In 1993, Dr. Anthony introduced the concept of a recovery-oriented mental healthcare system,1 based on the notion of recovery advanced by people with severe mental illnesses2 initially researched by Harding and colleagues.3 A lot of discussion over the past few years has been about the importance of developing recovery-oriented practices, bolstered by the President's New Freedom Commission's report that called for services to adopt a recovery vision for the mental healthcare system.4 Mental healthcare organizations (providing treatment, crisis intervention, case management, rehabilitation, wellness, self-help, and/or other services) can opt to deliver these services with or without a recovery orientation.5 The critical question of how to actually put the New Freedom Commission's recommendations into practice has since dominated discussions in the field.
Organizations often begin their change strategies by developing training programs with the idea that if the staff is retrained, the organization itself will change. Such an initial focus on staff training, while appealing to one's notion of “getting started,” may be premature and poorly targeted toward the goal the organization truly wants.
In addition to training to improve staff's capacity for recovery-oriented services, also important are two other elements: organizational culture and organizational commitment (the “3Cs”), as expressed through the organization's mission, policies, procedures, activities, record keeping, and so on. An effective implementation strategy, therefore, begins by identifying an organization's culture, commitment, and capacity in relation to the implementation goal.
This article lays out a simple framework for identifying the extent to which an orga-nization is ready to implement recovery-oriented practices, along with examples from a checklist based on that framework.
We (M.F. and W.A.A.) have suggested that best practice in recovery involves value-based practices that adhere to recovery values, such as the four critical values of personhood, full partnership or involvement, choice or self-determination, and hope or orientation to growth, as well as those practices that have some level of evidence associated with them (e.g., evidence-based and promising practices).6,7 We believe that implementing recovery-oriented practices requires an initial review of the extent to which the organization's 3Cs for delivering recovery-oriented services exist. Assessing the 3Cs is a critical early step in identifying an organization's readiness to implement recovery-oriented practices.
The organization's culture basically is the “way things are done around here.” Culture can involve organizational policies as well as more implicit rules governing social and professional interactions. An organization ready to implement a recovery-oriented practice demonstrates a culture based on recovery values.
Value-based practice assumes that core values guide and direct a particular service or intervention.6 For example, the value of personhood or simple human decency7 implies that the organization makes an effort to see participants in roles other than “patient.” This may include having a culture that acknowledges important events (births, deaths, graduations, birthdays, etc.) in the lives of all individuals equally (i.e., employees and the people they serve). The organization may make a conscious effort to identify talents, interests, and strengths of the people it serves by supporting opportunities to share these talents and strengths both in the “outside” world and within the organization. A culture of simple human decency governs everything from how bathrooms are allocated (e.g., for only staff members’ or for everyone's use?) to discussions about individuals in team meetings (Do staff members crack jokes about bizarre behaviors? Do staff members show empathy for individuals even when they are not present?).
The value of partnership or full involvement means “nothing about us without us.” Consumer involvement in designing, delivering, and evaluating mental healthcare is a critical component of a quality management system for any mental healthcare service,8 as well as critical to developing a sense of empowerment.9 Promoting the hiring of individuals with serious mental illnesses as peer providers and support personnel, as well as in the role of helping professionals and administrators, is becoming an important element in the development of a recovery-oriented service or system reflecting the culture of full partnership.
The third common value in recovery-oriented services’ culture is self-determination. Self-determination and self-choice are the cornerstone of a recovery process. A culture that promotes self-determination actively deals with the implied shift in power relationships between staff and participants. Self-determination requires staff to be able to relinquish power without feeling threatened.