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August 01, 2006

Some of the best minds in the behavioral health field have registered concerns lately about “pretend recovery.” They have noticed that many programs simply are putting a “recovery” sign on their front door yet continuing to do the same things they always have done. This leads to the concern that recovery principles will not be given a fair shake at changing the way we do business because they really aren't being practiced in the first place.

Being eternal optimists, we're hoping that programs aren't pretending but perhaps just aren't clear about how to initiate a recovery services transformation. Obviously, a lot more is involved in the transformation process than changing the sign on the front door.

Before a program's structure can be addressed, important philosophic shifts must occur that result in major changes in a program's content and substance. We have described many ways of doing this in previous columns to assist you in aligning program content with recovery principles. While we've touched on a few structural issues, we think that we haven't given them the attention they deserve. They are often less obvious than content but can make a huge difference in having a successful shift to recovery content.

So what are these puzzling structural rudiments that lurk in the background, either helping or hindering our quest for transforming programs? First, let's define “structure.” In the context of this conversation, structure refers to the organizational framework upon which we build a program's content. It provides a foundation for organizing interrelated parts that can function as an orderly whole.

Thus, the question is, “What kind of structure best supports the recovery philosophy?” We could write a book on this one question, but for now let's just scrape the surface for a few answers.

Saturation Factor

The more the structure reflects recovery principles, the better it will support recovery content. Think of this from a multidimensional perspective, with an organization's principles and values being replicated in all of its functions. Has the CEO fully embraced recovery principles (which involve a different mind-set than that of the traditional CEO)? Have policies and procedures been rewritten to reflect recovery principles? Are there still separate bathrooms and break rooms for staff and people using services? Are there career ladders for all staff? Is the structure itself saturated with recovery principles?

Relationship Factor

We know that relationships are one of the most important tools for helping a person move into recovery. No surprises here. Nearly every book about helping and healing comes to this conclusion. So how can we create a structure that maximizes the impact of helping/healing relationships?

The structure needs to support the development of relationships by valuing them and allowing space and time for them to develop. For example, can staff report to their supervisors that they are engaging in activities with the person primarily for the purpose of developing relationships? Does the management information system allow staff to record time spent connecting with the person served?

Over the long haul, a program structure that reinforces time spent developing relationships will be more efficient than one that encourages rushing through encounters with people without even knowing who they are or having eye contact with them. Relationship development with people and their families must be built into an organization's policies and procedures, as well as reflected in the organization's vision and value statements.

Recovery values also need to be reflected in the relationships between all the people in the organization. Are managers and staff expected to treat each other with the same level of respect and consideration that we've trained staff to show people who use services? Does staff have a voice in organizational decision making? The healing relationship between the person and the staff cannot be sustained unless the rest of the organization emulates the same values and principles.

Continuity Factor

A recovery organization's structure needs to intentionally create continuity with service providers by minimizing staff turnover. With high turnover, the powerful impact of the relationship is lost quickly. While salary could be an issue, the most common reason people leave jobs has to do with working conditions that do not allow for the development of meaningful experiences that give staff a sense of purpose.

Most people take jobs in public behavioral health programs not because it's a lucrative field, but because they want to make a difference; they want to make a contribution. Does the structure acknowledge and reward this contribution? Does it value and support staff members' relationships with their boss and colleagues? Do they feel like they are making a difference? Does the organization appreciate and value their efforts?

Beyond the matter of continuity between the person and the staff is the matter of continuity between services and programs. If people have to change staff and programs every time their needs change, the structure is not bolstering the continuity necessary to support the recovery process. Do people have to change providers when they have a crisis or are admitted to a hospital? Do they have to change programs when they move to less restrictive levels of care? A structure that can effectively sustain continuity will significantly fortify the recovery process.

Flexibility Factor

Since we constantly are learning more about how to promote and sustain the recovery process, our organizational structures need to be flexible enough to change and grow as we learn more effective ways to engender the recovery response. When we reach the point of thinking we know all there is to know about structuring a recovery program, this is a warning signal to loosen up and stay open so we can continue to learn, grow, and evolve into new and more effective ways of supporting the recovery process. This way we continue to be a learning organization not at risk of atrophy and entropy.

Accountability Factor

One of the recovery movement's hallmarks is empowering people to self-direct their services. This allows people to make their own choices, develop self-esteem and self- confidence, and to become self-determining. This involves people's accountability to live up to their potential. This same level of accountability needs to be present in the structure itself to hold the system responsible for modeling and reciprocating accountability. Does the structure have ways of holding leaders and staff accountable? Are there built-in checkpoints where quality is measured, and are staff measuring the processes and outcomes of recovery?

Alignment Factor

Aligning a structure's internal forces can free up a lot of energy that otherwise would be spent working around unnecessary barriers. A good place to start is to review policies and procedures, looking for requirements that made sense a few years ago but no longer serve any real purpose—and, in fact, may be hindering the organization from developing recovery programs.

Another place to look for alignment is in paperwork requirements. Is the information being collected really necessary, or is it just consuming time that could be spent building relationships?

Once internal forces are aligned, look at external forces and see if they can be more closely aligned with the recovery structure being built. These forces may include licensing entities, certification boards, law enforcement, vocational resources, and so forth. We usually assume we can do nothing to influence or change other organizations or the way they work with us, but this is not necessarily true. Once we change our organization and the way we do business, it behooves us to tell our regulating bodies, as well as the other organizations we work with, about our new way of doing business, and ask them what they can do to work with us in reaching our new goals. We know this sounds naïve, but you'd be surprised how many times we've been able to get cooperation and support from others that we thought would never even consider changing the way they relate to us. It's worth a try.

Momentum Factor

An organizational structure that understands the importance of momentum and uses that energy to move forward rarely will be out of breath. When structures are not prepared to move quickly, they often loose momentum. This can result in organizational exhaustion and lead to even more lethargy and missed opportunities. Is your organizational structure weighed down with lengthy protocols and referral procedures that cause sluggish and uninspiring responses and results? Does it feel like it takes forever to get anything changed or accomplished? Does it seem like burnout is the result of boredom and moving too slowly?

Enticement Factor

Every structure has built-in incentives, and it's important to make sure the incentives are rewarding the outcomes we are trying to attain. Take a close look and try to determine what your structure is rewarding. The rewards can range from recognition, praise, and promotion for those staff who exhibit certain behaviors, to financial bonuses for those who reach milestones. We know of a program that rewards the completion of paperwork with financial bonuses. The paperwork gets done, but unfortunately the content has nothing to do with the outcomes the organization hopes to attain. In this case, we would realign this structural incentive to focus on outcomes that benefit the person being served.

The structure that supports a program's contents is a subtle but influential factor in how buoyant and inspiring the program can be. Structural elements can take on a life of their own and exist way after an organization has decided to transform into a recovery program. We must constantly remind ourselves that the structure or organizational framework primarily exists to facilitate recovery and relationship building. We hope the above information can help you assess your organizational structure, make improvements, and develop it in ways that emulate and support transformation.

Lori Ashcraft, PhD, directs the Recovery Education Center at META Services, Inc., in Phoenix.
William A. Anthony, PhD, is Director of the Center for Psychiatric Rehabilitation at Boston University.
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