Missouri's recovery experience: the show-me state liked the results of its Procovery pilot so much that it is implementing the program statewide.

One can believe in recovery principles and the clinical and humanistic value of person-centered care yet find that implementing recovery primarily through policies of humanistic intention fail to change workforce and community behavior or transform systems. As a report on implementing recovery in behavioral healthcare notes:

Without any infrastructure for recovery-based mental health care, it's

no wonder that so many administrators and clinicians haven't bought in

to what is essentially a basic human right to feel better. In fact,

just mentioning the word recovery seems to cause a stir depending on

your training, beliefs, and role in the mental health rehabilitation

system. (1)

In the course of implementing a recovery model in the Missouri Comprehensive Psychiatric System, we have identified certain components essential in our own recovery implementation. The Missouri Department of Mental Health decided to adopt a specific recovery model as foundational to service delivery and ultimately to system transformation. In 2005, the department selected the Procovery program developed by Kathleen Crowley (2) as the recovery model for an urban-rural demonstration program in the St. Louis and Southeast Missouri regions.

Procovery is a reference to focusing on forward potential, versus traditional, common understandings of recovery as focusing on regaining a prior state of health. The program emphasizes a hope-centered, forward-focused, and skills-based partnership among the client, family, service provider, and community. The Procovery program includes 8 principles for resilience in healing and 12 strategies for action. It uses a highly structured system for group training and support, the Procovery Circle, across target populations and across diverse service settings.

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While we initially were considering 8 to 12 Circles, the pilot rapidly grew to accommodate demand across stakeholders, settings, and regions (both urban and rural). In the end, 1,075 people (treatment professionals, people living with mental illness, family members, and community members) attended voluntary full-day core trainings. By the pilot's completion more than 80 Procovery Circles were active across different settings. From June 2005 to May 2007, more than 3,750 Procovery Circle meetings were held with an average attendance of 8.6 people. Due to the popularity and success of the demonstration pilot, in June we announced that Missouri will launch statewide implementation of recovery services through the Procovery program.

The Missouri Institute of Mental Health's evaluation of the pilot noted:

Most important, it can be concluded from the evaluation of the

Missouri Procovery Demonstration Program that Procovery is a promising

catalyst of system transformation. The success of Procovery Circles to

instill hope and a forward focus among mental health consumer members

means that statewide implementation of this program could facilitate

progress towards an integrated system response to growing demands from

consumers for recovery-based services and supports to secure jobs,

housing, and training. (3)

Particular Procovery components that have been shown to be essential include the following.

Specificity. Strengths-based attitudinal principles of hope must be accompanied by concrete, practical, actionable skills across the range of wellness self-management and decision making to support and drive desired behavioral change.

Application across diagnoses, including behavioral and physical. Data from several states have shown that people with serious mental illness served by public mental health systems die on average at least 25 years earlier than the general population. (4) Recovery and person-centered care programming can and must serve as a point of integration for individuals with co-occurring addictions, traumas, and physical diagnoses.

Staff training. Recovery often is viewed solely in terms of how individuals support their own healing, but a recovery system must create a common dialogue and skill set for staff and a common view of what is possible for staff and those they serve as they work together. A unified set of principles and skills that apply equally to the workforce and an effective training model are essential to institutionalizing recovery, and are equally valuable for supporting staff members who themselves often face stress, isolation, and burnout from long years of challenging human service.

Application across a spectrum of settings, cultures, and stakeholders. Recovery principles, skills, and the implementation structure must resonate in urban and rural settings and be a vehicle for building cultural competence.

Fidelity and accountability. In institutionalizing a program across diverse stakeholders, agencies, and settings, we must not just ask providers to implement programs. We must also provide tools to enable them to ensure fidelity and, ultimately, accountability to those they are seeking to serve.

Complementary, not competitive, to existing services and programs. Rather than seeking to replace or compete, recovery programming should support and strengthen existing agencies and providers. Adoption based on consumer demand rather than regulation operates at significantly higher speed and impact.

Change agent. Peter M. Senge has written that "[often] new insights fail to get put into practice because they conflict with deeply held internal images of how the world works, images that limit us to familiar ways of thinking and acting." (5) Recovery implementation cannot be designed as the back end, hoping to ride on some other transformation initiative. It must have the substance and form to serve as a change agent to lead agencies, providers, and stakeholders to do business differently.

The Procovery program encompasses each of these components, offering a concrete set of principles and skills that cross services, diagnoses, and cultural barriers. Procovery is a unified program identical for staffs, clients, families, and communities (trainings are typically for mixed audiences), and it provides clear fidelity requirements and licensing structures to maintain accountability across all stakeholders and agencies. Procovery Circles, the group training and support system, operate identically in an inpatient forensic setting as in a residential care facility, homeless shelter, jail, community setting, or school, which enables development of system-wide referral and builds integration, collaboration, and access to care. We found that Procovery offers succinct recovery principles and strategies that both providers and consumers are able to operationalize regardless of setting.

At its heart, Procovery is about hope, moving forward, and change. To close, I offer a few comments from individuals in Missouri.

Comment from the Missouri Institute of Mental Health pilot evaluation (3):

Procovery has helped me become more independent.... I was living in

a group home and now I have a room of my own.... I live on my own, by

myself now. I feed myself, I bathe, I shower ... I go shopping and I

do a lot of other things .... all on my own. I am even looking for a

job ... I am able to take care of myself.

Post on the Missouri Department of Mental Health blog in June:

Procovery has given me a sense of control, where previously I felt I

had none; I felt as though I would be battered around by my illness

for the rest of my life. A disheartening, discouraging, depressing way

to live. I've had NO psychotic events since I got on board with

Procovery because by applying the ideas in the book, I know myself and

my fluctuations better. I've put together strategies for dealing

quickly with changes before they become real problems, and best of

all, although my illness continues to frustrate me, I no longer beat

myself up when things aren't as stable as I'd like them to be (yes, I

have some really tough times--Procovery can't prevent that, it just

enables me to deal with them more effectively). Bottom line: By

applying what I'm learning in Procovery (I've been through the book

countless times) my quality of life has improved dramatically.

Mickie McDowell, NAMI SW Missouri, Procovery Circle Facilitator:

I always believed that I could maintain a happy, productive life with

my mental illness. It took someone else believing in me as well to

make that become a reality. That is what Procovery does for people....

It believes in them.

Dr. Parks is a Clinical Assistant Professor of Psychiatry at the Missouri Institute of Mental Health and University of Missouri-Columbia. He practices psychiatry on an outpatient basis at Family Health Center, a community health center in the Columbia area. Dr. Parks received the 2006 American Psychiatric Association Bronze Achievement Award for a program controlling pharmacy costs by improving prescribing practices.

Procovery is a program and a registered trademark of the Procovery Institute. For more information on Procovery, visit www.procovery.com.

References

1. Implementing Recovery-based Care: Tangible Guidance for SMHAs. NASMHPD/NTAC e-Report on Recovery. Fall 2004. www.nasmhpd.org/spec_ereport_fall04intro.cfm.

2. Crowley K. The Power of Procovery in Healing Mental Illness. LosAngeles: Procovery Institute; 2000.