The following are examples of how language, thinking, and practice shift in the evolution of a recovery-oriented system of care

Presenting Situation

Deficit-based Perspective

Recovery-oriented, Asset-based Perspective

Perceived Deficit

Intervention

Perceived Asset

Intervention

Person re-experiences symptoms

Decompensation, exacerbation or relapse

Involuntary hospital-ization; warning or moralizing about "high risk" behavior (e.g., substance use or "non-compliance")

Re-experiencing symptoms as a normal part of the recovery journey; an opportunity to develop, implement, and/or apply coping skills and to draw meaning from managing an adverse event; symptoms are a way the self speaks to the self-a call for change; goal is not to eliminate but to listen.

Express empathy and help person avoid sense of demoralization; highlight how long it may have been since symptoms had reappeared; provide feedback about the length of time it takes to achieve sustained change; offer advice on strategies to cope; reinforce sense of self-efficacy; exposure to "living proof" of potential for sustained recovery

Person demonstrates potential for self-harm

Increased risk of suicide

Potentially intrusive efforts to "prevent suicide"

Indicators of potential for self-harm are important signals to respond differently. The person is likely to have a weakened sense of efficacy and feel demoralized, and thus may require additional support. On the other hand, the person has already survived tragic circumstances and extremely difficult ordeals, and should be praised for his or her prior resilience and perseverance.

Rather than reducing risk, the focus is on promoting safety. Supportive, ongoing efforts are oriented to "promote life," e.g., enabling people to write their own safety/ prevention plans and advance directives.  Express empathy; reinforce efficacy and autonomy; enhance desire to live by eliciting positive reasons and motivations, with the person, not the provider, being the source of this information.  Help promote a life that is incongruent with self-injury.

Person takes medication irregularly

Person lacks insight regarding his or her need for meds; is in denial of illness; is non-compliant with treatment; and needs monitoring to take meds as prescribed.

Medication may be administered, or at least monitored, by staff; staff may use cigarettes, money, or access to resources as incentives to take meds; person is told to take the meds or else he or she will be at risk of relapse or decompensation, and therefore may need to be hospitalized.

Prefers alternative coping strategies (e.g., exercise, structures time, spends time with family) to reduce reliance on medication; has a crisis plan for when meds should be used. Alternatively, behavior may reflect ambivalence regarding medication use which is understandable and normal, as appro-ximately half of people with any chronic health condition (e.g., diabetes, asthma) will not take their medication as prescribed.

Individual is educated about the risks and benefits of medication; offered options based on symptom profile and side effects; and is encouraged to consider using meds as one tool in the recovery process. In style and tone, individual autonomy is respected and decisions are ultimately the person and his or her loves one's to make. Explore person's own perspective on symptoms, illness, and medication and invite him or her to consider other perspectives. Person is resource for important ideas and insights into the problem and is invited to take an active role in problem solving process.

Presenting Situation

Deficit-based Perspective

Recovery-oriented, Asset-based Perspective

Perceived Deficit

Intervention

Perceived Asset

Intervention

Person makes poor decisions

Person's judgment is impaired by illness or addiction; is non-compliant with directives of staff; is unable to learn from experience

Potentially invasive and controlling efforts to "minimize risk" and to protect the person from failure, rejection, or the other negative consequences of his or her decisions

Person has the right and capacity for self-direction (i.e., Deegan's "dignity of risk" and the "right to fail"), and is capable of learning from his or her own mistakes. Decisions and taking risks are viewed as essential to the recovery process, as is making mistakes and experiencing disappointments and set backs. People are not abandoned to the negative consequences of their own actions, however, as staff stand ready to assist the person in picking up the pieces and trying again.

Discuss with the person the pros, cons, and potential consequences of taking risks in the attempt to maximize his or her opportunities for further growth and development. This dialogue respects the fact that all people exercise poor judgment at times, and that making mistakes is a normal part of the process of pursuing a gratifying and mean-ingful life. Positive risk taking and working through adversity are valued as means of learning and development. Identify discre-pancies between person's goals and decisions. Avoid arguing or coercion, as decisions made for others against their will potentially increase their learned helpless-ness and dependence on professionals. 

Person stays inside most of the day

Person is with-drawing and becoming isolative; probably a sign of the illness; can only tolerate low social demands and needs help to socialize

Present the benefits of spending time outside of the house; offer the person addi-tional services to get the person out of the house to a clubhouse, drop-in center, day program, etc.

Person prefers to stay at home; is very computer savvy; and has developed skills in designing web pages; frequently trades e-mails with a good network of NET friends; plays postal chess or belongs to collectors clubs; is a movie buff or enjoys religious programs on television. Person's reasons for staying home are seen as valid.

Explore benefits and drawbacks of staying home, person's motivation to change, and his or her degree of confidence. If staying home is discordant with the person's goals, begin to motivate for change by developing discrepancies. If leaving the house is important but the person lacks confidence, support self-efficacy, provide empathy, offer information/advice, respond to confidence talk, explore hypothetical change, and offer to accompany him or her to initial activities.

Person denies that he or she has a mental illness and/or addiction

Person lacks insight or is unable to accept illness

Educate and help the person accept diag-noses of mental ill-ness and/or addiction; facilitate grieving loss of previous self

Acceptance of a diagnostic label is not necessary and is not always helpful. Reluctance to acknowledge stigmatizing designations is normal. It is more useful to explore the person's understanding of his or her predicament and recognize and explore areas for potential growth.

In addition to exploring person's own understanding of his or her predicament, explore symptoms and ways of reducing, coping with, or eliminating distress while eliciting ways to live a more productive, satisfying life.  Providing normative information about AOD consumption & its consequences; eliciting client's own criteria of when AOD use would be defined as a problem.

Presenting Situation

Deficit-based Perspective

Recovery-oriented, Asset-based Perspective

Perceived Deficit

Intervention

Perceived Asset

Intervention

Person sleeps during the day

Person's sleep cycle is reversed, probably due to illness; needs help to readjust sleep pattern, to get out during the day and sleep at night.

Educate the person about the importance of sleep hygiene and the sleep cycle; offer advice, encourage-ment, and inter-ventions to reverse sleep cycle

Person likes watching late-night TV; is used to sleeping during the day because he or she has always worked the night shift; has friends who work the night shift so prefers to stay awake so she or he can meet them after their shift for breakfast. Person's reasons for sleeping through the day are viewed as valid.

Explore benefits and drawbacks of sleeping through the day, the person's motivation to change, the importance of the issue and his or her degree of confidence. If sleeping through the day is discordant with the person's goals, begin to motivate change by developing discrepancy, as above.

Person will not engage in treatment

Person is non-compliant, lacks insight, or is in denial

Subtle or overt coercion to make person take his or her medications, attend 12-step or other groups, and partici-pate in other treat-ments; alternatively, discharge person from care for non-compliance

Consider range of possible reasons why person may not be finding available treatments useful or worthy of his or her time. It is possible that he or she has ambivalence about treatment, has not found treatment useful in the past, did not find treatment responsive to his or her needs, goals, or cultural values and preferences. Also consider factors out-side of treatment, like transportation, child care, etc. Finally, appreciate the person's assertiveness about his or her  preferences and choices of alternative coping and survival strategies

Compliance, and even positive behaviors that result from compliance, do not equate, or lead directly, to recovery.  Attempts are made to understand and support differences in opinion so long as they cause no critical harm to the person or others.  Providers value the "spirit of noncompliance" and see it as sign of the person's lingering energy and vitality. In other words, he or she has not yet given up. Demonstrate the ways in which treatment could be useful to the person in achieving his or her own goals, beginning with addressing basic needs or person's expressed needs and desires; earn trust.  Exposure to recovery role models whose personal stories and energy make recovery contagious.

Person reports hearing voices

Person needs to take medication to reduce voices; if person takes meds, he or she needs to identify and avoid sources of stress that exacerbate symptoms

Schedule appoint-ment with nurse or psychiatrist for med evaluation; make sure person is taking meds as prescribed; help person identify and avoid stressors

Person says voices have always been there and views them as a source of company, and is not afraid of them; looks to voices for guidance. Alterna-tively, voices are critical and disruptive, but person has been able to reduce their impact by listening to walkman, giving them stern orders to leave him or her alone, or confines them to certain parts of the day then they pose least inter-ference. Recognize that many people hear voices that are not distressing. 

Explore with person the content, tone, and function of his or her voices. If the voices are disruptive or distressing, educate person about possible strategies for reducing or containing voices, including but not limited to medication. Ask person what has helped him or her to manage voices in the past. Identify the events or factors that make the voices worse and those that seem to make the voices better or less distressing. Plan with the person to maximize the time he or she is able to manage or contain the voices.

Family will not engage in treatment activities

Family is non-supportive, uncaring or bridges are "burned" and so relationship is permanently lost. 

After one or two attempts actively engaging the family is not attempted. 

Staff recognizes that the family has had a long journey of which they know very little and are coping with possible stress, grief and loss in the best way they know.  They are respected for what they have been able to give in the past.

Staff actively engage family in relating to them by phone or in person.  They listen carefully to what has been successful and difficult in family relationships in the past.  They explore with the family and the person about what kind of relationship might work for them at this point.  They work with helping to identify possible ways of relating that keep an old connection or establish a new connection step by step.