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NASW Practice Snapshot:
The Mental Health Recovery Model
Office of Social Work Specialty Practice
The mental health Recovery Model is a treatment concept wherein
a service environment is designed such that consumers have primary
control over decisions about their own care. This is in contrast
to most traditional models of service delivery, in which consumers
are instructed what to do, or simply have things done for them with
minimal, if any, consultation for their opinions. The Recovery
Model is based on the concepts of strengths and empowerment, saying
that if individuals with mental illnesses have greater control and
choice in their treatment, they will be able to take increased control
and initiative in their lives.
The Recovery “movement” refers to a mostly grassroots
initiative that also encourages these tenets, and has as a goal the
recovery from mental illness. Helping achieve these goals is
consistent with the values of the social work profession, which is
committed to the empowerment and self-determination for all populations,
particularly those who are traditionally disenfranchised. This
Snapshot discusses some of the ways in which the tenets of the Recovery
Model may affect clinical practice in facilities that support individuals
with mental illnesses. Some short recommendations are also
made for how to orient one’s own work to reflect the recovery
ideas.
What does recovery mean?
The concept of “recovery” originally began in the addictions
field, referring to a person recovering from a substance use disorder. The
term has more recently been adopted in the mental health field as
people realize that, similar to recovery from an addiction, recovery
from a mental illness is also possible. Efforts are now ongoing
to develop an appropriate definition for “recovery” as
used in the mental health field. The Substance Abuse and Mental
Health Services Administration (SAMHSA) and the Interagency Committee
on Disability Research (ICDR) began an effort in 2004 to develop
a consensus statement on a definition. Hoping to release it
in late 2005, they gave a sneak preview of the statement: “The
expert panelists agreed that recovery is an individual’s journey
of healing and transformation to live a meaningful life in a community
of his or her choice while striving to achieve maximum human potential” (U.S.
Department of Health and Human Services, 2005b, p. 4, as cited in
NASW, 2005).
What might concepts of the Recovery Model mean in a
clinical program?
A key point of the model is that it is not our role as providers
to make decisions for consumers, but we do have a responsibility
to provide education about the possible outcomes that may result
from various decisions. Many staff first react with concern
when they hear that mental health consumers should make decisions
about their own care. “What if someone decides they don’t
want to take prescribed medications?” is perhaps the most common
and worrisome concern. Legally, though, no adult can be forced
to take medications or undergo certain treatments unless there is
a court order or legal guardian directing them to do so. The
Recovery Model does not advocate anything different. The reality
of practice, though, is that mental health consumers (particularly
those with more chronic and debilitating disorders) are usually instructed
as to what treatments and medications to take, with minimal effort
to involve them in decisions. The Recovery Model states that
a program’s philosophy should acknowledge and encourage consumer
involvement and decision-making. Most consumers do ultimately
ask for, and take, clinicians’ treatment recommendations, but
consumers need to know that they have both the right and the responsibility
to make those decisions.
Consumers should be included from the beginning in decisions regarding
their care. When a consumer decides that he or she wants to
do something, his or her decision ought to be respected, and we,
as providers, should make reasonable efforts to assist. This
does not mean money should be taken from group activity funds so
that one consumer can take a vacation. However, if this is
something the consumer has decided to do, advice and assistance ought
to be provided for them to make it a reality. Maybe this means
they need to save money, get a part-time job, or learn to take medications
without reminders.
The Recovery Model also does not suggest that consumer choice should
be encouraged at the detriment of other consumers or program rules. A
day program that requires attendance three days a week should maintain
that rule, and consumers who do not follow it should have applicable
consequences. Likewise, a housing program that requires consumers
to have daytime activities should also enforce that rule. Or
a therapist who sets rules for active participation in treatment
should not take “I didn’t feel like it,” as an
acceptable response for failing to do an agreed-upon task. Program
rules that are set for the benefit of all should not have exceptions
made in the name of the Recovery Model. However, consumers
who do not like the rules of a particular program or residential
facility should have the right to find a program that will better
meet their needs.
What about decisions we think will be bad ideas?
What about when a consumer makes a decision that goes against clinical
judgment and/or scientific evidence? The Recovery Model still
suggests that wishes should be respected, and that we should assist
consumers in their attainment. If their goal does not seem
rational to us, then we need to help them understand the implications
and realistic possibilities, but they need and have a right to make
the decisions. We have a responsibility to “support
the dignity of risk and the right to fail” (attributed to Pat
Deegan, 1996, as cited at U.S. Department of Health and Human Services,
2005a).
Beyond clinical judgment or scientific evidence, concerns arise
if a consumer’s decision is likely to cause harm. We
have a responsibility by our Code of Ethics to intervene “to
prevent serious, foreseeable, and imminent harm to a client or other
identifiable person” (NASW, 1999, p. 7). A decision to
not go to a day-program for a certain day is unlikely to cause such
harm. Refusing medications, on the other hand, has a possibility
of more serious harm, depending on the medication. Each case
needs careful consideration and consultation with other relevant
providers. When a consumer’s decision is unlikely to
cause serious harm, our job is to help educate them as to possible
benefits and consequences of their decision (including if that means
a possibility of involuntary hospitalization), but in the end to
let them make those decisions. When a decision is likely to
cause serious harm, then we should, as always, intervene so as to
prevent the harm.
An important concept of the model:
Another key concept of the Recovery Model is that consumers should
have the right to make the same types of decisions that everyone
else in society makes. Any individual who wants to live in
an independent apartment in the community, for example, must make
certain decisions that balance such factors as finances and behaviors. Fortunately
there are laws designed to protect individuals with disabilities
from housing discrimination, but each individual still has a responsibility
to act in ways that are reasonably respectful of the rights of neighbors. An
individual who plays excessively loud music, regardless of who they
are, for example, runs the risk of receiving a warning or citation
from the police. Someone who continues to be disrespectful
of the rights of others would not be able to stay in the apartment. The
person has the right to play music loudly, but they also must take
responsibility for possible repercussions.
Consideration for the rights of others also applies to outside activities
in which people participate. For many individuals this might
include a gym membership or yoga class. For consumers of mental
health services, this might also apply to support groups or day-treatment
programs in which they participate. An individual who becomes
disruptive to others in a group therapy session would be asked to
leave in most cases. Individuals should have a choice about
how to address their interpersonal challenges, but they also need
to know of the responsibility of acting in a reasonably respectful
and safe manner towards others. Again, someone who chooses
to neglect their self-care, and becomes a dangerto themselves or
others, may need a more directive intervention such as hospitalization. This
is a possibility of which each person in society needs to be aware;
but each person also has the right to act in ways that will prevent
or incur such an intervention.
Additional thoughts:
There are many possible concerns that clinicians may express regarding
allowing consumers to make decisions about their own care. Along
with concerns about rejecting helpful medications, they might include
not going to a program, not going to a doctor’s appointment,
or not going to work. Consumers need to be as fully informed
as possible about the potential benefits and consequences of each
decision. They also need to know the possible results if they
become a danger to themselves or others. When they break program
rules, or decide that they no longer want to participate in a group,
they may need to find another program that is more amenable to their
interests. When such a program does not exist, then they need
to be informed of what that means for their situation.
Social workers have an obligation to continue serving, supporting,
and encouraging consumers to do what our clinical experience has
taught us to believe is best. However, we must understand and
accept that helping consumers to make their own choices—good
or bad—will ultimately be in the best interests of their recovery
and independence, even if we believe that a particular action is
a bad idea. As professionals, we need to learn to take a supportive
role, rather than one as a decision maker. This may take a
change in mindset for many clinicians, but it is imperative that
they make that change (Rommler, 2005). On the other hand, there
are constraints about how much we can help someone with what they
want. The Recovery Model does not call for us to do things
that are unrealistic, that would hinder the recovery of other consumers,
or that would involve treating one consumer more favorably than another. The
model calls for us to support consumers’ decisions, within
reason, to the best of our abilities.
Tips to orient your work towards a recovery-oriented
model:
- Never talk about
a consumer in the third person when he or she is present. In
that case, they should be referred to as “you”—“What
do you want to do or think?” or, “You have a follow-up
appointment in two weeks,” or, “You understand that John
will remind you of your appointment and take you there in two weeks?” Sometimes
this may seem awkward when you are informing a family member or other
caregiver of care instructions. However, you can, and should,
still work the consumer into the conversation in such a way that
he or she is a part of the conversation, rather than an object
next to you.
- When a consumer
makes a request that you don’t agree with, as your first response
do not ignore them or say “no.” Rather, ask them
to explain their request. Why do they want it? What will
they need to do to get it? What are the consequences and benefits? Is
it a realistic request? Yes, some people become recalcitrant,
and will struggle to understand explanations. Just don’t
make “no” your first gut-reaction for what seems to be
an irrational request. Help them to think about the request
and make their own rational decision. Chances are good that
you misunderstood their intent, and their request is reasonable.
- Remember your
body language and communication skills. These are frequently
forgotten, especially when working with consumers who have greater
disabilities. Never turn your back to a consumer when talking
about their care with another person. When talking with a consumer
and another provider or family member, talk to both of them, even
if only one person is responding or will have direct responsibility
for carrying out instructions. Look back and forth between
the consumer and other(s) to include a consumer in a conversation. Ask
the consumer if he or she understands a discussion, or understands
how another person will be helping them. Say things and use
your body language to ensure that a consumer is a part of a conversation
about his or her care.
- Respect consumers’ cultural
differences or views. A consumer who is Jewish should have
the right to light Chanukah candles in December. A consumer
who is Islamic should have the right to pray at sunset, even if it
means he or she has to leave in the middle of a group therapy session. You
and other staff need to be aware of, remember, and respect cultural
differences of the consumers you serve.
- The Recovery
Model is the focus of the mental health field, though its tenets
can and should be extrapolated to other service fields. The
goals of empowerment and self-actualization for traditionally disenfranchised
populations, which are inherent in the Recovery Model, are very
similar to the NASW Code of Ethics (1999), and the NASW’s
policy statements in Social Work Speaks (2003). Encouraging
these goals are inherent in what it means to be a social worker.
Finally, a critical underlying concept of the Recovery Model is
respect for the value and worth of each individual as an equal and
important member of society—another concept that social workers
will have no problem understanding.
REFERENCES:
- National Association of Social Workers. (1999). Code of Ethics
of the National Association of Social Workers. Washington,
DC: NASW Press.
- National Association of Social Workers. (2006). Social
Work Speaks, sixth edition: National Association of Social Workers
Policy Statements, 2006-2009. Washington, DC: NASW Press.
National Association of Social Workers, Office of Social Work Specialty
Practice. (2005). Social work snapshot: The transformation
of the mental health system. Retrieved from <http://www.socialworkers.org/practice/behavioral_health/1005snapshot.asp>
- Rammler, L. (2005). Person/Family-Centered Planning: The
Promise of Person/Family-Centered Planning. Welcoming remarks
at the U.S. Department of Health and Human Services, Substance
Abuse and Mental Health Services Administration, National Consensus
Conference on Person/Family-Centered Planning, Washington DC. Agenda
available from http://www.psych.uic.edu/uicnrtc/cmhs/pfcprecommendations.htm
-
- U.S. Department of Health and Human Services, Substance Abuse
and Mental Health Services Administration. (2005a, December).
National Consensus Conference on Person/Family-Centered Planning,
Washington DC. Available from http://www.psych.uic.edu/uicnrtc/cmhs/pfcphome.htm
- U. S. Department of Health and Human Services, Substance Abuse and
Mental Health Services Administration, Center for Mental Health Services.
(2005b, July/August). Mental health transformation trends: A
periodic briefing, 1 (3), 4.
NASW, February 2006
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