In your quest to make your organization recovery oriented, you may feel like you are boldly going toward something, but aren't sure what. What does recovery look like? What does it feel like? How will you know when you get there? Perhaps a more controversial question is, How do we measure it?
We think these are pretty good questions. If you've been asking them, you probably are on the right track. So this month we describe some outcomes for you to aim for as you hurtle headlong toward that often elusive target called “recovery.”
Before we get started, you may be interested to know that several evaluation instruments have been developed to measure recovery in behavioral healthcare organizations. Bill and his team at Boston University have created some very helpful tools, and Priscilla Ridgway and Larry Davidson, both at Yale, each have developed sophisticated ways of measuring an organization's recovery progress. This article is not in that league. Its purpose is to provide you with sort of a Reader's Digest version of recovery targets you can take aim at within your organization.
A welcoming environment
First, it's important to realize that becoming a recovery-based organization involves a lot more than adding the word “recovery” to your front door. This has happened not infrequently across the country and has become a major disappointment to a variety of funding sources and service participants alike. Unfortunately, having “recovery” on the front door has become meaningless.
What we would look for instead is a welcome sign. Yes, a welcome sign-imagine that! What if your organization had a big welcome sign on the front door? A subtitle might be, “Thanks for giving us an opportunity to partner with you on your recovery journey!” Such a sign commits the organization to being welcoming and friendly, as well as sets the stage for a recovery partnership. If we saw a sign like this on your front door, we would know you are willing to step out and create opportunities and environments that support recovery.
A welcome sign would tell us that your organization is committed to shifting its culture toward recovery-not just for participants, but for your staff and the entire organization. Once we got inside, we would look for a comfortable setting that was not intimidating and that reflected respect and dignity for those who receive services. Ideally, it would be clean and fresh, and there would be greeters instead of security guards, friendly and respectful receptionists, and positive signs on the walls that don't start with the word “no” (as in no smoking, no loitering, and so on).
Next, we would check out the staff. Here are some questions we would ask ourselves as we talked to them:
Are they welcoming and friendly? What do they do to connect with people?
Do they understand and practice the importance of developing real relationships with people?
Are they hopeful and excited about each person's plans and goals?
Do they have high expectations for themselves and for the people they are serving?
Are they inspiring and encouraging?
Do they treat each other and the people they serve with dignity and respect?
Do they have knowledge of recovery values?
Do they use recovery language?
Do they offer people choices and avoid force and coercion?
Are they willing to partner with the person in “risky” choices?
Are service users trained and hired as peer employees?
In addition, we would look for shifts in practice. From what we can tell, most staff have not been trained to elicit recovery responses, although some of them do it despite their training. Teaching staff recovery practices should be a high priority for a recovery-oriented organization. Answers to four broad questions would give us an idea of practice priorities:
Have staff been trained in recovery practices, and is there a way for them to continue learning new recovery skills?
Do staff have confidence in their ability to help a person recover, as well as confidence in the person's ability to recover? If not, this is a major cause of burnout that can be addressed, usually through interesting and provocative training.
Are staff able to use negative or challenging circumstances as learning opportunities for both themselves and for the service user, instead of experiencing them as failures?
Is there an attitude of mutuality and partnership?
Then we would take a look at the organization's paperwork and documentation. We would hope it wouldn't be boring and/or complicated. We would look for signs that the service user was the primary participant in the planning process, as well as that attention had been given to involving family and friends as supporters. Beyond this, we would ask ourselves these questions:
Does the treatment plan aim for self-determination?
Who seems to “own” the treatment plan? Is it the person? If so, does he/she know what is in the plan? Does it have any meaning for him/her? Or is it owned by the staff? The organization?
Is there an expectation that the person will recover and not just become “stable”?
Has the person been given information about the organization and its goals so he/she understands what is supposed to happen and what to expect?
Do forms use recovery language, and are they written in first-person language?
Is there a plan to periodically review the person's plan and measure accomplishments and progress toward goals? (This is about accountability for both the person and the staff.)
We also would examine the organization's distribution of power. Where is it? Who has it? How is it used? These are some of the most important questions to ask when determining the extent to which recovery is present in an organization. Since the person has to take the lead in his/her recovery process, he/she is the one who needs the power. The organization's job is to ensure it transfers power to the person. Here are some signs we would look for in a power shift:
Have staff been trained in transferring power to service participants? Are they skilled and knowledgeable in ways of empowering people to take the lead in their recovery process? Are they reluctant to give over the power for fear of creating risk?
Has the “agreement” to “fix” people been changed to an agreement to empower people so they can be instrumental in their own transformation?
Have participants been trained to recognize their own strengths and potential? Are their strengths and potential reinforced constantly by organizational interventions?
Have people been informed about their rights and responsibilities in the recovery partnership?
Focus on strengths
In addition, we would look for the organization's focus. Here are some clues we would look for:
Is the organization, through staff, documentation, and orientation, focusing on what is strong or what is wrong with each person? Obviously, we would want to find a focus on what is strong in both the staff and people being served. This also would give us a glimpse of the “spirit” of the organization.
Is there a focus on each person's abilities and accomplishments-a “whole person” focus instead of a singular focus on challenges?
Are challenges viewed through the lenses of potential instead of past disappointments?
Is the focus on the person rather than his/her problems?
Since recovery is mobilized through conversation, we would look for a dialogue with people that promotes recovery. Here are some specifics we would look for:
Is the conversation among staff, and between staff and people served, carried out with recovery language and not jargon or clinical/illness-based language?
Is the conversation more about listening instead of directing?
Is the conversation inspiring instead of controlling and managing the person?
Is there a lot of talk about choices and options?
Is there an absence of threat and coercion?
Is there talk about recovery instead of just stability?
Is the conversation sequenced to build self-confidence?
Recovery-oriented policies and procedures
Finally, we would be remiss if we didn't bring up issues related to policies and procedures. Since most policies were developed before we knew recovery is possible, they tend to get in the way of the recovery process, instead of enhancing it. So we would check out your policies. Do they promote recovery, or do they hold it back? You may be tempted to put off rewriting policies since it's a tedious task, but try to make it fun. Ask your service participants and staff to get involved in rewriting them. Use action-oriented language. You may need to pay attention to staying out of your own way by not letting your own fears about the barely visible course you've charted worry you.
Remember that setting targets is a way of making a commitment and creating some accountability. We often are reluctant to set targets (even though we insist on making the people we serve do so) because once we do, our success can be measured (Some rationalize that it's better to be vague in case we fall short). But transformation requires courage, guts, and risk taking, so we encourage you to go for it. As Ralph Waldo Emerson pointed out, “When skating on thin ice, our safety is in our speed.”
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.
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Behavioral Healthcare 2009 June;29(6):10-13