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Setting Rules—But Allowing Choices

July 01, 2008

Managing a recovery-oriented program can be one of the most rewarding experiences in the behavioral healthcare profession, especially when those who receive our services respond positively and begin their recovery journey. Each time this happens our commitment is reaffirmed, and we have renewed energy to continue offering hope, choice, and empowerment.

But what happens when things get tough and we face circumstances that challenge our commitment? That is, how do we respond to people who aren't motivated to recover? Are we like “fair weather friends,” reverting to inhospitable tactics in uncomfortable situations? How do we react when they insist on doing things that place themselves or others at risk? There even may be times when recovery-resistant people put our entire program at risk. What then? Do we write in their charts that they aren't ready for recovery? Do we revert to making more rules? Do we restrain and detain them? Shall we call in law enforcement and/or even press charges?

Don't Overreact

If our programs are to truly be recovery oriented, how do we handle situations that challenge our belief in each person's ability to recover? A good way to start is to resist the usual responses of either backing away (abandoning) or taking over (controlling). Avoiding these immediate reactions gives us a chance to use challenging situations as opportunities to grow both ourselves and the people using our programs by integrating recovery approaches when we respond to risk.

This means moving beyond simply using recovery programming when those who use our programs are cooperative and using it even more intentionally when risk presents. Responding to risk with recovery programming requires a lot more skill than simply shutting people down by threatening them with coercion and control. Some points that usually help us move beyond the risky moments and establish a healing partnership include the following:

Do all that we can to protect whatever relationship we've been able to develop with the person presenting risk.Relationship is the vehicle that can transport recovery intentions, connecting us in the best way possible with the person at risk.

Once the connection is established, our job is to inspire the person to stay on track with recovery. We cannot force someone to recover; coercion and control only move us further away from our common goals. Inspiring a person to react in ways that support recovery requires a much more sophisticated skill set than simply controlling behaviors.

When we feel threatened, we are most vulnerable to surrendering to former ways of managing risk. This is true for all of us: our staff, our customers, and our organizations. It's time for us to develop learning organizations and move beyond managing risk, instead using it to teach us all how to have better outcomes. We have to move out of our comfort zones in order to provide recovery opportunities for all of us. To quote Helen Keller, “Life is either a daring adventure or it's nothing at all.”

Emphasize Choice and Shared Values

By now you may think we are on the right track, but you probably have more questions, like the following.

How long do we offer a recovery option to people posing a threat to themselves or others? Continuing to offer opportunities for recovery when someone is putting him/herself or others at risk takes patience, believing in the person, plus believing in our own skills to bring about a positive improvement. Force should be the last alternative we turn to.1 Bill calls this the “no force first” approach to promoting recovery. We encourage you to only use force when all else hasn't worked. Be creative: Use your best skills to inspire and promote a self-determining response that leads toward recovery.

When we talk about force, we often think about the use of seclusion and restraint, but force can come in many disguises: Chemical restraints and overmedicating, threatening and coercing, and restrictive rule making are less obvious examples of force, but they have nearly the same effect of dampening self-determination.

Are we violating people's rights if we keep nudging them out of their comfort zone? Aren't we supposed to respect their wishes? A good recovery practitioner can see a person's potential, even when the person is not able to. This means believing in the person's strengths and abilities when he/she can't. The next step is to convince the person of his abilities by believing in him. So this does involve accepting him just as he is, but also seeing his potential and supporting him in stepping beyond his comfort zone.

Can we make policies that seem to be in the best interest of all of us even if they restrict choices of those who use our programs? After all, isn't choice one of the cornerstones of recovery? If we make rules that limit choices, aren't we again interfering with a person's rights and choices? If you've decided to restrict or eliminate a particular choice, we challenge you to create as many more choices as you possibly can. This will restore options that can promote self-determination.

Let's take the example of creating a smoke-free environment. In response to recent findings regarding the reduced life span of those diagnosed with mental illness,2 many programs are becoming more health conscious and as a result are declaring their programs and facilities to be nonsmoking. There's no denying that such a policy limits choice, so how can more choices be created to preserve opportunities to make individual decisions?

First, consider the manner in which the restriction is presented. Posting big, intimidating “no smoking” signs and patrolling the premises for violators are not “recovery friendly” approaches. A better way would be to first post a notice that staff and program participants will not be allowed to smoke on the premises as of a specific date. Include information on why the decision was made, especially the shared values that underlie the policy. In this case, your program is concerned about the health of participants and wants to provide an environment that can support good health.

Next, offer choices that can help participants successfully cope with the requirement. For example:

  • Offer a smoking-cessation class.

  • Offer help with obtaining nicotine patches.

  • Offer classes on how to cope with cravings of any kind.

  • If feasible, suggest places off-campus where participants can smoke.

If staff smoke, they will need to abide by the same restrictions in order to maintain the rule's integrity. If you offer staff nonsmoking options, also make them available to program participants.

In addition to banning smoking, many inpatient and residential behavioral healthcare facilities also prohibit sexual activity among people being served. We usually don't even think about explaining the “why” behind this policy; it just goes with the territory. After all, when such policies are breached, dire consequences are usually in store for the violators. There are a lot of good reasons to restrict sexual activity, which present us with rich opportunities for conversations that educate and create grounds for agreement. Here are a few to consider, based on the shared values of safety, trust, and health:

  • Many people who use our programs have been sexually abused. We want to create an environment where they feel safe enough to begin their recovery journey, so we ask all participants to help us create a safe environment.

  • Many people who use our programs have not had opportunities to form trusting, close relationships that don't include sexuality. We want to create some chances for people to connect with each other in meaningful ways based on their wholeness.

  • It's not easy to detect and manage the spread of venereal diseases, so abstaining from sexual activity while in our programs is a way of decreasing risk.

As an alternative to sexual behavior, you could suggest that program participants explore relationships in a nonsexual way, or wait to engage in sexual behavior until after they leave your program.

We've given you some ideas about how to manage risk without decreasing choices or self-determination. The challenge is to create as many opportunities for choice as you possibly can to balance the areas of restriction. We'd love to hear your ideas on this topic, since we have only scratched the surface of one of the important practical aspects of implementing recovery programming.

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 lori@recoveryopportunity.com.

References

  1. Ashcraft L, Anthony WA. Eliminating seclusion/restraint in recovery oriented crisis services. Psychiatr Serv. In press.
  2. Parks J. Morbidity and Mortality in People with Serious Mental Illness. Presentation at National Wellness Summit for People with Mental Illness. 2007.

Behavioral Healthcare 2008;28(7):10-12.

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