ระบบกิจกรรมบำบัดทางจิตสังคม - recovery model

โครงการประชุมเชิงปฏิบัติการเรื่องการจัดการความรู้ด้านการฟื้นฟูสมรรถภาพผู้ป่วยจิตเวชแบบองค์รวม กำลังจะจัดขึ้น ณ ห้องประชุมนายแพทย์สุรินทร์ ปิ่นรัตน์ ชั้น ๔ ตึกอำนวยการ สถาบันกัลยาณ์ราชนครินทร์ วันที่ ๒๕ - ๒๖ ตุลาคม ๒๕๕๐ เวลา ๘.๓๐ – ๑๖.๓๐ น.

Source I: 

http://www.fairfaxcounty.gov/csb/region/Resources/mhrecoverymodel.pdf

MENTAL HEALTH RECOVERY MODEL

Recovery is often called a process, an outlook, a vision, a conceptual framework, a guiding principle. There is no single agreed upon definition of recovery. However, the main message is that hope and restoration of a meaningful life are possible, despite serious mental illness (Deegan, 1988, Anthony, 1993). Recovery is …”both a conceptual framework for under- standing mental illness and a system of care to provide supports and opportunities for personal development. Recovery emphasizes that while individuals may not be able to have full control over their symptoms, they can have full control over their lives. Recovery asserts that persons with psychiatric disabilities can achieve not only affective stability and social rehabilitation, but transcend limits imposed by both mental illness and social barriers to achieve their highest goals and aspirations.” (The Recovery Model, Contra Costa County, California).

DISTINGUISHING FEATURES OF THE RECOVERY MODEL

The following are the fundamental assertions of the Recovery Model of mental illness cited in the Contra Costa County Recovery Model concept paper cited above.

1. • a holistic view of mental illness that focuses on the person, not just the symptoms;

    

2. • recovery is not a function of one’s theory about the causes of mental illness;

    

3. • recovery from severe psychiatric disabilities is achievable;

    

4. • recovery can occur even though symptoms may reoccur;

    

1. • individuals are responsible for the solution, not the problem;

    

2. • recovery requires a well-organized support system;

    

3. • consumer rights, advocacy, and social change;

    

4. • applications and adaptations to issues of human diversity.

    

More information about recovery can be found at:

http://www.mhrecovery.com

References

Anthony, W. (1993). Recovery from mental illness: The guiding vision of the mental health service system in the 1990’s. Psychosocial Rehabilitation Journal, 16(4), 11-24.

Deegan, P.E. (1988). Recovery: The lived experience of rehabilitation. Psychosocial Rehabilitation Journal, 11(4), 11-19.

Mahler, Tavano, Gerard, Baber (2001). The recovery model: A conceptual framework and implementation plan, Contra Costa County Mental Health Recovery Task Force, October 2001, 1-8.

Source II:  http://www.socialworkers.org/practice/behavioral_health/0206snapshot.asp NASW Practice Snapshot: The Mental Health Recovery Model Office of Social Work Specialty Practice The mental health Recovery Model is a treatment concept wherein a service environment is designed such that consumers have primary control over decisions about their own care.  This is in contrast to most traditional models of service delivery, in which consumers are instructed what to do, or simply have things done for them with minimal, if any, consultation for their opinions.  The Recovery Model is based on the concepts of strengths and empowerment, saying that if individuals with mental illnesses have greater control and choice in their treatment, they will be able to take increased control and initiative in their lives. The Recovery “movement” refers to a mostly grassroots initiative that also encourages these tenets, and has as a goal the recovery from mental illness.  Helping achieve these goals is consistent with the values of the social work profession, which is committed to the empowerment and self-determination for all populations, particularly those who are traditionally disenfranchised.  This Snapshot discusses some of the ways in which the tenets of the Recovery Model may affect clinical practice in facilities that support individuals with mental illnesses.  Some short recommendations are also made for how to orient one’s own work to reflect the recovery ideas.  What does recovery mean? The concept of “recovery” originally began in the addictions field, referring to a person recovering from a substance use disorder.  The term has more recently been adopted in the mental health field as people realize that, similar to recovery from an addiction, recovery from a mental illness is also possible.  Efforts are now ongoing to develop an appropriate definition for “recovery” as used in the mental health field.  The Substance Abuse and Mental Health Services Administration (SAMHSA) and the Interagency Committee on Disability Research (ICDR) began an effort in 2004 to develop a consensus statement on a definition.  Hoping to release it in late 2005, they gave a sneak preview of the statement: “The expert panelists agreed that recovery is an individual’s journey of healing and transformation to live a meaningful life in a community of his or her choice while striving to achieve maximum human potential” (U.S. Department of Health and Human Services, 2005b, p. 4, as cited in NASW, 2005). What might concepts of the Recovery Model mean in a clinical program? A key point of the model is that it is not our role as providers to make decisions for consumers, but we do have a responsibility to provide education about the possible outcomes that may result from various decisions.  Many staff first react with concern when they hear that mental health consumers should make decisions about their own care.  “What if someone decides they don’t want to take prescribed medications?” is perhaps the most common and worrisome concern.  Legally, though, no adult can be forced to take medications or undergo certain treatments unless there is a court order or legal guardian directing them to do so.  The Recovery Model does not advocate anything different.  The reality of practice, though, is that mental health consumers (particularly those with more chronic and debilitating disorders) are usually instructed as to what treatments and medications to take, with minimal effort to involve them in decisions.  The Recovery Model states that a program’s philosophy should acknowledge and encourage consumer involvement and decision-making.  Most consumers do ultimately ask for, and take, clinicians’ treatment recommendations, but consumers need to know that they have both the right and the responsibility to make those decisions.      Consumers should be included from the beginning in decisions regarding their care.  When a consumer decides that he or she wants to do something, his or her decision ought to be respected, and we, as providers, should make reasonable efforts to assist.  This does not mean money should be taken from group activity funds so that one consumer can take a vacation.  However, if this is something the consumer has decided to do, advice and assistance ought to be provided for them to make it a reality.  Maybe this means they need to save money, get a part-time job, or learn to take medications without reminders.  The Recovery Model also does not suggest that consumer choice should be encouraged at the detriment of other consumers or program rules.  A day program that requires attendance three days a week should maintain that rule, and consumers who do not follow it should have applicable consequences.  Likewise, a housing program that requires consumers to have daytime activities should also enforce that rule.  Or a therapist who sets rules for active participation in treatment should not take “I didn’t feel like it,” as an acceptable response for failing to do an agreed-upon task.  Program rules that are set for the benefit of all should not have exceptions made in the name of the Recovery Model.  However, consumers who do not like the rules of a particular program or residential facility should have the right to find a program that will better meet their needs.  What about decisions we think will be bad ideas? What about when a consumer makes a decision that goes against clinical judgment and/or scientific evidence?  The Recovery Model still suggests that wishes should be respected, and that we should assist consumers in their attainment.  If their goal does not seem rational to us, then we need to help them understand the implications and realistic possibilities, but they need and have a right to make the decisions.  We have a responsibility to “support the dignity of risk and the right to fail” (attributed to Pat Deegan, 1996, as cited at U.S. Department of Health and Human Services, 2005a). Beyond clinical judgment or scientific evidence, concerns arise if a consumer’s decision is likely to cause harm.  We have a responsibility by our Code of Ethics to intervene “to prevent serious, foreseeable, and imminent harm to a client or other identifiable person” (NASW, 1999, p. 7).  A decision to not go to a day-program for a certain day is unlikely to cause such harm.  Refusing medications, on the other hand, has a possibility of more serious harm, depending on the medication.  Each case needs careful consideration and consultation with other relevant providers.  When a consumer’s decision is unlikely to cause serious harm, our job is to help educate them as to possible benefits and consequences of their decision (including if that means a possibility of involuntary hospitalization), but in the end to let them make those decisions.  When a decision is likely to cause serious harm, then we should, as always, intervene so as to prevent the harm.   An important concept of the model: Another key concept of the Recovery Model is that consumers should have the right to make the same types of decisions that everyone else in society makes.  Any individual who wants to live in an independent apartment in the community, for example, must make certain decisions that balance such factors as finances and behaviors.  Fortunately there are laws designed to protect individuals with disabilities from housing discrimination, but each individual still has a responsibility to act in ways that are reasonably respectful of the rights of neighbors.  An individual who plays excessively loud music, regardless of who they are, for example, runs the risk of receiving a warning or citation from the police.   Someone who continues to be disrespectful of the rights of others would not be able to stay in the apartment.  The person has the right to play music loudly, but they also must take responsibility for possible repercussions.  Consideration for the rights of others also applies to outside activities in which people participate.  For many individuals this might include a gym membership or yoga class.  For consumers of mental health services, this might also apply to support groups or day-treatment programs in which they participate.  An individual who becomes disruptive to others in a group therapy session would be asked to leave in most cases.  Individuals should have a choice about how to address their interpersonal challenges, but they also need to know of the responsibility of acting in a reasonably respectful and safe manner towards others.  Again, someone who chooses to neglect their self-care, and becomes a dangerto themselves or others, may need a more directive intervention such as hospitalization.  This is a possibility of which each person in society needs to be aware; but each person also has the right to act in ways that will prevent or incur such an intervention.  Additional thoughts: There are many possible concerns that clinicians may express regarding allowing consumers to make decisions about their own care.  Along with concerns about rejecting helpful medications, they might include not going to a program, not going to a doctor’s appointment, or not going to work.  Consumers need to be as fully informed as possible about the potential benefits and consequences of each decision.  They also need to know the possible results if they become a danger to themselves or others.  When they break program rules, or decide that they no longer want to participate in a group, they may need to find another program that is more amenable to their interests.  When such a program does not exist, then they need to be informed of what that means for their situation.    Social workers have an obligation to continue serving, supporting, and encouraging consumers to do what our clinical experience has taught us to believe is best.  However, we must understand and accept that helping consumers to make their own choices—good or bad—will ultimately be in the best interests of their recovery and independence, even if we believe that a particular action is a bad idea.  As professionals, we need to learn to take a supportive role, rather than one as a decision maker.  This may take a change in mindset for many clinicians, but it is imperative that they make that change (Rommler, 2005).  On the other hand, there are constraints about how much we can help someone with what they want.  The Recovery Model does not call for us to do things that are unrealistic, that would hinder the recovery of other consumers, or that would involve treating one consumer more favorably than another.  The model calls for us to support consumers’ decisions, within reason, to the best of our abilities.  Tips to orient your work towards a recovery-oriented model: Never talk about a consumer in the third person when he or she is present.  In that case, they should be referred to as “you”—“What do you want to do or think?” or, “You have a follow-up appointment in two weeks,” or, “You understand that John will remind you of your appointment and take you there in two weeks?”  Sometimes this may seem awkward when you are informing a family member or other caregiver of care instructions.  However, you can, and should, still work the consumer into the conversation in such a way that he or she is a part of the conversation, rather than an object next to you.  When a consumer makes a request that you don’t agree with, as your first response do not ignore them or say “no.”  Rather, ask them to explain their request.  Why do they want it?  What will they need to do to get it?  What are the consequences and benefits?  Is it a realistic request?  Yes, some people become recalcitrant, and will struggle to understand explanations.  Just don’t make “no” your first gut-reaction for what seems to be an irrational request.  Help them to think about the request and make their own rational decision.  Chances are good that you misunderstood their intent, and their request is reasonable.  Remember your body language and communication skills.  These are frequently forgotten, especially when working with consumers who have greater disabilities.  Never turn your back to a consumer when talking about their care with another person.  When talking with a consumer and another provider or family member, talk to both of them, even if only one person is responding or will have direct responsibility for carrying out instructions.  Look back and forth between the consumer and other(s) to include a consumer in a conversation.  Ask the consumer if he or she understands a discussion, or understands how another person will be helping them.  Say things and use your body language to ensure that a consumer is a part of a conversation about his or her care. Respect consumers’ cultural differences or views.  A consumer who is Jewish should have the right to light Chanukah candles in December.  A consumer who is Islamic should have the right to pray at sunset, even if it means he or she has to leave in the middle of a group therapy session.  You and other staff need to be aware of, remember, and respect cultural differences of the consumers you serve.  The Recovery Model is the focus of the mental health field, though its tenets can and should be extrapolated to other service fields.  The goals of empowerment and self-actualization for traditionally disenfranchised populations, which are inherent in the Recovery Model, are very similar to the NASW Code of Ethics (1999), and the NASW’s policy statements in Social Work Speaks (2003).  Encouraging these goals are inherent in what it means to be a social worker.  Finally, a critical underlying concept of the Recovery Model is respect for the value and worth of each individual as an equal and important member of society—another concept that social workers will have no problem understanding. REFERENCES: National Association of Social Workers. (1999). Code of Ethics of the National Association of Social Workers. Washington, DC: NASW Press. National Association of Social Workers. (2006).  Social Work Speaks, sixth edition:  National Association of Social Workers Policy Statements, 2006-2009. Washington, DC: NASW Press. National Association of Social Workers, Office of Social Work Specialty Practice. (2005). Social work snapshot: The transformation of the mental health system. Retrieved from  <http://www.socialworkers.org/practice/behavioral_health/1005snapshot.asp> Rammler, L. (2005). Person/Family-Centered Planning:  The Promise of Person/Family-Centered Planning. Welcoming remarks at the U.S. Department of Health and Human Services, Substance Abuse and Mental Health Services Administration, National Consensus Conference on Person/Family-Centered Planning, Washington DC.  Agenda available from http://www.psych.uic.edu/uicnrtc/cmhs/pfcprecommendations.htm U.S. Department of Health and Human Services, Substance Abuse and Mental Health Services Administration. (2005a, December).  National Consensus Conference on Person/Family-Centered Planning, Washington DC.  Available from http://www.psych.uic.edu/uicnrtc/cmhs/pfcphome.htm   U. S. Department of Health and Human Services, Substance Abuse and Mental Health Services Administration, Center for Mental Health Services. (2005b, July/August). Mental health transformation trends: A periodic briefing, 1 (3), 4. NASW, February 2006

Source III:

http://www.wfot.org/wfot2006/pdf/Microsoft%20Word%20-%20031006%20Mental%20health.pdf 

WFOT 2006 Professional Issues Forum

World Federation of Occupational Therapists Congress 2006

Professional Issues Forum: MENTAL HEALTH

Facilitators: Karen Arblaster and Joy Pennock

Summary

Three questions were posed to the forum. The first focused on general issues for theoccupational therapy profession in mental health. Responses could be loosely

grouped into three categories:

(1) Workforce issues encompassing issues of recruitment, role focus, career

pathways, numbers of occupational therapists and links with professional

associations.

(2) Service development and organisation regarding the developing role of non

Government organisations, service pressures for acutely ill clients, community

resources

(3) Occupational Therapy focus / role in relation to assessment, evidence based

interventions, role clarity and focus

(4) Future issues including recent significant events in Australia, occupational

therapists in positions of influence, exploring new opportunities.

The second question focused on the drivers for mental health services and the forum

identified three main drivers:

(1) Funding and service models including MH funding (private and public), media,

consumer and carer input, occupational therapists themselves, clinical risk,

clinical models and treatment modalities, pharmaceutical influences.

(2) Population issues such as diversity, ageing, specific target groups or minority

groups, consumer and community awareness

(3) Occupational therapy focus / roles incorporating evidence based practice, general

and specific roles, influence of organisations and training

The third question focused on the possible significant contribution occupational therapy

could make to mental health services. The forum identified:

(1) Areas of clinical practice including occupational performance, client and strength

focus and broad perspective / training, life span, health promotion, specialized

clinical areas /input, relapse prevention, a variety of therapy modalities and focus.

(2) Future issues including advocating for rehabilitation, political issues, need for

networks, use of / development of influence, usefulness of the profession,

research and documentation, specific future planning.

WFOT 2006 Professional Issues Forum

Facilitators’ comments.

The inaugural mental health professional issues forum at the WFOT congress in July

2006 was a popular session as indicated by high attendance (approximately 70 to 80

occupational therapists). Attendees were predominantly Australian though there was

also representation from New Zealand, Canada, United Kingdom and Slovenia. The

session focused on three questions and a brief discussion about current initiatives within a

couple of countries.

The forum notes were subsequently sent to the participants prior to posting on the WFOT

website. One comment from a UK participant indicated a level of disappointment that

the discussion was drawn toward issues within the host country, Australia. This was the

likely result of high numbers of participants attending the forum from Australia, which

hence created a stronger voice due to the overwhelming numbers. General questions

were specifically developed for the forum that could equally apply to any country.

During the forum issues from various countries other than Australia were specifically

documented, usually from one or two individuals. This issue of balance is worth

consideration by future facilitators keeping in mind individuals should not be expected to

represent their entire country’s views but the views of the host country will be strong due

to numbers in attendance.

Responses to questions during the forum were the result of small group work and a

feedback process. Responses were collated and categorised and therefore, represent

ideas put forward on the day by both groups and individuals. The issues identified in the

forum were not debated or prioritized during the forum. However, the impression of the

facilitators was that the atmosphere within the forum was one of interest, enthusiasm and

engagement in the views put forward.

Karen Arblaster & Joy Pennock

August 2006.

WFOT 2006 Professional Issues Forum

Detailed forum notes

1. What are the issues for the occupational therapy profession in

relation to practice within mental health? Are these issues for

everyone or for some areas of mental health?

Workforce issues:

• Recruitment

o Victoria (Australia) – no grade 1 positions, only grade 2 – difficult to fill

o NSW (Australia) – difficulties with attracting people; retention; lack of

support and isolation

o Methods of advertising

• Generic vs discipline specific roles: problems with recruitment; shift to specialists

in Victoria (Australia); shift to generic roles in other areas/countries eg Scotland.

Specialist skills not always recognized within generic roles. Involuntary treatment

generally a feature of generic roles.

o Scotland – being pushed to take on other roles due to shortages of

multiple professions – “Mental Health Officers”; includes prescribing

medications, involuntary treatment.

• Lack of career path – difficult for occupational therapists to remain in mental

health as there are minimal opportunities to move into management or other

senior positions.

• Canada – 9% of occupational therapists work in mental health – very isolated

• Australia - MH occupational therapists 20-30% of Australian occupational

therapy workforce but under-represented in professional association – why?

Service development and organization:

• Growth in the role of NGOs, especially in rehabilitation and disability support.

o NGOs employ predominantly unqualified and casual staff who require

training up in client management and implementation of programs –

possible occupational therapist role with NGO workers – how to do this?

o Lack of outcomes for clients due to turnover in NGO staff (casual

workforce).

• Acute wards – pressure of beds despite increase in funding; high turnover/short

length of stay means minimal rehabilitative or recovery work can be achieved

within hospital and minimal opportunity for appropriate discharge planning.

• Supported housing - insufficient

• Funding is focused on acute phase; would be good to have more opportunity to

work with people to prevent admission

Occupational Therapy focus/role:

• Occupational therapy assessment – tends to be omitted from acute team

assessments; issues of function and occupational performance not identified early

in the treatment so timely intervention not possible.

• Evidence Based Practice

WFOT 2006 Professional Issues Forum

o perceived lack of outcomes research that supports the role of occupational

therapy.

o Clarifying occupational therapy role in the use of cognitive behavioural

approaches

• Clarity of roles

• Slovenia – all working in institutions – difficult to establish role in community

• Perceived loss of function (occupation) as a central focus.

The future:

• Australia: Recent meeting of health ministers (COAG) with a focus on mental

health. Increased funding was announced with some professional groups

identified for enhanced services. Occupational Therapy is not among the groups

who have been identified for enhanced funding. Occupational therapy did not

contribute to the consultation that preceded these announcements.

• Not enough occupational therapists in management positions – unable to

influence

• Used future – what are the opportunities?

o Develop the evidence for prevention/community services – more cost

effective – has been done with MBF.

2. What are the drivers for mental health services currently?

Funding and Service Models:

• COAG recent meeting re mental health funding announcement– OT not

addressed. How will occupational therapy gain access to increased funding

and enhanced services for clients?

• Medicare – AAOT strategy to gain eligibility for occupational therapy

treatments for mental health conditions for Medicare funding.

• Media – publicity and media campaigns re some mental health issues are

driving mental health onto the political agenda and creating a platform for

Mental Health reform.

• Carer/consumer movements and community opinion are having an impact.

• Growth of psychiatric disability support sector – particularly the nongovernment

sector.

• Funding – primary mental health teams; high prevalence disorders; Beyond

Blue; where are the low prevalence disorders? What is the occupational

therapy role with high prevalence disorders given the strong evidence base for

psychological approaches in combination with medication. Is this an

opportunity or are the barriers too great?

• Occupational therapists as drivers – need to take on strategic roles in

allegiance with relevant lobby groups/organizations etc– lobbying and

marketing to ensure we are able to contribute significantly to mental health

services.

• Risk – the management of risk of harm to self or others dominates the way in

which services are delivered.

WFOT 2006 Professional Issues Forum

• European countries – individual service model means some people not gainingaccess to services (Facilitator comment: It was unclear from this comment

whether this was an issue because current resources, that focus on individual

intervention, are not adequate to meet the demand. An individual service

model is valid in its own right. It is one appropriate therapy modality for

occupational therapists depending on the context and clinical need).

However, it is important to sustain awareness of the benefits of collective or

group-based approaches, which occupational therapists have considerable

expertise in. Government drive for illness self management now filtering into

mental health. How can occupational therapists use / work with this

philosophy with good effect?

• Recovery model – underpinning service organization and delivery models

• A medical model drives the conceptualization and organization of treatment

and services. This can mean a concentration of resources at the acute end of

the spectrum of services and makes it difficult to maintain a focus on recovery

and rehabilitation.

• Early intervention/prevention – funding directed to these areas.

• Pharmaceutical companies – exert some influence over mental health

practice?

Population issues:

• Multicultural population

• Ageing population

• Dual diagnosis – substance use, physical co-morbidities, intellectual

disabilities.

• Growth in forensic population – determining appropriate intervention with

“dangerous and severe personality disorders” (UK)

• Asylum seekers/refugees/forensic – occupational deprivation - how do we

address the occupational justice issue?

• Community awareness and consumer self education

Occupational therapy focus/role:

• Evidence Based Practice – a requirement/driver BUT occupational therapy

has little research evidence supporting occupation specific intervention. How

do we relate to the evidence base for practice across the range of mental health

services (eg clinical guidelines, evidence based practice literature such as

series published in Psychiatric Services Journal in ?2001)

• Generic vs specialist clinical roles. How do we approach this issue? Are

there different perspectives? Are there advantages and disadvantages with

either role?

• WHO process/influence – recent publications?

• Universities – how well are our graduates prepared for practice in real life

mental health settings?

• Specialist clinical positions – in some countries higher degrees required.

What is the impact on the profession?

WFOT 2006 Professional Issues Forum

3. What are the significant contributions occupational therapy can

make to mental health services within this context?

Contributions to clinical practice in mental health:

• Expertise in occupational performance – contributes to a recovery focus.

• Client centred practice – congruent with the recovery model

• Life span approach – congruent with current approaches to mental health ie

mental health across the lifespan

• Broad perspective – physical, psychosocial – fits with biopsychosocial model

and the wide ranging effects of mental illness.

• Health promotion – health promoting aspects of occupation congruent with

mental health promotion philosophy

• Children of Parents with a Mental Illness – occupational therapists have a

specific role due to knowledge of development, occupation, occupational

roles, AND the environmental aspects of occupational performance, human

growth and development and occupational role development

• High prevalence disorders; role in developing primary care services –

occupation based approach.

• Comprehensive assessment – occupational therapy assessment is

comprehensive in nature and congruent with the notion of comprehensive

mental health assessment which is essential in mental health services

• Skill and expertise in goal setting

• Contribute to early discharge

• Support people in community – relapse prevention

• Group work

• Ability to work alongside people – work well with consumers/carers

• Volition/personal causation – motivation. Improving function needs to be

related to this but this is often lost

• The package of occupational therapy skills enables us to engage with people

and provide useful intervention.

• Strengths based focus – congruent with recovery model

• Skills in helping people in transition

The future:

• Advocacy for rehabilitation

• Participate in the political arena – advocacy and lobbying for improved

services

• Occupational therapy networks

• Be in management positions and involved in service development

• Cost effective and sustainable; low technology

• Increased use of technology; at forefront of use of technology

• Australia:

WFOT 2006 Professional Issues Forum

o COAG agreement $4B for MH – AAOT working proactively; problem

analysis perspective needs to be taken – not enough flexibility; create a

commitment to the ideal that doing things is good for you.

o Working toward access to Medicare funding – creates a more flexible

work choice.

o Lost opportunity converted to an opportunity – a strategic plan to be

developed within NSW

• Research – multisite projects to demonstrate effectiveness of occupation based

approaches to recovery/rehabilitation would be useful.

• Writing what we do; letting people know.

• UK – strategic plan to be launched in December. Outlines the way forward to

an occupation centred approach to practice within mental health.

 

Need to read out more at these two major websites

http://www.mhsip.org/recovery/index.html

http://www.spiritualcompetency.com/recovery/lesson1.html#vsmed

Other Sources:

http://www.namiscc.org/MentalHealthRecovery.htm

http://www.schizophrenia.com/sznews/archives/002602.html

http://www.namiscc.org/Recovery/2005/EmpowermentModel.htm