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Don't let paperwork be a barrier

June 1, 2008
by Lori Ashcraft, PhD and William A. Anthony, PhD
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Well-crafted questions can elicit recovery responses

As we travel around the country talking with folks about recovery, the conversation, no matter how long or short, inevitably comes around to the drudgery of the paperwork process. Yes, this has been a source of complaints since the beginning of time, but it now seems more relevant than ever.

The root of the paperwork problem (in fact, the “taproot”) has to do with the larger issues of system dysfunction. Most of this dysfunction is a result of system change not keeping pace with best and promising practices aligned with the expectation for recovery. Since most of the requirements that govern the paperwork process were developed long before we knew people can recover, they aren't geared to promote or foster a recovery response in either staff or the person being served. In fact, they do just the opposite—they aren't even neutral! A recovery-oriented paperwork process actually could help bring about the results we hope for, instead of getting in the way.

Don't get us wrong—we aren't saying “Down with the paperwork.” We are saying “Let's get it right.” We know that paperwork is necessary and is a reasonable way to record the progress, benchmarks, and outcomes of the services we provide; and yes, it usually results in some sort of invoice that allows us to be reimbursed for our efforts. Our current procedures, however, continually force us to respond to people in ways that extinguish the fragile flames of recovery. We are put in a position of having to do our recovery work over the top of the paperwork requirements in order to fan those fragile sparks. Enough. We must rise to the challenge and come up with better ways to do our business.

Staff in programs determined to provide recovery services are using a long series of exhausting “workarounds” that gobble up precious time, which could be better spent on mobilizing recovery services. The result is the worst possible paperwork process:

  • It takes even more time than ever to complete.

  • It takes us in the wrong direction.

  • It uses resources that could be better spent on recovery.

We keep hoping someone will fix this. So far, there has been a lot of complaining but no targeted action that could result in resolving the issues and turning the paperwork process into something that not only doesn't get in the way of the recovery process but, in fact, encourages it.

We've joined the long list of complainers but would like to help in developing a solution. Right now, the best thing we think we can do is offer some examples of ways to provide recovery-oriented services in spite of the paperwork requirements. Let's turn to Mark for some examples and advice.

Mark is the intake coordinator and triage counselor at the Psychiatric Recovery Center, a level I subacute psychiatric hospital in Phoenix (operated by Recovery Innovations) that accepts both voluntary and involuntary admissions. Mark often is the first person with whom a guest has an in-depth conversation. He believes that this initial review is a unique opportunity to introduce the guest to recovery concepts.

“This is not to suggest that this is so readily achieved,” Mark says. As in most subacute settings, the state licensor and the Joint Commission require an initial paperwork assessment. This paperwork involves collecting a large amount of information, most of which has nothing to do with recovery. The emphasis is on the history of illness, medication, and hospitalization. This lengthy paperwork process results in an initial assessment that the psychiatric provider uses to help identify acute and positive symptoms amenable to medications.

The crisis center is a busy place, and while keeping records of the work-in-progress is important, the required content should keep us focused on the process and potential for recovery so our time can be used expeditiously to benefit the guest. The Initial Assessment must be completed in a timely fashion and, as mentioned earlier, is focused on what's wrong instead of what strengths the guest has that can be mobilized to initiate the recovery process.

We asked Mark how he manages to complete the deficit-based paperwork without extinguishing the fragile flames of recovery. He says, “Human beings have an innate ability to respond to opportunities to heal. However buried in the individual's personal experience, the well part of them is still there and is always ready to emerge. They only require a supportive recovery environment to bring it forward. The questions you ask and the way that you ask them are crucial to eliciting the recovery response. I ask the following questions, staying focused on building a relationship, and then often complete the paperwork afterwards, asking them to help me get it right.”

Recovery-Focused Questions

What do you want? This simple question is so important to the individual's recovery. Guests frequently answer with the reasons why the referral source recommended they come in. The reasons often are full of professional jargon meaningless to the guest (and us). It usually has little to do with what they really think will help them recover. We often repeat the question and frequently explain that we are interested in what they are feeling and what they want, in their own words. Comments such as “I am sad,” “I can't sleep,” or “I can't stop thinking” provide the framework for discussing feelings, thoughts, and desires that can lead to a recovery-oriented solution.