NASW Practice Snapshot:
The Mental Health Recovery Model

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:
  1. 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. 
  2. 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. 
  3. 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.
  4. 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. 
  5. 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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