Mental health articles

I developed the collaborative, appreciative approach using the recovery model elements identified in Onken, Craign, Ridgway, Ralph, and Cook’s (2007) analysis of existing recoverymodels, which have numerous parallels with postmodern therapies (see Part I of this article).The collaborative approach of Anderson and Goolishian (1992; Anderson, 1997) describes thequality of working relationship in which consumers’ voices are honored and equally valued inthe recovery process. Arguably, the entire recovery movement can be seen as a consumer movementsimply asking to be heard and treated as a partner in the recovery process. The profundityand import of developing a sincere collaborative stance with consumers cannot beoverestimated; recovery is virtually impossible without it. Thus, the therapist’s collaborativepositioning is the foundation of the approach.

The appreciative aspect of this approach refers to recognizing and valuing the strengths and abilities of consumers, which generates the necessary momentum for recovery. Developed for organizational settings, appreciative inquiry practices use questions and coconstructive exploratory processes to identify and reinforce strengths and maximize positive potentials(Cooperrider & Whitney, 2005). The utilization of strengths in therapy can be traced to early systemic family practices, including the work of Milton Erickson (Erickson & Keeney, 2006),and has been most clearly articulated by solution-based and narrative therapists (O’Hanlon &Weiner-Davis, 1989; de Shazer, 1988; White & Epston, 1990).

Although this is a strength-oriented approach, it is naı¨ve to assume that the work is easy,straightforward, painless, or without crisis and drama. Working with the severely mentally illcan be exceptionally challenging, even when using a recovery-oriented approach, and perhaps ismore challenging than traditional approaches (Davidson, Tondora, O’Connell, Lawless, &Rowe, 2009). A Pollyanna approach is quickly shattered by the numerous and varied obstaclesin every journey of recovery. Thus, practitioners should quickly realize that the collaborativeand strength-based elements of this approach are perhaps even more critical for them inmaintaining hope and positive vision as it is for the consumers.The remainder of this article will detail the practical elements of this collaborative, appreciative approach, which includes the following:

• Recovery partnership (i.e., therapeutic relationship)

• Mapping the landscape of recovery (i.e., assessment and case conceptualization)

• Recovery planning (i.e., treatment planning)

• Facilitating recovery (i.e., interventions)

• Accessing resources (i.e., case management)

• Recovery maintenance (i.e., aftercare planning)

• Context and format (i.e., treatment team and work contexts)

RECOVERY PARTNERSHIP

Partnership

The therapist in recovery-oriented settings is best described as a partner in recovery (Adams& Grieder, 2005) or recovery guide (Davidson et al., 2009) who provides support for the recoveryjourney. This partnership is similar to the conversational partnership described in collaborativetherapies (Anderson, 1997; Anderson & Gehart, 2007; Anderson & Goolishian, 1992): thetherapist is not a ‘‘change agent,’’ using a standard set of intervention techniques, but insteadjoins the consumer on a unique journey toward recovery. The motto ‘‘the client is the expert’’(Anderson & Goolishian, 1992) befits recovery but is exceptionally challenging to implementwith those diagnosed with severe and persistent mental illness, requiring a unique set of skillsand extraordinary patience.

Typically, consumers have difficulty communicating their ideas; their thoughts may be unusual,unrealistic, or impractical; and ⁄ or they may not trust the therapist enough to say muchof anything. In many cases, consumers and their families report feeling victimized and ill-treatedby mental health professionals, some referring to themselves as ‘‘survivors’’ or ‘‘ex-patients’’of psychiatry (Loveland, Randall, & Corrigan, 2007); in such cases, the therapist needs to senda convincing message that this professional relationship will be different from their past experiences.

Successfully building an effective partnership involves radical hope, human connection,and a strengths focus as well as promoting consumer agency and family involvement.

Radical Hope

Hope is the foundation of recovery. Without it, recovery is impossible. To have hope forthose diagnosed with severe mental illness is radical, at least at this time in history. Onlyrecently has there been evidence that recovery is possible; up to this point, professionals haveassumed that certain psychiatric diagnoses were a lifelong sentence. Arguably, the therapist’smost important role is to convincingly and consistently serve as a beacon of hope and to maintainunwavering faith that recovery is possible, even though days, weeks, and even months willgo by where recovery seems impossible—even to the therapist. The importance of hope has　been highlighted in solution-focused therapies and common factors research (Miller, Duncan, &Hubble, 1997), but its applications with severe mental illness are not for the faint of heart. Toconjure the radical hope necessary for recovery-oriented work requires that the therapist have aprofound and almost spiritual faith in recovery and that the therapist meaningfully communicatesand sustains this faith for the persons with whom they work. Academic knowledge ofrecovery research is insufficient to fuel this type of hope; this is not a skill that can be taughtbut rather a quality of person that must be sincerely cultivated. For this reason, many publicagencies use peer advocates, persons well on their way to recovery, who provide hope as rolemodels of recovery.

Human Connection

On one level, the recovery partnership is between a service provider and a service recipient.On another, it is between two human beings sharing a unique and highly personal journey thatinevitably touches the rawness of the human condition and tests the limits of the human spirit.

No textbook or lecture can prepare therapists for this type of work. Consumers will not partnerwith a therapist on this type of journey unless they sense the therapist’s sincerest caring, feelinga strong connection as humans on the journey of life. With each consumer, therapists mustdemonstrate their humanity before a recovery partnership can begin. The therapist’s sincereinvestment in the consumer’s welfare includes the ethical mandate to do no harm and extendsto do whatever it takes to meaningfully assist in the journey of recovery. Thus, a more personaland human level of commitment is required than is common in traditional family therapy practice.

Strength and Person Focused

Family therapists have a long history of relating to consumers using a strengths and personfocus (Minuchin, 1974; O’Hanlon & Weiner-Davis, 1989; de Shazer, 1988; Watzlawick, Weakland,& Fisch, 1974; White & Epston, 1990). In strength-oriented work, the focus on cultivatingand appreciating consumers’ strengths has two effects: (a) reducing the effect of problem behaviorsand symptoms and (b) increasing their ability to manage these issues. Relating to consumersfrom a strengths perspective is far more challenging than initially anticipated becausepersons diagnosed with severe and persistent mental health issues often have few friends, donot talk to their family, do not hold jobs, and have unusual talents and hobbies if any. Cliniciansneed to be keen observers and practice appreciating micro-achievements and successes(such as making an appointment on time; having a friend to call) that may be taken for grantedin other contexts.

A particularly applicable technique with this population, the narrative approach of meetingthe ‘‘person’’ apart from the problem can be used to help both the therapist and client developrich descriptions of client as a person, often one that the consumer has not heard in decades(Freedman & Combs, 1996). When consumers have a sense that professionals ‘‘see’’ and valuethe person that they are—apart from the diagnosis—they will be more likely to take actionsthat confirm this broader and generally preferred definition of self. Furthermore, cultivating acontext of appreciation and celebration of small successes creates a strong relational bond aswell as motivation for taking the steps necessary for recovery. This emphasis on strengths isused as a foundation for the recovery partnership and is also central in the mapping recoveryand facilitating recovery processes described below.

Agency and Empowerment

The therapist’s role in collaborative (Anderson & Gehart, 2007) and narrative therapies(White & Epston, 1990) is to create a space where consumers feel free to exercise their agency.Anderson(1997) emphasizes that promoting agency is different from empowering consumers:for the notion of ‘‘empowering,’’ consumers assume that therapists are in a position of givingpower (and therefore potentially withholding it) when they are not. Instead,Andersonexplainsthat consumers are inherently agents with the power to take action in their lives; therapists aresimply in a position to relate to consumers in a way that allows them to experience and effectivelyexercise that power. Similarly, systemic therapists also do not conceptualize therapy as empowering consumers; instead, consumers and families are viewed as already possessing intrinsicautonomy and that they cannot be controlled or otherwise manipulated into change:instead, change always comes from within the system (Watzlawick et al., 1974).In contrast, because of its roots in consumer and social justice movements, the recoverydiscourse often frames the recovery process in terms of empowerment, and clinicians areencouraged to empower consumers. Historically, family therapists have performed this by enteringthe therapeutic relationship with the assumption that consumers already possess power andagency; the therapist’s job is simply to interact in such a way that this power is experiencedand realized in useful ways. Thus, although family therapy and recovery models describe issuessurrounding power differently, they ultimately promote the same dynamic, which is to relate toconsumers in such a manner as to promote their sense of agency and autonomy.

Family and Significant Others

Similar to family therapists, recovery-oriented practitioners actively involve family membersand significant others in the recovery process. When working with persons diagnosed withsevere and chronic mental illness, therapists should be aware that their ‘‘families’’ may not onlyinvolve blood relations, but also roommates, peers, social service workers, religious personnel,and even pets (Davidson et al., 2009). In many cases, the person diagnosed with mental illnesshas been estranged from biological family members, and these relationships may need significantattention to be repaired and serve as a supportive force in the recovery process; familytherapists are uniquely equipped to address these issues and should make this a priority earlyin the recovery process.

Tags: recovery