliminated.
4. Early
mental health screening, assessment, and referral
to services are common
practice.
5. Excellent
mental health care is delivered and research
is accelerated.
6. Technology
is used to access mental health care and
information.
These goals are firmly
based on two overarching
principles, also presented in the NFC Final Report:
· Principle
1: Care must focus on increasing consumers’ ability
to cope with life’s
challenges, on facilitating recovery, and on building resilience.
· Principle
2: Services and treatments must be consumer and family
centered.
Resiliency
Resiliency is a concept that
initially emerged from
studies of youth and families and was used to describe those
individuals who
seem to not only survive in difficult situations but also seem to
constructively rebound from adversity.
There has been some discussion in the mental health field
as to whether
recovery is essentially the same as resiliency.
At this time, most experts view them as very different,
but related
constructs. The NFC Final Report defines resiliency as follows:
Resilience means the personal
and
community qualities that enable us to rebound from adversity, trauma,
tragedy,
threats, or other stresses --- and to go on with life with a sense of
mastery,
competence, and hope. We
now understand
from research that resilience is fostered by a positive childhood and
includes
positive individual traits, such as optimism, good problem-solving
skills, and
treatments.
Essentially, resiliency is a
personal characteristic that
combines individual traits and learned skills; recovery is a process of
positive growth, healing, and building meaningful and productive lives.
Learning and developing resilience skills (e.g. problem solving,
mindfulness,
nurturing positive attitudes, managing feelings) may be important
aspects of
the recovery journey of many persons.
The NFC states that for a system to successfully
transform, “care must
focus on increasing consumers’ ability to successfully cope
with life’s
challenges, on facilitating recovery, and building resilience, not just
on
managing symptoms”.
But,
We Already Do All That!
“But, we already
do that” is commonly heard in
recovery trainings and meetings for mental healthcare providers. Many providers do not see
how contemporary
images of recovery are different from the innovations instituted in the
past
decade, which included community support services, assertive community
treatment, psychiatric rehabilitation and peer-support.
This concern often
reflects the perception that
“recovery” is merely another service program or
that it negates the work of
past leaders and innovators. It
may also
embody frustration that the principles, programs, and approaches
promoted in
these earlier efforts were either not fully implemented or have been
distorted
or even lost over time.
This
“yesterday’s news” sentiment challenges
recovery advocates and educators to be more specific in identifying and
communicating the ways in which a recovery approach is not the same as
“business as usual”. The efforts of three different
educators to meet this
challenge are presented below to help illustrate what makes a recovery
approach
different from many more established service approaches.
The following chart is
adapted from the work of
Noordsy and colleagues, and highlights some of the basic differences
between a
recovery approach and more traditional services
|
|
Traditional
Rehabilitation Services
|
Mental Health
Recovery Approach
|
|
Theory
|
· Psychotic
disorders produce functional impairment from which there is no cure,
but can be assisted adaptation
|
· People
with “psychotic disorders” redefine themselves
through roles and relationships rather than disability
|
|
Prototype
|
· Mobility
impairment
· Cardiac
rehabilitation
|
· Cancer
support groups
· 12-step
programs & other self-help approaches
|
|
Goal
of service
|
· Maximize
functioning
· Skill
development
· Re-integration
into society
|
· A
meaningful life
|
|
Relationship
with workers
|
· Professional
and client roles. Client
is usually “less than” the worker
· Carefully
defined boundaries with minimal flexibility.
“Us/Them”
· Frequently
“power over”
|
· “Power
with”, shared risk, and responsibility.
Partnership
· Meeting
of “equals” with different expertise and experiences
· Negotiated
boundaries
|
|
Research
|
· Identify
effective methods of increasing functional involvement
· Models
and model fidelity
|
· Name,
measure recovery process; identify predictable stages
· Identification
of barriers
· Narrative,
participatory action and first person experience
· Healing
cultures: the effects of relationships and environments
· How
recovery outcomes corroborate with health, wellness, prevention
· Impact
of peer support & self help
· How to
build, enhance, support the recovery process
|
|
Assessment
|
· Identify
strengths
· Elicit
history, interests, and abilities.
· Document
capacity & disability
|
· Consumer
assessment of personally relevant consequences.
Professional assessment of sense of ownership in
life and desire to work/live beyond illness. Hope
|
|
Treatment
|
· Increase
strengths, reduce barriers; skills teaching; Vocational rehab/work
readiness
· Lifestyle
changes: grooming, housing, diet, exercise, substance abuse
· Medications
can play a vital role
|
· Consumer
driven. Worker as
ally, consultant
· Mutual
help & self help
· Seeing
possibility, building hopes, dreams.
· Address
issues & consequences important to consumer. Taking personal
responsibility
· Re-defining/
re-viewing experience. Changing the way we look at things and the
meaning given to them
· Move
from passive to active roles. Risk-taking
rather than care-taking
· Attention
to impact of trauma as well as substance abuse issues
· Conflict
negotiation
· Medications
can play a vital role
|
Another set of
comparisons of recovery-oriented
and non-recovery-oriented service cultures comes from META
agency of Phoenix, Arizona.
|
Non-Recovery Culture
|
Recovery Culture
|
|
Low
expectations
|
Hopeful
with high expectations
|
|
Stability
and maintenance are the goals
|
Recovery,
a full life, is the goal
|
|
No
clearly defined exit from services
|
Clear,
attainable exits. Graduates
return and share, become workers
|
|
Compliance
is valued
|
Self-determination,
critical thinking, and independence/ interdependence are valued
|
|
People
are protected from “trial and error” learning
|
People
take risks and have the “right to fail
|
|
One-size
fits most treatment approach
|
Wide
range of programs and non-program options
|
|
Consumers
live, work, and socialize in treatment settings
|
Emphasis
on opportunities for community linkages and building a life outside
mental health treatment
|
|
Emphasis
is on illness, pathology. Medication is the primary too
|
Emphasis
is on the whole person. Medication is one of several important tools
|
|
Once a
consumer, always a consumer
|
Today
a consumer, tomorrow a colleague
|
Finally, Ridgway offers a
comparison of the
pre-recovery mental health system and a recovery enhancing mental
health
system.
|
Pre-Recovery Mental
Health System
|
Recovery Enhancing
System
|
|
Message is:
“you’ll never recover” –
illness is a life long condition
|
Message is:
“recovery is likely” you can and will attain both
symptom relief and social recovery
|
|
Minimal attention to
basic needs
|
Attention to basic
needs, including housing, human and civil rights, income, healthcare,
transportation
|
|
Focus is on person
as patient, client, service recipient
|
Focus is on success
in social roles: parent, worker, tenant.
Activities to reclaim and support a variety of
social roles are emphasized
|
|
Treatment plan and
goals are primarily set by staff with minimal input by consumer. Plans often generic and
focus on illness/medical necessity of treatment
|
Personalized recovery
plan is mandated based on person’s individual goals and
dreams. Plan is
broad and ranging across many domains.
Often includes services and resources that are not
directly affiliated or controlled by mental health service system
|
|
People lack access
to the most effective or research validated services
|
There is ready access
to research validated practices and on-going innovation and research on
promising approaches
|
|
Peer support is
discouraged, lacking, or under funded
|
Peer support is
actively encouraged, readily available, adequately funded and supported.
|
|
Coercion and
involuntary treatment are common.
Staff act “in locus parentae”,
over use of guardianships, rep payee and conservatorships
|
Coercion and
involuntary treatment are avoided.
People are treated as adults. Temporary substitute
decision makers used only when necessary.
Advanced directives and other means are used to
ensure people have say even in crisis
|
|
Crisis services
emphasize coercion and involuntary treatment, often use seclusion and
restraint which can be (re)traumatizing
|
Crisis alternatives
such as warm lines and respite are available.
Staff has been trained to avoid seclusion and
restraint and is skilled in alternative approaches
|
|
Funds are lacking
for services and supports not directly related to illness
|
Rehabilitation
oriented options are funded, flexible funds and vouchers are available,
programs are response to consumer stated needs
|
|
Services often like
“adult babysitting” with focus on care taking, and
even child-like activities
|
Active treatment and
rehabilitation are tailored to individual.
Activities are age appropriate
|
|
Mental health
workers lack knowledge and skills to support recovery
|
Mental health
professionals and all staff are trained in rehabilitation and recovery
|
|
People held in jails
without treatment
|
Jail diversion,
mental health courts, and jail based services available
|
|
People with
drug/alcohol problems are served by two systems that are often in
conflict
|
Integrated
co-occurring disorder services are readily available
|
|
Families are left
out; they are not educated about recovery.
Little or no family support or education
|
Families are educated
about recovery as well as about mental illness.
Family support and conflict mediation are readily
available
|
|
Consumers have
little/no voice in system. Tokenism
and exploitation. Little
support for consumer input
|
Consumer voice on
planning councils, consumer affairs officers, systems and program level
advocacy, leadership development
|
|
System promoted
dependence or unnatural independent. Little or no attention to social
support or life after services
|
System focus on
interdependence, mutual support. Attention to social network
development, social integration
|
Indicators
of a Recovery-Oriented
Service System
You can do it.
We can help
We have taken the people out
of
institutions, but we have not taken institutional thinking out of
people.
For behavioral healthcare
organizations,
a recovery focus means genuine reflection about policies and practices
that
either enhance or detract from the individual process of recovery. It
is not a
new service to tack on to an existing program array… At its
core recovery is
about doing differently that what we must do every day.
˜™
Recovery
Is Not a New “Model”
Recovery is both
misunderstood and feared at many
levels. Sometimes recovery is viewed as an “add-on”
service and we find
“recovery teams” or programs with new names
appended to them. However,
at its core, recovery is not a new
service tacked on to the array of more traditional mental healthcare
programs.
Models may come and go, but people recover. Recovery is about
fundamentally
doing differently those things that we do every day.
Deegan contends that the focus on models is
one of the largest obstacles to implementing recovery-based care,
stating that
“the workforce is trained to offer services according to
models – and being
accountable to agencies which are also organized around such models
– instead
of service workers being accountable and paid by the person with the
psychiatric disability”.
The recovery-orientation
of a service system is
determined by the degree that it exemplifies a set of tangible as well
as
non-tangible indicators; that their policies, practices, funding,
training,
evaluation, services, and values are all oriented toward helping
individuals
with their personal process of recovery.
An orientation toward recovery is not a
“model” in the traditional sense
of the word in mental health and substance abuse services. Many models of service can
help facilitate
and support the process of personal recovery.
It is not necessarily the model of service used, but how
these services
are implemented and the degree of accountability to the individuals
served that
distinguish recovery-oriented services from those that are not. For example, some
inpatient settings are very
committed and oriented toward recovery while some rehabilitation and
peer-support services are oriented more toward care-taking, compliance,
and
acceptance of imposed limitations.
Often the challenge in
recovery-oriented
practices is not WHAT is being done, but HOW it is being done. Working from a
recovery-orientation does not
mean an “add-on” service or team, but a sincere
willingness to look at the
basic tasks and activities of mental health service provision and do
things
differently. Recovery-oriented services continue to provide basic
assessment,
service planning, rehabilitation/treatment/support to individuals with
a wide
range of needs and fluctuating willingness to make change. They grapple with
compulsory treatment and
risk/safety concerns, conflicting perspectives or opinions about
“best
interest” or “most facilitative”
practices, and so forth.
Being recovery-oriented
means that a service or
system makes a strong and
honest
commitment to a set of principles and beliefs about the ability of each
person
with mental health and addictions problems to grow, change, and have a
life
that is personally rich and fulfilling, with or without the presence of
symptoms of a disorder. When services and systems make a commitment to
putting
these values into action, it becomes evident that many existing polices
and
practices are not congruent with these beliefs.
The work of recovery-oriented service systems is to
continually evaluate
their attitudes, policies, and practices for this dissonance and to
actively
work to align their day-to-day activities with recovery values and
principles.
Basic
Domains
A considerable body of material has
emerged during the
past few years offering various markers of recovery oriented service
systems
and tools for measuring these basic benchmarks. There is a striking
consistency
among the various initiatives regarding the primary domains or areas
that
characterize a recovery-oriented service.
These basic domains are as follows.
· Validated
Personhood
· Person
Centered Decision-Making & Choice
· Connection
-- Community Integration, Social
Relationships
· Basic
Life Resources
· Self-Care,
Wellness, & Finding Meaning
· Rights
& Informed Consent
· Peer
Support/Self-Help
· Participation,
Voice, Governance & Advocacy
· Treatment
Services
· Worker
Availability, Attitude and Competency
· Addressing
Coercive Practices
· Outcome
Evaluation & Accountability
Within each of these
broad domains are specific
indicators that should be common practices in recovery-oriented
systems. There
are many ways each indicator can be demonstrated by individuals, by
programs/services, and by the mental health authorities. The more
indicators
present and the more ways those indicators are manifest within a
system, the
more that service or system can be described as recovery-oriented.
However,
these domains and indicators only tell part of the story. Often it is not just WHAT
is being done, but
also HOW it is being done that makes the difference.
For example, many agencies can appoint
consumers or family members to policy groups or bodies, but the
experience of
many of these individuals is tokenism, marginalization, feeling
placated and
not valued as participants. Some
agencies are now requiring that all consumers complete – for
the file – a
Wellness Recovery Action Plan (WRAP).
This potentially rich and rewarding process becomes
reduced to another
piece of mandated and meaningless paperwork, but the organization can
report
that most of the people it serves have WRAPs.
While measuring specific
benchmarks can be useful,
it only captures a part of the story. Often it is the intangibles that
make the
difference between systems or services that are truly focused around
helping
individuals with their personal recovery and those that are going
through the
motions. The recognition, development and measurement of these
intangibles are
where Pennsylvania
needs to make
its mark.
Indicators
of Recovery Oriented
Systems
The following tables
provide a basic set of
indicators of these domains. They are the heart of A Call for Change
and serve
as critical reference points for services, agencies and county mental
health
programs looking for specific strategies for transforming to more
recovery-oriented services.
The information presented
has been derived from the
considerable amount of work done by Pennsylvanians in focus groups,
meetings,
and formal work groups to identify the indicators of recovery-oriented
services, as well as current literature, the experience and planning
activities
of several states, various evaluation instruments designed to assess
the
recovery focus of a service or system, personal recovery or outcome
assessments, and from the experience of individuals and their families. They include things
identified by consumers
as needed in mental healthcare services and systems to promote and
support
recovery by policy-makers and consensus-bodies, researchers, as well as
by
those services and systems that are making efforts to become more
recovery-oriented.
The tables offer some
ways each indicator may be
demonstrated from an individual perspective, by a service or program,
and by a
county, regional or state mental health authority. As presented here,
the
tables are incomplete – leaving room for more ideas,
inspiration, and input.
The tables are offered as a starting point for discussion, creative
thinking,
and prioritization for future strategic planning.
It should be noted that
these tables do not
identify the specific mechanisms and other considerations that may be
pre-requisite to operationalizing these indicators in a complex service
system. These
prerequisites may include funding,
licensure/regulation/certification, union negotiation, personnel
training and
supervision, interagency coordination, and so forth. These issues will
need to
be addressed in time through strategic planning for specific
transformation
initiatives.
While these activities
may help stimulate,
support, and facilitate the process of personal recovery among
individuals served
by the mental healthcare system, the bottom line is accountability to
the
persons served and their attainment of personal outcomes. Successful
recovery-oriented systems will be
able to consistently show evidence that people served are achieving
personal
outcomes that are meaningful to them.
Unless services and the system can demonstrate that
personal recovery
outcomes are being attained, it is not a successful system, regardless
of how
many of the following factors or activities it has put into place.
RECOVERY DOMAIN 1:
Validated Personhood
|
|
Elements
of a recovery-oriented system
|
Ways
this indicator can be demonstrated
|
|
Indicator
|
Individual
Indicator/Outcome
|
By
Program/Services
|
County,
Regional, or Statewide
|
|
Demonstration
of hope & positive expectations
|
·Staff
expects that I can and will function well.
·Staff
believes that I can grow, change, and recover.
·Workers
help me feel positive about myself.
·I feel
confident about myself and my abilities.
·People
appreciate what I do.
·I do
things that make me feel good about myself.
|
·Consistent
use of person-first language in all written and verbal communication.
·Demonstrate
efforts to identify and eliminate stigma within the service system
itself.
|
·Evidence
of these values and indicators in each County Annual Plan.
|
|
Evidence
that consumers, workers, administrators understand recovery
|
·I am
treated as a whole person, not as a psychiatric patient or label.
·Staff
encourages me to take responsibility for how I live.
·I can
attend staff trainings about topics that interest me.
·I am
asked to “tell my story” and to help others learn
about recovery.
|
·Evidence
of explicit recovery language in mission, vision, and guiding
principles documents.
·Evidence
of visible and immediate availability of information about recovery and
recovery services/ options.
·Evidence
of regular and ongoing recovery-education for consumers and family
members.
·Evidence
that 100% of workers have participated in orientation training about
recovery.
·Evidence
of policies and enforcement of policies requiring person-first,
respectful language in all written and verbal communication.
·Evidence
of encouragement and support for “co-learning”
activities where staff and consumers participate in training together.
·Evidence
that 100% of board of directors and administrators have participated in
recovery education.
|
·Evidence
of explicit recovery language in mission, vision, and guiding
principles documents.
·Recovery
oriented outcomes and procedures evident in all contracts, training,
and policies.
·Institute
recovery training for administrators and staff.
·Require
agencies/contractors to demonstrate recovery orientation, and outcomes
are requisite for all contracts and grants.
·Provide
opportunities for “recovery dialogues” between
various stakeholder groups, including psychiatrists and consumers to
move toward shared understanding.
·Evidence
that 100% of staff in policy and administrative organizations have
participated in recovery training.
|
|
Respect
for diverse cultural backgrounds, ethnicity, sexual orientation, etc.
|
·I feel
my culture and lifestyle are understood and respected.
·I have
access to translators if needed.
·I feel
I can tell people about my heritage and healing traditions.
|
·Evidence
of information available in a range of locally relevant languages.
·Demonstration
of adaptation of services and treatment approaches to respect or
support cultural differences.
·Demographics
of provider staff reflect race/ethnicity demographics of consumers
served.
|
|
|
RECOVERY
DOMAIN 2: Person
Centered Decision-Making & Choice
|
|
Elements
of a recovery-oriented system
|
Ways
this indicator can be demonstrated
|
|
Indicator
|
Individual
Indicator/Outcome
|
By
Program/Services
|
By
County, Regional, or Statewide
|
|
Person-centered
/ person-authored service planning
|
·Staff
sees me as an equal partner in my treatment program.
·My
treatment goals are stated in my own words.
·Staff
respects me as a whole person.
·I chose
my services.
·Staff
understands my experience as a person with mental health problems.
·Staff
listens carefully to what I have to say.
·Staff
treats me with respect regarding my cultural background, (race,
ethnicity, language, etc.)
·I make
decisions about things that are important to me.
·I, not
workers, decide what should be in my treatment plan.
·I feel
comfortable talking with workers about my problems, treatment, personal
needs and hopes.
|
·Inclusion
of persons own language re goals, objectives, etc. Service plan clearly
reflects individual’s preferences, goals, lifestyle, and
interests.
·ROSA type
assessment and dialogue – conversational, broad based,
outcome focused.
·ALL
consumers have an in-pocket copy of their personal plan.
·Individuals
can easily state why they receive services, what their
service/treatment goals are, and how services help them achieve those
goals.
·Inclusion
of consumer selected others in planning process.
·Ongoing
discussions regarding progress and changes needed.
·Evidence
that consumers can change their plans upon request.
·Persons
have regular access to their personal records and charts upon request
for both review and input.
·Demonstration
of creative approaches to meet individualized needs.
|
·Mandates
all contractors and local systems to demonstrate evidence of
person-centered planning.
·Address
existing policies and standards to identify and remove barriers to
person centered planning.
|
|
Service
planning is built around building,
enhancing, and sustaining strengths
|
·My
service plan helps me build on my strengths and assets.
·My
provider asked who in my life is supportive of me.
· I get
help to prepare for and pursue employment that is acceptable and
rewarding to me.
|
·A
recovery oriented service plan is negotiated and developed with each
person served.
·The
provider uses a strength based assessment.
· Qualified
individuals are employed.
|
· Qualified
individuals are employed.
|
RECOVERY DOMAIN 3:
Connection -- Community Integration, Social
Relationships
|
|
Elements
of a
recovery-oriented system
|
Ways
this indicator can be demonstrated
|
|
Indicator
|
Individual
Indicator/Outcome
|
By
Program/Services
|
By
County, Regional, or Statewide
|
|
Focus
on community connections
|
·I have
friends I like to do things with.
·I have
people I can count on when things are difficult.
·I am
free to associate with people of my choice.
·I
receive support to parent my children.
·There
is at least one person who believes in me.
·I have
support to develop friendships outside the mental health system.
·There
are people who rely on me for important things.
·I have
support for challenging negative stereotypes, stigma, and
discrimination.
·I feel
comfortable interacting with businesses and organizations in my
community.
|
·Evidence
that workers help individuals develop positive personal relationships.
·Evidence
in service plans that workers encourage and help individuals to access
services and resources outside the mental health system.
·Evidence
that workers attend to consumers roles as regular people (e.g. parents,
workers, tenants, students), not just as patients.
· Signature
pages in service plans often reflect participation of persons across
programs, agencies, and families/friends.
|
·Develop
public education campaigns to increase awareness and reduce stigma
about mental health problems.
·Develop
mechanisms to coordinate service systems at regional and state levels,
e.g. mental health/vocational rehabilitation, public welfare services,
adult basic education, faith-based service initiatives, and so forth.
·Public
relations activities actively promote and help others understand
recovery.
·Consumer
success is highlighted in public education and relations campaigns.
· Consumers
are involved in all public education and relations campaigns.
|
|
Family
Support
|
·My
family gets the education or supports they need to be helpful to me.
|
·Evidence
of good working relationships with family support groups.
·Evidence
that consumers are encouraged and supported to involve family members
and significant others in treatment decisions.
·Evidence
that consumers are encouraged and supported to develop constructive
relationships with family members and significant others.
· Families
train providers about their experiences and needs.
|
|
|
Addresses
issues relating to stigma and discrimination both in the community and
within behavioral healthcare services
|
· Workers
really believe in me and in my future.
· I
believe my provider helps educate the community about mental illnesses.
|
· Evidence
of staff awareness and training programs that challenge common
stereotypes and assumptions about mental illness.
|
· Evidence
of staff awareness and training programs that challenge common
stereotypes and assumptions about mental illness.
|
RECOVERY DOMAIN 4:
Basic Life Resources
|
|
Elements
of a recovery-oriented system
|
Ways
this indicator can be demonstrated
|
|
Indicator
|
Individual
Indicator/Outcome
|
By
Program/Services
|
By
County, Regional, or Statewide
|
|
Attention
to basic material needs
|
· I have
transportation to get where I need to go.
· I have
enough income to live on.
· I
believe my basic needs are met..
|
· Evidence
that agencies assist individuals with basic material needs such as
transportation and income.
|
· Individuals
are paid for work by the county, region or state.
|
|
Strong
focus on Work/Employment/Education and Meaningful activity
|
· I
choose where I work or learn.
· I have
a job or work that I like doing (paid, volunteer, part-time, full-time).
· I have
things to do that are interesting and meaningful to me.
· I have
interesting options to choose from for where I work or learn.
· I have
a chance to advance my education if I want to.
· There
are things I want to do or achieve in my life that have nothing to do
with mental health treatment.
· My
provider believes that I can work and supports me in my efforts to
obtain employment.
|
· Attention
to and evidence of wide range of work and education options.
· Use of
interest inventories and other career selection tools, in addition to
skill assessments.
· Opportunities
to “job sample.”
|
· Ensure
funding for employment training and job-site support,
stipends/scholarships for educational development, etc.
|
|
Securing
safe, decent, affordable home/housing
|
· I
choose where and with whom I live.
· I have
housing I can afford.
· I feel
safe where I live.
· I feel
comfortable and at home where I live.
|
· Active
and ongoing assistance to help individuals find and keep community
housing of choice.
· The
County has a housing development plan.
|
· Complaints
about living facilities are addressed by advocates or ombudsman.
|
|
Ensuring
good physical healthcare
|
· Staff
talks to me about my physical health.
· I have
access to medical benefits that meet my needs.
· I have
access to health services I need.
· I have
information about health issues that relate to me.
· I have
the best possible health.
|
· Availability
of regular and low/no cost physical health screenings and wellness
services.
· Evidence
that workers help individuals get healthcare benefits that meet their
needs.
· Evidence
workers are knowledgeable about psychiatric manifestations of physical
illness.
· Evidence
that workers “rule out” physical illness before
assuming psychiatric etiology for problems.
· Healthcare
history is collected as part of basic assessment.
· Attention
to healthcare issues integrated into discussion about psychiatric
services/treatment.
· Evidence
of worker knowledge about physiological side effects and risky
interactions of common medications.
· Skilled
nursing staff available easily for consultation to both workers and
consumers about consumer health care issues.
|
· Nurses
are employed to assist with health issues.
|
RECOVERY DOMAIN 5:
Self-Care, Wellness, & Meaning
|
|
Elements
of a
recovery-oriented system
|
Ways
this indicator can be demonstrated
|
|
Indicator
|
Individual
Indicator/Outcome
|
By
Program/Services
|
By
County, Regional, or Statewide
|
|
Focus
on wellness/self-management
|
· Staff
supports my self-care and wellness.
· Staff
helps me to build on my strengths.
· Staff
helps me explore resources for spiritual growth, if I want such help.
· Services
have helped me to be more independent and to take care of my needs.
· I am
comfortable asking for help when I need it.
· I have
found ways to effectively manage symptoms (of mental illness, substance
abuse, trauma) and problems in my life.
|
· Evidence
of mechanisms, training, and support for consumers to develop personal
Wellness Recovery Action Plans (WRAP).
· Evidence
of support for and willingness to help individuals explore holistic or
alternative approaches to self-care.
· Evidence
of regular curriculum and resources for wellness education.
· Evidence
that workers model good wellness attitudes and activities.
· Demonstration
of willingness to help individuals find ways and resources for
spiritual growth.
|
|
|
Proactive
crisis planning, effective response and hospital alternatives
|
· I have
a say in what happens to me when I am in a crisis.
· I have
assistance in creating a plan for how I want to be treated in the event
of a crisis, such as an advance directive.
· I have
a personal plan to help me and my supporters get through a crisis.
· I have
found ways to manage with symptoms and difficult situations that work
effectively for me.
|
· Encouragement,
education, and support for consumer use of psychiatric advance
directives.
· Availability
of respite or other crisis prevention services.
· Established
mechanism for helping consumers be aware, understand, and complete
personal psychiatric advance directives.
|
· Evidence
of leadership in promoting and supporting advance directives.
· Identification
and minimization of policies or practices that may interfere with
implementation of advance directives when needed.
· Evidence
of providers working together to assure easy maneuverability among
programs.
· Individuals
have choice in where to receive crisis services independent of county
of residence.
|
|
Attention
to spirituality & finding meaning
|
· I have
support and encouragement to explore and express my spirituality, if it
is important to me.
· I have
support and encouragement to use my spirituality as a path to wellness.
|
· Evidence
of training and supervision for staff around spirituality in mental
health treatment and support.
|
|
RECOVERY DOMAIN 6:
Rights & Informed Consent
|
|
Elements
of a recovery-oriented system
|
Ways
this indicator can be demonstrated
|
|
Indicator
|
Individual
Indicator/Outcome
|
By
Program/Services
|
By
County, Regional, or Statewide
|
|
Emphasis
on rights and informed consent
|
· Staff
gives me complete information in words I understand before I consent to
treatment or medication.
· My
right to refuse treatment is respected.
· I know
my rights and what to do if they are abused.
· Staff
respects my wishes about who is and who is not given information about
my treatment..
· I
receive information about my rights as a client, as a citizen, and as a
human being in words I understand.
· Staff
“goes to bat” for me to help me protect and uphold
my rights.
|
· Provide
information about individual rights.
· Evidence
of actively upholding, protecting, and advocating for individual
rights..
· Evidence
that ensuring fully informed consent is day-to-day practice in all
aspects of care, treatment, planning, and personal decision-making.
· Promotion
and support for voter registration, voting, and other civic activities.
|
· Demonstrate
development and implementation of an informed consent policy applicable
to all services and programs.
· Establish
and ensure widespread understanding of consumer rights and
responsibilities by developing a state-wide consumer bill of rights.
|
RECOVERY DOMAIN 7:
Peer Support & Self-Help
|
|
Elements
of a recovery-oriented system
|
Ways
this indicator can be demonstrated
|
|
Indicator
|
Individual
Indicator/Outcome
|
By
Program/Services
|
By
County, Regional, or Statewide
|
|
Availability
and support for self-help, peer support, consumer-operated services
|
· I have
access to other consumers who act as role models.
· There
is a consumer advocate to turn to when I need one.
· I am
encouraged to use consumer-run programs.
|
· At
least 1% of total mental health budget set aside for development and
operation of peer services.
· Training
and education programs available to educate and prepare consumers for
employment in human service arena.
· At
least one independent (501-c-3) consumer operated service in each
locality.
· Evidence
that workers are knowledgeable about peer support, self help, and
consumer operated services available locally.
· Evidence
that workers support and promote consumer participation in these
services.
· Evidence
of collaborative agreements and positive working relationships between
consumer operated and traditional services.
|
· There
is at least one free standing peer/consumer operated service in each
service area.
· At
least 1% of the total mental health budget is allocated for the
development, operation, support, and evaluation of peer services.
|
|
Employment
of consumers as workers in traditional and non-traditional service
& administrative/
policy
organizations
|
· I
personally know consumers who are working as paid staff in the mental
health services.
|
· Evidence
of workers at all levels of traditional and non-traditional
organizations who are consumers – and
“out” as personal experiences with mental illness.
· Career
paths open to individuals within traditional organizations.
· Mechanisms
for dialogue regarding challenges presented by and faced by consumer
workers.
· Attention
to agency ethics policies and practices in light of impact of consumer
workers.
· Evidence
of affirmative action program within organizations.
· At
least 5% of all staff in mental health agency
are individuals who receive or received services.
|
· Evidence
of affirmative action program for hiring C/S/X into regular positions.
· Evidence
of advocacy for or use of Medicaid as source of funding for peer
delivered services.
|
RECOVERY DOMAIN 8:
Participation, Voice, Governance & Advocacy
|
|
Elements
of a recovery-oriented system
|
Ways
this indicator can be demonstrated
|
|
Indicator
|
Individual
Indicator/Outcome
|
By
Program/Services
|
By
County, Regional, or Statewide
|
|
Active
involvement of consumers and family members in advocacy, leadership,
with representative voice in governance
|
· I have
a say in how my agency operates.
· I
sometimes get active in causes that are important to mental health
consumers.
· If I
am not happy with services or conditions, I know what to do to file a
grievance or get changes made.
|
· Evidence
of consumers as voting members of governance boards, advisory
committees, and formal planning groups.
· Accommodation
mechanisms in place to assist/support consumer involvement in boards,
committees and other advisory and governance bodies.
· Regular
use of various input mechanisms for ideas, feedback, and complaints
(e.g. surveys, focus groups, etc.)
· Consumers/family
members report feeling heard and respected as part of these groups and
processes.
· Evidence
that consumer input is valued and used in decision-making and planning.
· Leadership/advocacy
training programs and mentorship available.
|
· Evidence
of consumers as voting members of boards, advisory committees, and
formal planning groups.
· Development
of an “expert pool” of trained/experience
consumers/families who can provide leadership/advocacy education and
mentorship.
· Evidence
of efforts to recruit, invite, train, accommodate and support consumers
and families in leadership, governance, advisory roles.
· Evidence
of consumer involvement in provider contract development and review.
· Evidence
of an “Office of Consumer Affairs”, or its
equivalent, at high levels in state, regional, and local
administrations.
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RECOVERY DOMAIN 9:
Treatment Services
|
|
Elements
of a recovery-oriented system
|
Ways
this indicator can be demonstrated
|
|
Indicator
|
Individual
Indicator/Outcome
|
By
Program/Services
|
By
County, Regional, or Statewide
|
|
Access
to appropriate and effective pharmacology
|
· The
doctor worked with me to get me on medications that were most helpful
to me.
· I get
information about medications and side effects in words I understand.
|
|
|
|
Access
to range of effective treatment approaches
|
· I have
good service options to choose from.
· Services
are helpful to me.
· Services
help me develop the skills I need.
· Staff
has up- to- date knowledge about effective treatment approaches.
· I have
information and guidance I want about services and supports both inside
and outside the mental health agency.
· I can
get services when I need them.
· I can
see a therapist when I need to.
· I have
enough time to talk with my psychiatrist.
|
|
|
|
Availability
and integration of trauma specific treatment and support
|
· I can
get specialized services for past or present trauma or abuse if I need
or want them.
· I feel
safe from violence, trauma, abuse, and neglect.
|
· Evidence
of work to identify and eliminate practices that may be
re-traumatizing.
· Consumer
operated self-help groups for individuals dealing specifically with
mental illness and trauma related issues.
· Employment
of staff trained in providing trauma-informed treatment.
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· Inclusion
of trauma support services in all contracts.
· Evidence
of work to reform insurance and Medicaid policies that do not include
trauma treatment or support.
· Development
and promulgation of training and technical assistance to promote trauma
informed services at local/regional levels.
· Establishment
of Trauma Advisory Committees to better identify needs.
· Evidence
of efforts to improve detection and prevention of abuse in
institutional settings
|
|
Integrated
substance abuse services and treatment
|
· I can
get combined treatment for mental health and substance abuse issues.
· I can
chose from a range of services that may help me manage substance use
issues.
|
|
· Evidence
of training for county staff about regulations and competencies for
co-occurring mental illness and substance abuse disorders.
|
|
Access
to jail diversion and jail-based services
|
· I have
access to jail diversion services if I need them.
|
· Evidence
of coordination and collaboration with law enforcement services.
· Evidence
that jail diversion services are available in the community for persons
with mental health problems.
· Evidence
that mental health services are available and delivered in jail
settings.
|
· Evidence
of inclusion of law enforcement and judicial personnel in county
recovery efforts.
|
RECOVERY DOMAIN 10:
Worker Availability, Attitude and Competency
|
|
Elements
of a recovery-oriented system
|
Ways
this indicator can be demonstrated
|
|
Indicator
|
Individual
Indicator/Outcome
|
By
Program/Services
|
By
County, Regional, or Statewide
|
|
Ongoing
attention to building worker positive
characteristics and competency in recovery practices
|
· Workers
have up-to-date knowledge about the most effective treatments for me.
· I feel
respected and understood by mental health workers.
|
· Evidence
of establishment of recovery-oriented competencies.
· Evidence
of recovery- oriented training included in all aspects of orientation,
in-service and professional development activities.
· Evidence
of organizational support for workers to develop and use
recovery-oriented approaches.
· Evidence
of ongoing training and supervision activities that help deepen worker
understanding of recovery practices.
· Evidence
of ongoing training in up-to-date promising and evidence-based
practices.
· Supervision
practices help workers develop and implement recovery-oriented
approaches for each person served.
|
· Evidence
of efforts to influence university curricula for all human service and
medical fields to include recovery information as part of basic
training.
· Establishment
of core competency standards regarding knowledge of recovery principles
and practices.
· Include
recovery competencies in credentialing and certification processes.
· Requirement
that recovery-oriented training is part of every application for
continuing education for renewal of state licensure.
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RECOVERY DOMAIN 11:
Addressing Coercive Practices
|
|
Elements
of a recovery-oriented system
|
Ways
this indicator can be demonstrated
|
|
Indicator
|
Individual
indicator/Outcome
|
By
Program/Services
|
By
County, Regional, or Statewide
|
|
Minimized
use of coercive
approaches (seclusion/ restraint, involuntary treatment, guardianships,
payeeships, threats, etc)
|
· Staff
helps me to stay out of psychiatric hospitals and avoid involuntary
treatment..
· Medication
and treatment is not forced on me.
· Staff
does not use pressure, threats or force in my treatment..
· If I
have a payee or community commitment order, I know why and know exactly
what I have to do to be released from these stipulations.
· I
chose how to manage my personal finances.
· I am
free from coerced treatment.
|
· Data
collected and tracked regarding use of coercive approaches, with
feedback to individual services.
· Training
for staff on alternatives to coercion.
· Time
limited: evidence that individuals are “graduating”
from involuntary care, guardianships, payeeships.
· Individuals
on involuntary treatment, guardianships, and payeeships know the
reasons why these mechanisms are in place and what they need to do to
get out from under them.
· Demonstration
that agencies respect and attend to the dignity and rights of
individuals subjected to involuntary or coercive practices.
· Evidence
that every person under a coercive mechanism (payee, conditional
release, outpatient commitment) has a written plan of achieving
self-management in this area of his/her life.
· Evidence
that alternatives to involuntary treatments or coercive approaches are
identified, promoted, used in services.
· All
data is reviewed regularly by the Board of Directors.
|
· Evidence
of mechanism to track data about incidence and prevalence of use of
wide range coercive practices within system.
· Transparency
in data about number of clients receiving voluntary and involuntary
inpatient hospitalization in public and private hospitals; involuntary
outpatient commitments, etc.
· Transparency
in data about use of seclusion, restraint, restrictive holds in all
settings.
· Evidence
of feedback loop to agencies, services, hospitals regarding coercive
practices data.
· Evidence
that alternatives to involuntary treatments or coercive approaches are
identified, promoted, used in services.
· All
data is reviewed regularly by administration, advisory committees, and
other key stakeholders.
|
|
Managing
risk & supporting safety for workers, consumers and family
members
|
· I know
what to do if I feel unsafe where I live, work, socialize, or travel.
· I am
aware of people, places, times, and things that cause me difficulty
– my “triggers”.
· I am
aware of ways to handle my “triggers” that work for
me.
|
· Workers
knowledgeable about assessing risk factors and probability.
· Evidence
of individualized approaches to managing and minimizing risk.
· Availability
of training and support for consumers about personal safety and develop
skills for identifying and managing risk presented in their living
situations/neighborhoods.
· Ensure
that workers have access to regular information and training about
personal safety and risk management for office and community settings.
|
· Evidence
that crisis response services are available and staffed with
individuals trained and competent in mental health and substance abuse
crisis intervention.
· Evidence
of service protocols that promote mental health crisis response prior
to police intervention in most mental health crisis situations.
|
RECOVERY DOMAIN 12:
Outcome Evaluation & Accountability
|
|
Elements
of a recovery-oriented system
|
Ways
this indicator can be demonstrated
|
|
Indicator
|
Individual
Indicator/Outcome
|
By
Program/Services
|
By
County, Regional, or Statewide
|
|
Orientation
toward continual learning and improvement through regular outcome
evaluation with data used to guide positive change
|
· I
achieve personal outcomes that are meaningful to me.
· Workers
help me recognize when I am making progress.
|
· Personal
outcomes identified and measured as evidence of progress and quality
services.
· Systemic
outcomes evaluated regularly.
· Evidence
that consumers are involved in the identification of outcomes and in
the process of evaluation of services.
· An
attitude of “catch ‘em doing it right” is
evidenced by workers who recognize progress and do not always focus on
problems and crises.
· Evidence
that consumers receive regular positive feedback on progress.
· All
outcome data is reviewed regularly by the board of directors.
|
· Develop
or adopt standardized recovery-focused outcome measures to be used as
part of regular quality assurance activities.
Included in this are both personal consumer outcomes
as well as service or system outcomes.
· Full
transparency in data collection and reporting.
· Evidence
that findings from outcome assessments and evaluations are used to
improve services and programs.
· |