Editor's note: In our November issue, the authors described some of the reasons the mental health and addictions fields have had trouble integrating in the past. They also discussed how recovery could be a conceptual bridge to the integration of the fields. Here they conclude their discussion by examining how emerging recovery systems are different from traditional models of care.
Understanding that system change, like recovery, must be led by people with lived experiences of recovery, the Connecticut Department of Mental Health and Addiction Services consulted with statewide recovery advocacy organizations to develop a set of core recovery values (e.g., self-sufficiency, dignity, and respect) and principles to drive their system transformation process. These principles included the following admonitions:
Focus on people rather than services
Monitor outcomes rather than procedural performance
Emphasize strengths rather than deficits or dysfunction
Educate the public to combat stigma
Foster collaboration as an alternative to coercion
Promote autonomy and decrease reliance on professionals1
As we have watched and helped facilitate these experiments in system transformation in states such as Connecticut and cities such as Philadelphia, we have been struck by the broad changes in practices in both mental health and addiction agencies that unfold as an outcome of recovery-focused system change. Some of the most profound of these changes have occurred in the following areas2:
Roles of clients, families, and recovery advocates.
People with mental illnesses or addictions are no longer viewed as problems a system has to deal with. People in recovery are considered valuable assets and partners, with involvement at all organizational levels and across major functions (e.g., policy development, planning, service delivery, and service evaluation). They are in advisory, volunteer, and paid roles. Their decisions are crucial to long-term recovery, and a philosophy of choice guides all levels of care.
Identification, engagement, and retention.
Assertive outreach programs shift from pain-based to hope-based intervention strategies and have lowered thresholds of admission, increased use of case management to resolve obstacles to participation, and used motivational enhancement and contingency management to lower the number of clients disengaging from services against medical advice or being administratively discharged.
Assessment protocols shift from being categorical (specialized), pathology-based, and individual-focused to being global, strengths-based, family-centered, and continual.
Symptom reduction/remission shifts from a goal to a strategy, focusing on quality of life, achievement of personal aspirations, and meaningful participation in and service to the community.
Service planning and service team.
There has been a rapid transition from professionally directed treatment plans to client-driven recovery plans, along with a move to multiagency, interdisciplinary service models and an inclusion of family and indigenous healers (clergy, folk healers, recovery peers, etc.) in treatment and recovery planning processes.
Role of the community.
There is an emphasis on local recovery education and policy advocacy. The community is no longer viewed as a context for or precipitant of relapse, but rather as a reservoir of resources, hospitality, and support. The focus is on collaboration with existing recovery support resources and community development strategies to expand the scope and quality of such resources.
The system shifts from crisis-based contact to long-term support focused on critical windows of peak functioning (to acknowledge and celebrate recovery) and critical windows of vulnerability (to provide support through situations that pose a risk for relapse). Regular recovery checkups are employed.
Locus of service delivery.
Instead of institutional environments, the locus of service delivery is the client's natural environment. Considerable focus is on the “ecology of recovery” (helping clients create recovery-conducive physical and social environments).
This shifts from an expert model of diagnosis and treatment to a sustained healthcare partnership. The relationship isn't hierarchical, transient, and highly commercialized, but rather less hierarchical, sustained, and natural. Peer-based models of recovery support increasingly are being used.
Service evaluation significantly involves clients, family members, and community elders. The emphasis shifts from pathology measures to key recovery indicators. Instead of evaluating discrete service episodes, evaluation focuses on the impact of service combinations and sequences on a person's overall life over time.