Recovery in Australia: Marshalling strengths and living values

Abstract

Clear national policy now exists in Australia regarding recovery. Personal accounts of recovery often include reference to meaning, purpose and issues regarding identity. Personal strengths and expression of personal values are closely related to the development of meaning, purpose and a stable sense of self, resulting in a sense of wellbeing. These constructs fall under the research umbrella of positive psychology. By combining aspects of the recovery policy with evidence from the science of positive psychology there are increasing attempts to include strengths and values work with mental health staff and consumers. This paper describes how the collaborative recovery model (CRM) with its emphasis on strengths and values, draws on the emerging evidence based on positive psychology. CRM has now been implemented in non-government community services in each mainland state of Australia. Implementation issues of the CRM as one example of recovery-orientated service provision are then described. Potential barriers and facilitators of growth-based approaches such as CRM moving to government clinical services is then discussed. Recent national reviews of recovery measurement instruments are also summarized. Specific recommendations are then provided to further national implementation of recovery-orientated service provision in Australia.

Introduction

In contrast to the USA's history of radical anti-psychiatry and human rights advocacy, underpinning recovery (Adams, this issue, pp. 70–78) the Australian development of recovery orientation has been less overtly consistent with Australian politics. Punctuated by reforms, e.g. the Burdekin report (Commonwealth of Australia, 1993), major developments in policy have occurred gradually, supported by national policy documents including the series of national mental health plans. Sociologists may argue that whilst the advocacy for human rights in Australia may be less explicit than in the USA, for example, the underlying ethos of egalitarianism in Australian culture is consistent with the ‘power reclamation’ component of the recovery movement. Whether or not the sardonic and irreverent humour arises from Irish immigrants challenging British aristocracy or not, most social analyses of Australia will demonstrate an intolerance of one class over another (Spillane, 2011). In many ways this, however, has not been fully reflected in the structures of mental health systems, possibly because many of the original mental health hospitals were designed in a post-colonial environment. Hence, a full movement towards recovery-orientated service provision, peer support approaches is not incongruent with Australian culture and the ethos of a ‘fair go’ for all, and an underlying concern about quality of life in Australia, not only economic gain.

Hence, at a policy level in Australia, recovery orientated service provision is mainstream and listed as the first priority alongside social inclusion. This is alongside what may be seen as a recent ‘flurry of activity’ at the political and policy level. In December of 2011, the federal government of the Commonwealth of Australia announced a cabinet reshuffle, promoting the Minister of Mental Health to cabinet, following the recent establishment of a national Mental Health Commission. Mental health commissions have also been recently established in New South Wales and Western Australia. Broadly speaking, tangible increases in mental health spending have also occurred recently at federal and state levels of government. Moreover, the federal government has recently announced its movement towards a national disability insurance scheme, consistent with broader measures of social inclusion. Hence, a visitor to Australia is likely to experience that the opportunities to realize recovery-orientated service provision are significant. Notwithstanding these developments, and international recognition of Australian approaches to early intervention, recovery-orientated practice based on principles of strengths, self-determination and growth remain an exception rather than standard practice across most government funded adult mental health services (Glover, 2005).

Social inclusion and recovery is named as priority area one in the Fourth National Mental Health Plan 2009–2014 in Australia (Australian Health Ministers, 2009). This ‘agenda for collaborative government action’ adopts the following definition of recovery:

A personal process of changing one's attitudes, values, feelings, goals, skills and/or roles. It involves the development of new meaning and purpose and a satisfying, hopeful and contributing life as the person grows beyond the effects of psychiatric disability. The process of recovery must be supported by individually identified essential services and resources. (Australian Health Ministers, 2009, p. 26)

The priority area of social inclusion and recovery within the current Australian national mental health plan asserts adoption of a recovery-orientated culture within mental health services, underpinned by appropriate values and service models.

The following is an excerpt from the reference to the priority of social inclusion and recovery in the Fourth National Mental Health Plan.

Elements of this approach include targeted workforce development, establishment of an effective peer support workforce, and expansion of opportunities for meaningful involvement of consumers and carers. From the perspective of people with emotional, physical, sensory or intellectual differences, they overwhelmingly report their experience as being one of social exclusion. The link between disability and social exclusion is well documented. Meaningful and diverse means of addressing structural barriers that exist for people excluded because of emotional and psychosocial experiences need to be developed to begin to expand opportunities for enhanced participation of consumers and carers. Consumer and carer leaders need to actively promote, lobby and encourage an approach that introduces and acknowledges best practice in policy and activity. This approach should promote the individual's value and strengths [our emphasis], encourage participation and relevant and equitable service provision. Best practice models that promote the development of a certified peer specialist workforce accountable to peers and to funders are elements of a recovery-orientated framework of service provision. (Australian Health Ministers, 2009, p. 28)

An emphasis on strengths and values appears common to both recovery orientations and the emerging sub-discipline of positive psychology. This convergence is described before considering an established Australian model of recovery-orientated service provision.

The convergence of recovery and positive psychology

Slade (2010) asserts that the emerging evidence surrounding well-being makes it possible for health services to orientate around promoting well-being as well as treating illness. Resnick and Rosenheck (2006) described parallels between positive psychology and personal recovery primarily focusing on strengths. Positive psychology and recovery do not use a negative starting point. Just as personal recovery research and practice may be informed by positive psychology principles, the sub-discipline of positive organizational scholarship (Cameron et al., 2003) provides a way to address organizational challenges in developing recovery-orientated mental health services (e.g. recovery-orientated services need optimistic staff members). Oades et al. (2012b) provide a range of examples of the use of positive psychology, and positive organizational principles may be used to underpin recovery-orientated service provision, with a particular focus on strengths and values.

Strengths and values underpinning recovery-orientated service provision

Bird et al. (under review) conducted a systematic review identifying 12 strengths assessments (five quantitative, seven qualitative). Psychometric properties of the assessments were assessed against set quality criteria. The Client Assessment of Strengths, Interests and Goals (CASIG) (Wallace et al., 2001) demonstrated the strongest psychometric evidence. Bird et al. identified 24 themes; they organized them into three overarching categories: individual factors, environmental factors and interpersonal factors. These categories form the basis of an empirically based definition of strengths that could be used as a conceptual foundation for new clinical assessments.

Within the positive psychology literature a range of strengths assessments exist including StrengthsFinder, Values in Action and Realise2. Research examining the relationship between strengths knowledge, strengths use and well-being continues to grow, and the process of strengths coaching has become well established (Linley & Harrington, 2006; Oades et al., 2009).

Values are closely related to strengths and can be understood as verbal representations of desirable life consequences or ways of behaving that are enduring and pervasive across situations and contexts (Hayes, 2004). Values are distinct from goals in that they are intangible and conceptual, whereas goals are more tangible and attainable. An example of a value may be ‘collaborating with individuals’, while a goal related to this could be ‘asking open-ended questions in my consultations.’

The Fourth National Mental Health Plan has identified the first of its five priority areas to be ‘Social Inclusion and Recovery’ (Australian Health Ministers, 2009) and asserts that mental health providers adopt cultres that are reflective of a recovery orientation, and which are founded upon appropriate values and models of service. Outside Australia, policy across much of the English speaking world emphasizes a recovery orientation to services (Slade et al., 2008).

There are significant limitations in the capacity of strategic initiatives to shape ground-level uptake of desired workplace practice. When values are espoused at the organizational level, or more broadly at the policy level, the risk is that these become distant, generic statements that are ‘imposed’ on services and their staff. Value statements are unlikely to be experienced as meaningful in terms of translating the ‘recovery vision’ into practice, or in answering the question ‘how do we, as staff members, approach our work with individuals if we are to promote their recovery journey?’ Ironically, controlling social contexts can actually decrease an individual's motivation and forestall their ability to internalize the doing of what has to be done (Sheldon & Houser-Marko, 2001). Farkas et al. (2005) further argue the point that it is not enough to simply espouse recovery values. For this reason recovery-orientated service requires both the explication of organizational values and beliefs that mirror core recovery principles, and the embodiment of these at multiple levels of operation.

Values-based practice designs and monitors programs based on explicated values. Values-based practice guides the way staff are hired, trained and supervised. (Farkas et al., 2005, p. 144)

Values play an important role in establishing organizational and systemic environments that facilitate recovery-orientated service provision. The potential applicability of values-focused interventions that seek to increase the motivation of individual staff to implement recovery-consistent practices is unexplored, both as a specific approach in organizations, and within the literature on promoting recovery-orientation within services. The collaborative recovery model (CRM) is now described as a model of recovery-orientated service provision that includes explicit exploration and use of personal strengths and values.

The Collaborative Recovery Model in Australia

The CRM is now being implemented in services, particularly non-government services, in all mainland states of Australia (Crowe et al., 2006; Oades, L. G. 2012b), and in one site in Canada (Piat & Sabetti, this issue, pp. 19–28), and one site in Hong Kong (Tse et al., this issue, pp. 40–47). Developed at the University of Wollongong, the CRM has recently been licensed to a non-government agency, Neami, to train and coach agencies in this approach across Australia. Demand and interest from clinical services is increasing. The components of CRM are now summarized.

Guiding principle number 1: Recovery as an individual process

The first principle emphasizes the personal subjective ownership of the recovery process, including hopefulness and personal meaning. It covers issues related to personal identity, particularly the need to move beyond the illness and towards one's best possible self. Finally it encourages individuals to take responsibility for their own wellbeing (Andresen et al., 2003).

Guiding principle number 2: Collaboration and autonomy support

This principle emphasizes important aspects of the working alliance in assisting human growth. Autonomy support as outlined in Ryan and Deci's (2008) self-determination theory, underscores the importance of autonomy to well-being. This is particularly salient in mental health contexts due to the history of paternalism and control that has pervaded so many aspects of the systems and patient care (Andresen et al., 2003).

There is substantial evidence regarding the association of the strength of the working alliance between the mental health worker and the person being supported in recovery and the degree of engagement and recovery outcomes (Martin et al., 2000). However, maintaining a strong working alliance often requires the mental health worker to: manage interpersonal strains or alliance ruptures, reflect on his/her own reactions to the dynamics of the working relationship (e.g. increased frustration, desire to fix things or rescue the person, etc.), and maintain professional boundaries whilst striving to remain present with the person they are supporting. As CRM is growth and future focused, it is conceptualized as a strengths-based coaching model, in which the relationships are coaching relationships rather than counselling relationships (Oades et al., 2009).

CRM component number 1: Change enhancement

This component recognizes that many people (including consumers, carers and practitioners) within the context of enduring mental illnesses such as schizophrenia tend not to believe that positive change is possible. Change enhancement draws on skills from motivational interviewing, and directly challenges fixed mindsets (Dweck, 2006), regarding the potential for change. This component of the model also highlights the importance of intrinsic motivation and the personal meanings underpinning human change.

Component number 2: Collaborative strengths and values

Directly relevant to much of this article, the clarification and use of personal strengths and values is central to the model, and is the most popular component for consumers and practitioners alike. Whilst Rapp's (1998) strengths model is well known to mental health practitioners in a case management context, the CRM predominantly draws from contemporary research on character strengths, values and committed action (e.g. Petersen & Seligman, 2004; Hayes, 2004).

Component number 3: Collaborative life visioning and goal striving

This third component assumes that, despite adversity, a person is still capable of developing a vision for life. The vision involves articulating their best possible self and striving towards approach goals that are consistent with their personal values and while using their strengths. Clarke et al. (2009) found that practitioners trained in CRM, which included the CGT, were more likely to apply these evidence-based principles. Additionally, Clarke and colleagues (Clarke et al., 2009) in another investigation of CRM found that the goal attainment of people with enduring mental illness mediated the relationship between the distress caused by their symptoms and their perception of personal recovery. This finding suggests that goals are central to the recovery process, and is consistent with the growth philosophy of the recovery movement. Positive psychology research continues to deepen our understanding of effective goal striving and its relationship to well-being (Clarke et al., 2012).

Component number 4: Collaborative action planning and monitoring

The fourth and final component of CRM is informed by research on the role of homework in cognitive behavioural therapies. The term ‘action planning’ is used in CRM because it does not carry the somewhat negative connotations of the word homework which often stem from unhappy school experiences. Working on agreed actions between meetings is thus an essential ingredient of CRM.

The CRM has been conceptualized as a strength-based person-centred coaching model (Oades et al., 2009). The Life Journey Enhancement Tools (Life-JET) (Oades & Crowe, 2008) have been designed to operationalize key components of the CRM delivered in a coaching style, where the relationship is more person-centred and focused on personal goals (rather than clinician-centred and focused on clinical goals).

Different from many discrete and individual positive psychological interventions (Magyar-Moe, 2009), the CRM (Oades et al., 2005) is a broad systemic framework guiding a range of interventions with consumers, carers, staff and organizational systems. The systemic nature of the interventions is imperative given the ingrained culture and history of psychiatric service provision. Park and Peterson (2003) assert that positive institutions enable people to use their positive traits such as strengths and values, which in turn yields positive experiences and positive emotions. In mental health services, organizations require change to enable staff and consumers to utilize strengths, to enable the possibility of the benefits of positive emotions. The CRM has been developed to assist with recovery-orientated service provision for people with enduring mental illness, and is informed by the principles, evidence and practices of positive psychology and positive organizational scholarship (Cameron et al., 2003).

Recovery measurement in Australia

Routine outcome measurement has been part of government adult mental health services in Australia for over 10 years. The measures used, however, remain predominantly symptom and function focused, constructs defined by professionals rather than consumers. Whilst some measures may be consumer rated, they remain largely negative in nature, i.e. related to symptoms of low functioning, rather than growth based or measures of well-being (Andresen et al., 2010). For recovery-orientated service provision to develop further in Australia, a broader use of measurement of personal recovery and recovery-orientated service provision is paramount. Because, in our view, the recovery movement itself was originally about who defines what recovery is – and in terms of outcomes and service provision evaluation, this debate remains alive in Australia.

In a recent review of potential recovery measures for the Australian context Burgess et al. (2010) identified instruments by drawing on existing reviews, searching MEDLINE and PsycINFO, and consulting with experts. Using a hierarchical criterion-based approach they assessed whether given instruments might be candidates for measuring recovery in the Australian context. These authors identified 33 instruments: 22 designed to measure individuals’ recovery and 11 designed to assess the recovery orientation of services (or providers). They concluded that four of the former (Recovery Assessment Scale, Illness Management and Recovery Scale, Stages of Recovery Instrument, Recovery Process Inventory) and four of the latter (Recovery Oriented Systems Indicators Measure, Recovery Self Assessment, Recovery Oriented Practices Index, Recovery Promotion Fidelity Scale) were identified as promising candidates for routine use in Australian public sector mental health services. Burgess et al. (2010) asserted that if Australia were to go in this direction, it would make sense to align indicators in each as far as possible, and to ensure that they were consistent with existing endeavours aimed at monitoring and improving recovery-focused aspects of service quality.

Recommendations for recovery-orientated service provision in Australia

The following recommendations are made to further develop recovery-orientated service provision in Australia, taking into account political, cultural, and health service human resourcing issues.

1. Increase peer specialist employment to 25% full time equivalent staffing of the workforce as a way of underpinning recovery-orientated service provision (Oades et al., 2012a). This recommendation relates to the need to bring further egalitarian change to services, incorporating complementary professional expertise and expertise from lived experience.

2. Using coaching as the style of relationship required for (i) service delivery with consumers and (ii) the culture within the organization (Crowe et al., 2011; Hadikin, 2004). This recommendation is based on the premise that a change to recovery-orientated service provision is essentially a change in the nature of the relationship between service provider and service user. A coaching style is seen to have more equal power differential, and is growth and approach based, rather than deficit and avoidance based.

3. Combine organizational change principles and a values focus to develop recovery-orientated service provision. Recovery-based practice may be conceptualized as a values-based practice. Values are important to individuals and organizations, hence relevant to personal recovery and recovery-orientated service provision respectively. Established organizational change principles need to be employed to bring service change, beyond a naive focus solely on practitioner skills training (Uppal et al., 2010).

4. Adopt strengths and well-being interventions at the individual and organizational level (i.e. with consumers as well as staff) to operationalize and underpin development of recovery-orientated service provision. Recovery-orientated service provision requires services that have staff with high levels of well-being. Hence, interventions to improve recovery-based services need to include assisting staff well-being, not only consumer well-being.

5. Examine more broadly the use of information and communication technology, including opportunities from Australia's new national broadband network, with the aim of greater connection between consumers and access to recovery-based and growth-based resources, beyond a symptom management focus.

6. Further develop links between non-government organizations (NGOs) and clinical services using a common language of recovery orientation. Actively avoid the trend that only NGOs are recovery orientated.

7. Mandate implementation of recovery outcome measures and consumer assessment of recovery-orientated service provision, involving peer specialists throughout the process (Burgess et al., 2011).

Conclusion

Policy supporting a mental health recovery orientation is prominent in Australia. The implementation of recovery-orientated services and related recovery-based outcome measurement is yet to be mainstream practice. The increasing science, practice and popularity of positive psychology-based approaches including strengths, values and well-being provide a link with recovery-orientated service provision, and combined with a coaching orientation and organizational change principles there is significant impetus within Australia for further service reform. With recent political and economic stimulation in the mental health sector, combined with an increasing impetus towards peer workers, it is likely that recovery-orientated service provision becomes more common. Several recommendations are provided to further develop this trend within the Australian setting.

Declaration of interest: The authors report no conflicts of interest. The authors alone are responsible for the content and writing of the paper.