Recovery and Person-Centered Care: , Collaboration, 7 and Integration

Wesley E. Sowers

the of was much more than Introduction establishing abstinence. They recognized that addictive disorders create thought processes and The concept of recovery is not a new one in conditioned responses that are far more powerful behavioral health, but it has experienced resur- than the physiological manifestations of depen- gence since the release of the President’s New dence. They offered an alternative to professional Freedom Commission report in 2003 (Hogan offerings that appeared to be more effective 2003) . The belief that persons with mental illness (Laudet et al. 2000) . The 12 steps and the various or substance use disorders can lead productive slogans related to thought processes common in and satisfying lives has been part of the philo- persons with are all related to current sophic core of for many concepts about recovery. years and was practiced most notably in psychiat- Although recovery has had a less prominent role ric rehabilitation through the latter in the community in the past, it has part of the twentieth century. While variations on been part of the scene for nearly as long as it has the theme of recovery have been noted since the been part of the addiction fi eld. Abraham Low, nineteenth century and perhaps even earlier, they MD, a , began developing recovery- were established more formally in the 1930s with enhancing techniques in 1937, and by 1952, the establishment of the Recovery, Inc was established (Lowe 1950 ; Sachs and Recovery, Inc. (Sowers 2003 ) . 1997) . Recovery, Inc. is an organization run by Mental Health consumers that employs many of the Brief Historical Perspective ideas developed by Dr. Low. It offers a peer-assisted healing program that focuses on changing thought The idea of recovery has been a mainstay of the processes, developing autonomy, and regaining addiction community for many years. It has its productive and satisfying lives. Like the 12-step roots in the 12-step movement that began in the approach, it attempts to empower people to take 1930s (White 1998 ) . It became clear to the found- responsibility for managing their illness or disabil- ers of Alcoholics Anonymous that overcoming ity. In contrast to 12-step programs, Recovery, Inc. has incorporated the of developing a partner- ship with helping professionals and has attempted to support this relationship (Sowers 2003 ) . W. E. Sowers, MD () An anti-psychiatry movement, originated within Center for Public Service Psychiatry, the profession in the later part of the twentieth cen- Western Psychiatric Institute and Clinic, Pittsburgh , PA 15213, USA tury, questioning the controlling and judgmental e-mail: [email protected] nature of common practices. The legitimacy of

H.L. McQuistion et al. (eds.), Handbook of Community Psychiatry, 79 DOI 10.1007/978-1-4614-3149-7_7, © Springer +Business Media, LLC 2012 80 W.E. Sowers diagnosis was also questioned, in light of the lack with behavioral health disorders and have signifi cant of biologic or etiologic explanation for them as impact on the evolution of services today. This in other branches of . Who should “transformation” aims to replace a system that has de fi ne “normal” experience? These threads were been described as prescriptive and paternalistic expanded by “survivors” of treatment who also saw with one that is collaborative, empowering, and psychiatry as being controlling and oppressive, and recognizes the potential for growth and change in were generally vili fi ed in some circles the individuals that it serves. While there are few such as Scientology. RD Laing and that oppose this transformation in principle, there were psychiatrists who were among the original are many who feel the obstacles to achieving the critics of the profession and social constructs of ideal are too formidable to overcome and that is not mental illness, but they were not critical of treat- applicable to everyone who suffers these maladies. ment per se, so long as people were interested in This chapter will consider the nature of recov- receiving it. However, as the movement evolved, it ery and resiliency and their usefulness as orga- began to ostracize those who sought and partici- nizing concepts in the evolution of our systems of pated in treatment, depicting them as brainwashed. care. It will examine the principles and practices These controversies continue today as diagnostic which may be most helpful in moving people systems evolve (Rissmiller and Rissmiller 2006 ) . toward recovery and the value of incorporating There are many people with mental illness or them into the way that services are delivered. substance use disorders who have felt that they have been mistreated by the system and they have become more organized and more vocal in recent The Elements of Recovery years regarding their rights as individuals, their conviction that they must control their own The concept of recovery has a long history as destiny, and that they should not be oppressed by noted earlier, but it is not a monolithic one, and authorities whose primary interests are control there have been many variations in how persons and public safety. The “Recovery Movement” or groups have de fi ned it. If recovery is an indi- has emerged from these convictions, and while it vidual experience as most contend, then each is not necessarily a uni fi ed movement, it has person who has experienced it may de fi ne it become a signi fi cant political force impacting somewhat differently. Even though recovery has policy and practice in the administration of individual meanings and is a dynamic concept, behavioral health services. Persons in “recovery” there are certain elements that can be identi fi ed have asserted that systems of care and profes- that are commonly included in the de fi nitions and sional attitudes must change if they are hoping to that remain fairly stable through changing cir- engage with them. Only then will they fi nd mean- cumstances (Whitley and Drake 2010 ) . This sec- ingful assistance in their struggle to attain auton- tion will attempt to identify some of those omy and meaning in their lives (Borkin 2000 ) . common elements and consider their signifi cance System transformation has emerged as a major (SAMHSA 2005 ) . priority in federal and state behavioral health ser- The term “recovery” implies that a person, vices administrations since the issue of the who has been disabled for some period of , President’s New Freedom Commission Report and returns to their previous level of function, but it the Surgeon General’s report on mental health has come to take on a much broader signifi cance issues (SAMHSA 2003 ; U.S. Department of Health with regard to persons with behavioral health and Human Services 1999 ) . Penetration to policy disorders. There are many who feel that the term makers and administrators has been fairly broad, is inadequate because in many cases people have but much work remains to be done with regard to not ever developed good capability and are work- training and actual practice (Jacobson and Curtis ing toward establishing it for the fi rst time. This 2000 ) . The movements mentioned above have been is especially true for children with emotional dis- progenitors of the current emphasis on “social turbances. Another objection is the implication inclusion” and securing the civil rights of persons that there is an end point, or cure. This point 7 Recovery and Person-Centered Care: Empowerment, Collaboration, and Integration 81 remains controversial, and there are many who Growth claim that recovery, even from severe mental ill- ness, may be complete, while others contend that Change leads to growth, to an expanding sense of it is an ongoing process, which, for most people, self and of the world. A growth or maturation is lifelong. process begins when one is able to embrace Whichever position is adopted, being “in” change and continues in an incremental fashion recovery, as opposed to being “recovered” as new experiences and behaviors are added to an describes a process. As various aspects of this individual’s palette. A state of stagnation implies process are considered, it may be of interest to a closed world of repetition circumscribed around consider how they mirror other theories of sets of stereotyped behaviors. Recovery, in con- development, mature strategies, and self- trast, implies expanding world, new possibilities, actualization. Even though the idea of recovery and customized responses to the signi fi cant chal- has been applied most commonly to situations in lenges presented by a changing environment which a person is struggling to overcome an (Deegan 1988 ) . identi fi able (or diagnosable) condition, in its most basic sense, recovery is about a growth and matu- ration process, not distinct from what all people Autonomy and Resilience must negotiate at some time in their lives (Erikson 1950; Vogel-Scibilia et al. 2009 ) . As such, it can Growth and the development of a broader array be considered a developmental process leading to of behaviors allow people to adapt to a wide a “mature” state of being (Mead and Copeland variety of circumstances. Adaptability and the 2000 ) . capacity to in fl uence the environment lead to a By contrast, people who do not engage in a greater sense of personal effectiveness. The way recovery process often appear to be “stuck” in a that one understands their reality changes from cycle of making the same decisions over and one in which they believe that they have no con- over, despite the fact that they are not happy with trol over or responsibility for what happens to the results. Most of us experience this state at them, to one in which they believe that the some time in our lives or in some aspect of our choices that they make and things they do are the living and fi nd that we are afraid of uncertainty most important determinants of their experience and the possibility that we could be even unhap- and circumstance. As the process of recovery pier if we choose to do something unfamiliar. progresses, there is a growing capacity to act This state will be referred to as “Stagnation” for independently and to make responsible decisions the purposes of our discussion. (Mead et al. 2001 ) .

The Aims of a Recovery Process Purpose and Meaning Change Ultimately, satisfaction in life must be derived A person enters a recovery process as an attempt from the ideas and activities that give it meaning. to break patterns of behavior that have been detri- We derive meaning from a number of sources: mental to their well-being. There are almost always spiritual connections, work, relationships, social choices that can be made about how to think and structures, education, recreation, and artistic act regardless of what type of limitations or dis- endeavors (King 2004 ; Green et al. 1997 ) . abilities with which one is confronted. Change As growth progresses and we see ourselves as the must often be radical in order to escape the rigidity agents that shape our world, we begin to create a of past patterns of behavior, and “reinventing one- set of beliefs to replace a nihilistic void that char- self” is a challenging and daunting prospect. acterizes a stagnant life. 82 W.E. Sowers

Courage, Diligence, and Tolerance Development of Enabling Qualities Change requires intense and consistent effort and In order to initiate and sustain a recovery process, causes a great deal of discomfort and . A per- a person must develop several qualities to enable son must fi nd the courage to face/experience it. These may be described in various ways, but this challenge and the tenacity to persevere under however they are conceived; there is an evolution physical and emotional . in the thinking process as people progress toward the changes they wish to make. Many of these qualities are included in various formulations of Integrity, Honesty, and Trust stages of change. The most common of these ele- ments will be presented here as a progression, but A person engaging in a recovery process is most in reality, they do not always appear in a linear or successful when able to consistently pursue and predictable chronologic order. represent the truth and judicious values and avoid misrepresentation and deception. Achieving this, and Responsibility it is possible to gain respect and trust in oneself and from others. These qualities make it possible Before a desire to change can take hold, a person to join a community and fi nd meaning beyond must recognize their limitations and/or disabili- immediate self-interests. ties. While there is often tremendous tenacity in resistance to admitting vulnerability, and to giving up the belief that factors outside one’s self Tolerance, Humility, and Forgiveness are responsible for one’s trouble, once it is sur- mounted, there is a possibility for change. With To be human is to make mistakes; sometimes acceptance comes responsibility, the recognition they may be egregious mistakes that cause a great that we must depend on ourselves to do what is deal of . In order to progress in a recov- required to make changes. ery process, a person must develop some capac- ity to accept the weaknesses of others and to recognize their own. Freedom and equanimity Desire and Determination come with the capacity to forgive both oneself and others. In order for change to occur, people must move beyond ambivalence and even willingness, and develop a genuine desire to live differently and a Characteristics of a Mature Recovery determination to do whatever is needed to do so. The development of the foregoing virtues is obviously an extended process which is likely and Faith to proceed in fi ts and starts and it may take many years to achieve great consistency. For most When people are stuck and stagnant, they are people, it is a lifelong struggle to stay on track. often unable to see that things can be any different This process, when successfully negotiated, and feel helpless to change their circumstances. leads ultimately to a certain balance and satis- When a person decides to enter a recovery pro- faction in life in which a person is also a reliable cess they are embracing the possibility of change and trusted member of a community. As these and they must develop the belief that they are qualities become more and more consistent, capable of it. con fi dence grows, as does the ability to adapt to 7 Recovery and Person-Centered Care: Empowerment, Collaboration, and Integration 83 and make changes. People fi nd new ways to • Recovery is independent of biological deter- manage their lives and relationships, drawing minants and is largely characterized by atti- on growing resources and a willingness to tudes and values rather than abilities. accept some of the risk that comes with self- • Developing resiliency is an essential aspect of disclosure and emotional investment. Openness a successful recovery process. to new ideas, self-observation and assessment, a • Resiliency may occur in the absence of a capacity for kindness and empathy, thoughtful- recovery process. ness, and fl exibility, and the realization that one need not denigrate others to value one’s self would all be aspects of maturity in recovery, Universal Aspects of Recovery whether in mental health or with substance use disorders. Over the years, the defi nitions of recovery and what it represents have been variable, and differ- ent groups may conceive of it in different ways. Resiliency and Recovery This raises the question of whether recovery is the same for everyone, regardless of their affl iction, As someone progresses with recovery, they or is it distinct for people recovering from a par- become more resilient, or better able to cope with ticular type of disability? Recovery may be adversity (Unger 2011 ) . These two concepts de fi ned narrowly or broadly. For example, recov- share many common elements, and they both ery from an addiction might be conceived of as imply an ability to thrive. They are generally used attaining abstinence or it may be de fi ned more in different contexts. “Resiliency” is most often broadly as life satisfaction and growth. Likewise used by clinicians and other stakeholders when in mental health, recovery may be seen as referring to the characteristics of children and the absence of symptoms and a reduction in the adolescents. The negative implications of recov- use of services, or alternatively as the ability to ery, described earlier, are more signifi cant for this live autonomously and make healthy choices. age group. “Recovery,” on the other hand, is more While there has been some controversy around often used when referring to adult development who “owns” recovery and how it should be for- but it is not easily separated from the resiliency mulated, there is a growing consensus on the concept. Many have commented on the inade- main elements that constitute a recovery process. quacy of the terminology, but it has not been easy This is fortunate, because it makes obvious sense to fi nd broadly acceptable alternatives. While the to have a uni fi ed understanding of recovery, espe- two terms are similar, there are some qualities cially as we struggle to better integrate services that distinguish them: for persons with behavioral health issues. • Resiliency describes a characteristic or state These elements of recovery provide a blueprint that allows positive adaptation within the con- for change, regardless of individual circumstances. text of signi fi cant adversity. Each person has Whether someone has a mental illness, a substance his or her own unique level of resilience. use disorder, a physical disability, had a traumatic • Recovery describes a process that allows res- experience, or is simply struggling against patterns toration or renewal following personal set- of behavior that make managing their daily lives backs related to disabling circumstances. diffi cult, the recipe for change is more or less the Individuals may or may not engage in a recov- same. Although the degree of disability and the ery process. diffi culty of engaging in a recovery process may • Resiliency is partly determined by one’s vary considerably, recognizing that everyone must genetic makeup, and partly developed through follow a common pathway to accomplish change experience and environmental in fl uences (i.e., has signifi cant implications for clinical processes, nurturing vs. neglectful). service delivery, and . 84 W.E. Sowers

• Respectful-strength based: The attitude of ser- The Value of the Recovery vice providers must be respectful and focused on the positive attributes that de fi ne an indi- Recovery creates a framework for change that vidual. They must be sensitive to and avoid can be applied in a variety of circumstances and the subtle condescension that has generally settings, so it provides a common language which characterized paternalistic approaches of the all clinicians and service users can understand past (Kaufmann et al. 1989 ) . and use to promote health and wellness. As such, • Empowering: ROS encourage service users to it can be the basis for integration of an often take control of their lives, accept responsibil- diverse array of providers that may be involved in ity for change, and use shared information to a person’s care (Mueser et al. 2002 ) . In clinical make informed choices (Fisher 1994 ) . settings, it can be the foundation for empathy and • Collaborative: Treatment is conceived of as collaboration through its formulation of shared a partnership between the person seeking human emotions, experience, and ambition. In the assistance and those offering care. Discarding broader community, its universal aspects form a the traditional roles of a controlling provider strong weapon to wield against stigma. As the and a passive consumer, in this paradigm the community comes to recognize the common two work as a team to accomplish the consum- experiences of all its constituents, it becomes the er’s goals (Noordsy et al. 2000 ) . basis for acceptance and inclusion and the pro- • Supportive-nurturing : Disabilities are destruc- tection of every individual’s human rights. Many tive to self-esteem and confi dence. Recovery observers have noted that the recovery movement is a progressive process and requires gradual is ultimately a civil rights struggle. fortifi cation of these qualities through support, encouragement, recognition of achievements, and trust (Mead et al. 2001 ) . Developing Person-Centered, • Capacitating : Growth implies an expanding Recovery-Oriented Services ability to live, learn, work, create, and inter- act. ROS should help every individual to de fi ne Having considered what constitutes a recovery and reach their potential with regard to these process, we can now turn our attention to how activities (Carlson et al. 2001 ) . psychiatrists and other clinicians can promote • Inclusive : ROS should offer and encourage and facilitate recovery and how we can create ser- inclusion of disabled individuals in all adminis- vices that support it. The development of trative processes that govern the operation of Recovery-Oriented Services (ROS) begins with services. They will also encourage involvement the recognition that services must be constructed in the larger community (Townsend et al. 2000 ) . to meet the needs of individuals and that individ- • Comprehensive: People should have access to uals should not be expected to benefi t from pro- a complete array of clinical and supportive grams or treatments designed for stereotypic services to meet their basic needs as well as patients with preconceived needs (Anthony 2000 ) . their emotional and spiritual needs. In the Person-Centered Care is sometimes used inter- planning process, these services should be changeably with Recovery-Oriented Services, but tailored to fi t individual issues. may also be seen as an aspect of these services • Outcome informed: To make informed health that particularly emphasize the key concept choices, people must have access to information described above. The following principles provide related to the likely results associated with avail- further description of ROS: able treatments. There should be opportunities • Hopeful-optimistic : The clinician’s role is to for them to learn about outcomes and evidence, inspire hope and create an atmosphere that and how to evaluate them (Roberts 2002 ) . assertively recognizes the possibility for • Culturally sensitive: Individuals may have mul- change in every individual (Borkin 2000 ) . tiple cultural in fl uences in their lives, including 7 Recovery and Person-Centered Care: Empowerment, Collaboration, and Integration 85

spiritual concerns (Huguelet et al. 2011 ) . ROS and life expectancy, between those with behav- should celebrate diversity, explore cultural expe- ioral health issues and the general population, rience, and value the unique contributions that it makes this aspect of recovery-oriented care ever makes to how one operates in the world and how more critical. Health cannot be subdivided into its people understand and experience a disability. components, as all aspects are interdependent. • Integrated: It may require several different ROS recognize that people can be healthy, even providers to meet the needs of a particular with an active illness, just as they maybe unhealthy person. ROS recognize the need to coordinate without identi fi able disease. and, if possible, consolidate the services Concerns are often raised about the applica- provided into a coherent and interactive plan bility of ROS to persons with very severe mental with the consumer at its center. illnesses who have periods of cognitive de fi cits • Voluntary: The use of seclusion, restraint, and rendering them unable to make prudent choices. coercion are not consistent with ROS and are They may consistently make choices that place only used if there are clearly no other them at risk of harm (Davidson et al. 2006 ) . It is alternatives. ROS recognize that individuals important to recall in these instances that recov- may have periods of incapacity and encourage ery is a developmental process, and it is not the formulation of appropriate plans for these always a linear one. We might think of “stages” circumstances (Davis 2002 ) . of recovery as analogous to the stages of change A signi fi cant aspect of Person-Centered Care often referred to in the addiction literature. Just is its focus on information sharing and offering as we would not offer a young child complete choices that are informed by that knowledge. freedom to do as they please, we would not offer It encourages individuals to formulate a personal this to someone who has uncontrolled and severe vision for their lives and to create plans that will symptoms of mental illness. The operating prin- give them an opportunity to fulfi ll those ideals. ciple in cases where a person has diminished The central role of the relationship in healing capacity is to gradually extend their capacity to processes is also a critical aspect of Person- make wise and responsible choices. Gradually Centered Care and ROS. The relationship- increasing degrees of freedom and choice are building process is ultimately the source of trust required to accomplish this. In the most severe that is essential for a clinical partnership. This cases of mental illness and intellectual disability partnership is what allows engagement in a this may be a very slow process. The intention of collaborative planning process, which is the best ROS is to consistently attempt to extend an indi- guarantor of investment in the product of that vidual’s capacity for self-management and self- process (Manfred-Gilham et al. 2002 ) . agency. When this is not possible, the use of A focus on health and wellness as opposed to advanced directives can be a very valuable tool to illness and disability is another hallmark of ROS. allow individuals to exercise some control even The prevention or the mitigation of relapse to when they are most debilitated (Srebnik et al. active illness is accomplished by developing skills 2005 ; Henderson et al. 2008 ) . that facilitate making healthy choices and exer- Finally, ROS must fi nd ways to challenge cising effective health management. In this regard, individuals to recognize their own possibilities it mirrors the chronic care and disease manage- and to pursue their vision without creating over- ment models promulgated in physical . whelming stress. Much of this work will be Recognition of the interaction of mental and accomplished through motivational techniques, physical processes as an important determinant of allowing individuals to gradually de fi ne their overall well-being leads to an integrated or holis- own needs, desires, and solutions. Rather than tic approach to service delivery which fi ts with striving for compliance or adherence, ROS hope recent concepts of medical/mental health homes, to create investment in a shared plan for change. or centralized, coordinated care models (Beardslee Change is disruptive and frightening, calling et al. 2011 ) . The great disparity in health status many beliefs and practices into question. ROS 86 W.E. Sowers must be comfortable in helping people to confront toward person-centered, recovery-focused care and fi nd answers to spiritual/existential ques- (Corrigan and Garman 1999 ) . Leaders and teach- tions; and it must help them to fi nd ways to ers will be most successful by taking a motiva- become part of a community and develop satisfy- tional approach, helping their staff to fi nd ing relationships with others. incentives for and value in making changes to their practice. To do so, there must be a signifi cant investment of time and energy to allow not only Implementation and System adequate information transfer but opportunities Transformation to process the information and its implications. Signifi cant change occurs most readily when The characteristics described above provide a people see that it will further their own interests, basic idea of the nature of services provided so it will be important to help staff de fi ne what by organizations that wish to promote recovery. those interests are. The American Association of Community Leadership, in moving the organization toward Psychiatrists developed the Guidelines for ROS, has an opportunity to model facilitative and Recovery Oriented Services. This document pro- collaborative practices rather than directive, vides further elaborated description of ROS by authoritarian methods. Transparency, informal- delineating 17 separate characteristics, and divid- ity, fl exibility, and suggestibility all contribute to ing them into three categories: Administrative, the empowerment of staff, and eventually treatment, and support. For each characteristic, a contribute to their ability to treat their clients set of measurable indicators follows a descriptive reciprocally. Solicitation of input and participa- paragraph. This document provides a “blueprint” tion in administrative activities and program for organizations that would like to develop this design and development also allow staff to feel model. Its companion Recovery Oriented Services invested in the organization and to take pride in Evaluation ( ROSE) is a self-assessment tool, its success. As one might expect, this idea of par- which translates the indicators of the Guidelines ticipation is one that facilitates clients’ invest- into anchors in its rating process. While not vali- ment in a treatment planning process and dated, the use of this tool creates capacity to adherence to the collaborative plan developed enable organizations to measure their progress in from it. Having this experience in the workplace developing ROS over time. There have been sev- begins to create a different and will make eral other tools that have become available a translation to clinical processes much easier. recently, which provide similar guidance. Nontraditional approaches to training may Several other issues will be encountered by also help to overcome some of the resistance to organizations wishing to implement ROS in place change. One method that has been well received of traditional practices. The existing behavioral and successful is the promotion of dialogues health workforce has, for the most part, not been between consumers and providers outside their well trained to work in a collaborative, egalitarian usual roles in the clinical context. Fears about the manner with the people that they serve. As noted consequences of honesty can be minimized if par- above, change is very diffi cult to embrace, and it is ticipants feel that they have no real life relation- commonly experienced as a threat. Clinicians can ship with their counterparts. This arrangement often be resistant to change that is not self- initiated, allows a genuine sharing of experience both from or they may minimize differences between these the consumer and the Behavioral Health profes- proposed practices and those currently in place. sional and is inevitably appreciated by the partici- Full implementation of ROS usually constitutes a pants. It promotes empathy and trust, and helps cultural change, and it is very dif fi cult to uproot participants to understand that they are less differ- established practices and attitudes. ent from one another than they have imagined. In this context, it requires visionary or trans- Creating a competent workforce for ROS is a formational leadership to move organizations long-term process, but can be expedited with 7 Recovery and Person-Centered Care: Empowerment, Collaboration, and Integration 87 organizational commitment and consistency in and an attitude for the delivery of services. If ROS applying the principles of ROS at all levels of the promote equality and justice for persons with organization. Even with these conditions in place, behavioral health disorders, then the issue of there may be some individuals in the organiza- “evidence” needs not be relevant. tion who do not feel comfortable with this new Others note that ROS are complex and multi- paradigm, and will want to leave. In most cases it faceted and as a result, it would be extremely is wise to facilitate these wishes, and accept the dif fi cult to generate evidence for its effectiveness idea that not everyone is ready for change or well using standard approaches. Furthermore, if suited to work in this way. “recovery” is the desired outcome, then tradi- Changing the content of professional training tional measures of successful treatment may no to incorporate the principles of ROS in both longer be appropriate. This would apply equally didactic and practical aspects of training will to quality improvement processes. Indicators of ensure that a new generation of clinicians success would be more closely aligned with becomes available to replace those leaving the consumer satisfaction and quality of life, rather workforce (Peebles et al. 2009 ) . Although it than service needs and utilization (Drake et al. may seem daunting to insert this new content 2003 ) . While evidence-informed interventions into the already overcrowded curricula com- are an important element of ROS, the nature of monly encountered in psychiatric training pro- “valid” evidence must be scrutinized, and per- grams, this is an overarching attitudinal shift haps broadened, to accurately refl ect the benefi ts that will not necessarily replace other topics, but of these approaches (Torrey et al. 2005 ) . instead should enhance them all. It will require Recovery and ROS are recurrent themes commitment from academic institutions to throughout this text and the concepts presented implement these necessary changes in curricula here provide a foundation for thinking about the and incentives are needed to facilitate have many implications these perspectives will have movement in this direction. on the typical activities of the community psychiatrist. They inform our relationships with clients, our approach to service design and deliv- Evidence, Quality, and Recovery- ery, and the scope of our involvement in the Oriented Services community. As noted earlier, a recovery perspec- tive has long been an aspect of good community psychiatry, and indeed, it is hard to imagine how As discussed above, one of the important ele- it could be otherwise. ments of ROS is to provide information to con- sumers and allow them to choose among available options based on what they have learned (Farkas et al. 2005 ) . A full discussion of evidence-based References practices is discussed elsewhere in this book, but it is important to state that the strength of evi- Anthony, W. A. (2000). A recovery-oriented service system: Setting some system level standards. dence for the effectiveness of each available clin- Psychiatric Rehabilitation Journal, 24 , 159–168. ical option is an essential part of ROS. Beardslee, W. R., Chien, P. I., & Bell, C. C. (2011). But what is the evidence for the effectiveness Prevention of mental disorders, , and of ROS? There is not yet a clear answer to that problem behaviors: A developmental perspective. Psychiatric Services, 62 , 247–254. question. Many people believe that, intuitively, if Borkin, J. R. (2000). Recovery attitudes questionnaire: people have more control over their care, they Development and evaluation. Psychosocial will be more invested and more likely to adhere Rehabilitation Journal, 24 , 95–1003. to the plans that they have made to progress in Carlson, L. S., Rapp, C. A., & McDiarmid, D. (2001). Hiring consumer-providers: Barriers and alternative their recovery. A variation of that theme is that solutions. Community Mental Health Journal, 37 , ROS is not a “treatment,” but provides a context 199–213. 88 W.E. Sowers

Corrigan, P. W., & Garman, A. N. (1999). Transformational Lowe, A. A. (1950). Mental health through will training . and transactional leadership skills for mental health North Quincy, MA: Christopher. 136. teams. Community Mental Health Journal, 35 , Manfred-Gilham, J. J., Sales, E., & Koeske, G. (2002). 301–312. Therapist and case manager perceptions of client Davidson, L., O’Connell, T. J., et al. (2006). Top ten con- barriers to treatment participation and use of engage- cerns about recovery. Psychiatric Services, 57 , ment strategies. Community Mental Health Journal, 640–645. 38 , 213–221. Davis, S. (2002). Autonomy versus coercion: Reconciling Mead, S., & Copeland, M. E. (2000). What recovery competing perspectives in community mental health. means to us: Service user’s perspectives. Community Community Mental Health Journal, 38 , 239–250. Mental Health Journal, 36 , 315–331. Deegan, P. E. (1988). Recovery: The lived experience of Mead, S., Hilton, D., & Curtis, L. (2001). : rehabilitation. Psychosocial Rehabilitation Journal, A theoretical perspective. Psychiatric Rehabilitation 11 , 11–19. Journal, 25 , 134–141. Drake, R. E., Green, A. I., Muesser, K. T., & Goldman, Mueser, K. T., Corrigan, P. W., Hilton, D. W., Tanzman, H. H. (2003). The history of community mental health B., Schaub, A., Gingerich, S., Essock, S. M., Tarrier, and rehabilitation for persons with severe mental ill- N., Morey, B., Vogel-Scibilia, S., & Herz, M. I. (2002). ness. Community Mental Health Journal, 39 , 427–440. Illness management and recovery: A review of the Erikson, E. H. (1950). Childhood and society . New York: research. Psychiatric Services, 53 , 1272–1283. Norton. Noordsy, D. L., Torrey, W. C., Mead, S., Brunette, M., Farkas, M., Gagne, C., Anthony, A., & Chamberlain, J. Potenza, D., & Copeland, M. S. (2000). Recovery (2005). Implementing recovery oriented evidence oriented psychopharmacology: Rede fi ning the goals based programs: Identifying the critical dimensions. of antipsychotic treatment. The Journal of Clinical Community Mental Health Journal, 41 , 141–157. Psychiatry, 61 (Suppl 3), 22–29. Fisher, D. B. (1994). Health care reform based on an Peebles, S., Mabe, P. A., Fenley, G., Buckley, P. F., et al. empowerment model of recovery by people with psy- (2009). Immersing practitioners in the : chiatric disabilities. Hospital & Community Psychiatry, An educational program evaluation. Community 45 , 913–915. Mental Health Journal, 45 , 23–45. Green, L. L., Fullilove, M. T., & Fullilove, R. E. (1997). Rissmiller, D. J., & Rissmiller, J. H. (2006). Evolution of Stories of spiritual awakening: The nature of spiritual- the antipsychiatry movement into mental health con- ity in recovery. Journal of Substance Abuse Treatment, sumerism. Psychiatric Services, 57 , 863–866. 15 , 325–331. Roberts, L. W. (2002). Informed and the capacity Henderson, C., Swanson, J. W., Szmukler, G., Thornicroft, for voluntarism. The American Journal of Psychiatry, G., & Zinkler, M. (2008). A typology of advance state- 159 , 705–851. ments in mental health care. Psychiatric Services, 69 , Sachs, S. (1997). Recovery, Inc.: A wellness model for 63–71. self-help mental health. Developments in Ambulatory Hogan, F. H. (2003). The President’s New Freedom Mental Health Care Continuum, 4 . Commission: Recommendations to transform mental SAMHSA. (2003). Transforming MH care in America. health care in America. Psychiatric Services, 54 , www.samhsa.gov/Federalactionagenda/NFC_ 1467–1474. EXECSUM.aspx. Accessed 12 Mar 2012. Huguelet, P., Mohr, S., Betrisey, C., Borras, L., Gillieron, SAMHSA. (2005). National Consensus Statement on C., Marie, A. M., et al. (2011). A randomized trial of mental health recovery. Washington, DC. http://store. spiritual assessment of outpatients with : samhsa.gov/shin/content//SMA05-4129/SMA05- Patients’ and clinicians’ experience. Psychiatric 4129.pdf. Accessed 12 Mar 2012. Services, 62 , 79–86. Sowers, W. (2003). Transforming systems of care: AACP Jacobson, N., & Curtis, L. (2000). Recovery as policy in guidelines for recovery oriented services. Community mental health services: Strategies emerging from the Mental Health Journal, 41 , 757–774. states. Psychiatric Rehabilitation Journal, 23 , Srebnik, D. S., Rutherford, L. T., Peto, T., Russo, J., Zick, 333–341. E., Jaffe, C., et al. (2005). The content and clinical Kaufmann, C. L., Freund, P. D., & Wilson, J. (1989). Self utility of psychiatric advance directives. Psychiatric help in the mental health system: A model for Services, 56 , 592–598. service user-provider collaboration. Psychosocial Torrey, W. C., Rapp, C. A., Van Tosh, L., McNabb, C. R., Rehabilitation Journal, 13 , 5–21. & Ralph, R. O. (2005). Recovery principles and evi- King, G. A. (2004). The meaning of life experiences: dence-based practice: Essential ingredients of service Application of a meta-model to rehabilitation improvement. Community Mental Health Journal, 41 , and services. The American Journal of Orthopsy- 91–100. chiatry, 74 , 72–88. Townsend, W., Boyd, S., & Griffi n, G. (2000). Emerging Laudet, A. B., Magura, S., Vogel, H. S., & Knight, E. best practices in mental health recovery . Columbus, (2000). Addictions services: Support, mutual aid and OH: The Ohio Department of Mental Health. recovery from dual diagnosis. Community Mental U.S. Department of Health and Human Services. (1999). Health Journal, 36 , 457–476. Mental health: A report of the surgeon general— 7 Recovery and Person-Centered Care: Empowerment, Collaboration, and Integration 89

executive summary . Rockville, MD: U.S. Department Vogel-Scibilia, S. E., McNulty, K. C., & Baxter, B. (2009). of Health and Human Services, Substance Abuse The recovery process utilizing Erikson’s stages of and Mental Health Services Administration, Center human development. Community Mental Health for Mental Health Services, National Institutes of Journal, 45 , 405–414. Health, NIMH. Accessed date for US Department of White, W. L. (1998). Slaying the dragon: The history of Health and Human Services 1999: 12-March-2012. addiction treatment and recovery in America . Unger, M. (2011). The social ecology of reslience: Bloomington, IL: Chestnut Health Systems/Lighthouse Addressing contextual and cultural ambiguity of a Institute. nascent construct. The American Journal of Whitley, R., & Drake, R. E. (2010). Recovery: A dimen- Orthopsychiatry, 81 , 1–17. sional approach. Psychiatric Services, 61 , 1248–1249.