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March 01, 2006

One of the common barriers to recovery has been a propensity to control and/or eliminate as many forms of risk as possible. Before the possibility of recovery from mental illness was confirmed by research, we were limited in what we could hope for in terms of the results of our work. Many behavioral health professionals believed that a core competency of their jobs was caretaking, a word that incorporated the idea of protecting people from risk. This belief reached into the zone of making major decisions for people, since it was presumed that mental illness had eroded their ability to make sound decisions.

Those were the days when we generally believed that the most we could hope for was to stabilize people and to slow down the process of deterioration—an expectation commonly described in the prognosis. This led us to direct people away from high expectations, and we advised them to avoid the stress brought on by employment, academic pursuits, and other aspirations. We thought the kindest and most humane thing to do was to protect people from any possibility of failure, since this could produce a major setback and threaten their stabilization, an indicator by which we measured our own success.

Now that we know people can recover from mental illnesses, this changes everything! It changes the way we approach our work, the way we measure our outcomes and, yes, the way we think about and respond to opportunities for risk.

Making decisions is the way we all begin to learn more about who we are, and remembering who we are is a key part of rediscovering and recovering self-efficacy, past accomplishments, and preferences. Thus, promoting personal decision making and choice is key to the recovery journey.

We have had many experiences of asking people who are new to recovery what they want to do, and we often hear, “I don't know. No one has ever asked me that before. I'll have to think about it.” But after awhile, they begin to think of things that they've liked doing in the past: “I haven't gone fishing for 15 years. I'd like to try it again.” “I'd like to try to work again. I always felt much better when I was working.” “I'd like to take a class and see if I can make it in school.”

Our new recovery emphasis is not to discourage these activities to avoid disappointment or the possibility of failure, but to help explore how these choices reveal who the person is and what the possible directions for growth are. We frame the outcome by saying, “No matter how this turns out, we will have learned a lot about how you can reach some of your dreams.” In other words, we talk about “learning experiences” instead of “failures.”

A real-life example of the tension between control and risk is provided by Kim Ingram, who was the director of Thomasville Mental Health Rehabilitation Center, a state hospital in Alabama (now closed under a state consolidation plan). Under Ingram's leadership, the hospital had transformed into a rehabilitation organization and received accreditation from the Joint Commission on Accreditation of Healthcare Organizations, followed three years later with commendation from the Joint Commission. Ingram tells the story of a voluntary patient who wanted to leave on foot on a Sunday to hitchhike to Mobile and then go on to Georgia. Aware of the potential risk involved, Ingram called in the clinical director to speak with the patient, but the patient was judged not to meet criteria for involuntary commitment.

Consistent with the organization's self-determination value, the patient was not prevented from leaving, but they talked to him about coming back if he had difficulty with the trip. They also wanted him to wait until Monday, when they could be more helpful in arranging transportation, but he was determined to leave. After he left, he returned quickly. Ingram says he began to work even harder on his rehabilitation plans and his eventual recovery, admitting, “I made a bad choice.”

“Brian” is another true story, whose experience is typical in the low-risk, pre-recovery model:

You can see how this low-risk environment was leading to a sense of helplessness and hopelessness for Brian, and how it eroded his ability to take responsibility for his own recovery process.

If recovery is new to you and you haven't explored what changes it brings to our role, you might be tempted to respond to a person's risky choices by saying, “I advise you not to proceed with this, but if you insist, I cannot work with you.” A recovery-based response would be, “Well, OK. Let's look at the pros and cons and get prepared to manage the hard parts. If it doesn't work out, we can learn from the experience, and make a new plan that might get you where you want to go. In any event, I'll partner with you and support you on this venture.”

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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