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Don't let paperwork be a barrier

June 01, 2008

As we travel around the country talking with folks about recovery, the conversation, no matter how long or short, inevitably comes around to the drudgery of the paperwork process. Yes, this has been a source of complaints since the beginning of time, but it now seems more relevant than ever.

The root of the paperwork problem (in fact, the “taproot”) has to do with the larger issues of system dysfunction. Most of this dysfunction is a result of system change not keeping pace with best and promising practices aligned with the expectation for recovery. Since most of the requirements that govern the paperwork process were developed long before we knew people can recover, they aren't geared to promote or foster a recovery response in either staff or the person being served. In fact, they do just the opposite—they aren't even neutral! A recovery-oriented paperwork process actually could help bring about the results we hope for, instead of getting in the way.

Don't get us wrong—we aren't saying “Down with the paperwork.” We are saying “Let's get it right.” We know that paperwork is necessary and is a reasonable way to record the progress, benchmarks, and outcomes of the services we provide; and yes, it usually results in some sort of invoice that allows us to be reimbursed for our efforts. Our current procedures, however, continually force us to respond to people in ways that extinguish the fragile flames of recovery. We are put in a position of having to do our recovery work over the top of the paperwork requirements in order to fan those fragile sparks. Enough. We must rise to the challenge and come up with better ways to do our business.

Staff in programs determined to provide recovery services are using a long series of exhausting “workarounds” that gobble up precious time, which could be better spent on mobilizing recovery services. The result is the worst possible paperwork process:

  • It takes even more time than ever to complete.

  • It takes us in the wrong direction.

  • It uses resources that could be better spent on recovery.

We keep hoping someone will fix this. So far, there has been a lot of complaining but no targeted action that could result in resolving the issues and turning the paperwork process into something that not only doesn't get in the way of the recovery process but, in fact, encourages it.

We've joined the long list of complainers but would like to help in developing a solution. Right now, the best thing we think we can do is offer some examples of ways to provide recovery-oriented services in spite of the paperwork requirements. Let's turn to Mark for some examples and advice.

Mark is the intake coordinator and triage counselor at the Psychiatric Recovery Center, a level I subacute psychiatric hospital in Phoenix (operated by Recovery Innovations) that accepts both voluntary and involuntary admissions. Mark often is the first person with whom a guest has an in-depth conversation. He believes that this initial review is a unique opportunity to introduce the guest to recovery concepts.

“This is not to suggest that this is so readily achieved,” Mark says. As in most subacute settings, the state licensor and the Joint Commission require an initial paperwork assessment. This paperwork involves collecting a large amount of information, most of which has nothing to do with recovery. The emphasis is on the history of illness, medication, and hospitalization. This lengthy paperwork process results in an initial assessment that the psychiatric provider uses to help identify acute and positive symptoms amenable to medications.

The crisis center is a busy place, and while keeping records of the work-in-progress is important, the required content should keep us focused on the process and potential for recovery so our time can be used expeditiously to benefit the guest. The Initial Assessment must be completed in a timely fashion and, as mentioned earlier, is focused on what's wrong instead of what strengths the guest has that can be mobilized to initiate the recovery process.

We asked Mark how he manages to complete the deficit-based paperwork without extinguishing the fragile flames of recovery. He says, “Human beings have an innate ability to respond to opportunities to heal. However buried in the individual's personal experience, the well part of them is still there and is always ready to emerge. They only require a supportive recovery environment to bring it forward. The questions you ask and the way that you ask them are crucial to eliciting the recovery response. I ask the following questions, staying focused on building a relationship, and then often complete the paperwork afterwards, asking them to help me get it right.”

Recovery-Focused Questions

What do you want? This simple question is so important to the individual's recovery. Guests frequently answer with the reasons why the referral source recommended they come in. The reasons often are full of professional jargon meaningless to the guest (and us). It usually has little to do with what they really think will help them recover. We often repeat the question and frequently explain that we are interested in what they are feeling and what they want, in their own words. Comments such as “I am sad,” “I can't sleep,” or “I can't stop thinking” provide the framework for discussing feelings, thoughts, and desires that can lead to a recovery-oriented solution.

Can you describe yourself when you're at your best? This brilliant question was added to our initial review some time ago. It provides some of the most useful information in the triage, both by what is said and how it is said. Some guests answer this question without hesitation. We see this as a positive sign: The guest can recall being well, and it is not far from his consciousness and therefore naturally closer for him to return to. Many guests struggle for the memory and may need to be directed to describe more focused aspects of their wellness, such as social relations or vocations. Still others may need to be encouraged to describe themselves when they will be well, as memories of healthy days are too difficult to recall. In any case, guests are encouraged to hold tightly to that picture of wellness—it is their destination.

What do you hope the outcome will be? Hope is the first and most essential aspect of recovery. Unfortunately, it often is in short supply and can be diminished even further by adhering strictly to documentation requirements focused on deficits and that stress dependence on professionals, adherence to medication protocols, and symptoms and illness. The recovery approach focuses on strengths and the ability to both define and create one's own recovery. Hope can be offered in numerous ways. Peer support is perhaps the most powerful approach. Also, just helping the guest identify past successes can have amazing results.

What will you do to further your recovery, and how can we help you do this? Recovery is based in actions of the individual on his own behalf, and acceptance that the responsibility for wellness rests squarely with him. Our job is not to try to fix him, but to support him as he finds his own path to recovery. Persons who choose to be well and work diligently and persistently on their own behalf will recover. This is perhaps the most difficult recovery concept for guests to grasp during the initial assessment. Many guests come to see the crisis center as an automotive garage, coming in “for repairs.” In fact, we do have the tools, but the guest must be willing to dig in and get his hands greasy.

Even though you are here against your will, what would you like to do? Far too often guests arrive at the crisis center “on petition.” Police officers bring them in handcuffed. They often are confused, frequently embarrassed, and almost always angry. This process violates all of the recovery principles.

If we took our cues from the required paperwork, we would only aggravate and elevate the problems. But a skilled recovery team often finds a way to offer hope, support, and empowerment. We start by connecting to each person as a human being who is just like us. We acknowledge that anger is a normal reaction to being brought in against one's will, and not necessarily a sign of illness. We offer choices immediately, which may be as simple as an opportunity to walk about or have a smoke or something to eat or drink. We agree that the person may not have a choice about being here, but he always has a choice about how he will experience his time here.

Keep the Focus on Recovery

We hope we've made you aware of the problems with outdated paperwork requirements that don't promote the recovery process. We hope you agree that there is a better way to do our business. We've shared with you Mark's sentiments and the approaches he uses to elicit recovery responses, even though he then has to go back and fill out paperwork that has little to do with recovery. Finally, we hope we all can pull together to align the paperwork process with recovery values to make our services more effective and our efforts more worthwhile. Let's get busy and fix this!

Lori Ashcraft, PhD, directs the Recovery Opportunity Center at Recovery Innovations, Inc., in Phoenix. She is also 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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