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Breaking Down Barriers

April 01, 2008

It takes a lot of guts to write about transforming professionals' relationships with the people they serve, as clinicians often view their boundaries with service users as “sacred.” Yet the issues we discuss this month come up in nearly every recovery training we've done for professional staff. We're supposed to be challenging you to think beyond what's comfortable, so we are challenging you to open the minds of professional staff in your organization.

Professional staff mostly are good folks who entered this business because they believed they could help others. But when we talk about the importance of “mutuality” (that is, meeting service users on equal ground as opposed to the traditional hierarchical positioning) in our trainings, professionals often respond with a conversation about boundaries. When we talk about giving service users choices and allowing them to take risks, professional staff start talking about liability. When we talk about the importance of forming relationships with people using services, professionals talk about not having time, telling us that the organizational priority is getting paperwork done on time. If we talk about holding the hope for everyone to recover, professional staff say that the people they see are sicker than everyone else's.

These types of responses are the expected first line of resistance. Yet time is money, and managers, supervisors, and executives who understand the power of recovery want transformation to happen sooner rather than later. To find out what really can help professionals adopt a recovery orientation, let's turn to the people who know best—those receiving services.

We often ask service users what professionals do to help them recover. A person might stop and think for a minute and then say something to the effect of “Well, he helped me in several ways, but I guess the most important thing he did was be a real person to me.” By talking with people using services we've learned that a “real” person connects with a service user on a personal level, sharing details from his/her personal life. The therapeutic relationship is a partnership and is not defined by the traditional professional boundaries.

It's interesting that one of the most important aspects to helping someone recover could be as simple as being a “real” person. Perhaps the most important and effective thing professionals can offer is something they have had all along—themselves. All the stuff in the DSM-IV and the information drug companies give us are helpful, but without their real selves showing up, professionals aren't able to connect with people in ways that inspire them to recover.

How have we missed this? Before we knew that people can recover, mental healthcare organizations emphasized “clinical distance,” “professional boundaries,” and “avoiding dual relationships.” We know we are treading on sacred ground, and many of you probably are squirming in your seats. But stick around. Jennifer, currently clinical director at Recovery Innovations, has some thoughts that might speak to you.

Jennifer's Experience

“When I graduated and began working, I found that the recommended treatment included a mental health professional giving someone a pre-made treatment plan. The person was usually asked to collaborate on the plan but not ‘too much’ because the professional was the one who knew exactly what the person needed. If someone wanted to change something in his treatment to better fit his lifestyle, he was redirected to the ‘correct’ way to proceed. At times people who had great insight into themselves were labeled as noncompliant. Occasionally these creative people were discharged from programs and told they had no chance for improvement.

“I discovered the opposite to be true. When given a chance, people who were asked and involved in creating their treatment would regularly prescribe for themselves a treatment that would work. Sometimes my only contribution to their success was believing in them until they believed in themselves. This belief and way of being with others were not shared by my employers. I was strongly encouraged to adopt the company philosophy. In this environment I quickly became discouraged.

“I later worked alongside peer support specialists and was awed and humbled by the powerful and honest interactions they had with the guests [service users]. It did not take much time at all before I began to see people were recovering beyond expectations my education had told me were possible. Now I consider myself a clinician who has recovered from being ‘clinical’ and am honored to be part of this process. I hold the hope that you too can experience recovery.

“My job as the clinical director of a large crisis alternative program requires me to teach recovery principles and practices to clinical staff. The hardest thing for them to get is the concept of mutuality. In the clinical world, mutuality threatens boundaries many clinical people are trained to keep. Boundaries, we are told, keep us and the people we serve from harm. We are trained and tested extensively to make sure that not only do we understand ethical boundaries, but by the time we leave school they have become part of who we are.

“Some counselors were more comfortable with disclosure than others. We realized that the fear was coming from having to give up the position of ‘expert.’ Mutuality calls for a partnership where both partners have expertise and decisions are shared, with the final word coming from the person being served. This can be seen as a threat to the professional.

“It has been my experience working with other ‘recovering’ clinicians that once they relate to the people they serve on a mutual level and drop the professional mask, the recovery of the person they serve is greatly impacted. I teach this by giving clinicians permission to self-disclose, and I role-model it for them.”


Let's give some thought to how managers and program directors can help professional employees to be “real” people. How can we navigate the issues of boundaries and ethics yet still inspire people to recover by being real with them? These are the real questions agencies pushing to become more recovery-oriented struggle with. This column can be an ongoing repository of some of your unique ideas about strategies for transforming professional relationships. Let us hear from you.

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.

To contact the authors, e-mail

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