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Anthony (2000) has described the features of a recovery focused mental health system. We summarize from his leading article about this subject the following aspects (p. 163-167) and add information from the American Association of Community Psychiatrists (AACC) which in 2003 issued guidelines for recovery oriented services, and some other sources.
The first issue is the design of a service system. In this design the mission and outcomes of the system “should incorporate the language of recovery”. Consumers and their families are integrally important in the design process. The identified mission and consumer outcomes include such dimensions as improvements in role functioning, empowerment, consumer satisfaction, and quality of life. The mission is achieved through a set of identified services (see figure 3.1) which, when combined together, contribute to the achievement of recovery outcomes (Anthony, 1993). A specific service (e.g., crisis intervention service, case management service) is defined by its unique process and outcomes. A setting is defined by its location (e.g., inpatient, community mental health centre). A programme is defined by certain administrative, staffing, and service standards (e.g. intensive case management programme, clubhouse programme). The system is designed around the Community Support System configuration of services and is not designed around a specific set of programmes or settings; rather programmes and settings must indicate which of the services they provide and on what consumer outcomes they will be held accountable. For example, an ACT programme may indicate that they provide treatment, rehabilitation, crisis intervention, and case management services, and that they are accountable for implementing the process associated with each of those services.
The AACC (2003) states in its guidelines for recovery oriented services: “Commitment to processes fostering recovery must be clearly articulated for organizations to successfully pursue and maintain recovery-oriented services (ROS). The organizational mission should commit to the vision that individuals with mental illness can reorient their lives to a recovery process. Professionals must articulate the goal of developing and strengthening the community of recovering persons. Strategic planning will include a focus on achieving the mission of strengthening the community of recovering persons.”
The AACC urges that consumer participation in service design and continuous quality improvement is essential.
A variety of services that support consumer self-sufficiency and decision-making should be available in comprehensive service systems. Available services should include flexible options for individual and group psychotherapy, rehabilitation and skills building opportunities, various intensities of empowering case management, crisis management and hospital diversion plans, and participatory psychiatric medication management. Prevention, health maintenance, and disease self-management principles should provide the guiding philosophy for all clinical services.
Indicators for this guideline are:
(a) Integration of consumer, family and peer supports, disease management education and crisis management planning will be reflected in policy and procedure documents.
(b) Establishment of services supportive of recovery processes and which incorporate self management principles
(c) Recovery oriented service design will be reflected in policy and procedure documents, including financial structures that encourage such service development
(d) Consumers and family members are enlisted to participate in the decisions regarding resource allocation and service development.
Evaluation of recovery outcomes
Anthony (2000) proposes that each programme providing services in the system must identity the unique consumer outcomes they will achieve. For example, in rehabilitation services, no matter what the rehabilitation program is called (e.g., IPS, Clubhouse) and no matter what the setting (e.g., psychosocial rehabilitation centre, mental health centre), the service must achieve improvements in the consumers' role functioning. Treatment services must achieve symptom alleviation, and so on. Outcomes assessments must always include the perspectives of consumers and family members.
Farkas & Gagne (2002) formulated a number of recovery outcomes for treatment and rehabilitation services:
• Gaining/regaining a valued role, i.e. student, worker, family member, tenant
• Experiencing increased success and satisfaction in these roles
• Reducing/controlling symptoms
• Increased sense of self-efficacy
• Increased feelings of well being
• Increased number or quality of interpersonal connections
• Increased measures of physical health
• Increased sense of self-esteem
The AACC (2003) include also in their guidelines outcome assessment. It states: “recovery oriented services will develop indicators that relate not only to concrete levels of function, but also to variables related to an individual's progress in recovery and personal growth. These somewhat qualitative and often abstract aspects of experience should be translated into quantifiable and measurable constructs that will provide evidence for quality of life as a valid aspect of service outcome. Outcome indicators will include items related to quality of life, recovery and self fulfilling function”.
Leadership and management
The vision of recovery must be present in most all of the leadership's written and public statements. Recovery is such a paradigm shifting notion that its fundamental assumptions and principles must constantly be reinforced (Anthony, 1993).
System management, through system level policies and procedures, must ensure that each individual service define itself by the unique process they use. Service protocols are developed and implemented so that the basic service processes are possible to monitor (Anthony, 1998). For example, the basic protocol for case management might include process components such as setting a service goal, planning, linking and negotiating for service access. The protocol for rehabilitation might include setting the overall rehabilitation goal, functional assessment, resource assessment, planning, skill development and resource development.
Shepherd (2002) mentions a number of characteristics of effective team leaders. They should be able to create ‘alignment’ around shared values and objectives. They have to ensure that all team members feel involved in decision making, that responsibilities are clear and tasks are completed. An effective team leader helps the team confront and resolve differences, while maintaining mutual respect. He/she sets clear standards, gives clear feedback to individuals, and encourages ‘reflexivity’. He/she helps the team reflecting on its own processes, learning more effective ways to work together. It is important to encourage constructive criticism from outside the team - especially from users and carers. The leader will represent the team to others and protect its interests. Finally an important characteristic is to maintain commitment and enthusiasm, ‘optimism in the face of adversity’.
Each service, within the array of services offered by the system, has a standardized planning process that shares some common process elements across services, that is, each service contains the major process elements that are standard across services. Common process elements might be: an assessment of the consumer's goal(s), a plan to reach the goal(s), and specific interventions to achieve the goal(s). For example, case management services might assess the person's service goal, plan for accessing those services, and intervene through linking and/or negotiating for those services. In addition, when referrals occur between different service programs, the referral includes a specific description of the consumer outcomes the receiving service is expected to achieve.
Anthony (2000) emphasises the comprehensiveness of a service system: “All the possible residential, work, educational and social environments in which a consumer might potentially function are included as a consumer goals) and measurable consumer outcome(s). Functioning in non mental health environments (e. g., schools, social clubs) is included as goals. It is the policy of the system that consumer supports that facilitate a consumer's functioning are provided in a wide variety of environments. A particular support exists in more than one environment. For example, intensive residential support may be provided in group residences, but also in an individual's own apartment.”
Selection and recruitment materials for staff throughout the system target consumers and family members for employment, as well as voluntary service on boards. User-controlled services are available in all the designated catchment areas served by the system.
Consumers are also closely involved in the planning process. The AACC guidelines (2003) state: “Respect for consumer participation and efforts to obtain meaningful input from them will be a hallmark for Recovery Oriented Services (ROS)”. This input should be solicited even when consumers are most debilitated and opportunities to make choices should be provided whenever possible. ROS will emphasize consumer choice in all types of planning processes including, but not limited to treatment, service, transition and recovery plans. ROS will emphasize the identification and use of a person’s strengths to design a plan to overcome their difficulties. AACC indicators include:
(a) Development of collaborative process for developing continuous comprehensive service plans between consumers and providers.
(b) Efforts to engage more impaired clients are reflected in agency planning records.
(c) Process in place to inform consumers of treatment/service options and to discuss pros and cons of each prior to service plan development.
According to Anthony (2000), the system should promulgate policies that reflect the culture of the consumers served. Specifically, policies on cultural competence address the training and experience of practitioners, the assessment, planning, and intervention process, and culturally relevant programs and procedures to access them.
The AACC guidelines (2003) speak about cultural competence: culturally sensitive treatment and services indicate respect for individuals and recognition that beliefs and customs are diverse and impact the outcomes of recovery efforts. Access to service providers with similar cultural backgrounds and communication skills, supports consumer empowerment, autonomy, self-respect, and community integration. Indicators are: the development of staff with an ethnic/racial profile representative of the community being served and the establishment of cultural competency standards for organization’s staff.
Advocacy and Mutual Support
System advocacy occurs for the recovery vision, for a holistic understanding of the persons served, and for consumers to have the opportunity to participate fully in community roles.
The AACC (2003) says that facilitation of contact with and participation in consumer advocacy groups and mutual support programs is an important aspect of Recovery Oriented Services. Liaison with entities involved in these activities should be established to enable this process. Intensive community based peer mentoring/sponsorship programs, consumer managed peer support networks and drop-in centres are examples of these services. Indicators are: (a) an active facilitation of participation of clients in advocacy organizations is demonstrated; (b) an agency liaison with local advocacy and support groups is identified and active; (c) a majority of consumers participate in peer support activities.
The AACC adds a guideline on coercive treatment: “The use of coercive measures for treatment is not compatible with recovery principles. Therefore, providers of ROS will make every effort to minimize or eliminate the use of coercive treatments to the greatest extent possible. When they are unavoidable, they should be used with great care and circumspection. Involuntary treatment arrangements should occur in the least restrictive environments possible to meet the needs of disabled individuals and maintained for the shortest period of time possible. Individuals must be treated with compassion and respect during episodes of incapacitation and should be offered choices to the greatest extent possible with regard to their treatment plan. Attempts to transition to voluntary treatment status should be strongly encouraged to assure that recovery principles might be restored to treatment processes.”
The use of seclusion and restraint should be used only in extreme situations where safety is threatened. When necessary, it should be kept to a minimum and should be implemented in the most humane manner possible. The use of simultaneous seclusion and restraint should never be used, and processes to assure that these measures are discontinued as soon as possible should be developed. Debriefing for all individuals involved in the incident should be required and effective quality monitoring and improvement processes should be in place. The AACC suggests the following indicators:
a) Development of crisis plans employing progression of interventions designed to deescalate volatile situations.
b) Constraint of individuals who are presenting clear threats to their own or other’s safety and welfare are guided by both individualized plans and agency policy.
c) Debriefing occurs after all incidents requiring restraint or seclusion.
d) All staff potentially able to respond to a volatile incident are trained in de-escalating techniques and alternatives to forceful constraint.
Training is essential to build the competences professionals need to provide rehabilitation.
Anthony (2000) says that system level policies on training are designed in such a way that delivery of specific services is improved. Training is grounded in the vision of rehabilitation and recovery, and not just in the interest of certain staff.
The AACC states in its guidelines for Recovery Oriented Services (2003) that training and continuing education should include an adequate understanding of recovery concepts, and of consumer perspectives and aspirations. Training standards and competency requirements should reflect this value. Processes should be developed for interactions and/or communications between consumer and providers in non-clinical settings. Another indicator is the establishment of core competency
standards regarding knowledge of recovery principles.
‘Ten Top Tips’ for recovery oriented practice
After each interaction, the mental health professional should ask her / himself,
(after Shepherd, 2007)
These texts are taken from:
Wilken J.P. and D. den Hollander (2005). Rehabilitation and Recovery. Amsterdam: SWP Publishers, p. 82 -86.
Shepherd, G. (2007). Specification for a comprehensive ‘Rehabilitation and Recovery’ service in Herefordshire. Hereford PCT Mental Health Services. (www.herefordshire.nhs.uk)
Shepherd G, Boardman J, Slade M (2009) Making recovery a reality. Briefing Paper. London: Sainsbury Centre for Mental Health.
Shepherd G, Boardman J, Slade M (2009) Making recovery a reality. Briefing Paper. London: Sainsbury Centre for Mental Health.
Shepherd G, Boardman J, Burns M (2010) Implementing Recovery. A methodology for organisation change, London: Sainsbury Centre for Mental Health.
National Institute for Mental Health in England (2004) Emerging Best Practices in Mental Health Recovery, London: NIMHE.
Care Services Improvement Partnership (2006) Pathways to Recovery Paper 1. Core Vision and Values for a Modern Mental Health System, London: Department of Health.
Care Services Improvement Partnership / Royal College of Psychiatrists / Social Care Institute for Excellence (2007) A common purpose: recovery in future mental health services, Leeds: CSIP.
Sainsbury Centre for Mental Health (2009) Implementing Recovery. A new framework for organisational change, London: Sainsbury Centre for Mental Health.
Davidson L, Tondora J, Lawless MS, O'Connell M, Rowe M (2009) A Practical Guide to Recovery-Oriented Practice Tools for Transforming Mental Health Care. Oxford: Oxford University Press.
last edited by Jean Pierre Wilken March 2013