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May 10, 2012 Volume 3, Issue 17
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Why Adding 'Recovery' to a Treatment Plan Does Not Make It a 'Recovery Plan'
by Larry Davidson, Ph.D., RTP Project Director
As a central component of transformation, numerous systems are grappling with the challenge of how to make their traditional "treatment plans" more recovery oriented. In addition to changing the name of the document from "treatment plan" to "recovery plan," two common steps taken by systems of care are to 1) add a place on the form for the person to identify his or her own goals and 2) add a place on the form for identification of the person's strengths (if strengths had not already been included). While these two steps are consistent with moving in the direction of recovery-oriented practice, it is important to point out that these steps alone do not transform a traditional treatment plan into a recovery plan. What is a recovery plan, then, if it is not the result of integrating recovery into a treatment plan? What additional steps must be taken to effect the desired transformation to a recovery plan? This week's highlight addresses these two important, if challenging, questions.

Treatment plans have been developed primarily to guide and document the treatment of illnesses or other medical conditions (for example, broken bones, infections). The treatment being planned is to be provided primarily by health care professionals, and the written plan is developed primarily for the use of those professionals in serving numerous related functions, such as guiding the care offered, assessing the effectiveness of the care offered, and justifying and documenting the care offered for the purposes of accreditation and reimbursement. It has been only recently that accrediting bodies have insisted that patients be included in the development of treatment plans and that they sign these plans to demonstrate their involvement, along with completing other documents that attest to their making informed decisions about the treatments prescribed or recommended for them. Signing such forms, however, neither requires nor reflects anything other than the patient's agreement with the professional's plan. In other words, signing a form does not make it the patient's own plan; it remains the practitioner's plan for how he or she will 'treat' the patient.

Limitations of the Traditional Treatment Plan
This model, for generations, has been extremely useful in guiding the medical care provided to people for acute illnesses and other conditions. And it may be equally useful in some instances of behavioral health conditions. This model may be adequate when a physician or nurse practitioner prescribes medication for an isolated, acute episode of anxiety or depression, for example, or when a behaviorally oriented psychotherapist "contracts" with a person for exposure and desensitization treatment of a phobia. In either of these cases, the person's own role in the treatment process is basically to do what the practitioner recommends—whether that be to take a pill every morning or to visit the reptile house of a zoo (in the case of a phobia to snakes). This approach has been found to be woefully inadequate, however, in the case of serious and persistent mental health and substance use conditions, in which the person must play a much more significant role in dealing with, managing, and overcoming what has become a disabling condition. In either case—and especially in the case of co-occurring conditions—simply following the recommendations of behavioral health professionals falls well short of what is required for the person to do the hard and strenuous work of recovery.

This has been true for several reasons. First, the treatments that are currently available are extremely limited in their effectiveness in treating serious mental health and substance use conditions. While some treatments may be effective for many people in reducing the more active aspects of these conditions (such as in reducing psychiatric symptoms or substance use), they typically do not address the more disabling elements (such as neurocognitive difficulties, deeply entrenched patterns of behavior, and social and interpersonal contexts that impede, rather than facilitate, improvement). Should medications be developed that were as effective in treating mental illness and substance use as antibiotics have been in treating certain infections, then we might not find it necessary to change the ways in which we plan and deliver care. Such a day, however, seems far off, should it be achievable at all.

Second, the vast majority of the challenges people face in recovery occur outside of, and beyond the scope of, traditional health care settings such as hospitals, clinics, day programs, or intensive outpatient programs. These challenges occur, and must be dealt with, within the context of the person's everyday life in the community. Assertive community treatment (or ACT) teams were developed 40 years ago to attempt to assist persons with serious mental illnesses in meeting these challenges, by deploying mental health staff to teach and role-model life skills in the everyday contexts in which they are needed. Staff from these teams would accompany a person to the grocery store, the Laundromat, the bank, or the movie theater so that he or she could learn how to negotiate such settings successfully. The more recent advances of recovery "coaching" and "mentoring" and peer support attempt to provide similar types of assistance for persons with either mental health or substance use conditions. Such activities do not fit neatly within the conventional framework of treatment plans, extending well beyond the scope of treatment to the realms of rehabilitation and community-based support.

Recovery Goes Beyond Rehabilitation
It is not simply a matter, though, of incorporating the use of rehabilitative interventions and community supports into a traditional treatment plan. In both of these realms, the role of the person with the behavioral health condition (or conditions) is an essential and central consideration; it cannot be either assumed or ignored. While it takes a skilled orthopedist to set a broken bone, it requires the activity of the person himself or herself—possibly in combination with an experienced physical therapist or trainer—for the person to regain the full use of his or her arm or leg. This is even more so the case within the context of behavioral health. In the case of a broken bone, there may be both a treatment plan (for example, reposition and stabilize the bone) and a rehabilitative plan (e.g., attend physical therapy three times weekly to perform certain exercises). But even in combination, these plans do not address what the person will need to do to rejoin his or her soccer team or pick back up his or her violin. In these instances, coaches, trainers, or instructors (e.g., experienced violinists) might also be required. The challenges of living an ordinary life with a serious mental illness or substance use condition often require a similar level of support, experience, and expertise. Planning for and guiding such efforts pushes us beyond the scope of treatment plans that are used primarily by health care practitioners to a plan that the person can develop and use, in partnership with others, to achieve the kind of life to which he or she aspires. Such a plan is called a recovery plan.

When the goal of behavioral health care was to reduce mental illness or eliminate substance use, it made sense to view treatment as leading to recovery. And, as a result, it made sense to incorporate recovery and personal strengths into treatment plans. Now, however, the goal of behavioral health care has become enabling people to lead full and self-determined lives in the community regardless of the presence and severity of a behavioral health condition (or conditions), and this goal cannot be accomplished for many people through the planning and provision of treatment and rehabilitation alone. Active treatment with medications and psychotherapy, even when coupled with skills training, may remain essential for some people to have the chance of leading a full life—but this alone is not enough for many. What is required is for the person to assume responsibility for, and take an active role in, learning about, dealing with, and overcoming the range of medical, social, and psychological effects of having a behavioral health condition within the current economic, political, and cultural context—for him or her to be "in recovery" in the face of ongoing challenges for which we do not yet have definitive solutions. For such people, recovery does not come after—and is not the direct result of—treatment. For individuals with prolonged conditions, a treatment or even a rehabilitative plan that only stipulates what practitioners will do is not sufficient for their goal of living full lives in the community.

Since it is understood that the majority of the effort involved in living one's life in the presence of a serious mental health or substance use condition is the person's own, recovery plans are framed as much as possible from the perspective of the person himself or herself. Here, too, it is not enough simply to describe the person's presenting complaint or recovery goals in his or her own language, only then to return to conventional clinical concepts. What is required is to reframe even the interventions and efforts of the behavioral health practitioners, and others, involved from this person's perspective as well. A doctor or nurse practitioner may prescribe antipsychotic medication for me because I have a psychotic disorder or because I am hearing distressing voices. But why should I take the antipsychotic medication if I do not believe that I have a psychotic disorder, or if those voices are the only form of company that I currently have (not to mention the fact that they protest against my taking the medication)?

Clarification About Supporting a Personís Goals
Addressing this situation within the context of a recovery plan does not require that I forget or ignore my clinical training; I do not have to lie to my patient or pretend that he or she does not have a psychotic disorder. What I have to do instead is figure out how to apply my medical and clinical expertise most effectively in this particular situation. I have to figure out how to put my clinical skill and professional knowledge to the person's use in pursuit of his or her own everyday life goals. It may require some clinical acumen to match a patient's symptom profile to an appropriate diagnosis and to inform the patient and his or her family what particular illness or condition the person has. But it requires both experience and more clinical acumen to find an effective way of helping the person understand how this particular condition is getting in his or her way, is making his or her life more difficult, or is undermining his or her own efforts to have the kind of life to which he or she aspires.

Given the ways in which our culture presently perceives mental illness and addiction, I have little motivation to believe you when you tell me that I have a psychotic disorder or a substance use disorder. I don't match the stereotypes of "mental patient" or "addict," and I am not ready to give up on having a good and decent life. But if you tell me that taking a certain medication might make it easier for me to concentrate in school and to get my grades back up to where they used to be before those voices started to bother me, I might give it a try. Or if you tell me that smoking weed is making it more difficult for me to get out of bed in the morning, and that continuing to smoke will put my job into jeopardy, I might consider using less. You can still use terms like "psychosis" or "cannabis abuse" within this context; it is not that the words are wrong or inappropriate. It is just that you cannot simply use those words and expect them to suffice. Many people will need to know what those words mean and how they explain important aspects of their everyday life experience, such as difficulties in concentrating or getting out of bed.

The art of recovery planning involves being able to imagine and articulate the steps a person can take in the next 3 to 6 months, along with the interventions other people can provide to enable and support those steps, to improve his or her life and move it in the direction of his or her longer term aspirations. The fact that a person has a condition we call schizophrenia may not change over that 3- to 6-month period, but lots else in the person's life can. This is one of the many reasons funders, auditors, and accrediting bodies prefer to see person-centered care plans in medical records, as these plans clearly articulate what objectives the practitioners are seeking to achieve through their provision of services and supports. To meet auditing criteria, these objectives need not only to be measurable, but they also are expected to change over the period relevant to the care plan (for example, 3 or 6 months). If the only goal that is stipulated in a care plan is to treat someone's schizophrenia, and the only objective that follows from this goal is to see a reduction in psychotic symptoms, then this plan will be useful only for the first few care plan cycles. Once the person derives optimal benefit from antipsychotic medication and/or cognitive behavioral psychotherapy, there is little else that behavioral health practitioners can do directly to decrease psychotic symptoms. Despite this fact, many care plans in the past have continued to have decreased symptoms as a goal, and patient compliance with treatment as an objective, with little change in clinical status documented in the medical record and few, if any, changes made in the care plan over periods of months, years, and even decades. Switching the goal from one of symptom reduction to maintenance of 'clinical stability' does little to improve this situation from either a clinical or an auditing point of view.

Potential for Person-Centered Outcomes
There remains, however, much that the person can do himself or herself to gain control over and eventually to lessen either the symptoms, the disruption they cause to his or her life, or both. Experimenting with self-care strategies, and finding those that work for a particular individual, as well as exploring and finding meaningful activities and relationships that begin to squeeze the voices out of the person's life, remain possible activities for someone whose symptoms have not responded fully to available treatments. The interventions that providers may use to facilitate such experimentation and exploration—while reimbursable in many States as part of a Medicaid Rehabilitation option—are not considered treatment per se, and depend almost entirely on the person's interest and activity in a way that goes well beyond conventional notions of 'compliance' or 'adherence.' Practitioners can plan and bill for conducting evaluations and assessments, and for prescribing and monitoring medications, whether or not the person agrees to participate or to comply. The same cannot be said for the person learning self-care skills or exploring meaningful social, recreational, educational, and/or vocational activities. Here the person must play a leading role, with the practitioner acting less directly and more in a consultative and facilitative role. As a result, recovery plans end up being much more tightly focused on what the person, and supportive others, can actually hope to do and to achieve over the next 3 to 6 months rather than containing a list of all the things that providers would like to see happen, but seldom do.

Since it is largely dependent on what the person will be interested in and willing to do over the next several months, it becomes crucial for the person to be the primary driver of the formulation and implementation of the recovery plan. This does not limit recovery plans to only those things the person will do, however, as practitioners and others can be extremely valuable partners in encouraging, supporting, and guiding the person's own efforts. There is even room within recovery plans for providers to attempt to increase a person's interest in or motivation for certain activities (that is, through motivational interviewing). But the inclusion of such efforts still requires the person's consent, even if that is the result of a negotiated compromise. By limiting recovery plans to what can actually be expected to occur over the next several months, the plans become useful documents both for the person and for his or her care team, as well as becoming an appealing, and cost-effective, strategy for health care reform.

In the past, what made a treatment plan a treatment plan was that it was a plan for what treatments would be provided by whom. What makes a recovery plan a recovery plan is that it is a plan for me, and my care or support team, oriented to helping me live my life as fully as possible in the way that I want. That does not mean that a treatment plan is irrelevant or no longer needed. Rather, it means that a treatment plan becomes one component of an overall recovery plan—that component that outlines what treatments will be provided by which professionals and for what purposes (and which satisfies both Joint Commission and Medicaid requirements). But in a reverse of the traditional logic, treatment becomes only one tool—even if it is an extremely valuable tool—for my ongoing recovery.

Tacking recovery onto a treatment plan may have made sense from the perspective of a practitioner. But from the perspective of the person, the question is rather how (and which) treatments, services, and/or supports might fit into and support my recovery. While from the perspective of a practitioner I may be viewed primarily as a patient who has an illness and who secondarily is trying to live his or her life, from my own perspective I am first and foremost a person who is living my life and who secondarily has to deal with a behavioral health condition within that context.


What may be confusing about the notion of a recovery plan is that it challenges professionals to approach their medical and clinical practice from the perspective of the person with the condition, understanding that he or she is the driver of the process and the key decision-maker. But this is what it means to say that recovery is what the person does. Recovery planning is one tool that encourages and supports the person in doing so.

For further reading:

Adams, N., & Grieder, D. (2005). Treatment planning for person-centered care: The road to mental health and addiction recovery. San Diego, Calif.: Elsevier Academic Press.

Borg, M., Karlsson, B., Tondora, J., & Davidson, L. (2009). Implementing person-centred care in psychiatric rehabilitation: What does this involve? Israeli Journal of Psychiatry and Related Sciences, 46(2), 84–93.

Davidson, L., Tondora, J., O'Connell, M. J., Lawless, M. S., & Rowe, M. (2009). A practical guide to recovery-oriented practice: Tools for transforming mental health care. New York, N.Y.: Oxford University Press.

Davidson, L. & Strauss, J. S. (1995). Beyond the biopsychosocial model: Integrating disorder, health, and recovery. Psychiatry: Interpersonal and Biological Processes, 58, 44–55.

Deegan, P. E. (1992). The independent living movement and people with psychiatric disabilities: Taking back control over our own lives. Psychosocial Rehabilitation Journal, 15(3), 3–19.

Diamond, R. (unknown). Recovery from a psychiatrist's viewpoint. New Directions in schizophrenia. A postgraduate medicine special report, 54–62.

Noordsy, D. L., Torrey, W. C., Mead, S., Brunette, M., Potenza, D., & Copeland, M. E. (2000). Recovery-oriented psychopharmacology: Redefining the goals of antipsychotic treatment. Journal of Clinical Psychiatry, 61(Suppl 3), 22–29.

Register Now Recovery Resource
Shared Decision-Making in Mental Health Decision Aid
Considering the Role of Antipsychotic Medications in Your Recovery Plan
The resource includes materials that support shared decision-making. This is an intervention that helps people make choices about treatment and mental health services. It contains issue briefs and tip sheets, workbooks, videos, and an interactive decision aid on medication-assisted therapy.

View the DVD.

Center on Adherence and Self-Determination
New 'People in Recovery' Page
The Center on Adherence and Self-Determination (CASD) recently launched a new tab on the CASD Web site that links to the "People in Recovery" page. Consistent with Core Value No. 5 of the Center on Adherence and Self-Determination (CASD), persons in recovery are esteemed by CASD as essential agents in the research process. In line with the principles of Community-Based Participatory Research, this page is meant to showcase the voices of people in recovery, including Consumer/Survivor Researchers and others who have lived experience with mental illness. On this page, one can find interviews with people in recovery meant to shed light on their views on issues relevant to the CASD. Also available here are national and international resources for people in recovery, recommended readings, and information about national and international events related to the mission of the CASD. The CASD's Assistant Director of Consumer Affairs, Janice Parker, welcomes any feedback regarding the People in Recovery page.

SAMHSA Releases New Treatment Improvement Protocol
'TIP 54: Managing Chronic Pain in Adults With or in Recovery From Substance Use Disorders'
Treatment Improvement Protocols (TIPs) are developed by the Center for Substance Abuse Treatment, part of the Substance Abuse and Mental Health Services Administration (SAMHSA), within the U.S. Department of Health and Human Services. Each TIP involves the development of topic-specific best-practice guidelines for the prevention and treatment of substance use and mental disorders. TIPs draw on the experience and knowledge of clinical, research, and administrative experts of various forms of treatment and prevention.

TIP 54 was developed to equip clinicians with practical guidance and tools for treating chronic noncancer pain in adults who have a history of substance use disorders. The management of chronic noncancer pain in patients with a comorbid substance use disorder is challenging for both patients and clinicians; however, it can be done successfully. This TIP advises clinicians to conduct a careful assessment; develop a treatment plan that addresses pain, functional impairment, and psychological symptoms; and closely monitor patients for relapse. Even the best treatment is unlikely to completely eliminate chronic pain, and efforts to achieve total pain relief can be self-defeating. Patients may benefit when clinicians team with other professionals (for example, psychologists, addiction counselors, pharmacists, holistic care providers). Patients must also assume a significant amount of responsibility for optimal management of their pain. Educating patients, family members, and caregivers in this process—and helping patients improve their quality of life—can be gratifying for everyone involved.

Read TIP 54: Managing Chronic Pain in Adults With or in Recovery From Substance Use Disorders

The RTP Resource Center Wants to Hear From
Recovery-Oriented Practitioners!
We invite practitioners to submit personal stories that describe how they became involved in
recovery-oriented work and how it has changed the way they practice.
The RTP Resource Center Wants to Hear From You, Too!
We invite you to submit personal stories that describe recovery experiences. To submit stories or other recovery resources, please call 877.584.8535,
or email recoverytopractice@dsgonline.com.

We welcome your views, comments, suggestions, and inquiries.
For more information on this topic or any other recovery topic,
please contact the RTP Resource Center at
877.584.8535, or email recoverytopractice@dsgonline.com.


The views, opinions, and content of this Weekly Highlight are those of the authors, and do not necessarily reflect
the views, opinions, or policies of SAMHSA or the U.S. Department of Health and Human Services.