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The Practice Guidelines for Resilience and Recovery Oriented Treatment
The Practice Guidelines represents the evolution of Philadelphia’s behavioral health system. Together people in recovery, their family members, treatment providers, advocates and system administrators have developed a shared vision which has been blended with the lessons learned from Philadelphia’s transformation efforts over the past 30 years.
The guidelines apply to all treatment providers and individuals who are reimbursed for working in a provider organization at all levels of care. However, they are not intended to encapsulate all possible services or supports that promote recovery and resilience.
The guidelines are designed to help our system in delivering services and supports that promote recovery, resilience, and self-determination in children, youth, adults, and families.
Creating a recovery-oriented system of care for adults with behavioral health challenges is a top priority. This movement represents a shift from a professionally driven acute care approach to an approach that provides long-term supports while recognizing the many pathways to recovery.
In this approach, professional treatment is one aspect among many that support people in managing their own conditions to the greatest extent possible.
Transformation to a recovery orientation in behavioral health service delivery becomes possible by focusing on the central role of individuals and families in responding to, managing, and overcoming these challenges. This focus must be used as an organizing principle for the entire system.
Recovery Transformation consists of four primary strategies:
- Building community capacity
- Enhancing treatment quality
- Changing administrative structures
- Mobilizing people with behavioral health and substance use challenges, their families and other significant person(s)
Recovery is the process of pursuing a contributing and fulfilling life, regardless of the difficulties one has faced. It involves not only the restoration, but also continued enhancement of a positive identity as well as personally meaningful connections and roles in one’s community.
It is facilitated by relationships and environments that promote hope, empowerment, choices, and opportunities that support people in reaching their full potential as individuals and community members.
Philadelphia Department of Behavioral Health and
Intellectual disAbility Services
Recovery Advisory Committee, 2006
The Philadelphia Compact is advancing a resilience framework. Under this framework, decisions made about children will be guided as much by children’s assets and competencies as by their needs or deficits.
Resilience is a protective process which enables individuals to reach good outcomes even though they have endured significant adversities. Resilience is a common phenomenon arising from ordinary human adaptation and strength. It is a dynamic process that can change across time, developmental stage, and life domain.
All children, youth, adults, families and communities have the capacity to demonstrate resilience. There are many factors that enhance a child’s resilience pathway including: positive relationships with caregivers, peers, or a caring adult; internal strengths such as problem-solving skills, determination and hope; and environmental factors like effective schools and communities.
With these types of strengths, supports, and (at times) services, we can bolster our capacity for resilience, manage challenges, and successfully reach developmental or life stage milestones as healthy and productive members of society.
It’s All About Community
The Mission of Intellectual disAbility Services (IDS) is to create, promote, and enhance the supports and services available to individuals with intellectual disability. Individuals will have access to quality supports and services that foster choices in their everyday lives, meaningful personal relationships with friends, family, and neighbors, presence and participation in their communities, and dignity and respect as valued citizens of Philadelphia.
In order to accomplish this mission, IDS contracts directly with 70 agencies, in addition to other vendors and service providers, to provide a broad range of supports and services that include:
- Supports coordination
- Early intervention services
- In-home supports and respite services
- Employment and adult day services
- Community living and lifesharing services
10 Core Values
Each of the ten core values that drive this framework is supported by principles rooted in research, and in the collective experience of individuals, families, providers and service systems.
The core values were drawn from the earlier work of the Recovery Advisory Committee and from the values identified in the report issued by the Mayor’s Blue Ribbon Commission on Children’s Behavioral Health. The list was further developed through the work of stakeholders in the Summer of 2009.
Strength-Based Approaches That Promote Hope
A strengths perspective is woven throughout these system transformation efforts. Services are focused on identifying and building strengths, assets, resources and protective factors within the individual, family, peer group and community, rather than focusing solely on identifying and addressing problems or challenges in the individual’s or family’s life. These strengths are mobilized to support the individual’s and the family’s journey to wellness. A focus on hope is equally essential—the message that people can and do show resilience in the face of adversity, and can and do recover from behavioral health conditions. Change is always possible, and the extent to which people’s lives can change is often beyond what we can imagine. We learn hope by seeing others lead meaningful lives in their communities, listening to their stories and having opportunities to give to others. Hope inducing environments can help people of all ages in their recovery processes.
Community Inclusion, Partnership, and Collaboration
The focus of care is on integrating individuals and families into the larger life of their communities, connecting with the support and hospitality of the community, developing community resources that support recovery and resilience and encouraging service contributions to and from the larger community. Resilience, recovery and wellness can be tapped, initiated, catalyzed and promoted in care settings, but can be maintained only in the context of people’s natural environments. Connecting services, individuals and families with the community is no longer considerer optional, but is understood as an integral factor in sustaining wellness.
Person- and Family-Directed Approaches
In recovery and resilience oriented systems, service designs shift from an expert model to a partnership/consultation model, in which everyone’s perspective, experience and expertise is welcomed and considered. Each person’s and each family’s values, needs and preferences are respected and considered central to any decision-making process. Services and supports are individualized, built with and around each person and family. All parties in the system recognize that there are many pathways to recovery and that people have a right to choose their own paths. People have the opportunity to choose from a diverse menu of services and supports and to participate in all decisions that affect their lives and those of their children. Multidisciplinary teams that include participants and family members reduce fragmentation and ensure the delivery of comprehensive, effective services.
Family Inclusion and Leadership
Family members are actively engaged and involved at all levels of the service process. Families—and particularly parents of children and youth—are seen as an integral part of policy development, planning, service delivery and service evaluation. Assessment and service planning are family focused. The system and its providers recognize that families come in many varieties. Families of birth, foster and adoptive families and families of choice are respected, valued and involved in meaningful ways. When multiple family members are involved in care in different programs and agencies, providers take steps to ensure that services are integrated.
Peer Culture, Support, and Leadership
Service systems and providers recognize the power of peer support and affirm that recognition by: a) creating environments in which peers can support one another in formal and informal ways and providing opportunities for that support; b) hiring people to provide peer support to individuals and/or families; c) ensuring representation of youth and people in recovery at all levels of the system; d) developing respectful, collaborative relationships between behavioral health agencies and the service structures of local recovery mutual-aid societies and assertively linking people to peer-based support services (e.g., mutual/self-help groups, other recovery community support institutions and informal peer support); e) acknowledging the role that sharing stories of lived experience can play in helping others initiate and sustain the recovery process; and f) developing opportunities for people in recovery and youth to engage in active leadership roles at all levels of the system.
Person-First (Culturally Competent) Approaches
The title of this core value reflects the fact that services that are appropriate to and respectful of culture—often referred to as “culturally competent”—must also respect the individuality and centrality of each unique individual. In a person-first (culturally competent) service system, all staff and volunteers are able to work effectively with individuals and families from different cultures. They possess knowledge of the values, worldviews and practices of the major cultural groups they serve—and, equally important, the humility to know the limits of their knowledge. They address culture broadly, not forgetting the importance of ethnicity, nation of birth and primary language, but also acknowledging the implications of gender, age, sexual orientation, religion, socioeconomic factors and other key characteristics. Rather than merely developing a generic understanding of the people they serve, however, they are also skilled at using cultural knowledge to develop an accurate and individualized understanding of each person they serve, each family and each community. Providers also possess an understanding of their own cultural worldview, the ways in which it enriches their work and the ways in which it may constrain their work.
All components of the service system are designed with an understanding of the role that serious adverse experiences can play in the lives of individuals and families. Services are delivered in safe and trustworthy environments and through respectful, nurturing relationships, to promote healing and avoid inadvertent re-traumatization. Individuals and families are always assessed for the extent to which the spectrum of traumatic experiences may have affected their lives and their ability to participate safely in care and establish recovery. They are offered services and supports that will help them reduce the destructive effects of traumatic experiences and maximize the growth that can emerge from the healing process.
Holistic Approaches toward Care
Services and supports are designed to enhance the development of the whole person. Care transcends a narrow focus on symptom reduction and promotes wellness as a key component of all care. In attending to the whole person, there is an emphasis on exploring and addressing primary care needs in an integrated manner. Providers and peers also explore, mobilize and address spirituality, sexuality and other dimensions of wellness in service settings.
Care for the Needs and Safety of Children and Adolescents
Service systems and providers recognize the incredible resilience of children and adolescents, along with their unique vulnerabilities and the complexities that attend their need for services and support. As a result, providers employ a developmental approach in the delivery of services. Like adults, children and their families are shown respect and given a partnership role in services and supports. Screening and assessment processes are informed by knowledge of the ways in which children’s and adolescents’ strengths, symptoms, needs and progress tend to differ from those of adults, and of ways in which those differences can be honored. Providers also recognize that attention to the safety, needs and well being of children and adolescents includes attention to the safety, needs and well being of their families—and back up that recognition with concrete action.
Partnership and Transparency
This system transformation effort is built upon the values of transparency and partnership at all levels of the system. This applies to the ways in which system administrators strive to work with providers, as well as the ways in which providers aim to collaborate with the individuals and families receiving services.
Though the core values are too global to represent action-oriented strategies that people can pick up and use, it is essential for all service providers to understand and embrace these values and the principles that support them. These core values are made operational in the strategies that follow, with multiple values often driving the same strategy.
Stakeholders have identified four service domains that are essential components of a recovery and resilience oriented behavioral health system:
Assertive Outreach and Initial Engagement
The many obstacles people face in entering and staying in services make this domain essential to the success of the system and the people it seeks to serve. Human tragedy has shown that many people die before they receive the help they need, but empirically supported practices have given us many ways of increasing motivation; eliminating obstacles; and making services more accessible, more acceptable and easier to navigate.
Screening, Assessment, Service Planning, and Delivery
There is a wealth of concepts and resources that can be used to make care more effective and to lay a better foundation for ongoing recovery. These include emphases on individual, family and community strengths, and on resilience and recovery capital, from the initial screening and assessment process through the interventions chosen. These emphases also extend to the integration of services for mental health, primary care, substance use and trauma-related issues and the mobilization of professional and community-based recovery support structures from the earliest days of treatment.
Continuing Support and Early Re-Intervention
Although recovery is a significant reality, some behavioral health challenges are chronic conditions that can move into and out of remission. Effective professional, peer and community support can, not only help individuals and families achieve their dreams and goals, but also prevent, identify and address recurrence of the symptoms of mental health and substance related challenges. This support can take many forms and occur at many times throughout the recovery process.
Community Connection and Mobilization
The forging of a meaningful life in the community must be driven by the true hopes and dreams of individuals and families—hopes and dreams that may have been worn down by years, decades or even generations of poverty, prejudice, trauma, illness and hopelessness. Traditionally seen as sources of danger, temptation and deprivation surrounding the treatment refuge, communities must instead be seen for and cultivated as sources of support, fellowship, civic engagement and healing. Behavioral health organizations and providers must recapture their roles as members of and contributors to their communities, so they can foster the exchange of resources between those communities and the individuals and families they serve.
To make these practice guidelines useful for real human beings doing real work, the action-oriented strategies within each of the four domains have been organized under seven functional goals.
- Provide integrated services
- Create an atmosphere that promotes strength, recovery and resilience
- Develop inclusive, collaborative service teams and processes
- Provide services, training and supervision that promote recovery and resilience
- Provide individualized services to identify and address barriers to wellness
- Achieve successful outcomes through empirically informed approaches
- Promote recovery and resilience through evaluation and quality-improvement processes
The Practice Guidelines is a living document that is intended to grow with use in the real world. Use the 10 Core Values, 4 Domains and 7 Goals as a foundation to discover your own strategies to enact a more resilience and recovery oriented approach in the treatment you provide. In fact, the Practice Guidelines were developed as a means to standardize some of the great innovations that have been made in the Philadelphia behavioral health system by stakeholders like you.