The Top 10 Concerns about Recovery Encountered in System Transformation

The second chapter begins with descriptions of some of the many ways in which people with serious mental illness are key agents in their own recovery. In these descriptions, we fi nd that the cornerstones of recovery are both the hope that a better life is possible and the desire the person has to pursue such a better life once this hope has taken root. For an individual, both hope and action appear to be required to make recovery a reality. As we begin to understand more fully the role of systems of care and of the practitioners within those systems in facilitating recovery, we suggest that achieving, in the words of the New Freedom Commission report, “profound change—not at the margins of a system, but at its very core” also will require both hopeful attitudes and concerted efforts. While the remaining chapters in this volume will deal more explicitly with the kinds of concerted efforts required to achieve transformation, this chapter focuses primarily on attitudes toward recovery and the kinds of concerns systems and practitioners have raised (to date) as they have gone about the process of understanding and implementing recovery principles in practice. It has been our experience, however, that the federal mandate to transform systems of care to promote recovery has left many policy makers, program managers, practitioners, and even the recovery community itself under increasing pressure to move to a recovery orientation without fi rst examining the concerns of stakeholders within those systems about this new notion of recovery and its implications. As a result, we are all at risk of overlaying recovery rhetoric on top of existing systems of care, failing to effect any real or substantial—not to mention revolutionary—changes due to our urgency to just “get it done.” In this chapter, we pause to consider some of the more common concerns we have encountered in attempting to introduce and implement care based on the vision of recovery that we have articulated thus far. Addressing these concerns, we believe, is a necessary fi rst step in changing the attitudes that underlie current practices in the process of replacing these attitudes with the more hopeful, empowering, and respectful attitudes demanded, and deserved, by people in recovery.

The Recovery Movement and Its Implications for Transforming Clinical and Rehabilitative Practice

We begin with a snapshot of the world we hope to leave behind. While it may not be necessary to reiterate the reasons why transformation is needed for most readers—who, as we noted in the Introduction, may be only too familiar with the challenges presented by our current systems of care—we think it useful nonetheless to establish a point of departure. We also strive throughout this volume to make our ideas concrete through the use of stories derived from our own experiences, putting a human face on what might frequently appear to be abstract or idealistic concepts. In our experience, and in our previous publications (e.g., Davidson, Stayner, et al., 2001), there has been very little about mental health concepts of recovery that are either abstract or idealistic. In fact, we have consistently stressed the everyday nature of recovery (Borg & Davidson, 2007), fi nding it embodied and exemplifi ed in such mundane activities as washing one’s own dishes, playing with a child, or walking a dog. We strive to continue this concrete focus in what follows, alternating our exposition of principles and practices with descriptions of real-life examples from our practice. This not only is our own preference in teaching and training but was strongly encouraged by the reviewers of an earlier draft of this book. We are happy to oblige. Passage of legislation such as the Rehabilitation Act of 1973 and the Americans with Disabilities Act of 1990 held great promise for individuals with disabilities, especially in relation to their opportunity to participate fully in all aspects of community life. Unfortunately, it is now widely recognized that the implementation of these acts for persons with serious mental illness lags far behind parallel efforts in the broader disability community, with expectations for expanded access and opportunity largely still to be realized (Chirikos, 1999; Fabian, 1999; Hernandez, 2000; Wylonis, 1999). In response to this national tragedy, several recent calls have been made for radical reforms to the mental health system. The Surgeon General’s Report on Mental Health, for example, called for mental health services to be “consumer oriented and focused on promoting recovery” (DHHS, 1999, p. 455).

Practice Standards for Recovery-Oriented Care

What does a recovery-oriented system of care look like in practice? As we suggested in the preceding chapters, the primary aim of recovery-oriented care is to offer people with serious mental illness a range of effective and culturally responsive interventions from which they may choose those services and supports they find useful in promoting or protecting their own recovery. In addition to diagnosing and reducing symptoms and deficits, a recovery-oriented system of care also identifies and builds on each individual’s assets and areas of health and competence to support that person in achieving a sense of mastery over his or her condition while regaining a meaningful, constructive sense of membership in the broader community (Davidson et al., 2007). While the goal of recovery-oriented care may appear, in this way, to be relatively clear and straightforward, the ways in which care can be used to promote recovery are neither so clear nor so straightforward—neither, unfortunately, are the ways in which care, as currently configured, may impede or undermine recovery. The following practice standards are offered as a beginning roadmap of this territory, bringing together what we think we know at this point about how care can best promote and sustain recovery, and how care may need to be transformed to no longer impede it. These standards are drawn from over two years of conversations with practitioners, people in recovery, families, and program managers and are informed by the current professional literature on recovery and recovery-oriented practice. These standards focus primarily on the concrete work of practitioners and provider agencies so as to provide practical and useful direction to individuals and collectives that are committed to implementing recovery-oriented care. We recognize, however, that many of the practices described will require a broader commitment of agency leadership to significant and ongoing administrative restructuring. In the future, we also anticipate that systems will want to add domains to the ones we propose here, in such areas as prevention, early intervention, cultural competence, and the assessment and monitoring of outcomes.

A Model of Being in Recovery as a Foundation for Recovery-Oriented Practice

We begin this second chapter where we left off in the preceding one, with the question of what is involved in the work of recovery and how practitioners can best support this work. On one hand, we understand the answer to this question to be very much a work in progress. There is much still to learn about recovery and recovery-oriented care, and we consider the field—including our own efforts in this regard—to be in the very early stages of its development. On the other hand, we have begun to learn some things about what processes of recovery entail and what the provision of recovery-oriented care looks like in practice, as well as about some of the structural conditions necessary for this kind of care to be implemented. In this chapter, we share some of these lessons by describing components and processes of being in recovery that we have integrated into a model that can then serve as the foundation for developing recovery-oriented practices. The assumption of this approach, as we mentioned in the previous chapter, is that this form of recovery is primarily the responsibility of the person with a serious mental illness. What practitioners do should thus be oriented to supporting and facilitating the person’s own efforts. We describe this perspective as a “bottom up” approach to service development, as it begins with the needs, preferences, and goals of the person in recovery— not only at the individual level of a person’s “recovery plan” but also at the collective level of the system as a whole. What services and supports should a mental health system offer? Those, we suggest, that will enable persons with serious mental illness to lead safe, dignified, and gratifying lives beyond the illness—when possible— or, when that is not possible, within the boundaries imposed by the illness. Before turning to the question of what services and supports we need to offer to promote and sustain recovery, we need to understand better what being in recovery entails. To frame the question in this way is not to ignore the other form of recovery (i.e., recovery from mental illness).

The Role of the Recovery Guide

We have defined and discussed the nature of various notions of recovery, grappled with the implications of a recovery vision for mental health system transformation, and begun to draw the outlines of a transformed system. Now we can turn to the question of how such services and supports can actually be offered to people who need them. Here we propose what we call the recovery guide model. Analogous to the role currently played by case management, the recovery guide model is an organizing vehicle by which practitioners can offer a range of services and supports to people, either directly or through others. As with case management, the intensity, scope, focus, and duration of a recovery guide’s work with a person will depend on that person’s needs, preferences, life circumstances, and goals at a given point in his or her unique recovery journey. In this chapter we describe the basic aims, tenets, and tools of this approach. First, though, we offer a brief review of advances in mental health case management that preceded and led up to the concept of recovery guides, including the present recognition that, in a recovery-oriented system of care, people with serious mental illness can no longer be considered “cases” that others manage (Everett & Nelson, 1992). With the failure of a combination of Thorazine and psychotherapy to achieve the aims of deinstitutionalization (Johnson, 1992), case management became the predominant service that mental health systems offered their clients with serious mental illness (Sledge, Astrachan, Thompson, Rakfeldt, & Leaf, 1995). In addition to being inadequately funded, community-based systems of care that were developed to enable people with serious mental illness to leave state hospitals were fragmented and uncoordinated “non-systems” of care (Hoge, Davidson, Griffith, & Jacobs, 1998). As it was practically impossible for people seeking care to navigate these complex and unintegrated health and social service systems on their own, the case manager role was created to identify and coordinate the provision of services to meet their multiple needs in the community (Hoge, Davidson, Griffith, Sledge, & Howenstine, 1994; Sledge et al., 1995). Case managers’ primary responsibility was to assess people’s needs, link them to services, and monitor their service use and outcomes.