Using appreciative inquiry to facilitate implementation of the recovery model in mental health agencies.
"Culture can be viewed as a bubble of meaning covering the world, a bubble we both create and live within" (Czarniawska-Joerges, 1991, p. 287). Organizational culture is created by stakeholders through words, manner of conversing, and other ways of interacting that reflect deeply held values and attitudes about the way an agency should function. As an organizational change tool, AI targets culture change by altering an agency's dominant discourse and empowering staff. AI has been used successfully in fields such as business and nursing and possesses a philosophy consistent with recovery, but it has rarely been considered in the mental health literature.
This article defines the recovery model, presents a literature review illustrating the importance of addressing organizational culture when implementing new services, and defines and explains AI. Use of AI is explicated by describing the experiences of two mental health agencies that used it to aid in making the change from medical model to recovery model care. Directions for future implementation research are also discussed.
The recovery model "is a treatment concept wherein a service environment is designed such that consumers have primary control over decisions about their own care" (NASW Office of Social Work Specialty Practice, 2006). Recovery can be seen as a way of living life with hope and possibility in spite of the presence of mental illness (Anthony, 1993). The recovery model challenges the traditional understanding of mental illness as chronic and debilitating. Recovery advocates point toward two classic longitudinal studies of mental health outcomes that challenge long-standing assumptions of chronicity and decline (Harding, Brooks, Ashikaga, Strauss, & Breier, 1986a, 1986b; Huber, Gross, & Scuttler, 1975). In addition, Warner (2009) cited recent work advocating an optimistic trajectory for sufferers of mental illness. Individuals diagnosed with severe mental illness have written about their experiences living rewarding and rich lives while coping successfully with their disease (Chamberlin, 1998; Chovil, 2005; Copeland, 2001; Deegan, 1996; Fisher, 2003).
Often, the recovery model is defined in opposition to the medical model. The medical model maintains that mental illness is a chronic condition, with a prognosis of decline in functioning unless there is appropriate diagnosis and treatment. The emphasis is on expert power and control over consumers' care. In contrast, recovery emphasizes the creation of an empowering community where clients are the experts in their own care. The medical model focuses on disease, whereas recovery focuses on wellness, strength, and resilience (Swarbrick, 2006). Such different worldviews implicitly engender disparate cultural perspectives.
Carpenter (2002) has provided a persuasive argument for the recovery model's consistency with social work values, noting that its emphasis on empowerment and hope parallels social work's valuation of self-determination. She observed that recovery's focus on alleviation of stigma should be shared by a profession that underscores the dignity and worth of all human beings. Social workers will be integrally involved in the current shift toward recovery-oriented care, and they should understand the impact that agency culture could have on implementation. A staff accustomed to hierarchical medical model cultures will not typically be empowered to contribute to the functioning of their agency. Yet, if this were changed, an attitude more consistent with recovery's privileging of community and empowerment could be cultivated.
The recovery model has detractors who perceive it as an ideological fad (Davidson, O'Connel,Tondora, Styron, & Kangas, 2006), as not appropriate for all clients, and as potentially in conflict with the move toward evidence-based care (Frese, Stanley, Kress, & Vogel-Scibilia, 2001). Others have confounded it with an antipsychiatric stance (Ianovski, 2009). It is very difficult to implement a client-driven approach in agencies accustomed to medical model care, which holds clinicians accountable for client symptom management, funding reimbursement, and maintenance of a positive image in a society with continuous concerns about a much-stigmatized group (Ianovski, 2009).
CREATING RECOVERY-ORIENTED SERVICE MODELS
Since the 1990s, many states have adopted the recovery model as a framework for mental health services. Guidelines have been published regarding implementation. Torrey and Wyzik (2000) noted the need to change mental health organizational structure. Farkas, Gagne, Anthony, and Chamberlin (2005) advocated developing guiding principles regarding how staffs are hired, educated, and overseen to be sure that they are faithful to recovery-oriented practice. However, research indicates that such structural and policy changes can be insufficient to truly ensure staff buy-in to recovery. Linhorst (2006) suggested that some settings have co-opted recovery rhetoric without substance. Davidson et al. (2006) documented 10 common concerns that mental health providers express regarding recovery: (1) positive, empowering helping alliances with consumers are already commonplace; (2) recovery adds to workloads; (3) recovery means clients are cured; (4) only a minority of clients recover; (5) recovery represents a reckless craze currently in vogue; (6) recovery occurs because of the medical model it seeks to supplant; (7) recovery requires new, expensive services; (8) recovery cannot be remunerated, nor can it be evidence based; (9) recovery seeks to render professional training pointless; and (10) recovery exposes mental health providers to liability by encouraging clients with severe impairment to make their own choices and treatment decisions. Gill (2009) has observed that in many settings,"the status quo remains unchanged" in spite of ongoing attempts to transform many state mental health systems.
Hemmelgarn, Glisson, and Lawrence (2006) explained that certain behavioral norms in an organization have "survival value," noting that some work environments make intense emotional demands and require a great deal of energy. Mental health is a challenging, demanding environment that requires noble character traits and personal strength for professionals to endure the inevitable strain. In such an environment, survival habits do become evident. Consciously or not, many providers in this field may resist change. They may feel a need to "survive" by coping with clients with severe illness in customary ways. The medical model provides a sense of control, which consumer-centered models appear to remove by placing decision making in the hands of clients. This loss of control may feel like a survival threat to some staff, and some will have difficulty believing in the potential for recovery among clients they feel are unable or unwilling to identify achievable life goals. Additional and ongoing training in the recovery model will be needed to increase workers' confidence in their ability to use this model with all clients. In addition, leadership must be committed to the recovery ideology.
Finally, the culture of an organization is the salient context for recovery model services and must be addressed if change is to be truly substantive. Culture provides a sense of stability and security in dayto-day actions, yet recovery introduces a profound cultural shift. AI can ease organizational stakeholders into a cultural shift by gradually transforming the dominant discourse.
INFLUENCE OF ORGANIZATIONAL CONTEXT ON NEW SERVICE IMPLEMENTATION
Important work has been carried out that demonstrates that human service organizations' social contexts affect how a core technology is implemented. Glisson (2002) demonstrated that an organization's culture affects the way staff perceive their work environment and how well evidence-based practices are adopted and implemented.
Glisson, Landsverk, et al. (2008) have developed a measure called organizational social context (OSC), which assesses an organization's climate and culture. Constructive culture is characterized by norms and expectations that organizational staff will be mutually supportive, develop their abilities, enjoy productive interpersonal relationships, and share an enthusiasm for succeeding (Glisson & Green, 2006). OSC scores of constructive culture correlate with how well new methods of practice are sustained (Glisson, Schoenwald et al., 2008). Positive organizational contexts also affect the nature of the helping relationship (Glisson & Green, 2006), and they correlate with measures of the appeal of evidence-based practices to providers and their openness to implementing them (Aarons & Sawitzky, 2006).
Culture and climate are important when considering any type of organizational change (Aarons & Sawitzky, 2006). Proctor et al. (2009) presented a compelling argument for considering organizational context when discussing effective implementation of new services. The recovery model entails a new way of perceiving and serving clients; thus, new agency attitudes and values will need to be developed and nurtured.
This article reports on two mental health agencies' experiences with the discursive tool AI, which was developed by David Cooperrider of Case Western Reserve University. Whitney and Trosten-Bloom (2003) noted that AI is effective in shifting an organization's perceived work environment because it builds relationships between participants and creates an opportunity for everyone to express their organizational vision and be heard. AI creates an environment of free choice, empowers staff to act, and encourages a positive perspective on the workplace. Boyd and Bright (2007) noted that AI differs from usual methods of organizational change by focusing on the positive rather than seeking solutions to problems.This focus shifts the dominant discourse of an organization by fundamentally altering unexamined, or "taken for granted," norms (Boyd & Bright, 2007). This positive emphasis is similar to recovery's privileging of strength.
AI emphasizes empowerment and encourages participants to see their organization as a community that can envision and create a positive future, emphases that are compatible with the philosophical stance of the recovery model. Recovery values hope, healing, community, and empowerment (Jacobson & Greenly, 2001). Barriere, Anson, Ording, and Rogers (2002) recommended that developing norms and expectations consistent with the culture an organization desires is important to successful change. The new norms and expectations that can be developed and nurtured by ongoing use oral are consistent with a recovery culture.
In addition, the AI process shifts the dominant culture by introducing a new kind of positive or constructive discourse. The recovery model is a new discourse about mental illness; it is a new way of thinking about and speaking about psychiatric conditions (Walker, 2006). AI empowers organizational participants, identifies and leverages the positive, and builds on strengths, all of which create hope (see Table 1).We chose AI as a tool that seemed logical because of the similarity of its values and those of recovery and its documented successful use in implementing positive change in other organizational settings, including business, schools, community development programs, and nursing programs (Moody, Horton-Deutsch, & Pesut, 2007; Royal & Hammond, 1998).
THE AI PROCESS
As an organizational change tool, AI may be an effective antidote to mental health professionals' conscious and unconscious difficulties adapting to the recovery model. In essence, AI assumes that organizational participants will respond positively to their inclusion in a process that elicits their valuation and awareness of the life-giving forces within their work group. Agency participants themselves must come to identify that which gives life and value to their occupation and its setting (Cooperrider & Avital, 2004). Once this appreciative perspective is experienced, participants become receptive to philosophical and structural transformations of their organization.
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AI, as its name implies, opens up a dialogue by inquiring (Adams, Schiller, & Cooperrider, 2004). AI begins with an area or topic participants agree to examine. A question is chosen in a positive manner so that it can be answered in terms of what "the best is" and "has been" (Whitney & Trosten-Bloom, 2003). Participants in the dialogue engage in a cyclical process, depicted in Figure 1, of discovering, dreaming, designing, and then living into a chosen destiny.
AI is a guided conversation that ultimately shifts how participants think about, discuss, and approach issues in their organization. First, the issues to be discussed must be defined. A trained AI leader can open up a conversation about an issue participants would like to address through a process of sharing stories to discover the positive. Common themes are noted by the AI leader and shared with the group for clarification and consensus regarding what the stories unveiled for everyone. These themes are used by participants to dream a desired future. Stakeholders use these dreams to inform a design through the development of a set of "provocative propositions," which are statements about "what should be" (Whitney & Trosten-Bloom, 2003). The final stage, design, is devising actions to implement the provocative propositions, which lead to a desired destiny.
AI in Action
We first describe the experience of Agency X, an urban mental health center trying to shift from the medical model to recovery. Then, the experience of Agency Y is presented. Agency Y is a rural mental health agency that used AI to implement recovery and continues to use it as an ongoing management tool.
Agency X had already introduced the recovery model in staff meetings and implemented training. The agency wished to explore whether AI might help in implementing recovery by engaging staff in the change process. The process began with a midlevel agency administrator creating a steering committee of relevant stakeholders,including direct care and clerical staff drawn from all agency treatment teams, to learn the AI process. Steering committee members would serve as "ambassadors" and engage others in an eventual agencywide process once they mastered the approach.
During the first meeting of the steering committee, staff verbalized a general feeling that recovery was being forced on them by management. They felt uncomfortable with the perceived imposition and excluded from the decision-making process. The first step was to move staff from this disempowered and problem-focused stance into seeing the agency as full of latent opportunities on which they could capitalize.
The Thin Book of Appreciative Inquiry (Hammond, 1996) was distributed to educate staff about AI. An AI consultant explained that staff could use the proposed shift to recovery to address their many concerns. As many AI sessions as needed could be implemented as various problems were solved, leading ultimately to a session focused on recovery, staff appreciation of its values, and their design regarding its implementation.
Eventually, the steering committee was ready to experience answering the type of positive question that would be posed in an AI discovery stage. The first inquiry developed the following question: "Think of a time in your experience when [Agency X] was the best it could he as a place to work. What made it that way?" Staff shared stories about working with all service providers collaboratively on behalf of a client, respectful collegial interactions, stories of being trusted by managers, and feelings of being committed and connected to a client. The end result of this first experience was a verbalized desire to learn the method and invite other stakeholders to participate.
One month later the steering committee, the mid-level manager, and the AI consultant met to review the ongoing change process. Staff reported tension between the mandate to become recovery-centered and another mandate to double productivity. The discussion revealed that the way productivity was being assessed failed to capture the volume of work staff actually performed. Staff felt that they operated as an assertive community treatment team, providing greater and lesser intensity of care, in nontraditional settings, depending on client needs. Not all of this was captured in productivity measures. The mid-level manager suggested that staff could participate in the design of a measure of productivity.
Finally, overall tension between upper management and frontline staff was also identified in this discussion. The tension had to do with lack of communication and staff concerns that management underestimated their work ethic and commitment. Staff felt that they could master AI but not be empowered to implement their dreams. The tension between upper management and frontline staff would have to be resolved for a successful move into recovery to be made, because the existing tension reflected a hierarchical culture and disempowered staff.
The second half of the meeting was an AI session. Committee participants paired off and engaged in interviews with each other. The questions used in these interviews are reproduced in Table 2. These questions are structured to fully engage respondents in a positively charged narrative.
Staff responses led to identification of the positive core values of the agency: resourcefulness, crisis intervention, caliber of colleagues, being able to serve all clients, and commitment. The dream phase resulted in creation of wishes for the future: being able to give clients as much time and resources as needed, professional growth, increased integration of care, dialogue as a way to solve problems, better means of capturing productivity, alleviation of a perceived frantic "fix-it" mode, more emphasis on strengths, and closer collaboration with team members. AI offered a chance to design means to make these wishes--all of which were consistent with recovery--realities.
Once the responses were reviewed, the group was asked, "How do we put our heads together to realize these dreams?" Participants felt that there was a need to try AI throughout the agency to move toward positive change. Staff verbalized feeling that AI could empower them, change their agency for the better, and gradually ease them into the creation of a new culture.
Agency X's experience illustrates how staff members were able to embrace AI and perceive it as potentially helpful and empowering. This hope needs to be continually nurtured by moving forward with use of the tool. Upper-level management needs to be successfully engaged, and efforts need to be made to resolve misunderstandings and tensions between administration and direct staff. Using the AI approach to identify and build on the positive aspects of administration-line staff relationships would be a good start. AI can empower staff and help create a constructive culture that is conducive to recovery. The choice regarding continued use of the tool remains with the agency leadership.
In October 2007, Agency Y was well into an era of recovery implementation. Yet staff experienced frustration over having little substantive influence over program issues in an environment where empowerment, ownership, hope, and choice were revered. In spite of these recovery values, Agency Y remained hierarchically structured. Although the staff of Agency Y agreed with the conceptual foundation of recovery-oriented care, the adoption of a new way of thinking and new practices seemed burdensome. Consequently, staff verbalized increasing frustration, with an observable decline in morale. A generally guarded disposition and perception of powerlessness began to emerge, with an attendant resistance toward adopting new practices that would require energy, creativity, and commitment to successfully implement. Staff requested an avenue to express their frustrations and power to overcome them.
In response, the management team decided to implement AI, because it was seen as a natural conceptual parallel to mental health recovery. A monthly AI forum was initiated to provide staff with an opportunity to voice concerns and frustrations, with the intention of determining the inherent strengths of the program to overcome these issues. At the first forum, a one-page overview of the AI process was given to staff and briefly explained. Staff members were encouraged to discover, dream, and design programmatic changes. The plan was to incorporate staff input into decisions and transform the sense of top-down management into a sense of a more flattened decision-making structure.
The AI process resulted in positive staff reports. Suggestions for minor changes were implemented, including a change in how billable time was recorded and a change in the process of scheduling on-call time. Management felt that the prevailing attitude in the agency shifted away from emphasis on limitations and toward possibilities. Staff began actively seeking new practices to replace what seemed ineffective, such as identifying creative ways of implementing recovery practices that were manageable for them. For example, the agency used wellness recovery action plans (WRAPs) to aid consumers in developing recovery goals and objectives. Consumers were overwhelmed by a 20-page packet that they were provided with to assist them in developing these plans. In response, a change was made that incorporated elements of WRAPs into a previously used form called the "Symptom Management Plan." This created a wellness tools format, which identified many wellness activities and was easy to use. Another victory included staff input to create a more strengths-based and flexible needs assessment tool that would capture client individuality.
Agency Y is a distinct example of how management methods can influence culture to be more open to new practice adoption. AI was effective in empowering staff to envision possibilities, and it engaged their inherent strengths much in the same way that recovery-oriented practices can empower and engage consumers. The agency was able to move front top-down decisions to a flatter process that incorporated decision-making input from all levels. Such a change is consistent with recovery-centered values. Agency Y continues to conduct monthly AI forums to sustain this desirable culture transformation.
These experiences with AI indicate that it can be a useful tool for effective implementation of recovery. Agency X staff found the experience of an AI discourse intriguing and potentially empowering. However, AI was introduced to the agency by an outside researcher who thought the model had potential. It is now up to agency leadership to decide whether to continue using the method. In the case of Agency Y, the tool was introduced internally. Because staff found the method empowering, management decided to continue to use AI on an ongoing basis.
Organizational culture in mental health agencies reflects providers' attitudes and behaviors, which are key targets for change in implementing recovery model services. Programs can be developed and staff can be reeducated, but unless fundamental values and attitudes about mental illness and consumers change, recovery implementation is unlikely to succeed. Ianovski (2009) cited implementation literature warning change agents against purely "paper implementation or lip service." Culture change is the antidote to paper implementation. The recovery ideology represents a discursive change, a way of linguistically reshaping how mental illness is perceived and managed, that essentially can create a new therapeutic reality for those who have been coping with conditions that society labels and stigmatizes (Walker, 2006). AI is a tool that changes discourse and, as such, may be very appropriate in helping mental health organizations to create recovery-oriented cultures. In addition, the values that underpin AI are similar to the values underpinning recovery.
Agencies X and Y's experiences demonstrate that AI may render the recovery model portable across diverse mental health settings through its empowerment of staff. However, to assess tools like this in a rigorous manner, research needs to scrutinize the organizational context of agencies that are implementing recovery. The availability of recovery-consistent elements in an agency, such as peer-run services, in and of themselves are probably not sufficient to ensure organizational fidelity to the recovery spirit. Culture is likely a mediating variable. It will be important for future research to identify the organizational services and culture that contribute to effective client recovery outcomes to have benchmarks against which to determine the effectiveness of culture change interventions. One promising area may be in assessing whether Glisson and colleagues' concept of constructive culture correlates with most effective recovery outcomes for clients. This could move the discussion of agency change to recovery beyond descriptions of implementation and into the development of scientifically tested organizational change methods to enhance fidelity to recovery.
Original manuscript received March 27, 2011 Accepted May 20, 2011
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Laurene Clossey, PhD, is assistant professor, Department of Sociology, East Stroudsburg University, 200 Prospect Street, East Stroudsburg, PA 18301; e-mail: email@example.com. edu. Kevin Mehnert, MBA, is a professional development and business partner for adult behavioral health services, Northwestern Human Services, Mount Pocono, PA. Sara Silva, MSW, LICSW, is in private practice, Milton, MA.
Table 1: Appreciative Inquiry and Recovery Model Values Appreciative Recovery Inquiry Value Model Value Empowerment Empowerment Community Community Positive emphasis Healing Hope Hope Table 2: Agency X Appreciative Inquiry Questions Question 1 Question 2 Question 3 Considering your Without being What do you consider whole career in this humble, what one to be the positive field, think of a thing do you value core value of time when you were most about yourself [Agency X], the one able to do your best as a person? What thing that makes work with people one thing do you [Agency X] uniquely with severe mental value most about powerful when it is illness. Tell me the yourself as you do at its best? Tell me story of that time. your work? What is the story of a time Describe the the most significant when you saw that situation: What was thing that your work value in action or a happening? What did at [Agency X] has time when you you do? What did contributed to your enacted that value others do? What made life? in your own it possible for this practice. experience to occur? Question 4 If you could have three wishes for the future of [Agency X] that would make it possible for you and your colleagues to do your best work more of the time, what would you wish?