This installment of Moving Forward, Together discusses how to create a culture of recovery. The PDF version includes an organizational self-assessment. (Authors)

Moving Forward, Together: Create a Recovery Culture in the Agency

Over the last decade, the concepts and principles of recovery gained wide acceptance in mental health, substance use, and trauma services. Part of that acceptance emanated from the understanding that almost everyone, at some point in life, will experience the impact of loss and recovery. The vision articulated in the President’s New Freedom Commission on Mental Health can be a guiding force as agencies work toward integrating consumers into their systems. The commission called for a fundamental transformation of mental health provision to a recovery-oriented system, with consumers and families at the heart (New Freedom Commission on Mental Health, 2003).

Creating a recovery culture begins with shifting assumptions about individuals from a deficit focus to a strength-based focus. In other words, such a shift means assessing people and organizations through the lens of possibility and strength. To incorporate a recovery-oriented culture, organizations have to shift fundamentally how they share power and responsibility (Jacobson & Curtis, 2000). Recovery cultures are dynamic and energizing because they provide opportunities for everyone, staff and consumers alike, to learn and grow in a safe environment.

When agencies take steps toward operationalizing the values, assumptions, and recovery principles illustrated in Table 1: Guiding the Transformation of Service Systems Using Individual Recovery Principles, it enhances the chances of attracting and sustaining the active participation of people with experiences of homelessness. Table 1 below provides guidance on the paradigm shift involved in moving from a traditional service delivery approach to a recovery-based, trauma-informed approach. The table draws parallels between how core dimensions of individual recovery apply to people receiving services (as illustrated in column B), and how those ideas translate into key areas of organizational change (see column C).

Agencies can use the statements as guidelines for developing questions or checklists to gather information from agency personnel along a timeline. Asking questions at a baseline and again 6 months later, programs can gauge their own progress as they move toward becoming more recovery-oriented and trauma-informed.

Download the attachment for a table of Guiding the Transformation of Service Systems Using Individual Recovery Principles.

Set the Stage: Prepare for Change

Making fundamental changes in organizational culture can be difficult, as noted by one participant, “Everyone talks about equality out loud, but the hard work is to create an atmosphere for self-reflection, so people can come to understand what they are really feeling about [consumer involvement]…not just what other people want them to feel or think.”

The success of consumer integration vastly improves through: (a) strong leadership willing to articulate a vision of integration and communicate those values to all staff; (b) meetings with people at multiple levels of agency operations to discuss consumer integration initiatives and gain buy-in; (c) assessing the environment to identify potential organizational strengths/support and obstacles/barriers to integration efforts; and (d) orienting agency members to a recovery philosophy.

Some agencies prepared their organizations for change using dialogue forums, program retreats, and facilitated workshops as opportunities for administrators and staff (including board members and volunteers) to reflect on a variety of topics related to recovery, including plans for integration. Dialogue forums give everyone a chance to explore new ideas, examine assumptions, and exchange information. Potent topics for raising awareness might include:

• Who are consumers?
• Benefits and drawbacks of disclosing personal experience.
• Everyone talks about recovery, but what does it really mean?
• What’s in a name? The power of labels and person-first language.
• What does it mean to be trauma-informed?
• Aren’t all services person-centered?
• Physical and emotional adaptations in creating reasonable accommodation.

More ideas for discussion are below under individual and environmental assessment.

In an effort to build trust and foster organizational transparency, Ellen Healion, Executive Director of Hands Across Long Island (HALI), implemented an open door policy. She finds that encouraging staff to ask questions, voice concerns, and offer solutions builds agency community. She notes that when people feel valued and respected, they are more empowered, flexible, and open to change.

Provide Opportunities for Individual and Environmental Assessment

One starting point for this kind of organizational effort is for staff and administration to examine personal assumptions and beliefs about integrating people with experiences of homelessness into the agency culture. The answers to these questions lay the groundwork for all other efforts to follow, including a general environmental assessment and specific review of policies and practices pertaining to integration.

When assessing the general environment, agencies may want to consider a number of existing instruments designed to measure the degree to which mental health and addiction programs promote recovery. Some of these instruments may adapt for use in programs delivering services to people who are homeless as well. The Recovery Self-Assessment (O’Connell et al., 2005) is a 36-item, self-reflective tool used in mental health and addiction agencies to measure the degree to which practices facilitate or impede recovery. There are four versions: person in recovery; family member/advocate; provider; and CEO and directors. In addition, the Recovery Oriented Systems Indicators Measure (ROSI) (Dumont et al., 2006) provides agencies with a tool for bridging the gap between the principles of recovery and the application of these principles to the work environment (Onken et al., 2004).

Examine Personal Assumptions and Beliefs

Taking time to ask open-ended questions makes it possible to tease out closely held assumptions that often covertly drive the organizational culture, policy, and practice.

• Do I personally believe that recovery is possible for everyone?
• Am I ready and able to do what it takes to create a recovery-oriented environment that puts these principles and values into action?
• What is the vision for involving consumers who are currently or formerly homeless?
• Can I identify sufficient resources and is the organization willing to commit them to consumer integration?

Creating an open atmosphere helps set the stage for environmental assessment that takes into account strengths as well as barriers. Focusing on what works is as important as identifying challenges when inspiring people to find solutions as partners. One California agency refers to this as the “nurturing heart approach,” emphasizing capacity, hope, strength, and connection.

Assess the Agency Atmosphere

The following questions pertain to assessing the overall tenor of the environmental atmosphere where people congregate, do business, and receive and deliver services. When people walk into a building, shelter, drop-in center, food pantry, or meet people on the street, how do they know if the environment or interaction is recovery-oriented or person-centered?

• Are people acting in ways that value connection and relationship?
• Are people interacting in a respectful way?
• Do people use person-first language in the environment?
• Is the environment tense? Or is it relaxed and open?
• Is the leadership visible, known, and accessible to everyone in the agency?

Identify Next Steps to Integrate Consumers and Formulate a Plan to Sustain Efforts

The next step in the assessment process is to answer additional questions specific to consumer integration in the agency. Ensuing discussions may encompass such topics as the degree of staff support for transformation, identifying barriers to consumer involvement, and formulating a plan to address next steps. Integrating people with experiences of homelessness is a large commitment requiring the participation of all staff including board members, volunteers, and administrators (Jonikas, Solomon, & Cook, 1997). Not all questions pertain to every environment and the addition of other questions depends on the specific service offered.

• Do the mission, vision, and policies of the agency promote consumer integration and reflect language and values confluent with recovery-oriented approaches?
• Is there a developed plan that includes specific goals for integration?
• Do staff members (volunteers, board members) know the agency goals for integrating people with experiences of homelessness?
• What is the perception of these goals?
• Are people aware of what role they can play in supporting agency efforts?

Establish Consumer Leadership Early in the Process

Establishing consumer leadership early in the process of organizational change makes a strong statement about the agency’s commitment to consumer integration. It immediately creates a visible and accountable presence for the integration process. Agencies involving consumer leadership proactively also save time and resources because of the benefit of consumer input into early decisions regarding budget, strategic plans, hiring practices, and policy. To effect lasting change, establishment of consumer positions should be at senior levels where the leadership deliberates on and makes decisions regarding strategic direction and resource utilization.

One way to formalize the integration process in an agency is to hire a “Director of Peer/Consumer Affairs” or “Director of Peer Integration” to lead the effort. When possible, this position can be a paid one. It is best if this person does not have to “go it alone.” One strategy is to develop a Consumer Advisory Committee to work closely in conjunction with the person in that position to help ensure organizational efforts are on track throughout the integration process. Under the leadership of the director, the duties of an advisory committee could include: (a) helping leadership to develop a strategic plan for integration; (b) tracking and reporting progress; (c) providing technical assistance on integration; (d) helping leadership develop accommodations in personnel policies; (e) identifying people in the community to contribute to the process; (f) screening applicants and making recommendations; (g) creating a pool of potential consumers; (h) training consumers; and (i) developing orientation materials and providing orientation.

Train and Orient Staff in Recovery Principles

Since cultural change can be an important step in system transformation, it is helpful to familiarize everyone with a recovery philosophy that emphasizes the importance of consumer integration from the beginning. An agency in New Jersey established a Wellness and Recovery Committee charged with disseminating the Wellness and Recovery Action Plan (WRAP) model throughout the organization of 300–400 staff. The goal is to provide education, training, and ongoing consultation to the various departments implementing the model as they attempt the transformation of their agency practice and environment to a recovery-oriented, healing place for staff and people receiving services. The WRAP model easily exports and adapts to various environments supporting proactive partnerships between consumers and staff. Two other models for training administrators, providers, consumers, and others who want to transform their systems to a recovery culture include the Georgia Peers Specialist Training model, and the Personal Assistance in Community Existence (PACE) model developed by Laurie Ahern and Dan Fisher, M.D., Ph.D. The PACE manual features information on the empowerment model of recovery, principles, and research (Ahern & Fisher, n.d.).

Check out the “Related Items” to the right of the screen.

References:

Ahern, L. & Fisher, D. (n.d.). Personal Assistance in Community Existence (PACE) Curriculum. Lawrence, MA: National Empowerment Center. Available from http://www.power2u.org/mm5/merchant.mvc?Screen=CTGY&Store_Code=NEC&Category_Code=curricula

Dumont, J., Ridgway, P., Onken, S., Dornan, D., & Ralph, R. (2006). Mental Health Recovery: What Helps and What Hinders? A National Research Project for the Development of Recovery Facilitating System Performance Indicators. Alexandria, VA: National Association of State Program Directors Technical Assistance Center. Available from http://www.power2u.org/downloads/ROSI-Recovery%20Oriented%20Systems%20Indicators.pdf

Jacobson, N., & Curtis, L. (2000). Recovery as a policy in mental health services: Strategies emerging from the states. Psychiatric Rehabilitation Journal, 23(4) 333–341.

Jonikas, J. A., Solomon, M. L., & Cook, J. A. (1997). An inclusion framework: Preparing psychosocial rehabilitation programs and staff for the consumer hiring initiative. In C. T. Mowbray, D. P. Moxley, C. A. Jasper, & L. L. Howell (Eds.), Consumers as Providers in Psychiatric Rehabilitation (pp. 419–455). Columbia, MD: International Association of Psychosocial Rehabilitation Services.

New Freedom Commission on Mental Health. (2003). Achieving the promise: Transforming mental health care in America: Final Report (DHHS Publication No. SMA-03-3832). Rockville, MD: Author.

O’Connell, M., Tondora, J., Croog, G., Evans, A., & Davidson, L. (2005). From rhetoric to routine: Assessing recovery-oriented practices in a state mental health and addiction system. Psychiatric Rehabilitation Journal, 28, 378–386. Available from http://www.yale.edu/PRCH/tools/rec_selfassessment.html

Onken, S. (2004). At the system level: Consumer self-report survey and administrative data profile. In Tools in development: Measuring recovery at the individual, program, and system levels. Available from http://www.nasmhpd.org/spec_e-report_fall04measures.cfm