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July 14, 2011 Volume 2, Issue 26
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Twelve Aspects of Staff Transformation
By Mark Ragins, M.D.
There is a lot of talk about transforming our mental health system into a consumer-driven recovery-based system, but little talk about transforming staff to work successfully in this new system. Recovery programs, to this point, tend to rely on creating small countercultures with dynamic leadership, staff that are different or want to change, and new nonprofessional and consumer staff. Successfully transforming existing programs with existing staff requires a proactively guided process of staff transformation. The following describes the 12 aspects of staff transformation.

1. Looking inward and rebuilding the passion. Recovery work requires staff to use all of themselves in passionate ways to help people. It cannot be done effectively in a detached, routinized way. Recovery staff tend to be happier, more full of life, and more actively engaged. To achieve this, we must look inward to remember why our hearts brought us into this field in the first place. Many of us have unfortunately been mired in bureaucracy, paperwork, underfunding, frustrations, and burnout. Staff must be nurtured, encouraged to play and explore, encouraged to bring their lives into their work, and cherished for their individual gifts and hearts—because staff with hope, empowerment, responsibility, and meaning can help people with mental illnesses build hope, empowerment, responsibility, and meaning. Administrative leadership must effectively promote their staff before further transformation can occur.

2. Building inspiration and belief in recovery. Staff spend the majority of their time and emotions on people who are doing poorly or in crisis. We neglect the stories of our own successes and our roles in supporting these successes. Staff members need to be inspired by hearing people tell their stories of recovery, especially the stories of people they have worked with and also known in darker times. Staff must also be familiarized with the extensive research documenting recovery and the concept of the “clinicians’ illusion” that gets in the way of us believing in this research. Ongoing experiences of people achieving things we “know are impossible” are crucial.

3. Changing from treating illnesses to helping people with illnesses lead better lives. The pervasive culture of medicalization is reinforced by the infrastructure, but recovery staff treat people like people, not like cases of different illnesses. Goal-setting needs to reflect quality of life, not just symptom reduction; thus, quality-of-life outcomes need to be collected. Treatment must be life based, not diagnosis based. Assessments must describe a whole life, not an illness with a psychosocial assessment on a back page. Progress notes need to reflect life goals, not just clinical goals. Finally, team staff meetings need to discuss the practical problems of life.

4. Moving from caretaking to empowering, and sharing power and control. Staff have generally adopted a caretaking role toward people with a mental illness. We act protectively, make decisions for them because of their impairments, even force them to do what we think is best for them at times. Recovery practice rejects those roles, although many staff and mentally ill people are comfortable with them. Just as parents must stop being caretakers for their children to become successful adults, staff must stop being caretakers for the people they work with to recover. As staff try to become more empowering, they face enormous issues around fear of risk-taking, feelings of responsibility for the people they work with, and liability concerns. There may also be personal issues around power and control. Most of us feel most efficient and effective when we are in control and people are doing what we want them to. Especially when facing repeated failures or crisis, frustration is likely to grow. We are likely to reject collaboration and want to take more power and control.

5. Gaining comfort with mentally ill co-staff and multiple roles. Recovery requires breaking down the “Us Versus Them” walls. People with mental illnesses must be included as collaborators, coworkers, and even trainers. Working alongside mentally ill people as peers (not as segregated, second-rate staff) is probably the single most powerful stigma-reducing and transforming experience for staff. For people with mental illness to recover and attain meaningful roles beyond their illness roles, staff need to take on roles beyond their illness-treatment roles. Various activities—like talent shows, cookouts, neighborhood clean-ups, and art shows, where staff and mentally ill people interact in different roles—can promote this transformation.

6. Valuing the subjective experience. Staff have been taught to observe, collect, and record objective information about people to make reliable diagnoses and rational treatment plans. Recovery plans are collaborative. To achieve this collaborative partnership, staff must appreciate not just what’s wrong with a person, but how that person understands and experiences what’s happening. Knowing what it would be like to be that person, what they're frightened of, what motivates them, what their hopes and dreams are—all are part of a subjective assessment. Charted assessments, “case conferences” (shouldn’t these be “people conferences?”), team meetings, and supervision all should value subjective understanding.

7. Creating therapeutic relationships. Recovery work emphasizes therapeutic work more than symptom relief. Our current system relies on illness diagnosis, treatment planning, treatment prescription, and treatment compliance: staff can be interchangeable, professionally distant, and even strangers, so long as the diagnosis, plan, and compliance are preserved. Recovery work relies on the same foundation as psychotherapy: (1) an ongoing, trusting, collaborative, working relationship; (2) a shared explanatory story of how the person got to this point; and (3) a shared plan of how to achieve the person’s goals together. Staff need to gain, or regain, these skills. Program designs must prioritize relationships.

8. Lowering emotional walls and becoming a guiding partner. People repeatedly tell us that we are the most helpful when we are personally involved, genuinely caring, and “real.” Psychotherapeutic and medical practice traditions, ethical guidelines, risk-management rules, and personal reluctance come together against lowering emotional walls. Staff need a lot of discussion and administrative support to change in the face of these strong contrary forces. To best support a person on his or her path of recovery, staff members need to act not as detached experts handing out maps and directions, but as involved guides walking alongside the person and sharing the trip. And to further lower the walls, we must also deal with our emotional and physical fears of the people we work with.

9. Understanding the process of recovery. Staff are familiar with monitoring progress as a medical process. We follow how effectively illnesses are diagnosed and treated, symptoms relieved, and function regained. We alter our interventions and plans based on our assessment of this process. Recovery work monitors a very different process: the process of recovery. Analogous to the grief process that hospices work with, the recovery process can be described as a series of four stages: (1) hope, or believing something better is possible; (2) empowerment, believing in ourselves; (3) self-responsibility, taking actions to recover; and (4) attaining meaningful roles apart from the illness. Where hospice staff help people die with dignity, recovery staff help people live with dignity. Staff grow in their understanding of the recovery process and their skills in promoting recovery.

10. Becoming involved in the community. Recovery tries to help people attain meaningful roles in life. These roles will require them to be reintegrated into the community, to be welcomed and valued, and to find their niches. Recovery cannot be achieved while people are segregated from their communities or protected in asylums. To support this, staff must work in the community: we can’t be segregated from our communities or act solely as protectors in asylums. We, too, need to be welcomed and valued and to find our niches. This is a substantial change for most staff and may trigger personal insecurities. Community development and anti-stigma work are important new programmatic and staff responsibilities.

11. Reaching out to the rejected. Recovery is being promoted, not just as a way of helping people who are doing well do even better, but also as a way of engaging with and helping people who do not fit well with the current system. Recovery programs have proven success with people who have dual diagnoses, homeless people, jail diversion people, “noncompliant” people, people with severe socioeconomic problems, and people lacking “insight.” Each of these people has different, serious obstacles to engagement and treatment, and staff often have serious prejudices against them. A counterculture of acceptance needs to be created to work with them. This often requires both an attitudinal change in staff and training in specialized skill sets. The system transformation will not be considered a success if we continue to reject these people in need.

12. Living recovery values. “Do as I say, not as I do” is never a good practice. When the walls and barriers are reduced and emotional relationships are enhanced in a good recovery program, it’s even harder to hide. Staff must live the values of recovery and be actively growing ourselves if we expect to be effective recovery workers. In recovery, the same rules and values apply to all of us.

These 12 aspects of staff transformation will hopefully help with the creation of a proactive curriculum for staff transformation, as well as offer a guide for recovery-oriented leaders to use in program design, supervision, and staff support.

Webinar Announcement
The RTP Resource Center is pleased to announce
the third Webinar in a four-step series:
Step 3 in the Recovery-Oriented Care Continuum:
Promoting Recovery Through Psychological and Social Means
Thursday, July 28, 2011

2:00–3:30 pm EDT

This Webinar will describe a few approaches to promoting recovery that involve psychological and social interventions. First, David Kingdon, M.D., will update participants on the state of the art in cognitive-behavioral psychotherapeutic approaches to serious mental illnesses (schizophrenia and bipolar disorder). Next, Larry Davidson, Ph.D., will describe the key common elements of psychiatric rehabilitation approaches that involve in vivo support (supported employment, education, housing, etc.). Finally, Jayme Lynch, CPS, will describe the role of consumer-run programs and businesses as offering alternatives to traditional programs and settings (e.g., clubhouses).

David Kingdon, M.D., is Professor of Mental Health Care Delivery at the University of Southampton, United Kingdom, and Honorary Consultant Adult Psychiatrist for the Hampshire Partnership NHS Trust. Over the past two decades, Dr. Kingdon has worked with Douglas Turkington from Newcastle and other colleagues to develop techniques for treating patients with persistent delusions and hallucinations, using cognitive-behavioral therapy. His research interests are in cognitive therapy of severe mental illness and mental health service development. He has published extensively on these topics.

Larry Davidson, Ph.D., is the Development Services Group, Inc., Project Director for the SAMHSA Recovery to Practice initiative. A Professor of Psychiatry and Director of the Program for Recovery and Community Health at the School of Medicine and Institution for Social and Policy Studies of Yale University, his work has concentrated on processes of recovery from and in serious mental illnesses and addictions, evaluation of innovative recovery-oriented practices, including peer-delivered services, and designing and evaluating policies to promote the transformation of systems to the provision of recovery-oriented care. In addition to being a recipient of psychiatric care himself, Dr. Davidson has produced more than 200 publications, including the 2009 book written with several of his colleagues, A Practical Guide to Recovery-Oriented Practice: Tools for Transforming Mental Health Care (published by Oxford University Press), and the more recent The Roots of the Recovery Movement in Psychiatry: Lessons Learned (Wiley–Blackwell). His work has influenced the shape of the recovery agenda and the translation of its implications for transforming mental health practice, both nationally and internationally.

Jayme Lynch, CPS, is the Director of the Peer Support and Respite Center, a Georgia Mental Health Consumer Network initiative offering 24/7 consumer-directed peer wellness and crisis respite services, in Decatur, Ga. The center uses peer support services in a safe, noncoercive, nonclinical, and homelike environment in a community setting, and is offered as an alternative to other crisis services. The goal of this project is to encourage consumers to use their crises as learning opportunities, developing their internal and external resources to better understand, manage, and avoid future crises and avoid future hospitalizations.

To register, go to

Please share this announcement with friends and colleagues who may be interested in learning more about recovery-oriented practice in behavioral health services. For more information on SAMHSA’s RTP project, please contact the RTP Resource Center at recoverytopractice@dsgonline.com or 877.584.8535.

Personalized Recovery-Oriented Services (PROS) Program in New York City
Susan Friedlander, LCSW; OMH, Queens Borough Coordinator/Rehabilitation & Recovery Services, New York City Field Office, has written an article titled “From the Field: PROS & The City.” This article provides a New York City PROS update, including hopeful recovery stories shared by PROS providers.

To read, go to

Staying in Balance: Managing Stress in an Uncertain Economy
The Mental Health Association of New York City has launched Staying in Balance, a resource toolkit to help social service organizations respond in healthy ways to the high levels of emotional distress created by the economic recession. Staying in Balance offers a toolkit, training, and materials to help organizations promote emotional wellness and organizational health during the economic crisis, including guidance and resources for reducing worker stress.

For more information, please contact Michelle at mangulo@mhaofnyc.org or 212.254.0333, x750.

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 currently practice.
The RTP Resource Center Wants to Hear From You, Too!
We invite you to submit personal stories that describe recovery experiences. To submit personal stories or other recovery resources, please contact Stephanie Bernstein, MSW, at 877.584.8535, or email

We welcome your views, comments, suggestions, and inquiries.
For more information on this topic or any other recovery topics,
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 HHS.