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 of the key differences between them were reflective of agency or team culture and articulate a preliminary list of critical ingredients for recovery-oriented ACT in : visual cues in environment endorse recovery, peer specialist fully integrated on the team, illness self-management training integral to team interventions, view consumers as regular people, positive expectations for consumers, use of strengths-based language, consumer and team collaboration on treatment decisions, team intervenes with demonstrated need, and team intervenes with consumer collaboration whenever possible and uses control mechanisms as last resort.
Based on team differences, we developed a visual model of the work of recovery on ACT teams (see ). Our model shows that teams consist of staff with a mix of skills, beliefs, and attitudes that can influence how work is done. Teams work with a particular caseload of consumers. For ACT teams in Indiana, admission standards are similar across the state, ensuring that ACT teams focus on consumers who are the most disabled by mental illness. However, teams may vary in the extent to which their caseload includes consumers who experience high symptom acuity, homelessness, substance use, or other complicating factors. The interventions that teams used (i.e., who made treatment decisions, when the team intervened, and how the team intervened) were guided by staff beliefs and client needs. The teams, however, are all set within the broader treatment context (e.g., programs held to state standards for funding, located in rural or urban areas), and this broader context is critical.
Model of Recovery Work on ACT Teams
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. The team environment would suggest trust, with open areas and amenities shared between consumers and staff. 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 (2007), coaching teams function like the Home Depot motto: “You can do it. We can help.”
The coaching role for the team is consistent with tenets of self-determination theory which posits that human potential is at its best when internal motivation is facilitated (Deci & Ryan, 2000
; Ryan & Deci, 2000
). Internal motivation is highest when people have a sense of control, perceive themselves as able to do the task, and feel supported to do so. Other clinical applications of self-determination theory have shown that supporting autonomy leads to greater internal motivation and perceived competence, which in turn has been related to clinical outcomes such as greater abstinence rates in smokers (Williams, et al., 2006
), better glycemic control in patients with diabetes (Williams, McGregor, Zeldman, Freedman, & Deci, 2004
), weight loss (Williams, Grow, Freedman, Ryan, & Deci, 1996
), and more effective medication utilization (Williams, Rodin, Ryan, Grolnick, & Deci, 1998
). By placing trust in the hands of the consumers, coaching teams may provide more autonomy support and foster the development of competence.
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 (Crane-Ross, Roth, & Lauber, 2000
), 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. During the follow-up visit, staff reinforced the notion that they wait until a consumer wants something and do not “shove it down their throats,” which was clearly a step towards a more passive team approach, perhaps swinging the pendulum beyond the more active coaching approach that we observed during the data collection phase of the study. A passive approach could represent how the work of recovery could be taken to an extreme without checks for service context, consumer needs, and process and outcomes desired by payers, families, and many consumers themselves (e.g., outreach, prevention of hospitalization, homelessness, incarceration). It is clear that some balance between the standards of professional care (in this case, service intensity and taking an assertive approach to provision of care) and consumer choice is needed (Salyers & Tsemberis, 2007
), but the balance appears difficult to maintain over time.
The service context was also a dominant feature in the parenting and risk management approach of Team B, particularly the rural nature of the setting. The stated concern by several staff was that one bad interaction with a consumer could “burn a bridge” for other consumers. In rural areas, resources such as doctors, landlords, and employers are scarce, and the team appeared to put a great deal of energy into protecting relationships with those resources. This protection evidenced itself in more frequent use of control mechanisms like daily medication monitoring, restricting access to money and housing, using outpatient commitments, and hospitalizing consumers. These findings are consistent with the work of Angell and colleagues (2006)
who also found rural ACT staff to perceive greater risk and responsibility for protecting consumers and to act more paternalistically than the urban team she studied.
Although our proposed model of recovery work () shows direct links between interventions and outcomes, the impact of recovery orientation on consumers and staff remains to be seen. In our companion paper (Salyers, et al., under review
), we found no differences between these teams in consumer reports of being active in treatment, degree of illness self management, hopefulness, optimism, perceived choice, or satisfaction. Given the striking differences in the culture of the teams, the lack of consumer differences on these measures calls for further investigation. It may be that our survey measures did not account for baseline consumer differences, were not sensitive, or reflected possible halo effects as found in other measures of quality of life (Atkinson, Zibin, & Chuang, 1997
) or satisfaction with housing (Levstek & Bond, 1993
). Conversely, it may be that the work of recovery on these teams truly is unrelated to consumer outcomes. Particularly for the team at risk for falling out of compliance with ACT, consumer outcomes may, in fact, suffer from taking recovery concepts too far and providing too few or infrequent services to consumers who refuse services but are clearly in need of intervention. Other work, though, has shown that relationship-centered care can have positive impacts in other areas of medicine. For example, relationships in which patients are activated to take greater control in their care appear to be particularly important predictors of physical health outcomes (Michie, Miles, & Weinman, 2003
). Clearly, the work of recovery has to be balanced against context, including consumer needs.
We initially viewed recovery work as a stable concept that could be applied to an entire team (i.e., a team would be more coaching or parenting). We found, however, that the approaches were probably variably applied within teams, depending on the staff and the clients being served. It is possible that staff turnover of some key roles, particularly a team leader, doctor, or nurse, may have a large impact on how teams operate. Outside forces such as impending de-certification can also change how a team approaches the work of recovery. If an agency’s funding is in jeopardy, the team’s staff may be pressured to make increased visits or apply additional constraints to consumers despite perceived consumer need. The predominance of our observations related to recovery work may lean towards one approach more than another, but the approaches are less consistently observed than we first assumed.
In terms of measuring ACT recovery orientation in the future, the data collection methods of this study are far too involved to be useful in large scale recovery measurement (e.g., to measure recovery orientation across an entire state’s ACT teams). With a preliminary set of critical ingredients identified, it is possible for future work to include qualitative methods but in a more streamlined fashion. To this end, we recommend a combination of observer ratings, consumer and staff ratings, and shortened interviews to measure recovery orientation. The recovery orientation ratings of key informants we used to select teams are not likely to be useful alone. Our informants had years of prior experience with the teams, and without that, we doubt that global items would be very useful to discriminate among programs. Our richest data sources, with strong participation rates, were interviews with staff and consumers. However, using traditional qualitative methods for identifying themes and constructing a theory of how they relate required a great deal of staff time and energy (both from researchers and participants) – something that would not be feasible for ongoing program evaluation unless done more efficiently. In our interviews, a few treatment areas elicited a great deal of information, particularly questions about medications, money, and personal goals. One approach may be to limit interviews to these key areas. Also, if themes and critical ingredients we found are consistent in future samples, then a coding system could be created that would reduce much of the time involved. Further, many of the concepts we identified were similar to the hope-inducing and spirit-breaking dimensions described by Rapp and colleagues (Goscha & Huff, 2002
; Rapp & Goscha, 2006
); however, a checklist based on each of these dimensions proved unwieldy. Instead, future work could pare the Rapp list to those items most closely embodying the critical ingredients and corresponding examples in . This quantitative methodology could be compared with abbreviated qualitative methods we suggest above in the next iteration of this research.
Our study closely examined the work of recovery on two teams with high ACT model fidelity but differing levels of recovery orientation. One limitation is how teams were selected – on the basis of key informant ratings in one state. Also, we did not conduct a full ethnographic study with repeated interviews and long-term observations. Our follow-ups with teams hinted at some slight philosophical shifts over time, also making us aware that these parenting and coaching approaches are two themes derived over a discrete period of time and may exclude other approaches, including more passive approaches that may be inconsistent with ACT services and other service contexts. Our work did not explore the possibility of other approaches as they develop over time or on other teams. It would be important to replicate our study among other treatment teams to validate our findings and refine the articulation of critical ingredients of recovery orientation.
This study sheds light on the factors that contribute to the work of recovery and critical ingredients that characterize a strong recovery orientation on ACT teams. Recovery work on these intensive treatment teams is possible, but clearly involves hard work and balancing by staff and consumers. The effects of the balancing act over time are unclear, though, and longer follow-up will be needed to see if recovery oriented ACT is sustainable. This study also identified potentially helpful ways to measure recovery orientation and point to future assessment possibilities in evaluating and supporting recovery on ACT teams. The measurement challenge, however, will be accounting for the constraints and enablements of local context in order to capture what it means to do recovery-oriented work.