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NASMHPD/NTAC e-Report on Recovery – Fall 2004

public dollars, by working with a public intermediary. This is the future we are looking at when we talk about the future of recovery care.

Jensen: I think from the consumer input I have heard that stigma is a significant obstacle. Further, consumers say that the stigma and ignorance is so bad that providers think they already are providing recovery-based care. In the United States, we have no central system of regulation that is in place that has been helpful in other countries such as in England, Australia or New Zealand, as they are moving toward cross-discipline services. We don’t have some sort of overarching system to provide an umbrella for core competencies across disciplines that are the same, and then people can add their own discipline-based competencies. This is one of the things that the Annapolis Coalition is looking to address. What happens is that the language—kind of like the tower of Babel—needs development. Recovery in mental health is not the same as recovery in substance abuse. The core of the matter is that the words needs to be useful across age groups, disciplines, cultures, service provision areas, and so we have a Tower of Babel situation where we may be talking about the same thing, but we can not come to the table to come up with the words. So what’s happened is that whether you are a provider, or a family member, or even a consumer, people still think that they can decide whether recovery exists or not. Fortunately, there are accounts of recovery for hundreds of years. Recovery has nothing to do with whether they believe it or not. But, the criss-cross of language gets us bogged down in the idea that ‘it can’t possibly be true.’

Knight: I think the largest obstacle is the funding mechanisms, the fee for service mechanism—this promotes that if you are paid by the hour, you keep on doing more and more by the hour. This method of funding promotes dependencies and a psychology of adjustment. If properly done, capitation can promote recovery. The promotion of recovery though alternative funding mechanisms is not through fee-for-service, but through some form of capitation. You can talk about case rates, for example, or other capitation mechanisms like block grants with outcomes tied to the grant. Those kinds of mechanisms can promote recovery. While we continue with funding fee-for-service, there is more and more dependency created. I think that consumer services, when they are funded that way, will eventually promote dependency. This is why there has been so much controversy about Medicaid funding of consumer services. If you are paid by the hour, you will be driven to do more by the hour—even consumer providers. It’s a simple survival mechanism. This tradition of funding mechanism helps create the psychology of adjustment culture. This culture has a set of roles and identities that professionals and other staff members occupy. They are essentially caretaking roles, not recovery roles, and so you’ll find professionals forming their social identities around taking care of a group of people they think are totally hopeless. The second large obstacle is the culture being built around a psychology of adjustment versus a psychology of respect. The phrase “psychology of respect” is credited to Andrew Phelps, with the Accountability Caucus in California. These two obstacles can be addressed by: changing the funding mechanisms to some form of capitation, and as for the culture and identity issue, this is best changed through dialogues with consumer/survivors about what helps and hinders recovery, and through training.

NASMHPD/NTAC e-Report on Recovery – Fall 2004

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