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The 3Cs for recovery services

February 01, 2008

In 1993, Dr. Anthony introduced the concept of a recovery-oriented mental healthcare system,1 based on the notion of recovery advanced by people with severe mental illnesses2 initially researched by Harding and colleagues.3 A lot of discussion over the past few years has been about the importance of developing recovery-oriented practices, bolstered by the President's New Freedom Commission's report that called for services to adopt a recovery vision for the mental healthcare system.4 Mental healthcare organizations (providing treatment, crisis intervention, case management, rehabilitation, wellness, self-help, and/or other services) can opt to deliver these services with or without a recovery orientation.5 The critical question of how to actually put the New Freedom Commission's recommendations into practice has since dominated discussions in the field.

Organizations often begin their change strategies by developing training programs with the idea that if the staff is retrained, the organization itself will change. Such an initial focus on staff training, while appealing to one's notion of “getting started,” may be premature and poorly targeted toward the goal the organization truly wants.

In addition to training to improve staff's capacity for recovery-oriented services, also important are two other elements: organizational culture and organizational commitment (the “3Cs”), as expressed through the organization's mission, policies, procedures, activities, record keeping, and so on. An effective implementation strategy, therefore, begins by identifying an organization's culture, commitment, and capacity in relation to the implementation goal.

This article lays out a simple framework for identifying the extent to which an orga-nization is ready to implement recovery-oriented practices, along with examples from a checklist based on that framework.

We (M.F. and W.A.A.) have suggested that best practice in recovery involves value-based practices that adhere to recovery values, such as the four critical values of personhood, full partnership or involvement, choice or self-determination, and hope or orientation to growth, as well as those practices that have some level of evidence associated with them (e.g., evidence-based and promising practices).6,7 We believe that implementing recovery-oriented practices requires an initial review of the extent to which the organization's 3Cs for delivering recovery-oriented services exist. Assessing the 3Cs is a critical early step in identifying an organization's readiness to implement recovery-oriented practices.

Culture

The organization's culture basically is the “way things are done around here.” Culture can involve organizational policies as well as more implicit rules governing social and professional interactions. An organization ready to implement a recovery-oriented practice demonstrates a culture based on recovery values.

Value-based practice assumes that core values guide and direct a particular service or intervention.6 For example, the value of personhood or simple human decency7 implies that the organization makes an effort to see participants in roles other than “patient.” This may include having a culture that acknowledges important events (births, deaths, graduations, birthdays, etc.) in the lives of all individuals equally (i.e., employees and the people they serve). The organization may make a conscious effort to identify talents, interests, and strengths of the people it serves by supporting opportunities to share these talents and strengths both in the “outside” world and within the organization. A culture of simple human decency governs everything from how bathrooms are allocated (e.g., for only staff members’ or for everyone's use?) to discussions about individuals in team meetings (Do staff members crack jokes about bizarre behaviors? Do staff members show empathy for individuals even when they are not present?).

The value of partnership or full involvement means “nothing about us without us.” Consumer involvement in designing, delivering, and evaluating mental healthcare is a critical component of a quality management system for any mental healthcare service,8 as well as critical to developing a sense of empowerment.9 Promoting the hiring of individuals with serious mental illnesses as peer providers and support personnel, as well as in the role of helping professionals and administrators, is becoming an important element in the development of a recovery-oriented service or system reflecting the culture of full partnership.

The third common value in recovery-oriented services’ culture is self-determination. Self-determination and self-choice are the cornerstone of a recovery process. A culture that promotes self-determination actively deals with the implied shift in power relationships between staff and participants. Self-determination requires staff to be able to relinquish power without feeling threatened.

Organizations that empower staff also create a climate in which empowerment of participants becomes “the way things are done around here.” The opportunity to choose one's long-term goals, the methods to be used to obtain those goals, and the individuals or providers who will assist in the process are all components of a service culture acknowledging this value.


Table. Elements from the Organizational Readiness for Recovery Practice Checklist

Culture

Commitment

Capacity

Our program operates hours that allow for people to work or do other business.

All staff in our program believe that people with psychiatric disabilities can and do resume valued roles in society.

Staff have the skills to develop a strong, respectful, interpersonal relationship to engage, support, and inspire people as experts in their recovery process.

Our program involves people with psychiatric disabilities in program development and operations.

Staff in our program make sure that individuals are present during planning and evaluation.

Staff have the skills to facilitate the development of an overall description of what life would be like when recovery occurs (what role, what setting, with whom, doing what everyday).

Our program helps people orient to the future. Our program celebrates successes.

Program administrators hire people who have used mental healthcare services.

Staff have knowledge and skills to link people to the recovery-oriented resources or services they want and are identified in choosing a direction.


In addition, hope for the future is an essential ingredient in all recovery-oriented services. A commitment to creating and maintaining hopefulness in both service participants and their practitioners is critical. The extent to which opportunities exist for both staff and participants to grow and develop can reflect the hopefulness of an organization's culture. The degree to which the organization actively strives to create support and opportunities for a life beyond the traditional mental healthcare system's expectations (e.g., professional careers, owning one's own home, obtaining higher degrees) also can promote a hopeful recovery-oriented culture.

Commitment

Readiness to develop a recovery-oriented service requires the commitment of not only leadership but also middle-level managers, line staff, and support staff—in short, all staff within the organization. Clearly it is possible for an organization to have staff committed to implementing recovery-oriented practices at one level of the organization but not another. A commitment to change begins with dissatisfaction with the status quo, a belief in the degree to which resources or support will exist to make the change, and a basic level of knowledge about the organization's proposed direction.

If staff at all levels are satisfied with the current situation, there will be little impetus or ownership of any need for change. If staff do not believe that resources and support exist for making a change in the direction of recovery-oriented services, they may feel that the process would be hopeless in the end even if they are eager for change. Employees’ level of knowledge about the implications of facilitating recovery for all participants impacts their determination to make a change. Therefore, the organization most ready to implement recovery-oriented practices has all staff demonstrate a solid commitment to change, borne out of dissatisfaction with current practice, a belief in the existence of resources and supports for change, and the knowledge to understand the change's implications.

Capacity

An organization's capacity to deliver recovery-oriented services is determined by the staff's knowledge, attitudes, and skills to assess, plan, and intervene using the particular tools relevant to the service and to recovery as an overall goal. Staff need to be knowledgeable about recovery itself, as well as understand and share at least the four core values underpinning a recovery culture. Some of the competencies identified as critical, regardless of the intervention or service, include developing a partnership or personal relationship based on listening and facilitating instead of proscribing or directing, as well as helping the individual identify his/her own vision of recovery goals and/or an image of what a “recovered life” would look like.

Other skills may be particular to a specific type of service. For example, recovery-oriented treatment service personnel need to have the skill of facilitating and understanding the individual's view of the cost/benefits of proposed medications vis-à-vis that person's recovery goals. Recovery-oriented rehabilitation service personnel need to have the skill of facilitating decision making about which valued role that person wants (e.g., worker, student, homemaker, club treasurer, etc.).

Organizational Readiness Checklist

The 3Cs framework involves reviewing an organization's culture, commitment, and capacity to identify the extent to which some recovery-oriented indicators exist. Of the three, commitment is perhaps the most critical. If commitment exists across all staff levels, a culture of recovery and a capacity for delivering recovery-oriented practices can be more easily developed with the help of consultation and training.

Boston University's Center for Psychiatric Rehabilitation has developed a process of consultation and training in recovery-oriented practices over the past 30 years. As a part of the consultation strategy, we have developed an organizational assessment process based on the 3Cs, including a brief checklist to begin the process. The table presents some of the checklist's elements. By interviewing staff at all levels and reviewing policies, procedures, record-keeping practices, and documents, organizations can be rated as to the degree to which each of the 3C elements are present. Where culture, commitment, or capacity are lacking, an organization needs to work in that area before moving toward full-scale implementation of a recovery service.

Lori Ashcraft, PhD, directs the Recovery Opportunity Center at Recovery Innovations, Inc., in Phoenix, and she is a member of Behavioral Healthcare's Editorial Board. William A. Anthony, PhD, is Director of the Center for Psychiatric Rehabilitation at Boston University. Marianne Farkas, ScD, is the Center for Psychiatric Rehabilitation's Director of Training. Contact Dr. Farkas at mfarkas@bu.edu for further information about organizational readiness, the checklist, and the consultation process for implementing recovery-oriented practices.

References

  1. Anthony WA. Recovery from mental illness: the guiding vision of the mental health service system in the 1990's. Psychosocial Rehabilitation J 1993; 16 (4):11–23.
  2. Deegan PE. Recovery: the lived experience of rehabilitation. Psychosocial Rehabilitation J 1988; 11 (4):11–14.
  3. Harding CM, Zubin J, Strauss JS. Chronicity in schizophrenia: fact, partial fact, or artifact? Hosp Community Psychiatry 1987; 38 (5):477–86.
  4. President's New Freedom Commission on Mental Health. Achieving the Promise: Transforming Mental Health Care in America. Final Report. Rockville, Md.: U.S. Department of Health and Human Services; 2003.
  5. Farkas M, Gagne C, Anthony W, Chamberlin J. Implementing recovery oriented evidence based programs: identifying the critical dimensions. Community Ment Health J 2005; 41 (2):141–58.
  6. Farkas M, Anthony WA. System transformation through best practices. Psychiatric Rehabilitation J 2006; 30 (2):87–8.
  7. Anthony WA. Value based practices. Psychiatric Rehabilitation J 2005; 28 (3):205–6.
  8. Blackwell B, Eilers K, Robinson D Jr. The consumer's role in assessing quality. In: Stricker G, Troy WG, Shueman SA, eds. Handbook of Quality Management in Behavioral Health. New York:Kluwer Academic Publishers; 2000. 375-86.
  9. Deegan PE. Recovery as a self-directed process of healing and transformation. In: Brown C, ed. Recovery and Wellness: Models of Hope and Empowerment for People with Mental Illness. New York:Haworth Press, Inc.; 2001.
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