Recovery model

1. Introduction

Version followed: the personal recovery model as made practical for clinicians by Slade, 100 Ways to Support Recovery (Rethink, 1st ed. 2009). The REFOCUS team intervention is followed as described in its trial papers (Slade et al. 2015). Concepts come from the CHIME framework (Leamy et al. 2011), Andresen, Oades and Caputi's five-stage model (STORI paper, c. 2006) and SAMHSA's Working Definition of Recovery (2012, PEP12-RECDEF). Tools come from the Strengths Model (Rapp & Goscha 2012, 3rd ed.), the WRAP Personal Workbook (2004 version, after Copeland) and Deegan's CommonGround (2013 description). The REFOCUS manual itself (Bird et al., 2nd ed. 2014) and the 2013 2nd edition of 100 Ways are not drawn on here [uncertain].

What it is. The recovery model is not a single therapy with a manual. It is a framework and a service philosophy that came out of the service-user/consumer movement. It changes what treatment is for and how the clinician relates to the person. You add it to whatever therapy you already practise and to the team you work in. The model separates two kinds of recovery [source: Slade 2009]:

Clinical recovery is defined by professionals: fewer symptoms, restored functioning.
Personal recovery is defined by people with lived experience. Anthony (1993) calls it "a deeply personal, unique process": a person's attitudes, values, goals and roles change so that they live a satisfying, hopeful life, with or without ongoing symptoms.

How change happens. Recovery is something the person does. It is an active, individual, non-linear journey. Services support it; they do not deliver it [source: Leamy 2011; Slade 2009]. Leamy et al. name five processes that drive it (CHIME):

Connectedness
Hope and optimism
Identity
Meaning
Empowerment

Slade describes four tasks for the person [source: Slade 2009]:

Build a positive identity beyond the illness.
Frame the illness so that it is one part of the self, not the whole.
Self-manage, which includes knowing when to seek help.
Take up valued social roles.

Relationships underpin all four. The clinician's job is to amplify hope, strengths, choice and roles, and to keep illness-focused treatment available as one resource among many.

2. Framework

Format. The model has no fixed number of sessions [source: Slade 2009; Rapp & Goscha via Napa County guideline]. It runs across the whole episode of care:

intake
assessment
care planning
regular contacts
crisis
review

In the Strengths Model, the work happens in the community rather than the office. A personal recovery plan is used at nearly every contact. In REFOCUS, a whole team is trained and keeps reflecting together [source: Slade et al. 2015 trial; Slade et al. 2015 BJPsych]. The person can also use WRAP alone or with a supporter [source: WRAP workbook 2004].

Stages the person moves through (descriptive, not a treatment protocol). These are Andresen, Oades and Caputi's five consumer-derived stages [source: Andresen et al. STORI paper]:

Stage	What it looks like	Clinician's emphasis [synthesis]
1. Moratorium	Withdrawal, a deep sense of loss, hopelessness	Hold hope for the person; engage; keep their life going; give no demands they cannot yet meet
2. Awareness	First realisation that not all is lost and a fulfilling life is possible	Recovery stories, peer contact, finding small successes
3. Preparation	Taking stock of strengths and weaknesses; starting to build recovery skills	Values and strengths assessment; learning about the illness; linking to peers
4. Rebuilding	Working on a positive identity, setting meaningful goals, taking control	Goal-striving and coaching; WRAP; positive risk-taking; social roles
5. Growth	A full, meaningful life; self-management; resilience; positive sense of self	Step back; services "on tap"; plan for setbacks; possibly peer or giving-back roles

Four processes run through every stage: finding hope, re-establishing identity, finding meaning, and taking responsibility [source: Andresen et al.]. Leamy et al. mapped 15 stage models onto the transtheoretical stages, from precontemplation through to maintenance and growth [source: Leamy 2011].

Moving between stages. No source gives formal criteria for moving on. Recovery is described as non-linear, and setbacks are expected [source: Leamy 2011; SAMHSA 2012]. In practice, use these markers [synthesis]:

Moratorium → awareness: the person can name anything at all they want, or show interest in another person's recovery story.
→ preparation: they will take part in a strengths or values conversation.
→ rebuilding: they set a goal of their own and act on at least one step themselves.
→ growth: they use self-management tools with little prompting, hold roles that have nothing to do with being a patient, and agree the contact plan with you.

The STORI can be used to estimate the current stage. The authors call it preliminary: cluster analysis found three groups of items, not five [source: Andresen et al.].

Suggested phases of clinical work [synthesis, assembled from the components in Section 4]:

Engagement and hope.
Values, preferences and strengths assessment.
Recovery goals and the personal recovery plan.
Self-management and crisis planning (WRAP, advance statements).
Roles, connectedness and citizenship.
Review and stepping back.

These phases overlap. Go back to earlier ones after any setback.

3. Guiding principles

SAMHSA's ten guiding principles (2012) [source: SAMHSA 2012 via College of DuPage text]:

Emerges from hope: believe out loud that recovery is possible; hope can be lent by peers, family and staff.
Person-driven: the person sets goals, chooses paths and controls which supports they use.
Many pathways: do not impose one route. Medication, therapy, faith, peers and family are all legitimate. Expect setbacks.
Holistic: cover housing, work, physical and dental health, spirit and community, not only symptoms. Coordinate these services.
Supported by peers and allies: actively link people to mutual support and peer workers.
Relationships and social networks: involve people who believe in the person; support the shift into new roles (partner, student, employee).
Culturally based: shape every intervention around the person's cultural values and beliefs.
Addresses trauma: work in a trauma-informed way: safety, trust, choice, collaboration.
Individual, family and community strengths and responsibility: the person is responsible for self-care, and communities are responsible for inclusion. Support the person to speak for themselves.
Based on respect: protect rights, oppose discrimination, and recognise the courage that each step takes.

Strengths Model principles (Rapp & Goscha 2012) [source: Napa County Strengths Model guideline; St Vincent's Mental Health]:

People can recover, reclaim and transform their lives: assume the capacity for growth is already present.
Focus on strengths, not deficits: acknowledge problems, but build from what works.
The community is an oasis of resources: look for natural, non-service resources first.
The client directs the helping process: you are expert in options; they are expert in their own values and experience.
The relationship is primary and essential: strengths are mobilised through the relationship.
Work in the community: office-based work is described as contraindicated, so meet people where they live.
St Vincent's lists reflection and learning as a further principle.

Service values and stance [source: Slade 2009]:

The main goal of services is personal recovery: judge every intervention by whether it helps the person's own recovery.
Work on the person's goals: recovery goals are explicit and separate from treatment goals.
Assume people are, or will be, responsible for their own lives: do not foster dependency.
The person is the final decision-maker, except where the law overrides: use compulsion only when other options are exhausted.
"Services on tap, not on top": treatment is a resource the person uses.
A diagnosis describes; it does not explain: offer it tentatively, as one way of making sense of experience among others.
Positive risk-taking: growth needs risk. Avoid a risk-averse culture, and assess, support and document positive risks.
Coaching style: assume the person can manage their life, and focus on their strengths and goals.
Medication is one support among many: share decisions and respect a choice not to take it.
Normalise setbacks: a crisis is part of recovery, not a failure [source: also WRAP workbook 2004].
Make values explicit and use feedback: organisations build values into routines and change through outcome feedback.

Practice domains to check yourself against [source: Slade et al. 2015 BJPsych; DH Victoria 2011 via St Vincent's]:

Supporting personally defined recovery.
Working relationships.
Promoting citizenship (challenging stigma, community inclusion).
Organisational commitment.
The Victorian framework adds: a culture of hope; autonomy and self-determination; responsiveness to diversity; collaborative partnership; holistic and personalised care; families and carers; and community participation and citizenship.

4. Intervention inventory

The items below are the practices named in the sources used here. Each source's own name for a practice is kept. The step-by-step detail inside each practice is usually the guide's own operational wording [synthesis] and is labelled as such. The sources name the practices but rarely give scripts.

4.1 Hope-supporting practice

Purpose / when: Hope is the first SAMHSA principle and a CHIME process. Use it from the first contact, and most of all in moratorium or after a setback [source: SAMHSA 2012; Leamy 2011]. Slade sorts hope strategies into three kinds of resource: interpersonal, internal and external [source: Slade 2009, Table 2; individual strategies not extracted in detail, so uncertain].
Steps [synthesis]:
1. Say plainly that you expect recovery to be possible for this person. Do not promise cure.
2. Find one area of the person's life that is still intact or valued, and talk about it.
3. Offer recovery stories, written or video, or contact with a peer worker.
4. Agree one very small achievable step. Notice when it is done and say so.
5. Record dreams and aspirations in the notes, even ones that are distant.
Example language (illustrative): "Many people who have been where you are now have gone on to build lives they value. I am expecting that for you too, even if you can't feel it yet."
Watch for: False reassurance, or hope that is tied to one outcome only ("when the voices stop"). It is working when the person begins to talk about any future, or starts holding some hope for themselves.

4.2 Understanding values and treatment preferences (REFOCUS Working Practice 1)

Purpose / when: Start the assessment from the person's identity, what matters to them, and what support they want from services. Use it at intake, at handover and at review [source: Slade et al. 2015 BJPsych].
Three formats named in REFOCUS:
- (a) A conversation guided by a Values and Treatment Preferences form.
- (b) A narrative approach: the person writes or tells their own life story.
- (c) A visual approach: life mapping. The form's content is [uncertain].
Steps [synthesis]:
1. Let the person choose the format.
2. Ask what matters most in their life, who they are apart from services, and what they want and don't want from you. Cover medication, therapy, admission and the people involved.
3. For the life story or life map, invite the person to mark high points, losses, turning points and what helped.
4. Write their preferences into the care plan in their own words.
5. Revisit at every review.
Example language (illustrative): "Before we get to symptoms, tell me what kind of life you want, and what you'd like services to do, or not do, to help with that."
Watch for: The person giving "right answers" to please staff. Preferences that never reach the plan. It is working when care-plan actions can be traced back to the stated values.

4.3 Strengths-amplifying assessment (100 Ways assessment)

Purpose / when: At any assessment, find strengths alongside difficulties. Support the person's own meaning-making rather than imposing a label, and encourage responsibility rather than dependency [source: Slade 2009, Box 3].
Steps [source: Slade 2009, paraphrased; ordering is synthesis]:
1. Keep the standard history headings.
2. Under each heading, also ask about:
  - personal goals
  - how the person has coped in the past
  - valued social roles
  - social supports
  - personal gifts and talents
  - dreams
  - what they do for fun
  - what gives their life meaning
3. Record strengths as fully as problems.
Example language (illustrative): "What has got you through hard times before?" "What are you good at, or what would people who know you well say you're good at?"
Watch for: A strengths section that is a token line under a deficit-heavy assessment. It is working when the formulation and the plan actually use the strengths listed.

4.4 Strengths Assessment (Strengths Model, Rapp & Goscha; REFOCUS Working Practice 2)

Purpose / when: Identify personal and environmental resources, past and present: qualities, talents, skills, aspirations, family and friends, and resources. Use it early, and keep it as a living document that feeds the personal recovery plan [source: Napa County guideline; St Vincent's; Slade et al. 2015 BJPsych].
Framework: REFOCUS frames assessment in four quadrants: personal deficits, personal strengths, environmental lacks and environmental resources. Traditional assessment fills mainly the deficit quadrants, and this practice adds the strengths quadrants. REFOCUS trains staff in the Strengths Assessment Worksheet, which its review found to be the most widely used qualitative strengths measure [source: Slade et al. 2015 BJPsych].
Steps [synthesis; the worksheet's exact life domains and columns are uncertain]:
1. Fill it in together, as a conversation, over several contacts, preferably in the person's own setting.
2. Go through the life areas one at a time: home, money, work and education, social life, health, leisure, spirituality.
3. For each area, note three things: what is happening now, what the person wants, and resources they have used in the past.
4. Use the person's words.
5. Ask which area they want to work on first.
Example language (illustrative): "Let's go through different parts of your life. For each one, I'd like to know how it is now, what you'd like it to be, and what has helped before."
Watch for: Turning it into a form-filling exercise. It is working when the person adds to it themselves and a goal emerges from it.

4.5 Framing the illness experience and sharing a diagnosis tentatively

Purpose / when: Recovery task 2 is to make the illness one part of the self. A framing may be a diagnosis, a formulation, or a spiritual or cultural understanding. Use it once the person wants to make sense of what happened [source: Slade 2009].
Steps [synthesis built on Slade's principle that diagnosis is descriptive]:
1. Ask how the person understands their experiences.
2. Offer the diagnosis as one possible description, along with what it does and doesn't tell them.
3. Explore other framings: trauma, stress, spiritual, cultural.
4. Agree a working understanding that the person finds useful.
5. Keep it open to revision.
Example language (illustrative): "Doctors would call what you've described X. That is a label for a pattern; it isn't the whole explanation of you. How do you make sense of it?"
Watch for: Engulfment, where the person comes to see themselves only as a patient, or a sense that the label was forced on them. With minority-ethnic clients, Leamy et al. found more emphasis on spirituality and on race-based stigma, and some people valued traditional or faith healing [source: Leamy 2011].

4.6 Recovery goals vs treatment goals

Purpose / when: Keep the person's own dreams in view next to the service's obligations [source: Slade 2009]. Do this at every care plan.
- Recovery goals are the person's own, look forward, and are set by the person.
- Treatment goals meet professional and societal requirements, such as avoiding relapse or admission.
- Both are needed, and they are not the same.
Steps [synthesis]:
1. Write the recovery goal first, in the person's words.
2. Write any treatment goals separately and say openly whose goal each one is.
3. Show how the treatment goals serve the recovery goal, where they do.
4. Where the two conflict, name the conflict and negotiate.
Example language (illustrative): "Your goal is to get back to your allotment. My team also has to think about keeping you out of hospital. Let's see how those fit together."
Watch for: Plans where every action is a staff action. REFOCUS found that about 71% of recorded care-plan actions were assigned to staff [source: Slade et al. 2015 BJPsych].

4.7 Supporting goal-striving: the personal recovery plan and GROW (REFOCUS Working Practice 3; Strengths Model)

Purpose / when: Help the person identify, work toward and reach goals they value. Support them rather than doing it for them [source: Slade et al. 2015 BJPsych]. In the Strengths Model, the Personal Recovery Plan is an active to-do list used at nearly every contact. It keeps the main goal in view even during a crisis [source: Napa County guideline]. REFOCUS names the GROW coaching model as its goal-planning tool [source: Slade et al. 2015 BJPsych].
Steps:
1. Goal: what does the person want?
2. Reality: where are they now?
3. Options: what could they do?
4. Way forward: what will they do, and when?
5. Break the goal into small steps, each with who does it and by when. The plan's exact fields are [uncertain].
6. Assign most steps to the person.
7. Review the plan at each contact and celebrate steps achieved, which builds agency [source: Slade 2009 on celebrating success]. The expansion of GROW and the step mechanics in points 1 to 5 are the guide's wording [synthesis].
Example language (illustrative): "What would you like to be different in six months? ... What's already in place? ... What are some ways to get there? ... Which one will you try before we next meet?"
Watch for: Goals that are really the clinician's, or steps too big to complete. It is working when steps get done between contacts and new goals appear.

4.8 Coaching conversations (REFOCUS recovery-promoting relationships)

Purpose / when: Coaching is the relational style for all contacts. It assumes the person can manage their life and focuses on strengths and goals rather than problems [source: Slade 2009; Slade et al. 2015 BJPsych]. REFOCUS used a locally developed programme, "Coaching Conversations for Recovery", delivered as about 2 days, or 16 hours in the trial report [source: Slade et al. 2015 trial; BJPsych].
Steps [synthesis, consistent with the core skills in the Napa County guideline]:
1. Use reflective listening.
2. Ask open, future-focused questions.
3. Hold back unsolicited advice.
4. Let the person decide the next steps.
5. Offer information only with permission.
6. Summarise the person's own plan back to them.
Example language (illustrative): "What do you think the next step is?" "Would it help if I shared some options people have used?"
Watch for: Coaching used as a reason to withdraw practical help that is needed. It is working when the person does more of the talking and planning.

4.9 Motivational interviewing

Purpose / when: Use MI where the person is unsure about a change. It uses reflective listening and explores the person's own reasons to change [source: Slade 2009]. The MI method itself is outside this guide's sources; use a standard MI text.
Steps [synthesis]:
1. Ask about the person's reasons for and against the change.
2. Reflect back the reasons for change they voice themselves.
3. Summarise.
4. Ask about readiness.
Example language (illustrative): "Part of you wants to try college again, and part of you worries it'll go wrong like last time."
Watch for: MI used to steer people toward the service's goals rather than their own.

4.10 Wellness Recovery Action Plan (WRAP)

Purpose / when: WRAP is a self-management framework. The person works out what keeps them well and gains control over distressing symptoms and patterns. It can be done alone, with a chosen supporter, or in a group. The person owns the plan and decides who sees it [source: WRAP workbook 2004].
Status: WRAP is a registered programme associated with Mary Ellen Copeland. Formal WRAP groups are run by trained WRAP facilitators. Facilitator training and certification requirements are not given here, so check with the Copeland Center or your local WRAP provider before running groups under the WRAP name [uncertain].
Steps (sections of the plan, paraphrased) [source: WRAP workbook 2004]:
1. Wellness Toolbox: list three things: what supports wellness, what gives life meaning and reflects the person's values, and new things to try.
2. Daily Maintenance Plan: describe yourself when well, which is your baseline. List what you do every day to stay well, what you do less often, and what you know helps but tend to skip.
3. Triggers: list the events that set off unhelpful chains of thought, feeling or behaviour. For each, plan how to avoid it where possible and how to cope when it happens.
4. Early Warning Signs: note subtle changes that signal it is time to act, and what you will do then.
5. When Things Are Breaking Down: describe how you are when things become serious. Plan self-care as the top priority and the steps that will stop escalation.
6. Crisis Plan: dated, and replaces earlier versions. It has ten parts:
  - your baseline when well
  - the signs that others should take over some or all decisions
  - supporters and their tasks, people you don't want involved, and how to settle disagreements between supporters
  - clinicians, current medication, medication you prefer and medication to avoid
  - other helpful treatments and treatments to avoid
  - alternatives to hospital
  - preferred facilities and facilities to avoid
  - what helps and what doesn't, and who does what
  - what supporters should do if there is danger
  - signs that the plan is no longer needed It can be signed in front of two witnesses.
7. Post-Crisis Plan: when the person has the energy, review with a trusted person what happened, what was learned, which parts of the plan didn't work, and what to change.
Clinician's role [synthesis]: introduce WRAP, offer to be a supporter if asked, and help the person draft sections in sessions without writing it for them. Where the person agrees, attach the crisis plan to the clinical record. Honour the plan in a crisis.
Example language (illustrative): "This is your plan, not ours. You decide what goes in and who sees it. Shall we start with what you're like when you're well?"
Watch for: Staff turning WRAP into a compliance form. Early-warning work making the person anxious or over-vigilant [source: Slade 2009]. It is working when the person uses their own toolbox before contacting services.

4.11 Advance statements, shared care agreements and patient-held records

Purpose / when: Keep as much of the person's responsibility as possible during a crisis. Set these up during a well period [source: Slade 2009].
Steps [synthesis]:
1. Draft, with the person, their preferences for treatment, the people to involve, practical matters (children, pets, bills) and what to avoid.
2. Check the legal standing of advance decisions in your jurisdiction.
3. File the document where crisis staff will see it, and give the person a copy.
4. Review it after every crisis.
Example language (illustrative): "If things got very bad again, what would you want us to know and do, and what should we definitely not do?"
Watch for: Plans that are filed and then ignored, which damages trust. It is working when crisis responses follow the plan.

4.12 Recovery-oriented crisis work

Purpose / when: Prevent crises, keep the loss of responsibility to a minimum, and protect identity during and after a crisis [source: Slade 2009].
Steps [source: Slade 2009, paraphrased; the itemisation is synthesis]:
1. Work on early warning signs without creating anxiety.
2. Treat setbacks as normal.
3. In a crisis, use the advance plan, and use compulsion only when other options are exhausted.
4. Keep the person's ordinary life and skills going as far as possible.
5. Involve their support network.
6. Start from who they are, not from admission procedures.
7. Afterwards, help them make sense of the crisis (see the WRAP post-crisis plan).
Suicide risk: carry out standard risk assessment and safety planning alongside this. Counsel on lethal means only in terms of safe storage and removal [synthesis].
Example language (illustrative): "This is a setback, not the end of your recovery. What has to keep going in your life while we get through this?"
Watch for: Crisis care undoing hard-won roles, for example losing a tenancy or a job. Check these in the post-crisis review.

4.13 Shared decision-making about medication, including choosing to stop

Purpose / when: Medication is one support among many, with benefits and downsides. Support informed choice, make sure medication is available to those who want it, and do not assume that universal prescribing reflects real choice [source: Slade 2009].
Steps:
1. Explore the person's goals for treatment.
2. Give balanced information.
3. Record their preferences.
4. If they want to stop, give balanced information on stopping, plan alternatives and a gradual, prescriber-supervised reduction, set up an early-warning plan, and validate their decision [source: Slade 2009]. Steps 1 to 3 are the guide's wording [synthesis]. No dosing or schedules are given here: reduction is the prescriber's decision.
Example language (illustrative): "What do you want the medication to do for you, and what is it costing you?"
Watch for: Coercion, either toward taking medication or toward stopping it. Abrupt stopping without a plan.

4.14 Personal medicine, power statements and CommonGround (Deegan)

Purpose / when: Bring the person's own wellbeing strategies and voice into medication consultations [source: Deegan 2013].
- Personal medicine is what a person does, as distinct from the pills they take, to support their wellbeing. Peer staff help the person find its "active ingredient".
- A power statement is a short personal statement. It presents the person as a person, says how they want treatment to help, and invites a shared decision.
CommonGround workflow [source: Deegan 2013]:
1. The clinic waiting area becomes a peer-run Decision Support Centre.
2. The person arrives early, about 30 minutes before the appointment.
3. With peer help, they complete a survey on their recovery, current concerns, medication worries and their goal for the visit.
4. The survey produces a transparent health report, with the power statement shown prominently.
5. The prescriber reviews the report with the person, and they reach a shared decision. The CommonGround software itself is a licensed product [uncertain: current licensing terms not checked].
Adapting it without the software [synthesis]:
1. Help the client write down their personal medicine and a brief power statement.
2. Encourage them to bring it to prescriber appointments.
3. With consent, share it in liaison letters.
Example language (illustrative): "What do you do for yourself that helps as much as, or more than, the tablets? Let's write that down so your doctor sees it."
Watch for: Power statements written for the person rather than by them.

4.15 Positive risk-taking

Purpose / when: Growth needs risk, so separate harmful risk from positive risk. Use this when a valued goal carries risk, such as work, travel, living independently or reducing support [source: Slade 2009].
Steps [source: Slade 2009: assess, support and document; the detail is synthesis]:
1. Name the goal and its benefits.
2. Name the realistic risks.
3. Agree the safeguards and the early signs to watch for.
4. Agree who does what.
5. Record the shared decision and the reasoning behind it.
6. Review the outcome.
7. Use collaborative harm reduction where relevant.
Example language (illustrative): "Let's plan this so it's a risk worth taking: what could go wrong, how would we know early, and what's our back-up?"
Watch for: A team culture that is defensive and avoids risk. Positive risk-taking used as cover for withdrawing support.

4.16 Peer support (refer, partner, integrate)

Purpose / when: Peer support builds hope, belonging, skills and roles. It includes mutual self-help groups, peer support specialists and peer-run programmes [source: Slade 2009; SAMHSA 2012]. Peer-run services are not delivered by the clinician.
Steps [synthesis]:
1. Offer peer support routinely, not only when other options fail.
2. Explain the options.
3. Make a warm introduction.
4. Respect the peer worker's distinct role and their confidentiality norms.
5. Invite peer staff into reviews where the person wants this.
Example language (illustrative): "Would it help to talk with someone who has been through this themselves? I can introduce you."
Watch for: Peer workers being pulled into a clinical, enforcing role. For fidelity of peer-run services, Slade cites the FACIT measure [source: Slade 2009].

4.17 Valued social roles, wider relationships and citizenship

Purpose / when: Recovery task 4 and the CHIME processes of connectedness and meaning [source: Slade 2009; Leamy 2011]. Support:
- spirituality
- meaningful activity
- giving back to others
- self-discovery
- citizenship
- cultural activity
- time for reflection Also support the move into roles such as partner, student, employee or caregiver [source: SAMHSA 2012]. Use the community as a resource, looking for natural supports first [source: Strengths Model via Napa County].
Steps [synthesis]:
1. Pick one role from the strengths assessment.
2. Find community, non-service routes into it.
3. Accompany the person on the first contact if they want.
4. Plan for stigma and disclosure decisions.
5. Track the role in the recovery plan.
Example language (illustrative): "Outside of being a patient here, what roles matter to you, or used to?"
Watch for: Activities confined to mental-health services. It is working when the person's network includes people who are not staff or other service users.

4.18 Empowerment and agency mechanisms

Purpose / when: Build agency and control [source: Slade 2009]. The mechanisms named are:
- accessible complaints processes
- the option to change worker
- user-led evaluation
- assertiveness training
- a rotating "recovery hat" role in team meetings, where one member speaks for the recovery perspective
- a welcoming environment and first contact
- celebrating success
Steps [synthesis]:
1. Tell every client how to change worker and how to complain.
2. Assign the recovery hat in each team meeting.
3. Ask clients for structured feedback.
Example language (illustrative): "If we're not a good fit, you can ask for a different worker. That won't count against you."
Watch for: Token involvement.

4.19 Partnership projects (REFOCUS)

Purpose / when: Staff and clients from the same team plan and run a non-clinical activity together, with a small budget (about £500 per team in the trial), to reduce "us and them" thinking [source: Slade et al. 2015 trial; BJPsych]. In the trial only 5 of 14 projects went ahead.
Steps [synthesis]:
1. Recruit volunteers from both sides.
2. Choose the activity jointly.
3. Share roles equally.
4. Hold a celebration afterwards and reflect on it.
Watch for: Staff taking over the planning.

4.20 Team training and reflection (REFOCUS)

Purpose / when: REFOCUS works at team level. It builds a shared understanding of recovery across the team and gives staff a safe space to examine their own values. Patients are also encouraged to expect active involvement in their care [source: Slade et al. 2015 BJPsych].
Components:
- Briefings, held separately for staff and for clients/carers.
- Recovery training: about 1.5 days, or 12 hours in three sessions, co-delivered by a trainer with lived experience and a professional trainer.
- Coaching training.
- Team manager reflection groups.
- Team reflection sessions.
- Reflection in individual supervision, using a reflective practice tool.
- An information session and a letter to raise patients' expectations. [source: Slade et al. 2015 trial; BJPsych]. The two papers give slightly different numbers of sessions [uncertain].
Watch for: Implementation falling short. In the trial, few facilitated team reflection groups took place.

4.21 Strengths Model group supervision and field mentoring

Purpose / when: These are named as core Strengths Model implementation tools. Basic training is described as a two-day workshop [source: Napa County guideline]. The procedure for group supervision is [uncertain]. See the Goscha, Blankers and Knowles training manual cited there.

4.22 Involving family and carers

Purpose / when: Relationships and social networks are a SAMHSA principle, and families are a domain in the Victorian framework [source: SAMHSA 2012; St Vincent's]. St Vincent's names a FRAP tool for involving families in recovery and the Strengths Model. Its content is [uncertain].
Steps [synthesis]:
1. With consent, invite the person's chosen supporters.
2. Share the recovery plan and the WRAP crisis section if the person wishes.
3. Explain the stance: hope, choice, positive risk.
4. Offer carers their own support.
Watch for: Family goals overriding the person's goals. Collectivist expectations, which can support recovery but can also add pressure [source: Leamy 2011].

4.23 Measuring recovery orientation and outcomes

Purpose / when: Check whether practice supports personal recovery [source: Slade 2009].
Tools named (none reproduced here):
- Practice Guidelines for Recovery-Oriented Behavioral Health Care
- FACIT, for peer-run services
- PoRSAT, an audit tool
- Recovery-Promoting Relationships Scale
- For individuals, the STORI. It has 50 items rated for how true each is now; the person is placed at the stage with the highest subscale mean [source: Andresen et al.].
Outcomes to track:
- objective quality-of-life markers: housing, safety, employment, relationships
- progress on the person's own goals
Watch for: Measures used only for audit and never fed back to the client.

5. Handling problems

The sources give principles, not troubleshooting protocols. Responses below are tagged by source; most of the concrete handling is [synthesis].

Stuck in moratorium: no goals, hopelessness. Do not ask for goals the person cannot yet set. Slade warns against expecting people early in recovery to meet demands they cannot yet meet [source: Slade 2009].
- Hold the hope for them and keep their ordinary life going.
- Offer peer contact and recovery stories.
- Shrink goals to the next day or week.
- Assess for depression and suicide risk using standard practice. [synthesis, built on SAMHSA's hope principle]
"My goal is for the voices to stop / to be normal." Accept it as a real goal. Explore what life would look like if it came true, then work on the parts that can start now (work, a relationship, a hobby) alongside symptom treatment [synthesis].
Goals the team thinks are unrealistic or risky. Use positive risk-taking:
- Break the goal into steps, start small, and agree safeguards.
- Do not veto it outright.
- Write down both the recovery goal and the treatment goal, and say openly where they conflict [source: Slade 2009 for the principles; procedure synthesis].
Passivity or dependence: "you decide".
- Hand small choices back to the person.
- Use coaching questions rather than advice.
- Assign plan steps to them and celebrate the ones they complete [source: Slade 2009; REFOCUS on rebalancing actions; detail synthesis].
- Check whether the passivity is learned from past coercive care.
Non-adherence to medication or the plan. Treat it as information about the person's preferences, not as defiance.
- Explore their goals and what each option costs them, using MI.
- Offer shared decision-making or power statements.
- If they wish to stop medication, plan it with balanced information, gradual prescriber-led reduction and an early-warning plan [source: Slade 2009; Deegan 2013; framing synthesis].
Overwhelm from planning tools. WRAP and strengths work can feel like homework.
- Do one section at a time, in conversation, at the person's pace.
- Let the person choose a format: talking, a life story or a life map [source: REFOCUS formats; pacing synthesis].
- Reduce early-warning monitoring if it is raising anxiety [source: Slade 2009].
Crisis and compulsion. Follow the person's advance plan and WRAP crisis plan. Keep their identity and roles intact. Use compulsion only when other options are exhausted.
- Afterwards, hold a post-crisis review that names openly what was done against their wishes and why [source: Slade 2009; WRAP 2004; open-naming synthesis].
- Report and record compulsory measures as your jurisdiction's law requires.
Ruptures: "you say it's my choice, but you sectioned me". Acknowledge the contradiction. Clarify where the law limits choice and where it does not. Ask what would rebuild trust, and offer a change of worker as a real option [source: Slade 2009 on changing worker; the rest synthesis].
Clinician scepticism or burnout: "recovery isn't realistic for my caseload". Slade notes that recovery relieves staff of unmeetable expectations [source: Slade 2009]. Use team reflection groups and supervision, co-training with trainers who have lived experience, and contact with people further along in recovery [source: REFOCUS components; framing synthesis].
Organisation not supportive. REFOCUS did not target organisational commitment, and the trial authors suggested that domain needs more attention. Raise recovery values explicitly, use outcome feedback, and push for peer roles [source: Slade et al. 2015; Slade 2009; advocacy steps synthesis].
"Recovery" used to cut services or discharge early. This misuses the model. Supports should be stepped down only when the person agrees and has a plan for getting back in quickly [synthesis].
Cultural mismatch. Ask about spiritual and faith framings, traditional healing and collectivist family expectations. Be ready to adapt the individualist language of "self-management" and "personal goals" [source: Leamy 2011 on minority-ethnic findings; SAMHSA 2012; adaptation synthesis].
Trauma history. Work in a trauma-informed way: safety, trust, choice, collaboration. Avoid re-enacting coercion. Offer trauma-focused therapy by choice [source: SAMHSA 2012; therapy offer synthesis].
Co-occurring substance use. SAMHSA's definition covers mental and substance use disorders and treats abstinence as the goal in addiction. Many recovery-oriented services also practise collaborative harm reduction [source: SAMHSA 2012; Slade 2009]. Agree the stance openly with the client [synthesis; the two sources differ in emphasis, so uncertain].
Peer worker and clinician role conflict. Protect the peer role from being drawn into clinical, enforcing tasks. Agree in advance how information is shared [synthesis].

Sources

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