Recovery
Recovery - - Oriented Practices Oriented Practices Index: Development, Use, and Index: Development, Use, and
Role in Policy Implementation Role in Policy Implementation
Anthony D. Mancini, PhD Anthony D. Mancini, PhD
Teachers College, Columbia University Teachers College, Columbia University
April 30
April 30th,th, 20072007 Scottish Recovery Indicator
Scottish Recovery Indicator ConferenceConference
Outline of Talk Outline of Talk
1. Background on theory and research on recovery-orientation
2. Development process for recovery- oriented practices index (ROPI)
3. Modifications for the Scottish Recovery Index (SRI)
4. Use of the ROPI (or SRI)
5. Description of system-level changes in New York
Background on Recovery Background on Recovery
Orientation Orientation
• Mental health recovery:
– Increasing focus of mental health policy in the US, UK, and around the world
– Traces to consumer-survivor literature and
longitudinal studies on recovery from severe mental illness
– No single criterion—often self-determined
• As process (non-linear, personal journey, embrace of hope, overcoming effects of institutionalization)
• As outcome (fulfillment of life roles, reduced involvement in formal services, greater self-agency)
• As transaction with environment (rejection of “normal,”
acceptance of limitations, supportive relationships, role of policy-making)
Background on Recovery Background on Recovery
Orientation Orientation
• Despite varying definitions, some common themes have emerged:
– Identity formation (mental illness one facet of a more differentiated self)
– Autonomy/self-agency (greater capacity for self- initiated action; internal vs. external motivation) – Hope (renewed sense of possibility)
– Supportive-healing relationships (both professional and personal)
– Enhanced role functioning (employment, parenthood)
Background on Recovery Background on Recovery
Orientation Orientation
Indeed, the process of recovery has been well-
described…but what are its implications for mental health organisations and carers?
One obvious implication is that organisations should seek to leverage their services to enhance these facets of
recovery.
• But how?
• And is there evidence that recovery-enhancing strategies would work?
Background on Recovery Background on Recovery
Orientation Orientation
“The fullest representations of humanity show people to be curious, vital, and self-motivated.
At their best, they are agentic and inspired,
striving to learn; extend themselves; and apply their talents responsibly…Yet, it is also clear that the human spirit can be diminished or
crushed and that individuals sometimes reject growth and responsibility…
Background on Recovery Background on Recovery
Orientation Orientation
“The fact that human nature…can be either active or passive, constructive or indolent suggests more than mere dispositional
differences…It also bespeaks a wide range of reactions to social environments…Social
contexts catalyze motivation and personal growth.” (Ryan & Deci, 2000)
Background on Recovery Background on Recovery
Orientation Orientation
• Self-determination theory (SDT) provides a theoretical framework for recovery-orientation (Ryan & Deci, 2000):
– A motivational theory of human need fulfillment
– Three fundamental human needs: 1) autonomy, 2) competence, and 3) relatedness
– Satisfaction of these needs promotes well-being, feelings of security, and self-motivated behavior
Background on Recovery Background on Recovery
Orientation Orientation
• Empirical findings on SDT:
– Behavioral management of diabetes is predicted by perceptions of an autonomy-supportive health care environment
– Employees that report more need satisfaction (autonomy, competence, and relatedness) show better objective job performance
– Learning environments characterized by more autonomy support result in deeper processing of material, better test performance, and more persistence
– Enhancing autonomous motivation results in better treatment retention for substance abuse programs
– Many other studies have confirmed SDT’s postulates
Background on Recovery Background on Recovery
Orientation Orientation
Conclusion:
– Mental Health organisations can address these basic human needs through their
services, policies, and underlying philosophy – Broadly speaking, recovery-oriented practices
are intended to enhance service users’
feelings of autonomy, competence and relatedness
Developing a Scale for Recovery Developing a Scale for Recovery - -
Oriented Practices Oriented Practices
Six Steps:
1) Identified 11 prior self-report recovery scales and 4 typologies of recovery practice
2) Content analysis and classification of items across scales (e.g., consumer involvement in treatment, use of self-help, family involved in services,
employment services)
3) Further refinement based on latent content (e.g., choice, community integration)
4) Principles of recovery-orientation abstracted based on latent themes
5) Item construction to capture principle
6) Subsequent refinement through expert review and further revision
Developing a Scale for Recovery Developing a Scale for Recovery - -
Oriented Practices Oriented Practices
Eight principles* of recovery-oriented care resulted:
1. Meeting basic needs
2. Comprehensive services 3. Customization and choice
4. Consumer involvement and participation 5. Network supports/community integration 6. Strengths-based approach
7. Self-determination 8. Recovery focus
*The SRI uses these same principles but with different language appropriate to the Scottish service context
Developing a Scale for Recovery Developing a Scale for Recovery - -
Oriented Practices Oriented Practices
• We translated the 8 principles by focusing on basic program functions:
– Nature of services
– Documentation (assessment, care plans) – Policies and procedures
– Program brochures, literature – Staffing
• 20 items emerged with 5-point behaviorally anchored response alternatives
• Approach was modeled on fidelity scales, which have demonstrated the value of an organisation-level
assessment
Developing a Scale for Recovery Developing a Scale for Recovery - -
Oriented Practices: Validation Oriented Practices: Validation
• We piloted the ROPI at a variety of mental health programs in New York State (N = 14)
– Assertive community treatment (ACT) – Day treatment
– Vocational
– Consumer-run clubhouse
• Most programs were participating in large New York State policy initiative
– New licensed program type designed to embody recovery principles—Personalized Recovery Oriented Services
(PROS)
– ROPI used as an evaluation tool for this initiative
Developing a Scale for Recovery Developing a Scale for Recovery - -
Oriented Practices: Validation Oriented Practices: Validation
• To assess construct validity, we used the recovery self- assessment scale (RSAS), a self-report measure for recovery-oriented practices
• RSAS was administered to staff and administrators
• We examined the program-level association between the RSAS and ROPI scores
• A strong correlation emerged (r = .74, p < .01)
• Finding demonstrated that staff reports of recovery orientation were consistent with the organization-level data of the ROPI
Developing a Scale for Recovery Developing a Scale for Recovery - -
Oriented Practices Oriented Practices
Modifications: ROPI
Modifications: ROPI → → SRI SRI
• SRI is substantially the same as the ROPI
• Changes reflect different cultural and service contexts (e.g., “consumers” vs.
“service users”)
• Some additional content was added (e.g., regarding supervision)
• Overall, changes are minor and the instruments are essentially equivalent
Using the ROPI (or SRI) Using the ROPI (or SRI)
• 4½ – 6 hours to complete
• At least 2 surveyors
• Three separate processes:
– 1) Interviews with senior administrators, carers, and service users
– 2) Document review, including a) treatment records;
b) policy manuals; c) program materials—brochures, newsletters, etc.
– 3) Consensus scoring based on accumulated data while on site
Using the ROPI (or SRI) Using the ROPI (or SRI)
• Interviews (2 - 3 hours)
– Senior administrators or managers (1 - 1.5 hrs)
• Organization-level philosophy of care
• Policies relating to care provision
• Treatment services provided
– Carers (.50 - .75 hrs)
• Nature of services (e.g., type of services and degree of personalisation)
– Service users (.50 - .75 hrs)
• Perception of services (e.g., personalised, goal focus, involvement of support system)
Using the ROPI (or SRI) Using the ROPI (or SRI)
• Review of documentation and materials (about 2 hrs):
– 10 treatment records/care plans (1.25 hrs)
– Program policy manual (.5 hrs)
– Program documentation, brochures (.25 hrs)
Using the ROPI (or SRI) Using the ROPI (or SRI)
• Scoring (1 hour)
– Done at conclusion of visit
– Based on accumulated data and subjective impressions
– Surveyors share impressions and arrive at consensus for scoring each of the
indicators
Using the ROPI (or SRI) Using the ROPI (or SRI)
Feedback to program:
• Brief report itemizing SRI scores
• Cite data and observations to support scores
• Invoke broader themes and encouraging findings
• Concrete suggestions (e.g., care plans more personalised)
• Meet with senior managers to communicate findings
Implementing Change in New York Implementing Change in New York State: Lessons from Two Initiatives State: Lessons from Two Initiatives
Recovery-Oriented Practices Initiatives:
1. Personalised Recovery-Oriented Services (PROS) program
– Mandated restructuring to consolidate diverse program types (e.g., vocational, consumer-run, and day treatment)
– Fiscal guidelines created incentives (and requirements) for recovery-oriented practices
– ROPI used as an evaluation tool to measure pre- and post- recovery orientation
– Initiative is ongoing
Implementing Change in New York Implementing Change in New York State: Lessons from Two Initiatives State: Lessons from Two Initiatives
2. Assertive Community Treatment (ACT):
– Community-based model of care for persons with severe mental illness
– Created a fiscal structure for community-based services
– New program license
– Hired consultants and trainers to help programs meet standards and understand the ACT model – Used audits and technical assistance to promote
adherence to the practice model
Implementing
Implementing Change in New York State: Lessons from 2 Initiatives
• New York’s approach emphasized fiscal restructuring and program monitoring
• Audits monitored program adherence to ACT model
• Poor scores were linked to sanctions
• Approach was more stick than carrot
Implementing Change in New York Implementing Change in New York State: Lessons from Two Initiatives State: Lessons from Two Initiatives
Some Drawbacks of New York’s approach:
• Standards for practice were implemented
inflexibly and varied by administrative region
• Negative audits had a demoralizing effect on administrators and practitioners
• Heightened tensions between providers and NY state
• “Reified” practice standards
Implementing Change in New York Implementing Change in New York State: Lessons from Two Initiatives State: Lessons from Two Initiatives
Some conclusions:
• A more supportive approach that
emphasized partnership would have been more effective
• Implementation of policy should be consistent with the policy itself
• Service providers and administrators
should be empowered to make choices
Final Thoughts
Recovery-oriented practices are:
• Increasingly agreed-upon
• Supported by theory and research
• Measurable at the organisation level
An index of recovery-oriented practices can:
• Orient providers to basic practices and principles
• Mark change over time
• Be used collaboratively and supportively
• Form the basis for further discussion and refinement of ideas regarding practice
