Promoting Choice: A Cornerstone of Recovery Facilitating Services and Interventions
by Marianne Farkas, Sc.D. Guest Columnist SAMHSA Recovery to Practice E News October 26, 2012
Over the past 10 to 20 years, the behavioral health field has been in intense discussions about recovery-debating what recovery is and what it's not, and whether it's a model, a personal journey, or a set of outcomes. Still, no issue is more controversial among providers than the notion of "choice."
Why Is Choice So Important to Recovery?
SAMHSA defines recovery as "a process of change through which individuals improve their health and wellness, live a self-directed life, and strive to reach their full potential." Other definitions emphasize the development of new meaning and purpose, but all recovery definitions recognize the individual as the central actor in the recovery process. The individual "improves his or her health and wellness." The individual develops a new sense of meaning in life. At its core, recovery contends that "people are not passive sites where biological and social forces meet-but [actors] who interpret their experiences." To a certain extent, recovery is the recapturing of a sense of agency-in other words, the transition from being a passive recipient of life to an active agent of one's future. Making self-determined choices and decisions about one's life and goals and the means to reach those goals is the first step in becoming empowered to be a full actor in one's life.
Although evidence has shown that choice and shared decision making are more effective than traditional authoritarian approaches to treatment, providing choice as a cornerstone of recovery-oriented services acknowledges the importance of rights and full citizenship, not just evidence. Ensuring the individual receiving services remains at the center of his or her care and giving that person autonomy are underlying premises of modern general health care.,
Why Is the Concept of "Choice" So Difficult?
Most service providers who promote recovery are not, by nature, trying to infantilize or control adults with serious behavioral health conditions. Providers who offer services to people with serious mental illnesses or behavioral health conditions primarily deliver these services when people are at their worst. They are in crisis, their symptoms have taken control of their lives, and the risks for "allowing" self-determination seem very high-loss of a job, home, relationships, finances, physical health, and occasionally life itself. At those times, choice seems to fly in the face of common sense, not to mention the basic principles of caring that attract providers to the field in the first place. A reasonable provider can ask, "Does a humane person simply stand back while another is hearing voices or drinking to the point of frequently being drunk, and allow that person to choose his or her own path?"
Furthermore, providers occasionally see people (when not in crisis) who appear to be doing very little with their lives-perhaps sitting on the couch watching TV and smoking cigarettes, with seemingly low motivation to change. Under these circumstances, providing an opportunity to make choices seems to support the inertia and lack of motivation impeding that person's ability to succeed. Lastly, providers may have offered choices to a person who responded in what seemed to be a totally unrealistic or inappropriate way. For example, when asked what kind of work position an individual would like to pursue, responses like "doctor," "astronaut," "rock star," etc., may have seemed completely out of the question, given the person's situation or skills.
How Does a Recovery Perspective Inform the Concept of "Choice?"
Are People "Too Ill to Choose?"
People with mental illnesses and addictions tend to have exacerbations and remissions. But most individuals are not ill or in crisis 24 hours a day, 7 days a week. When people are not in the midst of an episode, providers can facilitate proactive decision making about the ways in which people want to handle crises, the kind of medication they feel works most effectively, and the interventions and people they perceive as helpful. Types of Advance Directives, elements from Wellness Recovery Action Planning, and similar crisis preparation tools provide methodologies to help people plan before they experience symptom exacerbations or crises. When taking the value of choice seriously, recovery-oriented providers look for ways to engage a person when he or she is well (or functioning better) in selecting beneficial and desirable ways to intervene if that person cannot speak for him or herself, rather than operating from the assumption that taking control is the only possible option.
Are People "Too Unmotivated to Choose?"
A recovery-oriented provider does not accept the notion that people are "unmotivated" but instead sees motivation as a function of the fit between a person and his or her environment. In other words, once all factors are understood, most behaviors can be analyzed as rational responses to the environment. For example, many people, with or without disabilities, find it difficult to make important changes in their lives. Few can tolerate frequent change, choosing (consciously or unconsciously) to consolidate the changes they make and live with the results for quite some time. In the recovery journeys of those with serious mental illnesses, evidence shows many people let fairly lengthy periods pass during which nothing much appears to be happening. Rather than viewing such times as proof of lack of motivation, John Strauss called these phases "wood shedding," meaning a person could be in maintenance mode for an extended time-occasionally years-during which he or she appeared to be putting energy in a "shed" and storing it up for the next big change.
People go through periods of what appears to be aimlessness for other reasons, often related to their lack of hope about the future. If it seems unlikely that a good job, decent housing, or friends and partners will ever come along, many people lose the hope needed to strike out on a new path. In a similar vein, when a person has experienced a change with very negative results, that individual may well feel unmotivated to try change again. Engaging a person in developing a long-term vision of what a meaningful life would look like requires the person to believe change is possible, positive, and manageable. A recovery-oriented provider can arrange opportunities for a person to experience different options, try tasks and responsibilities he or she could do well, and meet peers who have made similar changes, which often helps people begin to believe in a future. That belief can inspire a person to take an active role in creating his or her vision for a meaningful life, choose the important components of that life (e.g., home, work, education, friends), and eventually select other recovery goals within the overall vision. Services such as clubhouses and peer support are especially well designed to inspire hopefulness, which makes choosing seem feasible and worthwhile to the individual.
Are People "Too Unrealistic to Choose?"
No one is born knowing how to choose. For most of us, trying things out, discovering what we like and don't like, and determining what's flexible and non-negotiable are experiences that continue from adolescence to young adulthood and beyond. Many of us held after-school or summer jobs, for example, that helped us learn about the world of work, our work preferences, and the tasks we are capable of doing well and being compensated for. Individuals with serious mental illnesses or behavioral health conditions often experience their first episodes at exactly the time when this kind of self-knowledge is being formed-i.e., during adolescence. As a result, many people spend their formative years learning about mental health and substance abuse services instead of learning about work, home, and school options. Consequently, promoting choice should involve helping people explore a variety of opportunities they can actually experience, with a way to process or debrief afterwards to determine their preferences (e.g., working with their hands or with data, being in a highly structured school or one with less rigidity). Volunteer positions, visits, summer courses, workshops, internships, job shadowing, and mentorship are methods that give people experience they may lack in a domain of interest. Recovery-oriented providers identify opportunities to help people learn about themselves and their interests, understand what they experienced relative to their own values and standards, and use decision-making tools that focus on comparing one option with another in terms of the person's standards. Tools like shared decision making are particularly useful. For example, decisions about medication regimens require expertise in medicine as well as insight into the personal experience of taking medication. Some decisions are shared less often. For example, where to seek work, go to school, and live tend to be decisions selected by the individual, and as such self-determined decision-making tools are more normative and common.
Choosing is the essence of what it means to be a citizen of democracy. It implies living with freedom as well as the responsibility that accompanies the choices we make. No one can claim or reclaim a meaningful life without the right to make decisions along the way. Therefore, providers who believe in promoting recovery must develop the knowledge and skills needed to help support informed choice as an integral part of their practice.
Dr. Farkas is a Clinical Professor at Boston University's Center for Psychiatric Rehabilitation. Contact her at firstname.lastname@example.org.
1(SAMHSA) Substance Abuse and Mental Health Services Administration. (2012). SAMHSA's working definition of recovery updated. Retrieved July 2012 from http://blog.samhsa.gov/2012/03/23/defintion-of-recovery-updated.
2Anthony, W.A. (1993). Recovering from mental illness: The guiding vision of essential mental health service systems in the 1990's. Psychiatric Rehabilitation Journal, 16, 11–23.
3Lysaker, P., & Lionhardt, B. (2012). Agency: Its nature and role in recovery from severe mental illness. World Psychiatry, 11(3), 165–66.
4Priebe, S., McCabe, R., Bullenkamp, J., Hansson, L., Lauber, C., & Martinez–Leal, R. (2007). Structured patient–clinician communication and 1-year outcome in community mental healthcare: Cluster randomized controlled trial. British Journal of Psychiatry, 191, 420–26.
5Farkas, M., & Anthony, W.A. (2010). Psychiatric rehabilitation interventions: A review. International Review of Psychiatry, 22(2),114–129.
6Grol, R. (2001). Improving the quality of medical care: Building bridges among professional pride, payer profit, and patient satisfaction. Journal of the American Medical Association, 286, 2578–2585.
7Sensky, T. (2002). Withdrawal of life-sustaining treatment. British Medical Journal, 325, 175–176.
8Strauss, J. (2011). Subjectivity and severe psychiatric disorders. Schizophrenia Bulletin, 37(1), 8–13.
9Farkas, M., Cohen, M., McNamara, S., Nemec, P., & Cohen, B. (2000). Assessing readiness. Psychiatric rehabilitation trainer technology practice series. Boston, Mass.: Center for Psychiatric Rehabilitation.
10Cohen, M., Farkas, M., Cohen, B., & Unger, K. (1991, 2007). Psychiatric rehabilitation training technology: Setting an overall rehabilitation goal. Boston, Mass.: Boston University Center for Psychiatric Rehabilitation.
11Deegan, P. Shared decision making. (2010). Pat Deegan PhD & Associates, LLC. Retrieved from https://www.patdeegan.com/commonground/tour/shared-decision-making