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Relationships-based recovery revisited

October 01, 2009

Last month we told you about a great conference workshop by Dr. Bob Bohanske, Chief of Clinical Services and Clinical Training at Southwest Behavioral Health Services in Phoenix, Arizona. Dr. Bob maintains that a therapeutic relationship focused on the strengths of the individual being served is essential to producing a better recovery outcome. When this method was compared to the outcomes reached using a variety of other modalities, Dr. Bob concluded that we would be much more successful at promoting recovery if we trained our staff how to form effective, strength-based relationships with each individual.

Dr. Bob decided to put this theory to the test with a peer workforce because he wanted to know if peer-provided services really were viable or if they were based merely on political beliefs born out of past frustration with traditional services. For the sake of time we'll leave out the “research talk,” except for one fundamental point that Bill has repeated over the past three decades: the most empirically supported principle of “helping” is that people who experience a positive relationship with a helper are more apt to achieve their goals.

This point reflects what Dr. Bob wanted to examine when he raised this question last month: “Since using strengths-based relationships promotes recovery better than a variety of modalities, why don't we just teach staff how to form strengths-based relationships?”

One important tool in Dr. Bob's examination was the Relationship Rating Scale (RRS) by Duncan (2005). This four-item scale was designed to be completed by the person receiving services at the completion of each visit with a Peer Support Specialist. The people receiving services were asked to provide additional feedback to the Peer by completing the Core Relationship index, an eight-item sub scale of the Recovery Promoting Relationship Scale (RPRS). This is in Bill's territory, since this scale was developed at Boston University by his colleague, Zlatka Russinova, with the help of Sally Rogers and Marsha Ellison.

Zlatka's goal was to develop an instrument to measure recovery-promoting competencies of mental health providers. She knew this would help program administrators assess the skills and competencies of staff and that it could also be used to help target areas for staff development and training. Zlatka asked people receiving services to tell her what “ingredients” should be used to identify “recovery-promoting” relationships. Here are the ingredients she heard about and used to develop the scale:

  • Having genuine respect for us

  • Helping us develop skills to cope and manage symptoms

  • Seeing us as persons apart from diagnosis and symptoms

  • Helping us accept and value ourselves

  • Listening to us without judgment

  • Believing in our potential to recover

  • Trusting the authenticity of our experience

  • Caring about us

  • Being accessible to us when we need help

  • Understanding us

As mentioned, Dr. Bob used a sub-scale from the Recovery-Promoting Relationship Scale known as the Core Relationship Index (8 questions), as well as 4 items from the Relationship Rating Scale. In both cases, the scales were completed by the person receiving services. In Dr. Bob's study, those delivering the services and being evaluated were 30 Peer Support Specialists working in various parts of his company.

Remember, Dr. Bob wanted to know if adding peers to the workforce really was a good idea. Knowing the power of strength-based relationships, he thought this evaluation of peers would be a good test of their effectiveness.

We've all been through “client satisfaction” surveys that often tell us little; so often, they are too vague and broad, failing to target specific staff or staff functions that need improvement. In this study, however, the results showed exactly which staff needed help in learning specific competencies.

So what was the standard outcome? While Zlatka and her colleagues have suggested a raw cut-off score of 72 for recovery-promoting competence, Dr. Bob used a more stringent raw score of 80, and, even with that. only four peers scored lower, ranging from 49 to 78.

Dr. Bob' study demonstrated three interesting results:

  • Peers possess recovery-promoting skills above those expected from traditional behavioral health staff;

  • Peers report that exercising recovery-promoting skills with others enhanced their own recovery; and,

  • Individuals served by the peers improved or maintained their recovery over the four months of the study, as self-rated on the Outcome Rating Scale (Miller and Duncan, 2000).

So, thanks to Dr. Bob and Dr. Zlatka, we now know that peer support is a viable approach to promoting recovery and, when used appropriately, can be at least as effective as traditionally trained staff. We also know that traditionally trained providers can achieve high levels of recovery-promoting competencies when they receive relevant training and organizational support.

A few final cautionary notes about the use of peers in the workforce: Their effectiveness can drop dramatically if they are relegated to fetching food boxes, straightening up waiting rooms, or doing junior case management work. Make sure your organization enables peer employees to contribute their unique gifts-personal engagement, mutuality of interests-so they can enhance the services provided to individuals by others on the team. Make peers equal contributors to the healing process.

Peers possess recovery-promoting skills above those expected from traditional behavioral health staff.

In summary, no matter what an employee's prior training has been, each must learn recovery-promoting skills to produce better recovery outcomes. We must commit to train all staff in these skills and to measure our effectiveness using tools like that offered by Zlatka. Let us know how this approach works for you!

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. Behavioral Healthcare 2009 October;29(9):12-13

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