Towards Promoting Recovery in Vancouver Community Mental Health Services


Regina Casey Dip OT, MA, PhD student
School of Rehabilitation Sciences
Department of Occupational Science and Occupational Therapy
University British Columbia, Vancouver, BC, Canada.


Citation:
Casey, R.  (2008). Towards Promoting Recovery in Vancouver Community Mental Health
Services, BC, Canada   International Journal of Psychosocial Rehabilitation. 12 (2),

Contact:
Regina Casey Dip OT, MA, PhD student
Department of Occupational Science and Occupational Therapy
University British Columbia, Vancouver, BC, Canada.
Address: T325-2211 Wesbrook Mall, Vancouver BC Canada V6T 2b5
Email: Regina.Casey@gmail.com

Acknowledgements
Thank you to all those who gave permission to use material generated during a recent retreat of rehabilitation leadership professionals at VCMHS. Thank you to Dr. Diana Kane for her insights and experience in promoting recovery in NZ, UK, and in VCMHS. Thanks to Kim Calsaferri, manager of rehabilitation and recovery services in VCMHS. Sincere thanks to Jim Burdette from New Zealand who has challenged my thinking about the possibilities of recovery for the past two years. Thank you also to numerous consumers of services and family members who have worked alongside me and continue to deepen my understanding of recovery and finally, a warm thank you to Dr. Lyn Jongbloed my supervisor and mentor from University British Columbia.

Abstract
The concept of recovery has moved to the centre of mental health policy and service delivery for persons who have been diagnosed with a mental illness in Vancouver BC Canada. This article provides a review of the literature on recovery in mental health. A brief definition of recovery is given, followed by a historical review of the development of the philosophy of recovery with emphasis on the cultural implications of recovery for different countries and organizations. Much like other community mental health systems Vancouver Community Mental Health Services (VCMHS) has not yet identified a specific model or framework to guide the development of recovery-oriented services. To that end three models and a framework of recovery are presented and possible next steps in integrating recovery are highlighted for VCMHS. The discussion on model development with a focus on the cultural implications and the process of implementing recovery has relevance for the development of mental health services internationally (Schinkel & Dorrer, 2007).

Key words: Recovery, Models, Implementation

Background
The aim of this paper is to provide an overview of the literature with a particular focus on recovery-oriented models in mental health, as a way of contributing to the dialogue on how Vancouver Community Mental Health Services (VCMHS) in Vancouver BC Canada can continue to implement relevant key concepts of recovery within the system (VCMHS, 2006a, 2006b; VCMHS, 2007a, 2007b). For more details on VCMHS see the section on the Canadian perspective on page nine.  As indicated by the current literature, recovery is presented as an outcome, a process and a philosophical approach. As well, this paper briefly discusses the concept of recovery as both a model and a framework for service delivery. Finally, consideration is given to applying the concept of recovery to the Canadian context and in particular within the local VCMHS context. The review begins with a definition, history and background of recovery.

Definition of recovery
Despite two decades of discussion and debate around  the word recovery, and what it means in mental health, much confusion still exists regarding its definition (Davidson, O'Connell, Tondora, Styron, & Kangas, 2006). However, there is considerable agreement that recovery in mental health may be defined in terms of an outcome (Onken, Craig, Ridgeway, Ralph & Cook, 2006), such as the ability to lead a good and satisfying life despite the illness or presence of symptoms (Deegan, 1993; 1988). With respect to the notion of  process, recovery is frequently described as being a non-linear lived experience involving both self-discovery and transformation and culminating in an understanding that symptoms of the illness are not definitive in terms of one’s self-identity (Davidson, Sells, Sangster, & O'Connell, 2005).  A third common theme in the literature is the philosophical underpinnings of recovery, such as hope, connection, healing, empowerment (Jacobson and Greenly, 2001) self-help, mutual-help, self-determination, family involvement, resiliency, choice, justice, responsibility, skill building, a positive culture for healing, a focus on strengths and possibilities, community involvement, education and role development (Mental Health Commission, New Zealand, 2006; Ohio Mental Health Commission, 2001).

Not surprisingly, the lack of a consistent definition adds to the complexity of developing empirical evidence and engaging in research on the subject (Jacobson & Greenley, 2001; Liberman & Kopelowicz, 2005). Despite the challenge of multifaceted approaches and the lack of consistency, Barker (2003) offers what he refers to as the tidal model of recovery for nursing staff. The model aims to protect the ever-evolving story, language, and understanding of each individual and has been used to study outcomes with some success in several countries (Buchanan-Barker & Barker, 2006).

Other perspectives of recovery
Mary O’ Hagan, commissioner for mental health services in New Zealand (NZ), articulates some of the criticisms of recovery as both a word and concept, from service users’ and providers’ points of view. For instance, some service users say that the word recovery implies being restored to a place where they were prior to their illness when in fact they feel they been transformed by the experience. Other service users disregard the need for recovery as they feel that either they do not have an illness in the first place, or they do not find the madness undesirable. O’Hagan notes that some providers criticize recovery as being “‘esoteric nonsense … hard to grasp and … lacking in evidence base’” (2004, p. 1). Importantly, O’ Hagan discusses the difficulty that recovery originated in the United States (US), whose individualistic approach may be less useful in a more socially oriented society such as New Zealand. The individualistic approach may lead to a belief that “the problem” and its solution lies with the individual in contrast, a socially orientated approach may foster society assuming some responsibility.  A final criticism is that in the US, recovery grew more from professional literature and therefore has a slightly different emphasis. Further discussion regarding the cultural implications of recovery is presented below. 

In addition, a comprehensive review of recovery perspectives would not be complete without referring to the critical psychiatry movement, described by consultant psychiatrist Phil Thomas from the UK, as being “part academic, part practical” (n.d., n.p.). The main thrust of this influential organization and others like it is to promote careful consideration regarding how society and mental health stakeholders think about the concept of mental illness. Critical psychiatry emphasizes “social and cultural contexts, places ethics before technology, and works to minimize the control of medical interventions” (Braken & Thomas, 2001, p. 724). Indeed, critical psychiatry can challenge the traditional biopsychosocial approach of mental health systems and aims to make “experiences of psychosis meaningful rather than psychopathological” (p. 727). The ultimate aim of the movement is to move toward collaboration (Roberts & Wolfson, 2004).  As with the recovery approach, critical psychiatry seeks to democratize mental health systems so that the “voices of service users and survivors … move centre stage” (p. 727). However, the level to which our systems include or collaborate with service users is generally on a continuum and remains an area for further study (Casey 2006; Schinkel & Dorrer, 2007).

Surprisingly, the recovery literature rarely refers to the health promotion framework, which could potentially offer a scientific structure for evaluating recovery from the perspective of the social determinants of health.  The World Health Organization [WHO] defines health through its promotion when it states that “health is created and lived by people within the settings of their everyday life; where they learn, work play and love … by being able to take decisions and have control over ones life circumstances” (WHO, 1986, n.p.). Similarly, two prominent researchers in the recovery field propose a shared decision making model between consumers and staff for effective medication usage as a means to promote autonomy and wellness (Deegan and Drake, 2006). In addition, Onken et al’s (2006) framework for recovery, outlined below, seems to lend itself well to a health promotion approach and yet makes no reference to the crucial founding document the Ottawa Charter (WHO, 1986). Authors Lando, Williams, Williams and Sturgis (2006) offer a logic model defined as a visual representation of “inputs, activities and desired outcomes” (p. 1). Further, Lando et al. propose integrating mental health into chronic disease prevention and health promotion; the underlying message is that here is “no health without mental health” (p. 4). Stated goals of this model are to improve service utilization, create more supportive social and work environments, deepen our understanding of the link between physical and mental health and promote service user empowerment. In this model, the focus on chronic disease prevention and illness continuum may seem somewhat at odds with the espoused values of hope and optimism of recovery, often described as a separate wellness and health continuum (Health and Welfare Canada, 1998). 

How recovery evolved
In the US, according to Allott, Loganathan & Fulford (2002), the recovery movement emerged as a result of the civil rights movement of the 60s and 70s, as marginalized groups developed an awareness of their rights and found their voice. The result was a belief that self-determination (defined as people having the right to make their own decisions regarding their psychiatric disability) became a central concept in recovery (Holland & Johnson, 2005; Onken, Dumont, Ridgway, Dornan, & Ralph, 2002). Schinkel  and  Dorrer (2007)  add that interest in the recovery movement was fuelled by the disability movement and deinstitutionalization in the  1990s and was further supported by peer support movements such as Alcoholics Anonymous (AA). The discipline of psychosocial rehabilitation grew with emphasis on utilizing a recovery approach, and as no national implementation system existed, differing frameworks for implementing recovery emerged within each state. Interestingly, these frameworks were complex and developed primarily by professionals and academics rather than by users of service as was the case in New Zealand (Kane, 2007). It is observed that in the US the culture of recovery was influenced by a number of forces and further impacted by federal documents such as the American Declaration of Independence, resulting in a strong emphasis on self-determination which Schinkel and Dorrer caution could lead to neglecting the larger societal factors at play in recovery (2007).

Of interest, the UK mental health transformation, based largely on health reforms both in the US and New Zealand, was introduced to policy in England and Wales in 2001 (Schinkel & Dorrer, 2007). Schinkel & Dorrer note that the recovery approach fit well with was happening in Europe regarding approaches to mental health, in particular the document released by the World Health Organization in 2005 titled The Mental Health Declaration for Europe: Facing the Challenges, Building Solutions which advocated a strengths-based approach and the inclusion of service users and providers in developing our mental health systems.

 In a parallel jurisdiction, recovery in Scotland is currently driven by the Scottish Executive’s National Program for Improving Mental Health and Wellbeing which  centers on “social justice and inclusion” (Schinkel & Dorrer, 2007, p. 12). Further, the Scottish Recovery Network aims to advance the implementation of recovery by learning and sharing ideas. For example, the tidal model of mental health recovery, discussed further below, is being used in Glasgow as a pilot in acute settings. Shinkel & Dorrer (2007) outline some of the challenges in implementing recovery, such as skepticism on the part of service providers and service users and a culture of inertia and hopelessness. A key recommendation is to develop a “context-specific” recovery approach in collaboration with stakeholders rather than “imposing a framework developed elsewhere” (p. 14). Such content-specific research is evident in the work undertaken by the Mental Health Commission of New Zealand in 1988, in its efforts to understand how to adjust the US recovery approach in order to meet the needs of New Zealanders (Kane, 2007; Schinkel & Dorrer, 2007). It seems this process of understanding the cultural and contextual mental health needs of New Zealand took approximately one and a half years and uniquely employed a number of service users in the process (D. Kane, personal communication, June 6, 2007).  Interestingly, Nayar & Tse (2006) contend that learning how to meet the cultural needs of a growing New Zealanders Asian population is an ongoing challenge requiring attention to the cultural competence on behalf of mental health employees, policy makers and researchers who build theory.

O’Hagan (2004) says that since 1988, all mental health services in NZ are mandated by government to use a recovery approach and have a national policy to support the implementation. She clarifies that a small group of service users were given the challenge of defining the concept of recovery for the NZ cultural setting in the following areas: social, economic, political processes, citizenship, stigma, cultural diversity and were to include consumer survivor movements such as the critical psychiatry mentioned above (Mental Health Commission, 1998). In 1993 (later than in other places), the deinstitutionalization movement began in NZ, and consumers were employed at various levels and positions throughout the mental health system. Three such distinct positions available in NZ at present include consumer advisors (who hear the concerns regarding service or policy and can negotiate with managers), consumer advocacy positions and mental health support workers. Mental health support workers have relevant coursework and training and are viewed as an integral part of the multi-disciplinary team along with other professionals in mainstream roles (D. Kane, personal communication June 6, 2007).

Important and relevant key points of difference in how recovery is conceptualized, such as various models, frameworks and systems in countries mentioned above include: the reflection of historical and cultural context of a country (for instance in New Zealand [NZ] there is a strong emphasis on including the Maori culture); the understanding and weighting of elements such as service user involvement (in NZ the concept of recovery was articulated by users of service, not professionals); the acceptance of a mental health diagnosis as opposed to what service users identify as the problem (for instance in Ohio, the acceptance of a diagnosis is an indicator of recovery; in contrast a competency for a mental health professional in NZ is to accept and understand the person’s view of their illness); the balance between personal responsibility versus social and environmental causation for example in NZ social factors such as housing are ameliorated prior to the recovery journey in contrast to other models of recovery that propose focusing on the individual’s motivation for change early in the recovery process); the knowledge to facilitate various treatment choices; and finally the emphasis on developing and utilizing a range of credible peer support services (Schinkel & Dorrer, 2007). These enlightening differences regarding how systems interpret recovery may prove to be excellent material for VCMHS, and perhaps other organizations, to reflect on during future discussions regarding the meaning of recovery within the specific culture.

The Canadian perspective and Background on VCMHS
Notably, Canada is as yet without a mental health plan (Kirby and Keon, 2006), and unlike other countries such as New Zealand or Britain, Canada has no legislation indicating the expectation to implement a recovery approach to service delivery. In Canada Legislation in this field is mostly within provincial jurisdiction however, the new federally funded mental health commission, whose mandate it is to “become a national focal point for making progress on mental health issues”, will assist in the development of a “national mental health strategy” (Kirby, 2007, p. 4). The commission will build on the recommendations of an earlier report titled Out Of The Shadows At Last (Kirby & Keon, 2006) which calls for radical system transformation to make Canadian mental health systems recovery-oriented. At the local level, in April 2000, VCMHS (designed to provide services for people with mental health issues) became part of the larger Vancouver Coastal Health Authority (VCHA). The larger VCHA serves 1, 044, 750 people which is 25% of the population of BC, and employs over 21, 000 staff with a budget of 21 billion (VCH, n.d.). The smaller VCMHS employs 800 staff, operates out of eight multidisciplinary teams, and serves approximately 9,000 Vancouver residents. In terms of recovery, VCHA states its strategic direction is to engage "the voices of our patients, clients, and residents into VCH policies and procedures" (VCH, 2006a, n.p.). VCMHS (2006b) recently released an operational plan for mental health service delivery that firmly puts recovery at the heart of service planning, delivery, evaluation and research. Interestingly, many staff members feel that becoming part of the larger organization has slowed the implementation of the recovery approach (VCMHS, 2007a). For instance, it seems that becoming part of the larger organization may have been an impediment to promoting consumer involvement. Specifically, in the past people who used services also served on the board of the organization; this is no longer what happens (Casey, 2006). As an organization we are struggling to understand how best to implement recovery in VCMHS (Casey, 2006; VCMHS, 2006a, 2006b; 2007a, 2007b, 2007c), and have began a number of important dialogues regarding what recovery means to stakeholders. In preliminary discussions people who use VCMHS services currently, staff, users of service who are employed in the system, families, and management have been thoughtful in considering how recovery may best meet our specific cultural needs.
How do models and theories of recovery apply?

An initial review of the literature indicates that recovery is described as a process (Deegan 1998), a vision, (Anthony 1993), a set of values (Anthony, 2004), and as an end goal or outcome (Liberman, & Kopelowicz, 2005). This section of the paper discusses recovery as a model (Barker 2003; Jacobson & Greenly, 2001; Roberts & Wolfson, 2004; Rogers, Farkus & Anthony, 2005). For Rodgers et al., the term recovery is “critically in need of a multifaceted theoretical model informed by both mental health and behavioural (sinc) science” (2005, p. 1999). Additionally, in terms of research design recovery is generally deemed well served by using a qualitative approach to data collection and interpretation (Roberts & Wolfson, 2004). On the other hand, some researchers may propose that qualitative research methods impede the development of traditional more theoretical kinds of models. However, according to Roberts and Wolfson, both qualitative and quantitative research approaches and their respective “different kinds of data” are needed (2004, p. 38). While acknowledging these observations and challenges, the question remains: is it possible to describe recovery as a theory, or a model of practice, and if so what is the evidence for such a claim?  Another brief review of the terminology in this area may be helpful despite the fact that such terminology is frequently inconsistent and complex.

To begin with, theories pose and answer large questions and provide a way to organize empirical findings about phenomena (Krefting, 1985). Humanistic and behavioral theories, for example, contribute to our understanding of human behavior. Fawcett and Downs (1992) identify three components of a theory. First, the existence of concepts and or constructs is required, (concepts are concrete and directly observable building blocks; constructs are indirectly observable are more complex and difficult to measure). An example of a concept in the area of recovery in mental health is consumer involvement in service delivery and an example of a construct is hope. The second component of a theory includes propositions (statements about concepts or the relationship between concepts). A hypothesis can be developed when the variables of concepts can be measured. The final component of a theory is the construction of a diagram of a theory. The diagram is completed only after the concepts, definitions and propositions have been articulated. It may be argued that recovery has not reached this stage in its development at this time as specific tested empirical evidence is scarce at this level.

On the other hand, a model forms the basis of a theory. Models are not fully tested but generate an organized way of clarifying phenomena and have a smaller scope and level of abstraction than a theory. As Krefting suggests “One might say that a model is a ‘“theory in training”’ (1985, p. 174). Krefting also notes that models can be generic or specific depending on the level of particularity of application. The models described below could be described as specific since they apply to mental health. One early conceptual model of recovery was proposed by Jacobson and Greenly in 2001. Conceptual models identify what should be studied and why (Krefting, 1985). In the conceptual model proposed by Jacobson and Greenly (2001) the what is to “link the abstract concepts that define recovery with” the why of identifying the “specific strategies that systems, agencies, and individuals can use to facilitate it” (Jacobson & Greeenly, 2001, p. 482). A criticism of this model is that the reciprocal relationship between the internal and external conditions of recovery … [is] implicit” in their presentation of the model (p. 485). Making these connections explicit through the use of a diagram could provide much needed insight into systematically evaluating which internal and external factors are more efficacious for recovery. 

A later, more developed example of a recovery model comes from Rodgers et al., (2005). These authors propose an “initial conceptual framework and model of recovery processes and outcomes” (p. 209) that may be useful for service delivery, development, evaluation and research. The model is grounded in both a positive psychology approach and behavioral science research. It is based on seven assumptions that emerged from the Centre of Psychiatric Rehabilitation in Boston over the past 30 years and contribute to the credibility of the model. Of note, an underlying belief system or frame of reference is essential for model development (Krefting, 1985). The central construct of the model is that there are “environmental, sociocultural, and individual factors that affect both the processes and outcome of recovery” (p, 210). The model aims to promote discussion of what recovery means, why some people recover, those people’s characteristics and the ideal circumstances for recovery to occur. Helpfully, Rodgers et al. (2005) provide a visual diagram that includes external and internal factors relating to recovery and also objective and subjective components of recovery outcomes. The authors employ a qualitative approach in this research and make mention of studying individual role performance and subjective outcomes such as quality of life, self-esteem, and subjective wellbeing. Given the information above, Krefting (1995) would assert that the rigor of this model of practice is assured as it contains the three required components: a philosophical base, key concepts and their inter-relationships and has implications for further practice. Also, though there are 77 concepts and constructs in the model they are well laid out, structurally clear (Chinn & Kramer, 1995), flexible, easy to understand, complementary, and that represent a wide scope (Chinn & Kramer, 1995) of specialist areas of the person’s life such as social welfare, criminal justice, education, health and employment systems. This model appears easy to transfer to practice as it outlines both objective and subjective measures for success. However, while this model may be important and helpful to clients, families and practitioners, no actual illustrative case study accompanies it as it is presented.  

A final model of recovery comes from Barker, who offers a radical (Brookes, 2006) values-based person-centered, universally applicable model for recovery and empowerment, from a nursing perspective (Buchanan-Barker & Barker 2006). This humanistic model developed in the mid-1990s is based on constructs such as “caring processes” (Barker, 2001, p. 235), being human, the concept of helping one another (Barker & Buchanan-Barker, 1999), and the philosophy that change is constant. The model  was developed using an “expert nurse” focus group that attempts to understand the person’s story from their perspective through use of metaphor and is designed to be complementary to care provided by other disciplines. The model was also validated by a group of former “psychiatric patients led by Barker’s colleagues of many years” (Brookes, 2006).

In the tidal model of recovery the person is approached via three separate dimensions that interact as a system, the self, the world and others. The model requires mental health staff to believe that recovery is possible; that the person has the ability to begin their journey and knows what they need; and that staff need to learn from the person what needs to occur happen at this time – in this way, staff act as a pupil in an ever-changing environment (Barker, 2001, 2003; Buchanan-Barker & Barker, 2006). The concept of mental illness itself is viewed as a disturbance of everyday living and is indicated by the actions or stories these disturbances illicit. Uniquely, the tidal model asserts that “mental illness is a symbolic force, which is known only, in phenomenological terms, to the person involved” (Brooks, 2006, p. 708).

The final portion of the model is based on ten values or commitments, including, valuing the person’s voice and their language choice, demonstrating a genuine interest in the person and learning from them, understanding that people are experts in their own story and demonstrating transparency in decision-making both as a staff and as a recipient of service, listening to the person’s story for clues, and understanding what needs to be done in the present. Finally, staff need to demonstrate an understanding that time facilitates change (Barker, 2001, 2003; Buchanan-Barker & Barker, 2006). Essential guiding principles include developing the persons curiosity and resourcefulness, having respect for the persons wishes, that crises should be viewed as an opportunity, that small initial goals are desirable and that simple elegant solutions are best (Brookes, 2006).     

Consistency, an essential element for model development according to Chinn and Kramer, is evident though consistency of semantics apparent in the above terminology (1999). Certainly, compassion and mutual influence seem to be at the heart of the model. In order to promote consistency training is available and a network has been established to help new projects around the world. Barker also notes that this model is not intended to be prescriptive but rather should be adapted to meet the specific cultural and operational needs of the setting (Brooks, 2006).

Interestingly, this model is being implemented in the UK, Ireland, New Zealand, Canada, Japan, Scotland, Wales and Australia (Buchanan-Barker & Barker, 2006), which speaks to its ability to cross cultural and diagnostic boundaries and adds to its importance and generalizability. The authors acknowledge difficulties in providing proof of the relationship between recovery outcomes and the tidal model (hypothesis);  however, improved nursing morale and client satisfaction, as well as a reduction in self-harm, suicide attempts and absconding incidents and decreased aggression were cited as positive outcomes for using the model (Cook as cited in Buchanan-Barker & Barker, 2006). These cited outcomes indicate that the relationships between concepts can be empirically measured, substantiating the theoretical soundness of the model that is, its utility, precision and accessibility.

Aptly, Dr Nancy Brookes (2006) of Ottawa recently described the tidal model as an important middle range theory for “any setting, [and] relevant to any discipline” (2006, p. 715). Middle range theories attempt to bridge the gap between grand intellectual theory and empirical knowledge. These theories are described as having a number of related concepts, used in limited settings that can be represented by a model. According to Brooks, concepts within the tidal model provide a helpful solution-focused “philosophical approach to recovery versus a model of care or treatment of mental illness” (2006, p. 698).

In terms of model clarity, the concepts are defined and the relationships between those concepts are defined which promotes new theory development. One such development is the reframing of the original term “logic of experience” which developed into “practice based evidence” (Brookes, 2006, p. 711). The term logic of experience is defined as what might work in this particular situation and may contribute to our learning in other situations. Concepts and relationships are presented parsimoniously or elegantly in the holistic assessment of the person fro instance. The visual representation of this assessment is titled “Structure of Care” (Brooks, 2006, p. 713). The person’s story is represented as a heart at the centre of three concentric circles and influencing the first two innermost circles. The central circle is titled the care plan based on holistic assessment and the next outer circle is titled the security plan. The largest circle surrounds the heart and is titled multidisciplinary teamwork. This visual demonstrates how important the person’s story is to the development and implementation of care plans. The simplicity of the model is demonstrated through the use of simple terms such as being human and respectful however, the concepts and their relationships are complex (Brooks, 2006). The focus is on the process involved in recovery and  I believe is in line with Dr Terry Krupa’s work on complexity theory, (Associate Professor at the School of Rehabilitation Therapy, Queens University in Toronto), is powerful and may prompt further thinking in model development providing a way to study process of change involved in recovery (Krupa, 2007).

As noted in the foregoing discussion of models, recovery can be described both by the internal conditions of someone who is engaged in recovery – conditions such as hope, healing, empowerment, and connection and by a focus on strengths and external conditions, such as the person’s rights and a positive culture of healing. This conceptual perspective generates interest in applying the philosophical underpinnings of recovery (and the development of a model) of recovery to service delivery, development, evaluation and research (Jacobson and Greenley, 2001), enabling mental health systems to generate a foundation of evidence on recovery. The result is a recovery-oriented system based upon evidence-based practice (Farkas, Gagne, Anthony & Chamberlin, 2005).

In recent years Dr William Anthony and Stephen Onken have been leaders in producing a much-needed literature on recovery. A framework based on the principles of recovery that holds enormous promise comes from Stephen Onken, Catherine Craig, Priscilla Ridgway, Ruth O. Ralph and Judith Cook (2006). For the purposes of this paper a framework is described as a basic conceptual set of ideas used to describe a useful course of action. Onken’s “ecological framework” which builds on the person’s strengths and the exchange with the environment, encompasses a number of theoretical approaches and conceptual frameworks resulting in a comprehensive strengths-based person-centered approach to recovery. These approaches and frameworks include but are not limited to positive psychology, the transtheoretical change model, capability approach, social justice and cultural competence (Onken et al. 2006).

In this context the person-centered elements of recovery are hope, as defined by having at least one person who believes in you; a sense of agency, as defined as goal directed action; self-determination, which may not be cohesive; meaning and purpose, as defined by understanding what has happened to the person; and finally an awareness and potentiality. Onken et al. (2006) posit that if people are not aware, they are unable to make necessary changes to promote their own recovery. Re-authoring or telling stories to make sense of what has happened and to uncover strengths and meaning generates energy to move forward and is critical to promoting the culture and energy necessary for recovery. Onken proposes that individuals move from surviving or coping to healing and wellness, and finally to thriving. As with the tidal model, these authors assert that recovery is indeed a change process from both the individual perspective and the systems perspective and propose using the transtheoretical change model developed by Prochaska & DiClemente (1983) to facilitate the change. Significant emphasis is placed on healing from the trauma of having a “psychiatric disorder”.

Further, a connection with others and an opportunity to practice skills is paramount for learning and skill building. Significant emphasis is placed on the relationship between the service user and provider. The service provider’s approach should match the person’s or service user’s coping style, stages of change, expectations, and resistance. Empathy, positive regard, genuineness, feedback, and self-disclosure are used to better understand the person and goal agreement and consensus between service user and provider is essential. These strategies aim to promote personal learning and adaptation through problem solving. Cultural competence is deemed essential for person-centered service delivery and responsiveness. The concept of human rights is used to promote equity and accountability. Choice is the final critical component of this framework and is used to promote meaningful options for individuals in terms of risk-taking, social roles, independence, and vital engagement (this last term defined as being involved in something meaningful and absorbing) (Onken et al, 2007). Perhaps the strength of this framework is that it enables service users and systems to think critically and in a broad inclusive way in terms of service delivery, development, evaluation and research. 

Summary
It is suggested that users of service, providers, family members and researchers continue the quest to define recovery in more scientific ways. As noted above, one of the critiques of the recovery approach is that empirical knowledge on the subject is lacking (Buchnan-Barker, 2006; Davidson et al., 2006; VCMHS, 2007a, 2007b). Further, the Ohio Mental Health Commission notes that “Historically, there has been inadequate testing of service models and even less testing in improving quality …however interest is now improving” (2001, p. 33). Importantly, with regard to knowledge translation and the implementation of the recovery approach, Anthony (2004) says that the delay in incorporating recovery into our systems is due not to a lack of science underlying practices but rather as a result of the lack of articulated values underlying those same practices.

Next steps for VCMHS
It is apparent that VCMHS will need to continue to involve users of services, staff, families and researchers in formulating the organization’s specific, evolving values, definition, and framework or model of recovery in our mental health system. Involving stakeholders in this way may further develop new partnerships with individuals who hold diverse perspectives and thus promote new learning. As an organization we will need to pay careful attention to the cultural implications of recovery for British Columbia and more specifically for Vancouver Community Mental Health Services (VCMHS, 2007a). As a city comprised of individuals from a variety of different ethnic backgrounds a significant challenge may arise in the need for a continuum regarding self-determination and the range of culturally relevant social supports offered in service delivery. Measuring the promise: A Compendium of Recovery Measures provides a number of tools that may help to measure recovery outcomes within our system (Campbell-Orde, Chamberlin, Carpernter, & Leff, 2005).  Articulating a model or framework to guide thinking may also be a helpful process. To conclude from a series of recent dialogues, it seems clear that VCHS plans to build on past successes as we walk the path ahead to develop more evidence-based recovery-oriented service delivery (VCMHS, 2007a, VCMHS, 2007b).

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