While reading an academic paper it made me smile when I came across this line:
“…coaching teams function like the Home Depot motto: “You can do it. We can help.”
That is a wonderful reminder of how ACT clinicians ought to see their role in working with clients!
The line is from a paper titled The Work of Recovery on Two Assertive Community Treatment Teams by Salyers et al. In it they explore how to best measure recovery orientation. Looking at two Indiana ACT teams and using observational measures and interviews over time, they identified “Recovery Critical Ingredients” in four areas: Environment, Team Structure, Staff Attitudes and Process of Working with Consumers (see table below or click to view online).
In visiting the teams they found that “Despite teams’ similarities in baseline fidelity to the ACT model, we experienced many differences between the teams during our visits – both teams were meeting similar ACT model standards, but were approaching the work very differently.”
Some recovery measures are more objective, such as rating the environment looking for such features as “Open waiting area, posters about recovery, posted team mission included recovery” versus “Separate waiting area and bathrooms, several signs with rules posted.” More challenging to quantify are Staff Attitudes, which included looking at components of Positive view of Consumers, Positive expectations of consumers and Strengths-based Language.
They note that “Concepts of risk and trust appeared central to treatment decisions and differentiated two distinct models of recovery work: coaching and parenting. Coaching teams have high trust in consumers’ ability to self-manage and view the risks as low” noting that “ The majority of consumers on coaching teams would manage their own medications and receive more intensive monitoring if repeatedly demonstrating need. This approach seems closely related to staff beliefs that consumers are “like us” in fundamental ways and should be afforded the greatest freedoms possible. As in Davidson’s view, coaching teams function like the Home Depot motto: “You can do it. We can help.”
So, should all teams be striving to become more coaching/recovery-oriented? The answer isn’t as clear as one might think.
“It may be easy to see these programs as though one team is “good” and the other ”bad,” particularly in light of recovery concepts. But both teams expressed feelings of genuine concern and care for the consumers and took pleasure in positive events in consumers’ lives. And, there were some downsides to the coaching approach. The team’s hands-off approach may foster independence quickly, but at least one consumer reported that the process was too fast — the team believed the consumer was more ready than he did. Differences in staff and consumer expectations of need are common, even in teams that are actively trying to be more consumer-directed. Another difficulty was that the team struggled with maintaining fidelity to the ACT model over time. At the time of our follow-up visit, the team was in danger of being de-certified for infrequent consumer contacts. Although the less frequent contacts could reflect staff vacancies, it is also possible that the initial coaching drifted into a mild form of neglect with the team not intervening enough, perhaps in service of the recovery ideal.”
I’ve touched on this issue in previous blogs – in Tough Gig I expressed my view that “Perhaps the most important role of the team leader is to set the underlying direction for the team. Is our team focused on long term recovery or are we more focused on medication treatment and stabilization?” In the blog Forcing Treatment and addressing the issue of outpatient commitment I wrote” I believe forced treatment is of value. I don’t believe my conviction in any way diminishes my firm belief in recovery principles and client-centeredness. At times it’s the illness, not the individual that’s making the decision to refuse treatment. The goal of forcing treatment is to allow the individual to find their healthy, true voice”.
Consider using Salyer’s paper for a team education session to look at how your team operates. Maybe put out questions such as
- Are we maintaining our recovery orientation?
- Are we too assertive?
- Does everyone on the team have to be of the same mindset?
I think leadership has to bring a recovery-orientation to the team, not as a mandate but as a guiding principle. Otherwise teams can fall into the trap of becoming mobile medication clinics. Medication is unquestionably necessary – if someone is psychotic they can’t really engage in meaningful work – but medication should never be an end in itself. (see my blog Ultimat-hmms?)
As always thank you for your time. Happy Holidays!
Shalom Coodin MD FRCPC
November 29, 2017