Synopsis of Changes

             The organizational structure of mental health services has changed over the last few decades by shifting from institutional treatment to community-based treatment that focuses on a recovery-oriented approach (Gehart, 2012; Kaplan, Salzer, & Brusilovskiy, 2012; Onken, Craig, Ridgway, Ralph, & Cook, 2007; Pilgrim, 2009). These changes within the organizational structure of mental health services have made it possible for more individuals with a neurobiological disorder to live in communities. The United States government passed legislation which halted large group health plans (51 or more employees) from imposing annual or lifetime dollar limits on mental health benefits, because discriminating health insurance practices placed limits on insurance coverage for mental health and addictions treatment (SAMSHA, 2013). This was known as the Mental Health Parity Act (MHPA) of 1996. Yet, many consumers continued to receive inadequate services and treatment, and most communities continued to have inadequate resources (Corrigan, 2004; Komiya, Good, & Sherrod, 2000; Vogel, Wade, & Haake, 2006).  

            Consumer is a term that is preferred to be used; rather than, ‘client’, ‘patient’, or ‘service recipient’ (Gehart, 2012, Part I, p.431; President’s New Freedom Commission on Mental Health, 2003, p.4). This term is not meant to be derogatory or demeaning to people who are dealing with mental health challenges. In fact, the consumerism movement is the joining together of any individual who has had or is experiencing emotional and mental health challenges in a movement to regain their rights; thereby, “ridding society of discrimination and prejudice” (Holter, Mowbray, Bellamy, MacFarlane, & Dukarski, 2004, p.51).

The U.S. Supreme Court heard the case Olmstead v. L.C. (1999), and the justices determined that the Americans with Disabilities Act of 1990 requires states to place individuals with a neurobiological disorder in community settings when it is determined that community placement is appropriate; for that reason, the Olmstead v. L.C. case is used as the basis for making determinations about placement of individuals with a neurobiological disorder. As a result of the Olmstead v. L.C. case and the Consumerism movement, the New Freedom Commission on Mental Health (2003) recommended a policy shift that would transform mental health services and supports towards a ‘recovery-oriented approach.’ The idea of this type of transformation was a move in the right direction. According to Gehart (2012), “this approach draws upon some of the field’s best practices to create an approach that harmonizes with and supports the principles and ethics identified in the consumer-based, mental health recovery movement” (Part II, p.443). But, recovery is a broad term and without a clear definition and understanding of the term there were many misunderstandings surrounding its use by professionals and consumers. Since the policy that was developed lacked a clear definition Pilgrim (2009) pointed out that there was “little consensus on what recovery means in relation to mental illness” (p.477).  In order for there to be more of a consensus between professionals and consumers there needed to be a better description of what recovery meant and how recovery could be attained.

            In 2005, the Substance Abuse and Mental Health Services Administration (SAMSHA) came out with a definition of recovery, and they defined recovery as “A journey of healing and transformation enabling a person with a mental health problem to live a meaningful life in a community of his or her choice while striving to achieve his or her full potential.” Despite this definition of recovery there was still confusion surrounding the definition of recovery. Davidson and Roe (2007) tried to decrease the confusion that surrounded recovery by dividing recovery into two categories: ‘recovery from’ which involves an individual with a neurobiological disorder diagnosis becoming symptom free and not being admitted into a hospital or facility as a patient, and ‘recovery in’ which is when an individual with a neurobiological disorder endures their fluctuating symptoms as they change.

            SAMSHA was central to the transformation of the recovery system when they made the commitment that, “The Concept of recovery lies at the core of SAMSHA’s mission, and fostering the development of recovery-oriented systems of care (ROSC) is a SAMSHA priority” (Center for Substance Abuse Treatment, 2006, p.8). During this time period some other issues arose: sixty percent of consumers were leaving mental health and substance use disorders treatment before completion of their treatment (Substance Abuse and Mental Health Services Administration Office of Applied Studies Treatment Episode Data Set 2005, 2008); organizations were finding it difficult to measure the results of recovery and the government started feeling the pressure to reduce spending. As a result, the government started holding organizational programs, and professionals, accountable to provide measurable results.

It was apparent that the entire mental health system needed to be changed, so in 2009 SAMSHA started releasing recovery-oriented publications to provide direction in making efficient use of resources (Sheedy & Whitter, 2009; Gaumond & Whitter, 2009; Halvorson & Whitter, 2009; Laudet, 2009). Furthermore, SAMSHA created best practices and common terms that could be incorporated into the mental health and addictions field (Sheedy & Whitter, 2009; Gaumond & Whitter, 2009; Halvorson & Whitter, 2009; Laudet, 2009). The United States government realized that there were millions of Americans with neurobiological and/or substance disorders that were not receiving the same level of care as Americans with other general medical conditions; as a result, the U.S. passed the Paul Wellstone and Pete Domenici Mental Health Parity and Addiction Equity Act (MHPAEA) of 2008 (Humphreys & McLellan, 2010). Then, SAMSHA (2010) released a three phase plan entitled Access To Recovery (ATR) Implementation Toolkit which was intended to help organizations receiving ATR grants to understand how to plan and implement recovery-oriented changes within their organization.

The MHPAEA's legislation was helping some Americans, but it was leaving millions of Americans without the needed medical insurance to get mental health services. Consequently, the U.S passed the Affordable Care Act (ACA) of 2010 (SAMSHA, 2013). However, there are challenges when implementing organizational changes. For example, some studies point to funding, administrative, and infrastructure challenges when implementing organizational changes (Halvorson & Whitter, 2009, p. 21). Halvorson & Whitter (2009) point out that “it’s important for all parties to be flexible during the alterations of the current mental health system;” however, the changes would continue over the next few years with the biggest changes being implemented in 2012 when the recovery process was transformed (p.17).

Stigma

Support groups are an important tool for facilitating recovery; for instance, recent studies have shown positive recovery outcomes/results with Wellness Recovery Action Planning (WRAP) (Copeland, 1997; Cook et al., 2009; Barbic, Krupa, & Armstrong, 2009; Sterling et al., 2010), the Recovery Workbook (Cook et al., 2009), and Pathways to Recovery: A Strengths Recovery Self-Help Workbook (PTR) (Fukui, 2010; Ridgeway, McDiarmid, Davidson, Bayes, & Ratzlaff, 2002). To illustrate, The WRAP program was developed by Mary Ellen Copeland, who is a mental health consumer. She wanted to live well and promote recovery (1997); with that being said, it is important for consumers to know that they are the central base of their own health and wellbeing. While some organizations have implemented WRAP into their programs, Scott and Wilson (2010) point out that it is important to allow consumers to decide if the WRAP lifestyle is something that they can achieve, because some consumers might feel that WRAP is not for them. It is vital to allow consumers to try skills and to determine what works for them and what doesn’t, so that they don’t become frustrated with the mental health system. Therefore, allowing consumers to remain engaged in services, and providing them with the elements of recovery that will help them to develop a set of tools that are beneficial to them.

            SAMSHA has recognized the family-to-family program, which is offered by the National Alliance on Mental Illness (NAMI), as a ‘prominent example’ of a program that promotes recovery by involving and supporting families. (SAMSHA, 2011). The NAMI organization offers a range of free educational programs and support programs. The educational and support programs are offered throughout the United States, and information about programs in specific locations can be assessed on their website. These programs include: Peer-to-Peer, NAMI Support Group, In Our Own Voice and much more (NAMI, n.d.: SAMSHA, 2011).

Spiritual Views

            When a consumer wishes to explore their spiritual views and religious resources, mental health professionals should be respectful and supportive because “spiritual well-being is moderately related to psychological well-being;” furthermore, Fukui, Starnino, & Nelson-Becker (2012) discovered that “involvement in religious activities contributed to increased self-perceptions regarding making sense of life…” and “…Attending religious community activities might help people find their path when searching for meaning in life” (p. 208). There are values that can be found in the bible that elevate one to learn forgiveness, honesty, love, self-respect, and other moral values[1]. For instance: 

The second is this: 'Love your neighbor as yourself.' There is no commandment greater than these (Mark 12:31, New International Translation).

 

Return evil for evil to no one (Romans 12:17, New World Translation, 2013 Revision).

 

Bear with one another; if anyone has a complaint against someone else, forgive him. Indeed, just as the Lord has forgiven you, so you must forgive (Colossians 3:13, Complete Jewish Bible).

 

            Life can be likened to a sailboat gliding along the water when the captain experiences a storm. The captain is forced to adjust the boats sails. Why? Because he is not in control of the storm, the strong winds and crashing waves. But by making adjustments, he may remain in control of his sailboat. In a comparable way, people often have no control over adversities that they encounter in life. But they can keep control of their life, to the extent possible, by adjusting the way they use physical, mental, and emotional resources. Thus, it can be beneficial to direct spiritual ones to versus found in the bible that will help them find more joy in life during trying times. For example:

It is important to focus on the here and now, because dwelling on past mistakes or bad deeds are not beneficial…

 

 But there is forgiveness with thee {GOD}, That thou mayest be feared (Psalm 130:4, American Standard Version).

 

It is possible to change with the help of God and his spirit…

 

Do not be conformed to this world, but be transformed by the renewal of your mind, that by testing you may discern what is the will of God, what is good and acceptable and perfect (Romans 12:2, English Standard Version).

 

Do not worry about tomorrow…

 

So never be anxious about the next day, for the next day will have its own anxieties. Each day has enough of its own troubles. (Matthew 6:34, New World Translation, 2013 Revision).

 

            Professionals have to make sure they don’t push religion on a consumer; as that could be a violation of some organizational policies and code of ethics. On the other hand, failure to recognize one’s spirituality can result in unethical treatment and be a failure of the helping professional to provide effective coping skills (Souza, 2002, p.216).

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[1] This does not mean, or imply, that individuals that don’t believe in the bible or god cannot display moral values.

Support Groups

Support groups are an important tool for facilitating recovery; for instance, recent studies have shown positive recovery outcomes/results with Wellness Recovery Action Planning (WRAP) (Copeland, 1997; Cook et al., 2009; Barbic, Krupa, & Armstrong, 2009; Sterling et al., 2010), the Recovery Workbook (Cook et al., 2009), and Pathways to Recovery: A Strengths Recovery Self-Help Workbook (PTR) (Fukui, 2010; Ridgeway, McDiarmid, Davidson, Bayes, & Ratzlaff, 2002). To illustrate, The WRAP program was developed by Mary Ellen Copeland, who is a mental health consumer. She wanted to live well and promote recovery (1997); with that being said, it is important for consumers to know that they are the central base of their own health and wellbeing. While some organizations have implemented WRAP into their programs, Scott and Wilson (2010) point out that it is important to allow consumers to decide if the WRAP lifestyle is something that they can achieve, because some consumers might feel that WRAP is not for them. It is vital to allow consumers to try skills and to determine what works for them and what doesn’t, so that they don’t become frustrated with the mental health system. Therefore, allowing consumers to remain engaged in services, and providing them with the elements of recovery that will help them to develop a set of tools that are beneficial to them.

            SAMSHA has recognized the family-to-family program, which is offered by the National Alliance on Mental Illness (NAMI), as a ‘prominent example’ of a program that promotes recovery by involving and supporting families. (SAMSHA, 2011). The NAMI organization offers a range of free educational programs and support programs. The educational and support programs are offered throughout the United States, and information about programs in specific locations can be assessed on their website. These programs include: Peer-to-Peer, NAMI Support Group, In Our Own Voice and much more (NAMI, n.d.: SAMSHA, 2011).

Spiritual Views

            When a consumer wishes to explore their spiritual views and religious resources, mental health professionals should be respectful and supportive because “spiritual well-being is moderately related to psychological well-being;” furthermore, Fukui, Starnino, & Nelson-Becker (2012) discovered that “involvement in religious activities contributed to increased self-perceptions regarding making sense of life…” and “…Attending religious community activities might help people find their path when searching for meaning in life” (p. 208). There are values that can be found in the bible that elevate one to learn forgiveness, honesty, love, self-respect, and other moral values[1]. For instance: 

The second is this: 'Love your neighbor as yourself.' There is no commandment greater than these (Mark 12:31, New International Translation).

 

Return evil for evil to no one (Romans 12:17, New World Translation, 2013 Revision).

 

Bear with one another; if anyone has a complaint against someone else, forgive him. Indeed, just as the Lord has forgiven you, so you must forgive (Colossians 3:13, Complete Jewish Bible).

 

            Life can be likened to a sailboat gliding along the water when the captain experiences a storm. The captain is forced to adjust the boats sails. Why? Because he is not in control of the storm, the strong winds and crashing waves. But by making adjustments, he may remain in control of his sailboat. In a comparable way, people often have no control over adversities that they encounter in life. But they can keep control of their life, to the extent possible, by adjusting the way they use physical, mental, and emotional resources. Thus, it can be beneficial to direct spiritual ones to versus found in the bible that will help them find more joy in life during trying times. For example:

It is important to focus on the here and now, because dwelling on past mistakes or bad deeds are not beneficial…

 

 But there is forgiveness with thee {GOD}, That thou mayest be feared (Psalm 130:4, American Standard Version).

 

It is possible to change with the help of God and his spirit…

 

Do not be conformed to this world, but be transformed by the renewal of your mind, that by testing you may discern what is the will of God, what is good and acceptable and perfect (Romans 12:2, English Standard Version).

 

Do not worry about tomorrow…

 

So never be anxious about the next day, for the next day will have its own anxieties. Each day has enough of its own troubles. (Matthew 6:34, New World Translation, 2013 Revision).

 

            Professionals have to make sure they don’t push religion on a consumer; as that could be a violation of some organizational policies and code of ethics. On the other hand, failure to recognize one’s spirituality can result in unethical treatment and be a failure of the helping professional to provide effective coping skills (Souza, 2002, p.216).

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[1] This does not mean, or imply, that individuals that don’t believe in the bible or god cannot display moral values.

Professional Accountability

          According to a 2009 SAMSHA study, professionals in the mental health field need to be trained in the recovery model. Most professionals have been introduced to recovery concepts and principles through federal program requirements or their agency’s administration policy. Sheedy and Whitter (2009) report that there is support for the principles of recovery, and after consulting 375 studies, their findings show that:

Extensive research has been conducted in the addictions field to support the following principles and systems elements: There are many pathways to recovery; Recovery exists on a continuum of improved health and wellness; Recovery is supported by peers and allies; Recovery is a reality; Inclusive of family and other ally involvement; Individualized and comprehensive services across the lifespan; Continuing care part of the continuity of care element; Partnership-consultant relationships; Responsiveness to personal belief systems; Commitment to peer recovery support services; Integrated services; and  Ongoing monitoring and outreach… (p. 39).

 

            With the current SAMSHA (2012) definition of recovery; the four dimensions that support a life in recovery; and the ten guiding principles of recovery, it is important for professionals to have  current, up-to-date education and training on practices that promote recovery. For example, as caregivers, the mental health care professional would want to work as a team with the consumer and take the time to listen and talk (Williams & Tufford, 2012). According to Gehart (2012), the goal of the Marriage and Family Therapist (MFT) should be to integrate the recovery principles into their practice; in fact, in order to reduce the confusion and resistance that the professional might feel Gehart introduces a “four-phase model for adopting a recovery orientation. Phase One: Horror, Outrage, and Righteous Indignation; Phase Two: Overconfidence; Phase Three: Integration and Balance; Phase Four: Creative Implementation” (Part.I, p.437-8). In Part II, Gehart (2012) insists that recovery can be facilitated between the MFT and the consumer when they “…develop a ‘reasonable’ course of action based on (a) what the therapist knows to be effective based on theory research, (b) what the consumer is willing to commit to, and (c) what is reasonably safe but not necessarily risk free” (p.451). In addition to consulting the consumer about their needs and wants, it is important to include families in the available resources of the mental health system and in the recovery process (President’s New Freedom Commission on Mental Health, 2003, p.9).

            Mental health care providers have many barriers to providing adequate and effective care, because there are many gaps between mental health care needs and actual services that are delivered; for instance, inadequate human resources for mental health (President’s New Freedom Commission on Mental Health, 2003, p.16; WHO, 10 facts on mental health); poverty and unemployment (Power, 2010); crime and violence in the community (Whitley, 2011); and the many facets of the recovery process (Gehart, 2012; Onken et al., 2007; Pilgrim, 2009; Segal, Silverman, & Tempkin, 2010). At times, these multiple facets of the recovery process and the nonlinear process of recovery cause individuals with a neurobiological disorder to fluctuate along the recovery process, thus making it challenging for mental health care professionals (Gehart, 2012; Onken et al., 2007; Pilgrim, 2009; Segal, Silverman, & Tempkin, 2010). In addition, professional have to maintain not only the health and safety of the individuals that are seeking treatment, but they have to maintain the health and safety of the community (Gehart, 2012).           

            Mental health care providers should provide support in a non-judgmental, non-stigmatizing, and supportive manner that follows ethical guidelines (American Counseling Association, 2010; Gotham, 2006; McHugh & Barlow, 2010). Most mental health care professionals have received training on evidence-based approaches, and they know that it is important to take into account individual client needs (Gotham, 2006; McHugh & Barlow, 2010; Kazak, Hoagwood, Weisz, Hood, Kratouchwill, Vargas, & Banez, 2010). Yet, some clinicians can find themselves unskilled or torn between the complexities involved in deviating from empirically supported approaches to meet the client’s needs; nevertheless, the APA Presidential Task Force (2006) defines ‘evidence-based practice of psychology (EBPP)’ as utilizing all available methodologies and focusing treatment on the client’s needs:

Evidence-based practice in psychology is the integration of the best available research with clinical expertise in the context of patient characteristics, culture, and preferences…It is important to clarify the relation between EBPP and empirically supported treatments (ESTs). EBPP is the more comprehensive concept. ESTs start with a treatment and ask whether it works for a certain disorder or problem under specified circumstances. EBPP starts with a patient and asks what research evidence (including relevant results from RCTs) will assist the psychologist in achieving the best outcome (p.273).

Introduction

It is estimated that 450 million people worldwide are affected by neurobiological disorders in a given year; in the United States that translates to one in four adults, age 18 and older, or 61.5 million people (based on the 2010 U.S. Census; Kessler, 2005; WHO, 2001). Of the 61.5 million people approximately 13.6 million people or ‘one in seventeen’ are dealing with serious mental health challenges; such as, schizophrenia, major depression or bipolar disorder (National Institute of Mental Health, 2005). Researchers believe that stigma, discrimination, and a lack of financial resources are major barriers that prevent people who are dealing with mental health challenge from seeking the care and treatment they need (Corrigan, 2004; Komiya, Good, & Sherrod, 2000; Vogel, Wade, & Haake, 2006).

According to National reports, reducing mental illness stigma and improving mental health knowledge are national health objectives that have the potential to enhance the mental health outcomes for individuals with a neurobiological disorder (U.S. Department of Health and Human Services, 1999; U.S. Department of Health and Human Services 2000; President’s New Freedom Commission on Mental Health, 2003). Other countries are transforming mental health polices to promote some type of recovery model, it is not restricted to only the United States (Australian Institute of Health and Wellness (AIHW), 2013; Scottish Government, 2012; Ireland, 2012). Dr. Gro Harlem Brundtland, the former director general of the World Health Organization (WHO), emphasizes that “Mental illness is not a personal failure…In fact, if there is failure, it is to be found in the way we have responded to people with mental and brain disorders,” because they can live productive lives and be vital members in their community which has been verified through studies  by the National Institute of Mental Health (NIMH) and the National Alliance for the Mentally Ill (NAMI) (2001, p.1; SAMSHA, 2009).