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MENTAL HEALTH RECOVERY: WHAT HELPS AND WHAT HINDERS?. A National Research Project for the Development of Recovery Facilitating System Performance Indicators. The Notion of Recovery.

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mental health recovery what helps and what hinders


A National Research Project for the Development of Recovery Facilitating System Performance Indicators.

the notion of recovery
The Notion of Recovery
  • Recovery or Procovery is being coined as a way of acknowledging that people can successfully contend with severe mental illness and still create positive lives.
  • Recovery is grounded in resiliency - existing key internal processes that enable an individual to surmount crises and persistent stresses (Walsh, 1996) – the innate strength, self-righting capacity and hardiness of that individual.
working definition of recovery
Working Definition of Recovery:
  • An ongoing dynamic interactional process between a person’s strengths, vulnerabilities, resources and the environment that involves a personal journey of actively self-managing psychiatric disorder while reclaiming, gaining and maintaining a positive sense of self, roles and life beyond the mental health system (in spite of the challenge of psychiatric disability).
  • It involves learning to approach each day’s challenges, to overcome disabilities, to live independently and to contribute to society and is supported by a foundation based on on hope, belief, personal power, respect, connections and self-determination .
  • Recovery does not mean an outcome of cure (Deegan, 1996; Walsh, 1999).
  • Recovery occurs even though symptoms reoccur (Anthony, 1993). People still struggle with the episodic nature of their symptoms, grieve the losses they have sustained and struggle with the reoccurring multiple traumas they have experienced.
  • The recovery process itself can trigger symptomatic responses as a person becomes more active on his or her own behalf and opens up to more vulnerabilities (Spaniol, Gagne & Koehler, 1999). Part of recovery is this process of risk taking.
  • To increase knowledge about what facilitates or hinders recovery from psychiatric disabilities,
  • To devise a core set of indicators that measure elements of a recovery-facilitating environment, and
  • To integrate the items into a multi-state “report card” of mental health system performance in order to generate comparable data across state and local mental health systems.
overview of project phase one
Overview of Project: Phase One
  • A qualitative research design to create grounded theory
  • It incorporates a structured focus group approach with a purposive variability sample frame
  • The data collected from each focus group undergoes structured content analysis identifying individual meaning units and emerging groupings
  • A common set of critical concepts and interpretive themes is then developed for the pooled data set across all focus groups
  • A member check is conducted to maintain rigor and assure credibility
  • While recovery is a deeply personal journey, there are many commonalities in people’s experiences and opinions.
  • Recovery is facilitated or impeded through the dynamic interplay of many forces that are complex, synergistic and linked.
cross site themes
Basic Material Resources

Self/Whole Person

Hope, Sense of Meaning & Purpose



Social Relationships

Meaningful Activities

Peer Support

Formal Services

Formal Service Staff

Cross-Site Themes
recovery is a product of dynamic interaction among
Recovery is a product of dynamic interaction among
  • characteristics of the individual (the self/ the whole person, hope, sense of meaning & purpose),
  • characteristics of the environment (basic material resources, social relationships, meaningful activities, peer support, formal services, formal service staff), and
  • the characteristics of the exchange (hope, choice/empowerment, independence/interdependence).
findings the universal
Findings: The Universal

Often times it’s not about pathology, it’s just about life. (AZ 739)

the american dream
The American Dream
  • Basic Material Resources
    • Livable Income
    • Safe and Decent Housing
    • Health Care
    • Transportation
    • Communication Technology
  • Social Relationships/ Connectiveness
    • Families
    • Friends
    • Intimacy
  • Meaningful Activities
    • Educational Advancement
    • Real Jobs and Meaningful Careers
    • Volunteer Opportunities
    • Community and Organizational Advocacy
    • Role in Policy and Program Decision Making
findings the personal
Findings: The Personal

Live your life, not your diagnoses. (CO 1309)

self agency
Self Agency
  • Personal Responsibility
  • Beliefs and Attitudes
  • Self Reliance/Personal Resourcefulness
  • Self Care
  • Self Determination
  • Self Advocacy
the whole person
The Whole Person
  • Hope
  • Sense of Meaning and Purpose
  • Spirituality
  • Goals
  • Engaging in the Change Process
findings the activation
Findings: The Activation

It would be nice if a mental health center would say, “These are the services that we should be able to provide to you. We can’t because of funding. But if we could, they might actually be more helpful to your recovery process than what we do have to offer.” Because there’s something that’s really empowering in having at least that knowledge. (OK 856-860)

  • Choice
    • Information on
    • Access to
    • Range in
    • Meaningful and Useful
    • Support in Making
    • Risk Taking
  • Independence
    • Interdependence
  • Hope
findings referent power
Findings: Referent Power

Support from others is very important, especially from others who are in the same predicament that you are. They know what you go through. They've been through it, and they survived, which could help you survive. (TX 1258-61)

tribal strengths
Tribal Strengths
  • Peer Support
  • Peer Education
  • Peer Outreach
  • Alternative Services
  • Peer Role Models
  • Peer Mentors
  • Peer Advocates
findings the system
Findings: The System

The system should assume that every person that walks through the door has the potential for recovery rather than the opposite – just automatically assume that recovery is possible. (SC 1286)

formal services
Formal Services
  • Culture and Organization
    • Consumer Voice/ Driven/ Outcomes
  • Structure
    • Funding
  • Information and Education
  • Access
    • Choice
  • Quality
    • Range
  • Continuity
findings partnership
Findings: Partnership

The right staff with patience, time and understanding can help you move along toward recovery. (NYC, 239)

system staff
System Staff
  • Beliefs and Attitudes
  • Respect
  • Partnership
  • Training and Knowledge
  • Authenticity
  • Availability
moving from a chronicity to a recovery paradigm
Diagnostic groupings; “Case”; Lumped and labeled as “chronics”/ SPMI/ CMI

Pessimistic Prognosis; “Broken Brain”

Pathology/ Deficits; Vulnerabilities Emphasized; Problem-Orientation

Fragmented Biological/ Psychosocial/ Oppression Models

Professional Assessment of “Best Interests” and Needs/ Paternalism 

Unique identity; Person orientated; Person First Language

Hope and Realistic Optimism

Strengths/ Hardiness/ Resilience; Self-Righting Capacities Emphasized

Integrated Bio-Psycho-Social-Spiritual Holism; Life-context

Self-Definition of Needs and Goals/ Voice/ Consumer-Driven/ Self-determination 

Moving from a Chronicity to a Recovery Paradigm
paradigm shift
Professional Control/ Expert Services

Power Over/ Coercion/ Force/ Compliance

Reliance on Formal Supports or “Independence”

Social Segregation; Formal Program Settings; Deviancy-Amplifying Artificial Settings

Maintenance/ Stabilization; Risk-Avoidance

Self-Help/ Experiential Wisdom/ Mutuality/ Self-Care/ Partnering with Professionals

Empowerment/ Choice

Emphasis on Natural Supports;


Integration; “Real Life” Niches; Natural Community Resources/ In Vivo Services and Supports

Active Growth/ New Skills & Knowledge/ Dignity of Risk

Paradigm Shift
paradigm shift26
Patient/ Client/ Consumer Role

Resource Limitations/ Poverty

Helplessness/ Passivity/ Adaptive Dependency

Normative Roles/ Natural Life Rhythms

Asset building/ Opportunities

Self-Efficacy/ Self-Sufficiency/Self-Reliance

Paradigm Shift
overview of project phase two
Overview of Project: Phase Two
  • The findings from Phase One are being operationalized into prototype performance indicator item sets that measure system-level variables that help or hinder consumers/ survivors in their process of recovery.
  • The resulting instrument will then be fine-tuned for pilot testing in participating states.
  • Steady movement toward evidence-based practice – science matters
  • Clinical need outstrips research – experience matters
  • Recognition that the body and brain are connected – the body matters
  • Recognition that the present is always determining the future – dreams matter
  • Recognition of role of social support, social norms, social meaning and responsibility – people, families, culture, communities matter
  • Recognition of important role of meaning-making – religion, spirituality, philosophy matter
  • Recognition of important role of mind-body-spirit integration – the whole matters
  • Growth in understanding of multicausality, need for integrated conceptual framework, treatment, and systems approach = complexity
item development
Item Development
  • Brainstorming multiple performance indicator statements as review each domain/theme and corresponding branching
  • Editing and refining the indicator items brainstormed, a process of reaching consensus on wording of the indicators items, eliminating redundancies, etc.
  • Checking the items against the codebook and findings to ensure comprehensiveness (sometimes resulting in additional generation of indicator items)
item development31
Item Development
  • Reviewing current performance measurement efforts as a further means of refining, editing and developing a full range of indicators
  • Selecting appropriate response scales (e.g., frequency, agreement or valuation) and identify the source of response
  • Conducting a think aloud session with a diverse group of consumer/survivors, working with the participants to refine each item in such as way that its meaning is clear while retaining fidelity to what is intended to be measured
item development32
Item Development
  • Proto-testing the resulting self-report survey with 100 consumers/survivors, resulting in further refinements and elimination of redundant items (e.g., assessing Chronbach’s alpha for internal consistency, etc.)
  • Soliciting review and feedback with the SMHAs, project sponsors, and the MHSIP 2.0 Workgroup regarding such elements as significance, relevance, and implementation burden of the self-report survey indicator set and of the individual administrative-level performance indicators
member check priorities
Peer support groups & peer run services 60

Choice in treatment/ services 44

Meaningful employment/ work 42

Liveable income 39

Helpful staff attitudes/ qualities 32

Hindering staff attitudes/ qualities 31

Partnering/ collaborative relationships w/ providers 30

Helpful system culture and orientation 27

Affordable housing 26

Consumer driven service system 25

Helpful self internal states/attitudes 25

Hindering system culture and orientation 24

Member Check Priorities:
member check priorities34
Hindering formal system qualities 23

Access to services problems 22

Benefits/ entitlements 22

Peer recovery models 22

Spirituality 19

Self reliance/ resource-fulness/responsibility 18

Disabling conditions (hindering) 15

Education about disorder/ recovery 15

Ex stigma/prejudice 14

Having someone who believes in me 11

Responsive roles staff 10

Choice where live/ housing 10

Medications 9

Hindering staff-consumer relationship 9

Educational activities 9

Member Check Priorities:
demystifying recovery
Demystifying Recovery
  • In all my years experience with psychiatric professionals, the one thing that’s been most heartening is when the professional acknowledges the common humanity, theirs and mine, ours together. (CO 2172)
  • Recovery is not so much getting mainstreamed, but expanding the mainstream to incorporate the fringes (Deegan, 1996).
  • The goal is not so much as that of becoming normal as to become more deeply, more fully human in whatever unique way one is meant to be (Deegan, 1996).
concluding quote
Concluding Quote

We can’t stop here but there’s hope in watching the system evolve and the changes that are taking place (OK 2350-2352).