Using appreciative inquiry to facilitate implementation of the recovery model in mental health agencies.

Author:Clossey, Laurene
Position:Report
 
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Changing an organization's philosophy is not a simple task. New mission statements, policies, and procedures are frequently insufficient to fundamentally change entrenched attitudes and customary methods of accomplishing tasks, especially when those methods are deeply rooted in organizational cultures. The recovery model represents a new philosophical approach to the treatment of mental illness that differs from established medical model approaches. Thus, difficulties adapting to recovery are likely to be common in agencies seeking to implement this model. The present article argues that organizational culture must be taken into account to ensure effective implementation of the recovery model. Recovery requires client empowerment. It is important that a recovery-oriented agency model this approach by empowering direct care staff (Clossey & Rowlett, 2008). Staff empowerment can result in change in an agency's cultural context. Appreciative inquiry (AI) is an organizational change tool that empowers agency participants, thus helping to create a recovery supportive context.

"Culture can be viewed as a bubble of meaning covering the world, a bubble we both create and live within" (Czarniawska-Joerges, 1991, p. 287). Organizational culture is created by stakeholders through words, manner of conversing, and other ways of interacting that reflect deeply held values and attitudes about the way an agency should function. As an organizational change tool, AI targets culture change by altering an agency's dominant discourse and empowering staff. AI has been used successfully in fields such as business and nursing and possesses a philosophy consistent with recovery, but it has rarely been considered in the mental health literature.

This article defines the recovery model, presents a literature review illustrating the importance of addressing organizational culture when implementing new services, and defines and explains AI. Use of AI is explicated by describing the experiences of two mental health agencies that used it to aid in making the change from medical model to recovery model care. Directions for future implementation research are also discussed.

RECOVERY MODEL

The recovery model "is a treatment concept wherein a service environment is designed such that consumers have primary control over decisions about their own care" (NASW Office of Social Work Specialty Practice, 2006). Recovery can be seen as a way of living life with hope and possibility in spite of the presence of mental illness (Anthony, 1993). The recovery model challenges the traditional understanding of mental illness as chronic and debilitating. Recovery advocates point toward two classic longitudinal studies of mental health outcomes that challenge long-standing assumptions of chronicity and decline (Harding, Brooks, Ashikaga, Strauss, & Breier, 1986a, 1986b; Huber, Gross, & Scuttler, 1975). In addition, Warner (2009) cited recent work advocating an optimistic trajectory for sufferers of mental illness. Individuals diagnosed with severe mental illness have written about their experiences living rewarding and rich lives while coping successfully with their disease (Chamberlin, 1998; Chovil, 2005; Copeland, 2001; Deegan, 1996; Fisher, 2003).

Often, the recovery model is defined in opposition to the medical model. The medical model maintains that mental illness is a chronic condition, with a prognosis of decline in functioning unless there is appropriate diagnosis and treatment. The emphasis is on expert power and control over consumers' care. In contrast, recovery emphasizes the creation of an empowering community where clients are the experts in their own care. The medical model focuses on disease, whereas recovery focuses on wellness, strength, and resilience (Swarbrick, 2006). Such different worldviews implicitly engender disparate cultural perspectives.

Carpenter (2002) has provided a persuasive argument for the recovery model's consistency with social work values, noting that its emphasis on empowerment and hope parallels social work's valuation of self-determination. She observed that recovery's focus on alleviation of stigma should be shared by a profession that underscores the dignity and worth of all human beings. Social workers will be integrally involved in the current shift toward recovery-oriented care, and they should understand the impact that agency culture could have on implementation. A staff accustomed to hierarchical medical model cultures will not typically be empowered to contribute to the functioning of their agency. Yet, if this were changed, an attitude more consistent with recovery's privileging of community and empowerment could be cultivated.

The recovery model has detractors who perceive it as an ideological fad (Davidson, O'Connel,Tondora, Styron, & Kangas, 2006), as not appropriate for all clients, and as potentially in conflict with the move toward evidence-based care (Frese, Stanley, Kress, & Vogel-Scibilia, 2001). Others have confounded it with an antipsychiatric stance (Ianovski, 2009). It is very difficult to implement a client-driven approach in agencies accustomed to medical model care, which holds clinicians accountable for client symptom management, funding reimbursement, and maintenance of a positive image in a society with continuous concerns about a much-stigmatized group (Ianovski, 2009).

CREATING RECOVERY-ORIENTED SERVICE MODELS

Since the 1990s, many states have adopted the recovery model as a framework for mental health services. Guidelines have been published regarding implementation. Torrey and Wyzik (2000) noted the need to change mental health organizational structure. Farkas, Gagne, Anthony, and Chamberlin (2005) advocated developing guiding principles regarding how staffs are hired, educated, and overseen to be sure that they are faithful to recovery-oriented practice. However, research indicates that such structural and policy changes can be insufficient to truly ensure staff buy-in to recovery. Linhorst (2006) suggested that some settings have co-opted recovery rhetoric without substance. Davidson et al. (2006) documented 10 common concerns that mental health providers express regarding recovery: (1) positive, empowering helping alliances with consumers are already commonplace; (2) recovery adds to workloads; (3) recovery means clients are cured; (4) only a minority of clients recover; (5) recovery represents a reckless craze currently in vogue; (6) recovery occurs because of the medical model it seeks to supplant; (7) recovery requires new, expensive services; (8) recovery cannot be remunerated, nor can it be evidence based; (9) recovery seeks to render professional training pointless; and (10) recovery exposes mental health providers to liability by encouraging clients with severe impairment to make their own choices and treatment decisions. Gill (2009) has observed that in many settings,"the status quo remains unchanged" in spite of ongoing attempts to transform many state mental health systems.

Hemmelgarn, Glisson, and Lawrence (2006) explained that certain behavioral norms in an organization have "survival value," noting that some work environments...

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