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Lindsay OadesLecturer, Illawarra Institute for Mental Health, Universityof Wollongong, Wollongong, NSW, Australia.

Frank DeaneDirector, Illawarra Institute for Mental Health, Universityof Wollongong, Wollongong, NSW, Australia.

Trevor CroweCoordinator, Illawarra Institute for Mental Health,University of Wollongong, Wollongong, NSW, Australia.

W. Gordon LambertSenior Fellow, Illawarra Institute for Mental Health,University of Wollongong, Wollongong, NSW, Australia.

David KavanaghUniversity of Queensland, Department of Psychiatry,Brisbane, Qld, Australia.

Chris LloydSenior Lecturer, School of Health and RehabilitationServices, University of Queensland, Brisbane, Qld,Australia.

Correspondence: Dr Lindsay Oades, Illawarra Institute forMental Health, University of Wollongong, Wollongong,NSW 2522, Australia. Email: loades@uow.edu.au

PSYCHIATRICSERVICES

Collaborative recovery: anintegrative model for workingwith individuals who experiencechronic and recurring mentalillness

Lindsay Oades, Frank Deane, Trevor Crowe, W. GordonLambert, David Kavanagh and Chris Lloyd

Objectives: Recovery is an emerging movement in mental health. Evidence forrecovery-based approaches is not well developed and approaches to implementrecovery-oriented services are not well articulated. The collaborative recoverymodel (CRM) is presented as a model that assists clinicians to use evidence-based skills with consumers, in a manner consistent with the recovery move-ment. A current 5 year multisite Australian study to evaluate the effectivenessof CRM is briefly described.

Conclusion: The collaborative recovery model puts into practice several as-pects of policy regarding recovery-oriented services, using evidence-based prac-tices to assist individuals who have chronic or recurring mental disorders(CRMD). It is argued that this model provides an integrative framework combin-ing (i) evidence-based practice; (ii) manageable and modularized competenciesrelevant to case management and psychosocial rehabilitation contexts; and(iii) recognition of the subjective experiences of consumers.

Key words: chronic mental disorders, collaborative recovery model, treatments.

T he collaborative recovery model (CRM) translates a recovery vision ofmental health to specific principles and practices, which can in turnbe used to define related practitioner competencies that are shared

across professional disciplines in mental health.1 The CRM synthesizesevidence-based practices in community mental health contexts with broaderevidence based on constructs consistent with psychological recovery.Through its emphasis on nurturing hope, supporting autonomy and sub-jective goal ownership of consumers, CRM is explicitly configured to beconsistent with the recovery vision of both consumers and services. Read-ers should note that collaborative recovery is a different intervention andresearch programme than collaborative therapy.2

A substantial body of empirical research identifies effective psychosocial in-terventions in the treatment of psychoses, including family intervention,social skills training, cognitive–behavioural therapy for psychosis, case man-agement, psychosocial rehabilitation and supported employment.3–8

Underpinning the effective implementation of these and other evidence-based interventions is a core set of evidence-based procedures, includingresearch on the relationship between working alliance and outcomes,motivation enhancement, the relationship between goals and well-being, and the effect of homework on outcomes.9–12 Moreover, there ismounting evidence from the recovery literature, which emphasizes theimportance of hope, autonomy, self-determination and consumer partici-pation when developing evidence-based approaches.13,14 The CRM draws

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evidential support from these sources in developing itsprinciples and practices.

RECOVERY MOVEMENT IN MENTALHEALTHThe term ‘recovery’ has become widely used in men-tal health policy and service delivery contexts and isin danger of losing specific meaning.15 The CRM doesnot assume that recovery will necessarily mean a full re-turn to a former state of health or functioning.16 Instead,CRM emphasizes the development of new meaning andpurpose as the person grows beyond the catastrophe ofmental illness.17

COLLABORATIVE RECOVERY MODELThe CRM consists of two guiding principles and fourcomponents, totalling six training modules. Four spe-cific protocols for clinicians to follow are motiva-tional enhancement (ME), needs assessment, collabo-rative goal technology (CGT) and homework assign-ment. Clinicians require specific knowledge and skillsto follow these protocols, and particular attitudes towork within a recovery orientation. The six compe-tencies, as illustrated in Table 1, involve the flexibleuse of these protocols and the associated knowledge,skills and attitude. The six competencies correspond tothe six modules of the collaborative recovery trainingprogramme.

Guiding principles

Recovery as an individual process

The CRM champions the individuality of the lived ex-perience and the ownership of the recovery process bythe consumer. A recent review by Andresen et al., of28 experiential accounts, 14 articles by consumers andeight qualitative studies, identified four common recov-ery processes: (i) finding hope; (ii) redefining identity;(iii) finding meaning in life; and (iv) taking responsi-bility for recovery.18 The personal manner in which amental health consumer experiences these processes ishighly variable.19 The CRM respects the personal jour-ney and self-determination of consumers.

Collaboration and autonomy support

Although a recovery process is personal, it need not beisolated. The CRM recognizes the benefit of an effectiveworking alliance. Hence, the term ‘collaborative recov-ery’: a dialectic between a person who is recovering andone or more persons assisting this process.

A substantial psychotherapy research literature has con-sistently found a significant relationship between thestrength of the working alliance and mental health out-comes.20 However, a recent review of therapeutic al-liance in case management of serious mental illnessshowed that evidence for an impact on outcomes re-

mained sparse, despite a recent increase in studies ex-amining these issues.21

The term ‘autonomy support’ is drawn from self-determination theory, and involves three components:(i) taking the perspective of the consumer; (ii) providingchoice to the consumer; and (iii) providing a rationaleto the consumer for what is occurring. Sheldon et al.emphasize that being autonomous or self-determineddoes not mean being isolated or independent ofothers.22

Collaborative recovery model components

Change enhancement

The change enhancement incorporates ME and therecognition of cognitive capacity. This takes into ac-count the motivational and cognitive capacities thatpeople with chronic and recurring mental disorders, par-ticularly schizophrenia, may experience as barriers totheir recovery process.

Motivational enhancement (originally termed ‘motiva-tional interviewing’) is a style of counselling and a setof techniques that aims to engage and motivate theindividual towards change.23 The use of motivationalenhancers recognizes that change occurs at differentrates for different people, and may involve several cyclesthrough the different stages of change before individualsgain some mastery in terms of active self-managementof their health and well-being. Motivational enhance-ment involves the clinician helping the individual toidentify advantages and disadvantages of specific exist-ing behaviours and planned behaviours.

The cognitive deficits experienced by people withchronic and recurring mental disorders, particularlyschizophrenia, are well documented.24 The CRM recog-nizes the limitations that cognitive capacity place onthe identification and pursuit of appropriate recovery-related goals by an individual. Clinicians are encouragedto adapt their practice to optimize communication andcollaboration with the consumer, by taking cognitivecapacity into account.

Collaborative needs identification

The CRM recognizes that unmet needs are a key source ofmotivation for mental health consumers and hence areimportant to identify. The CRM adopts a negotiated ap-proach to need, using measures such as the CamberwellAssessment of Need Short Appraisal Schedule (CANSAS)as part of needs assessment and as a precursor to collab-orative goal setting.25

Collaborative goal setting and striving

Collaborative goal setting within CRM is one way inwhich self-determination and consumer ownership ofthe recovery process is operationalized. There is strong

280

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Psychiatry•Vol13,N

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empirical support for the benefits of goal setting and re-lated striving for human goal attainment, and a greatdeal is known about the nature of goals that may assistrecovery in a mental health context.26 Collaborative goaltechnology is a modified version of goal attainment scal-ing that is designed to operationalize goal-related pro-cesses central to CRM.27,28 Goals within CGT may bepromotion goals, aiming at achieving a desired outcomesuch as employment, or prevention goals, aimed at pre-venting an undesired outcome such as relapse or physi-cal disorder.29 Both types of goal are common, althoughthey do involve different motivational processes.30

Little’s concept of the ‘meaning and manageabilitytrade-off’ within goal striving underpins CGT.31 Whenindividuals set and strive towards goals, they balancethe meaningfulness of the goal with its perceived man-ageability. This is seen as central to psychological re-covery. Also, important to the model is the distinctionbetween distal and proximal goals.32 Distal goals tendto have high meaningfulness, even though the personmay currently lack self-efficacy in attaining them in thenear future. The proximal goals that feed into thosedistant prospects have a high level of manageability,although they may have a lesser level of perceived im-mediate meaningfulness. The presence of the distal goaltends to imbue the proximal ones with greater mean-ing and commitment. The distinction often enablesclinicians to avoid disputes over distal goals that theclinicians believe are impractical. Experience with suc-cessive proximal goals will show both consumers andclinicians whether the distal goal really does need modi-fication. Consistent with these considerations, and withthe emphasis on hope and a meaningful future rele-vant to psychological recovery, the CGT includes specificsteps in which clinicians and consumers collaborativelydevelop and document (i) a personal recovery vision;and (ii) measurable 3 month goals to work towards thisvision. These goals are then achieved by way of morespecific tasks, usually set as homework tasks that com-prise the fourth component of CRM, now described.

Collaborative task assignment and monitoring

Between-session task setting or homework is essential tothis component, and integrates with the goals and visionof personal recovery. Although homework assignmentshave been used effectively within psychological treat-ments for a wide range of problems for some time, onlyrecently has their role been explicitly summarized anddescribed within interventions for schizophrenia.33 Thisdevelopment provides great promise, given that gen-eralization from psychosocial rehabilitation settings tothe natural environment has provided a significant chal-lenge in the past. By definition, homework provides theopportunity to generalize skills learned to naturalisticsettings. The CRM includes three major stages for sys-tematic homework administration: review, design andassignment, along with a range of strategies for identify-ing and overcoming obstacles to successful implementa-tion.

EVALUATING THE EFFECTIVENESSOF CRMThe impact of CRM on the recovery of adults withchronic and recurring mental disorders is currently be-ing evaluated by way of a multisite study in four gov-ernment and five non-government organizations withinNSW, Queensland and Victoria. This study constitutesone of three major research streams of the Australian In-tegrated Mental Health Initiative (AIMHI). Research siteshave been randomly assigned to an immediate or 1 yeardelayed training condition. The collaborative recoverytraining programme is a six-module training programmebased on the learning objectives outlined in Table 1.34

Training is of 2 days duration with two 1 day boostersessions at 6 and 12 months after the initial training.Training is predominantly for clinical staff, althoughconsumer advocates are encouraged to attend. As ofDecember 2004, over 124 staff working with individualswho have chronic and recurring mental disorders (pre-dominantly schizophrenia) and 189 consumers agreedto participate. Inclusion criteria for consumer partici-pants are a diagnosis of schizophrenia, schizoaffectivedisorder or bipolar disorder of at least 6 months dura-tion and high support needs, with six or more needsidentified using the CANSAS.25 Individuals with de-mentia, severe mental retardation or brain injury wereexcluded. Comorbid substance misuse or personalitydisorders were not excluded. Following baseline, datacollection is at 3 monthly intervals, consistent with na-tional routine data collection. Measures include theHealth of the Nation Outcome Scales (HoNOS), LifeSkills Profile (16-item) and Kessler-10, supplementedwith the Recovery Assessment Scale.35 Both conditionshave a 1 year follow-up intervention. Preliminary theo-retical and immediate training outcomes suggest (i) thatrecovery is likely to be a measurable staged process;(ii) case managers frequently use homework with thetarget consumers but not very systematically withouttraining; and (iii) collaborative recovery training leadsto immediate improvements in staff knowledge and atti-tudes regarding recovery for consumers. Articles describ-ing these initial findings are currently submitted and areunder review.

Although formal evaluation is still pending, it is an-ticipated that the benefits of such an approach is theflexibility that it allows across services with highly vari-able resourcing and diverse structures (e.g. intensive vsless intensive case management approaches). The train-ing has occurred in community mental health teams,rehabilitation services and supported housing contexts.Understanding the impact of the CRM requires system-atic measurement of fidelity. However, the systematicmeasurement of psychiatric rehabilitation models hashistorically been a major area of neglect.36 Given thelack of good quality measures, we chose the DartmouthAssertive Community Treatment Scale (DACTS)37 to pro-vide some reference point across settings. Although theDACTS was designed to discriminate more intensivecase management services, it has also been suggested

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that it ‘may be useful for delineating a typology ofcase management services in general’ (p. 79).36 Addi-tional fidelity indicators have been included for ourrecovery-specific training implementation. Implementa-tion problems have varied to some extent dependent onthe service and setting, but the most universal concernhas been staff complaints about the lack of time theyhave to work with consumers who have less acute andmore long-term needs. Working collaboratively withconsumers and actively involving them in the treat-ment decision-making process takes time. The proto-cols expect an average of one contact every 2 weeks andsome staff have found it difficult to provide this level ofconsistency with even one consumer. Workers in non-government organizations have become primary mentalhealth supports by default when the public sector doesnot have the resources. However, for some, taking a moresystematic and active approach in their work with con-sumers is new. We anticipate a future publication thatelaborates upon the fidelity and implementation issuesrelated to the project.

CONCLUSIONAchievement of a recovery orientation for mental healthservices requires training and development of attitudesand skills of the workforce. The CRM and its associatedtraining programme were developed based on the ex-isting evidence base, the identification of key skills andrecognition of the importance of the subjective expe-rience of recovery by consumers. The effectiveness ofCRM to assist people with chronic and recurring men-tal disorders is currently being evaluated within severalgovernment and non-government agencies in EasternAustralia.

ACKNOWLEDGEMENTSThis work is supported by a National Mental Health and Medical Research Council StrategicPartnership Grant in Mental Health (219327). Contributing organizations to the High SupportStream of this project, in alphabetical order, include Aftercare, Illawarra Health, MentalHealth Service, La Trobe Valley Health, Prince Charles Hospital Health, District Mental HealthService, NEAMI, Psychiatric Rehabilitation Association, Richmond Fellowship Queenslandand NSW, University of Wollongong, Wentworth Area Health Service.

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