2017 Recovery in Mental Health & Slides PDF

Report on the Professional Issue Forum on
Recovery in Mental Health

Charlottetown, PEI – CAOT Conference 2017
Professional Issue Forums (PIFs) are held annually at the Canadian Association of Occupational
Therapists (CAOT) Conference. PIFs address priority health and social issues, and emerging practice
areas in occupational therapy. PIFs involve presentations from a panel of experts and participants are
invited to contribute their perspectives. The discussion leads to strategies and recommendations for
action for CAOT, individual occupational therapists and stakeholders to advance occupational therapy
practice and the profession’s presence in these areas.
Introduction
Recovery is a recognized best practice paradigm for delivering mental health services (Mental Health
Commission of Canada, 2015), yet advancing recovery so that it permeates all levels of the service
system is an ongoing and evolving process. The Mental Health Commission of Canada (2015) has
committed to ensuring that recovery and recovery-oriented services become the norm across the
country. Recovery-oriented practice is not the domain of any one discipline or professional group;
rather, all disciplines are challenged to determine how they will be positioned within the recovery
landscape. However, issues have arisen because the concept of recovery has been defined from
different perspectives.
The idea of recovery as advanced by the Mental Health Commission of Canada acknowledges that
people with mental illness can experience meaningful lives and engage in meaningful activity within the
community even while symptoms of mental illness may be ongoing. Proposed by William Anthony, a
widely-used definition of recovery is that: “… a deeply personal, unique process of changing one’s
attitudes, values, feelings, goals, skills, and/or roles. It is a way of living a satisfying, hopeful, and
contributing life even with limitations caused by illness” (p. 527). Recovery-oriented practice draws on
strengths, and values the input and choices of individuals with lived experience of mental illness at
multiple intersections within the community and healthcare systems. The complex interaction between
the individual and social environment is key, as recovery approaches are less about “fixing the person”
and more directed towards supporting meaningful participation within the community. This can include
supporting independent living, employment or volunteering, contributing to family,
social/leisure/recreation activity and a range of other activities associated with full participation and
citizenship.
Occupational therapists must reflect on how occupational therapy can contribute to the growing
recognition, evidence, and practice-base of recovery.
Objectives
The purpose of this PIF was to help occupational therapists identify where to focus strategic efforts in
relation to recovery-oriented practice for the next five years. This session challenged occupational
therapists to consider the following: 1) What can occupational therapy offer the recovery-oriented
approach in the mental health system? 2) How can occupational therapists address gaps in the system?
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and, 3) What strategic actions can our profession take to advance recovery-oriented services within
Canada?
Panel Presentations
Dr. Catherine White worked for many years in the acute care psychiatry unit of the Dr. Everett Chalmers
Regional Hospital in Fredericton, New Brunswick. She completed her PhD, which focuses on recovery
and housing research, in 2013. Her ongoing research focuses on the role of leisure and recreation in
both recovery and social inclusion. During her presentation, she addressed the multiple definitions of
recovery that are discussed in our service systems. Recovery can be seen as an outcome or cure, a
process, or a journey—or it can be considered within clinical, personal, social or functional domains.
Catherine highlighted the work of the Mental Health Commission of Canada, drawing attention to
Changing Directions, Changing Lives: The Mental Health Strategy for Canada (MHCC, 2012), and follow-
up documents such as the Guidelines for Recovery-Oriented Practice (2015). These documents offer
Recovery as a guiding principle for mental health care, and embrace knowledge translation strategies to
support the integration of recovery with a range of populations in multiple settings.
Dr. Karen Rebeiro Gruhl has practiced in mental health since 1985, retiring from clinical practice in
August 2016. Karen has been involved in clinical research since 1997; her work focuses on employment
and consumer initiatives in northern Ontario, as well as the development of the peer support worker.
Karen’s presentation highlighted the social and political landscape of recovery in Canada. She described
current practices—and areas for growth and change—within the complex intersection of economic,
social, and mental health policy. Her talk explored the potential of small communities to influence the
development of participation and recovery-based policy. Karen also emphasized the need for
occupational therapists to invite themselves to the table of policy creation.
Dr. Terry Krupa has completed extensive research related to mental health, with her research program
focusing primarily on the development and evaluation of community-based initiatives to improve the
health, wellbeing, and full community participation of people with mental illnesses. She is interested in
employment, productivity and mental illness, activity-health and time use, and community and societal
responses to mental illness. During her presentation, Terry discussed how occupational therapy is
situated to provide a unique and valued contribution to the evolution of recovery-oriented services. She
presented a vision for national, provincial, and territorial leadership by occupational therapists in
research, educational, and political spheres. Her talk explored methods to integrate clinical and personal
visions of recovery, such as the use of participation and occupation-based outcomes in service delivery.
Terry also noted areas for future action, including developmental issues within the recovery approach,
such as aging in place for people with a mental illness.
Dr. Shu-Ping Chen is an Assistant Professor in the Department of Occupational Therapy, University of
Alberta. Shu-Ping’s teaching and research focus on two main themes: social inclusion for individuals with
mental illnesses and mental health promotion. Shu-Ping explored how occupational therapists can use
evidence-based strategies to strategically disperse their contributions, sharing an example of recovery-
oriented practice in an inpatient context. Within these settings, restrictions on service providers’ scope
of influence can create an environment that is not recovery-oriented at the system or the individual
levels. Most inpatient service providers think that they cannot be a component of recovery-oriented
approaches, and that they would not be supported if they were to try to implement new practices in
their workplaces. Shu-Ping highlighted tensions within practice that limit providers’ abilities and their
© Canadian Association of Occupational Therapists / Association canadienne des ergothérapeutes, Ottawa

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confidence in recovery-oriented strategies. Her discussion placed these tensions within a recovery
competency framework, outlining a way forward in both educating clinicians and changing practice. Her
work has highlighted the leadership role that occupational therapists can play in advancing recovery in
inpatient settings.
A copy of the panelists’ presentation can be found at the end of this document.
Round Table and Facilitated Discussions

Following the panel discussion, participants were divided into three small groups, to discuss the central
question: “How should we strategically position occupational therapy to advance the recovery vision in
the coming years?”
The small groups were asked to identify their distinct priorities as to where efforts should be targeted,
and to identify possible action plans to move forward. After 30 minutes of discussion, one member from
each group presented the results of their discussion to the large group. The results from the small group
discussions are provided below:
Group 1:
• promote a universal recovery language usage by occupational therapists
• find out how do we do it differently – social outcomes, client outcomes
• link recovery models and occupational therapy
• actively pursue partnerships
o profession to profession
o CAOT to relevant agencies/funding agencies
o Provincial associations
o Consumer groups
o OT practitioner to OT practitioner
• Action plan: CAOT – provide info/guidance to articulate language and role, mediate working
group
Group 2:
• educate about recovery models and position of OT at provincial and federal level
• Find outcomes that we as a profession agree on
o line outcomes up with stakeholder and funder priorities
• leverage the Canadian Mental Health Strategy to frame a recovery focused approach and the
role of OT
• Map how OT explicitly fits within the Canadian Mental Health Strategy
• Bridge gap between provincial initiatives/actions and federal
• For jobs entitled “Mental health clinician” which OTs can do:
o need to develop and promote leadership in these roles, to move occupation-based
intervention and outcomes to be recognized
o promote and develop advocacy skills to get OTs at the table
• Build stronger evidence for what OT interventions do
• Action plan: white paper from CAOT, politician, briefing notes
o role of OT in helping people lead full and health lives (promote consistent language)

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Group 3:
• Raise awareness
o at interprofessional level
o at government level
• Find ways to collaborate with other associations
• Improve measurement of outcomes in order to talk to decision makers
• Advocate for support in decision making and client-centered practice
• Support community-based agencies
• Tap into and communicate our capacity to appraise holistically
• Adopt a strength-based approach: identify resources, champions
• Work at higher level to enable others
• Provide exposure to students/practitioners on advocacy work
Following the presentation of each group’s priorities, all of the ideas were displayed on the stage, and all
participants were given three red dot stickers. Each person was then asked to place the red dot stickers
beside the priorities that they felt were most important. This allowed the group to identify their top
three priorities to advance the recovery vision in the coming years.
The top three priorities to advance occupational therapy’s contribution to the area of mental health
recovery are:
1) Mapping occupational therapy contributions to the Canadian Mental Health Strategy focused on
recovery-oriented services;
2) Develop occupational therapy practitioners’ capacity to advocate for inclusion of an
occupational perspective to recovery-oriented services;
3) Secure partnerships with key stakeholders to advance an occupational perspective to recovery-
oriented services; including, but not limited to:
• Government representatives,
• Private and not-for-profit sectors,
• Clients and consumer groups,
• Other professionals.
Additional Comments and Considerations Arising from Discussions

The participants were enthusiastic in sharing challenges and opportunities within their own practice
areas, and were keen to be a part of next steps. Contact information was collected from participants,
and will be used to maintain the connection.
Summary of Events
Three priorities aimed to inspire collaborations poised to advance an occupational perspective within
recovery-oriented services were identified through this Professional Issue Forum. First, a Practice
Network could be created to map out our role (i.e., what we can contribute) as well as our unique
perspective within the current Canadian context (i.e. how we can collaborate with others to advance
services). Second, these maps could be translated into a framework and knowledge translation tools
that would support the wide dissemination of this vision and the training of our future advocates. Third,

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these tools can be used to secure partnerships and convince decision makers in investing in the type of
recovery we are envisioning could and should happen in our country.
Acknowledgements
CAOT would like to gratefully acknowledge the contributions of the panelists and organizers.
References
Anthony, W. (1993). Recovery from mental illness: The guiding vision of the mental health services
system in the 1990's. Psychosocial Rehabilitation Journal, 16(4), 11-23.
Mental Health Commission of Canada. (2015). Guidelines for Recovery-Oriented Practice. Retrieved from
http://www.mentalhealthcommission.ca/sites/default/files/MHCC_RecoveryGuidelines_ENG_0.
pdf
Mental Health Commission of Canada. (2012). Changing directions, changing lives: The mental health
strategy for Canada. Retrieved from http://strategy.mentalhealthcommission.ca/pdf/strategy-
images-en.pdf
Nos excuses. Ces ressources ne sont pas disponibles présentement pour traduction.

Professional Issue Forum:
a
Recovery in Mental Health

Cathy White
Karen Rebeiro Gruhl
Terry Krupa
Shu-Ping Chen
CAOT Conference 2017  Friday, June 23, 2017
Canadian Association of Occupational Therapists Association canadienne des ergothérapeutes

Today’s Agenda
• Identify multiple definitions of recovery discussed in our service systems

• Consider the social and political landscape of recovery in Canada
• Discuss how occupational therapy:
– might be situated to provide a unique and valued contribution to the
evolution of recovery-oriented services
– can use evidence-based strategies to strategically disperse their
contributions

Throughout these presentations, consider the
following question:
“How should we strategically position

occupational therapy to advance the recovery
vision in the coming years?”

What is Recovery?
Past, present, and future relevance for occupational therapy
Catherine White, PhD, OTReg (NB, NS)

Assistant Professor, Fieldwork Education Coordinator
School of Occupational Therapy, Dalhousie University

Recovery from Mental Illness: The Guiding Vision of the
Mental Health Service System in the 1990s
(Anthony, 1993)
Recovery:
…a deeply personal, unique process of changing one’s attitudes, values,

feelings, goals, skills, and/or roles. It is a way of living a satisfying, hopeful,
and contributing life even with limitations caused by illness. Recovery
involves the development of new meaning and purpose in one’s life as one
grows beyond the catastrophic effects of mental illness (p. 527)

Other Definitions
Recovery as an outcome? (cure)
Recovery as a process? (journey)
Recovery domains? (e.g. clinical, personal, social, functional)

(Lloyd, Waghorn, & Williams, 2008)
Recovery components? (e.g. hope, self-determination, inclusion)

(Davidson, Tondora, Lawless, O'Connell, & Rowe, 2009)

Reflections on ... the recovery paradigm: should
occupational therapists be interested?
(Rebeiro Gruhl, 2005)
• “occupational therapists are uniquely positioned to assume a

leadership role in the area of recovery-related research and
practice” (p.96)

• Krupa, T., et al. (2009). Doing daily life: How occupational
therapy can inform psychiatric rehabilitation practice.
Psychiatric Rehabilitation Journal, 32(3),155-161.
• Krupa, T., et al. (2010). Action over inertia: Addressing the

activity-health needs of individuals with serious mental illness.
Ottawa, CAOT Publications ACE.
A critical perspective…
“It will be important to explore the meaning and process of
recovery cross-culturally, across the lifespan, and at different
levels of service delivery from the perspectives of potential and
existing mental service recipients, caregivers, service providers,
and other stakeholders” (Lal, 2010, p. 88)
Attention at the National Level
• Out of the Shadows at Last: Transforming Mental Health, Mental Illness
and Addiction Services in Canada (Kirby & Keon, 2006)
• Recovery identified as a guiding principle, “placed at the centre of

mental health reform”
• 2007 marked an important milestone when the Mental Health

Commission of Canada was instituted

• Part of the solution...or part of the problem? Addressing the stigma of
mental illness in our midst (Krupa, 2008)
Toward Recovery and Well-Being: A Framework for a Mental Health

Strategy for Canada (MHCC, 2009)
• Recovery as a journey, unique to each person
• Understands the complex interaction between the individual and social
environment
• People with MH problems…are able to enjoy meaningful lives in their
community while striving to achieve their full potential

Acknowledging misunderstanding of the word “recovery”,
the Framework reached consensus that recovery involves:
• Finding, maintaining, and repairing hope: believing in oneself; having a
sense of being able to accomplish things; being optimistic about the
future.
• Re-establishing a positive identity: finding a new identity which
incorporates illness but retains a core, positive sense of self.
• Building a meaningful life: making sense of illness; finding a meaning in
life, despite illness; being engaged in life and involved in the community.
• Taking responsibility and control: feeling in control of illness and in
control of life. (p. 28)

Mental Health Strategy for Canada
In Changing Directions,
Changing Lives, the concept of
‘recovery’ refers to living a
satisfying, hopeful, and
contributing life, even when
there are on-going limitations
caused by mental health
problems and illnesses.

The Guidelines for Recovery-oriented practice posit that
“recovery” approaches stand on two pillars:
1. They recognize that each person is a unique individual with the
right to determine his or her own path towards mental health and
well-being.
2. They understand that we all live our lives in complex societies

where many intersecting factors (biological, psychological, social,
economic, cultural and spiritual) have an impact on mental health
and well-being (p. 4)

The Focus of the Guidelines
• Creating a culture and language of hope
• Recovery is personal
• Recovery occurs in the context of one’s life
• Responding to the diverse needs of everyone living in Canada
• Working with First Nations, Inuit, and Metis
• Recovery is about transforming services ands systems

Making the Link
• Recovery as an occupational journey: A scoping review

exploring the links between occupational engagement and
recovery for people with enduring mental health issues
(Doroud, Fossey & Fortune, 2015)

Social and political landscape in Canada
Situating occupational therapy practice within a
recovery-focused mental health system
Karen Rebeiro Gruhl PhD., O.T. Reg (Ont)

Adjunct Professor, School of Rural and Northern Health,
Laurentian University

Objectives
• To understand the historical context of Federal and provincial mental
health policy frameworks and how these policy legacies persist with
respect to the social and occupational participation for persons with
mental illnesses
• To understand how social and economic policy further complicates the

ideas and interests of occupational therapy mental health practice
• To identify policy gaps and opportunities for occupational therapy

practice within this landscape.
Social policy in Canada
• Social policy shapes our daily lives
• Identifies what a majority of Canadians accept as legitimate public
issues for which we see the state as having responsibility
• Social policy is a continuous process
• New issues emerge as the economic, demographic and political
landscape in Canada shifts
• Social policy is a collective statement about the kind of society we want
to create/live in
• Westhues, A. (2006) Becoming acquainted with social policy (p 5).

Social policies of interest
• Poverty and welfare • Medicare (Universal health
• Child welfare//FN care policy legacy)
• Housing and homelessness • Mental health policy
• Immigration • Institutionalization
• Workfare • Deinstitutionalization
• Employment • Community-based practice
– Intensive case management
• Caring and aging – ACT
• Disability • Community-based supports
– Supported housing, employment,
education

Mental health policy in Canada
• A policy of Institutionalization
• 1836 in New Brunswick
• Segregated from public mind, out of site, and no opportunity for
advocacy
• Not a policy consideration other than construction of the hospitals and
the creation of jobs.
• Policy left to the medical profession, superintendents
(Trainor, Pape, & Pomeroy, 1997)

• A policy of Deinstitutionalization:
• 1960’s; based in economics, not mental health policy reform
– The right policy with inadequate supports (MHCC, 2012, p.62)
– People in the community, but not part of the community, affording few
opportunities beyond survival
– Asen (1986) argued,
• that deinstitutionalization of psychiatric patients is based on a false assumption that a community exists
to which they can return (at least not over the past 100 years). That is, the traditional structures of
family and neighborhood that might once have offered support and continuity have been dissolved in
the processes of geographic and social mobility and economic and technological change. Therefore, the
present-day geographical "community” is no longer a meaningful framework of support for
psychosocial rehabilitation.

• A policy of Community mental health services:
– $ to general hospitals/not CMHS (matched $$)
– Created impoverishment
– Unanticipated side-effect of being in the community without support
• Roots of mental health reform from system users and their families
• People with lived experience were no longer segregated in Provincial
hospitals on the outskirts of towns; they and their families could begin
to create a policy community of their own!
• Periodic efforts at reform but until recently few had sufficient
groundswell (Simmons, 1990).
• “Phoenix Rising” publication
• “On Our Own” by Judy Chamberlain in Vancouver (1978)
• Patricia Deegan’s suggestion of an alternative vision for care (1988)
• Each created a press for policy reform (Nelson, 2006)
• Increased funding into community
– However, this did not realize a change in mental health policy*
– Old wine in new bottles (Trainor et al., 1997)
– Community programs retained institutional paradigm of care (Mulvale, 2007)
• Notions of advocacy, peer support co-opted by gov’t (Usar, 2014)

• Ideas and interests
– Low practitioner expectations regarding employment are embedded
in policies and practice (Killeen & O’Day, 2004)
– Professionals often underestimate the capacities of service users to
work, learn, form relationships, live independently, recovery and
manage their illnesses (Trainor, Pomeroy & Pape, 2004)
– Creation of a culture of disability
– These low expectations helped to shape mental health policy

• Policy legacy of Institutionalization
– Policy legacies of psychiatric hospitals in the 1800s as well as public health
insurance (Medicare) to explain slow mental health reform
– Canada has a long history of frustrated attempts to move from hospital and a
physician-based tradition to a coordinated system with greater emphasis on
community-based mental health care.
• A system,
– Focused on acute care based in hospitals
– Functions largely on basis of biomedical model of illness, pharmacy
– Little effort in health promotion and illness prevention
(Mulvale, 2007)

• Presses within government led by Senator Kirby who stated that the
“status quo is not an option”; influential policy community
• Reports that have helped to shift mental health policy in Canada:
1. Out of the Shadow’s At Last (2006),
• Advocating for a consumer-focused system with a focus on recovery and personalized care (p. 9)
2. Toward recovery & well-being: A framework for a mental health strategy for
Canada. Mental Health Commission of Canada, (2009)
from http://www.mentalhealthcommission.ca.
3. Changing Directions, Changing Lives (MHCC, 2012)
• Draws upon many prior-expressed c/s ideas

Economic policy
• Social policy and mental health policy are not mutually exclusive of the
economic landscape in Canada
• Neoliberalism, a dominant global economic model has legitimized
certain political interests and ideas, including individualism, equality of
opportunity and market competition within health care arenas
(Tsatsanis, 2009).
• Neoliberal ideas may challenge recovery-based mental health programs
and practices especially in community supports,
– Employment policy and programs for persons with mental illnesses
– Other SH of D important to recovery, including income, housing, food security
– Access to professional services and supports beyond those of Medicare
Neoliberalism
• Baranek (2004), funding based in economic and political decisions rather than client-
expressed needs
• Talbot and Walker (2007) argued how neoliberal policy undermines the efforts of
communities to work together; creating a situation in which policy outcomes are at
odds with stated agendas of building community capacity, community supports (or
progressive recovery frameworks).
• Funding models based upon neoliberal ideas of efficiency, individualism and
competition are incompatible with
– 1) the comprehensiveness of services needed by persons with SMI to be successful in
employment;
– 2) the need to consider differences amongst people; and,
– 3) the need to consider context in the implementation of services within extensive geographies.
(Rebeiro Gruhl, 2011)

Intersect of mental health & economic policy
• The social policy landscape—expressed through the funding model and
the organizational structure of employment support programs in
Ontario—was found to be inconsistent and in many ways incompatible
with the policy landscape of the health and community mental health
sector.
• Income support programs served as disincentives to employment
(Krupa et al., 2005),
• Individual brokerage models’ focus on assessment and prevocational
activities, and on risk and liability are antithetical to helping people with
SMI into employment (Rebeiro Gruhl, 2011)

Who said practice wasn’t political?
4. Partnerships
1. Leadership
- Who shares our ideas and interests?
– Nationally
- Actively pursue these partnerships
– Provincially/Territorial
5. Expand knowledge
2. Jurisdictional claim - Regarding the system; Continuous learning;
– Target policy gaps in areas of participation Be an informed practitioner.
– Advocacy efforts- social policy 6. Research
3. Political - Supporting this jurisdictional focus, practice
– Critically interrogate ideas and interest that and advocacy efforts; collaborative
do not fit a recovery philosophy. Speak up! 7. Education
- FN/Inuit/Métis students
- Northern School; role emerging placements?

Making a valued contribution to the evolution of
recovery-oriented services:
An opportunity for occupational therapy in Canada
Terry Krupa PhD, Queen’s University

With all of the many….
• Developments in recovery knowledge
• Recovery–related tools and resources
• Efforts to improve recovery-related competencies across the broad

range of service providers
• Advancements in recovery-oriented practice delivery and evaluation

Where can occupational therapists contribute to making meaningful
advancements in knowledge and practice?
Both to
• secure a recognized role as leaders
• ensure the integration of relevant occupational therapy philosophy and
knowledge in the field

“There currently are glimmers of hope that the recovery movement may
bring about a bit of renaissance of occupational therapy and science
within psychiatry……
We would heartily welcome such a development, and suggest that the
recovery movement would have much to learn from this discipline”
Davidson, Rakfeldt & Strauss (2010). The roots of the recovery movement.
West Sussex, UK: Wiley-Blackwell.

How might we strategically design our efforts to
have the most impact?
Examples:
1. Addressing issues that have challenged the field
2. Creating real opportunities for productivity participation that are meaningful
personally and socially
3. Taking a leadership role in advancing the integration of clinical and personal
visions of recovery

1.Addressing issues that have challenged the field
BACKGROUND
Many, many professionals and other stakeholders are involved in the delivery of
recovery-oriented services
Many effective recovery-oriented services have been implemented without the benefit
of occupational therapy and occupational therapists
How can we use our expertise to develop potential solutions to areas of tension in
practice?

1. Addressing challenges – a few thoughts
• A. Addressing tensions in application of the philosophy and
ideals of recovery
• Example: Client centred practice/ Self-determination
• How can we apply these principles in the context of people living:
– With significant cognitive impairment?
– In forensic settings, prison, experiencing involuntary hospitalization or other

highly restrictive and occupationally deprived environments ?

• B. Advancing developmental issues in the application of
recovery ideals
For example:
Youth
Aging**

• C. Addressing needs of specific populations
For example:
• Enabling the transition from homelessness to housed (Marshall et al, 2016)
• Enabling participation of people with extreme social detachment and occupational
disengagement (Edgelow et al, 2011)
• Enabling community living among those with significant cognitive impairments
(Kidd, Herman, Barbic et al, 2014)

2. Creating real opportunities for productivity participation
that are meaningful personally and socially
• There is a large focus on productivity, and specifically supporting people to gain
access to paid positions in the community economy
• Guided by principles of fair wages, inclusion, personal preferences
• Only recognized evidence-based approach to supporting productivity is supported
employment, and in particular the individual placement and support model
• What other recovery-oriented approaches can be developed to address the
marginalization of people with mental illness in the community economy?

2. Creating real opportunities for productivity participation
that are meaningful personally and socially
Examples:
• Approaches to developing individual interest and commitment to
pursue productivity in the community economy
• Constructing paid employment opportunities in the community
economy, such as work integration social businesses and other forms of
social enterprise
• Building an evidence-base for other productivity activities – such as
voluntarism, supported apprenticeships and internships
(Krupa & Chen, 2013; Roy, Lysaght & Krupa, 2017; Kirsh et al, 2010)

3. Taking a leadership role in advancing the integration of
clinical and personal visions of recovery
BACKGROUND
Conflicts related to definition of recovery often fall at the intersect of clinical and
personal visions of recovery
Personal definitions of recovery are at risk of being misappropriated within highly
clinical services
Advancing the development of recovery-oriented services depends on the integration
of personal perspectives on recovery in to clinical services
Occupational therapists are in a good position to advance this

3. Taking a leadership role in advancing the integration of
clinical and personal visions of recovery
Examples:
Strategically engaging people with lived experiences to influence the delivery of
clinical services
Building opportunities for communication of positive narratives of personal recovery
within highly clinical services
Strategically building alliances of personal recovery “champions”
Building the evidence base for the link between occupation and participation and
traditional clinical outcomes
Advancing occupation and participation as outcomes of interest in clinical service
delivery

Summary
• There is much work left to do to advance truly recovery-
oriented services
• Occupational therapists can think strategically to consider how
they can contribute to meaningfully advance recovery and
develop their own roles as leaders in the field

Evidence-based Recovery Practice
An Example in the Inpatient Context
Shu-Ping Chen, PhD, Assistant Professor

Department of Occupational Therapy, University of Alberta

Background
• During the recovery journey, a person may re-experience acute distress
and need in-patient services
• The downsizing and/or closures of psychiatric hospitals and the increase
of community-based services
– Acute units: People admitted to acute in-patient units can be vulnerable and in
extreme distress.
– Long-term units: Although the number of long-stay patients in tertiary
psychiatric hospitals declined during the past 30 years, a group of patients are
still served in these hospitals.

Characteristics of the in-patient context
• Restrictions
• Unpredictability
• Control - maintaining stabilization by means of rules and
routines
• Problem-oriented interventions
 Not compatible with the recovery orientation

The gap is …
System Level: The in-patient context

Control to ensure patient safety
Can a focused,
context specific
Program level: More illness and problem education program
focused improve the
recovery
competencies of in-
Individual level: In-patient providers have patient mental
fewer recovery-positive attitudes, are not health providers?
equipped with adequate competencies to provide
recovery-oriented services

The research process
Phase One: The Development of Recovery Competency Framework
• Purpose: Identifying the most salient components of recovery
competencies and the learning needs of the in-patient providers
Phase Two: The Development of Recovery Education

Program
• Purpose: Construct and validate a recovery education program
for in-patient mental health providers
Phase Three: Education Program Evaluation

• Purpose: Examine the effectiveness of the education
program

The Recovery Competency Framework
Chen, S-P, Krupa, T., Lysaght R, McCay, E., & Myra, P. (2013). The development of recovery
competencies for in-patient mental health providers working with people with serious mental illness.
Administration and Policy in Mental Health and Mental Health Services Research, 40, 96-116, DOI:
10.1007/s10488-011-0380-x.

The tension-practice-consequence model The recovery enabling framework Core Competencies
1. Competencies to reduce
Process 1: Reduce environmental level tensions
Reduce Reduce providers’
Engage with environmental personal level tensions 2. Competencies to reduce
patients level tensions tensions personal level tensions
Build
to reduce tensions relationship 3. Competencies to reduce
providers’ own tensions
Engage patients in setting 4. Competencies to set goals

Process 2: goals and planning and planning and provide
individually tailored services
Provide individually
Provide choices and
tailored services individualized services 5. Competencies to engage
patients in decision making and
satisfy their needs
hope 6. Competencies to foster

empower recovery: know best practices
advocacy
Process 3: -ment of recovery
Foster recovery network skills 7. Competencies to promote
readi-
ness and advocate recovery
8. Competencies to ensure
Process 4: Ensure continuity of continuity of recovery process
recovery process
Transition
Tension-based practice
• Using tensions in practice to promote the integration of
treatment and rehabilitation in a recovery-oriented system
(Krupa & Clark, 2009)
• Tension-based practice:
– Confront and identify tensions showed in day-to-day practice
– Evaluated to gain an understanding of the dynamics
– Propose potential solutions to reconcile the tensions and promote
true integration of recovery-oriented services

Example: Tension 1
• Lack of agreement between patients’ needs/choices and the
structure of the unit
– For example, it is difficult to address different patients’ needs in a
restricted environment
Ward rules and routines can be However, providers have to

perceived by patients as rigid with maintain the order of the in-
respect to what activities are patient setting and ensure
permitted, and restricted with regards patient safety.
to the time and space for these
activities.

Example: Tension 2
• Challenges in delivering services that are strength-based

in a context that is largely problem-based
Problem-based approach Strength-based approach

- Evaluation, identify problems, - Providers can enable
fix the problems … individuals to use their
- Nothing can be done until strengths to overcome their
symptoms and problems have symptoms
been alleviated.

Example: Tension 3
• Challenges/tensions related to sharing power with patients
Service users are vulnerable to Providers’ feeling…

power - Providers can feel uncomfortable when
- They are vulnerable to feel sharing power with in-patients, because they
attacked and hurt by providers worry that professional boundaries and
because of the power imbalance authority may be undermined.
that is expressed through provider - Providers may not have confidence in in-
language and behaviors
patients’ judgment

• Tensions embedded in delivering recovery-oriented services in
the in-patient context:
– Personal level: discomfort with power sharing; negative beliefs about
in-patients; conflicts about risk management
– Organizational level: heavy workload; lack of support; inflexible
structure of the in-patient setting; the medical model
• Tensions: learning opportunities
– Providers have to be enabled to
• identify the tensions and find solutions to reconcile the tensions
• find a balance between different practical paradigms

The Recovery Education program
1.A 172-page user’s manual
2.An interactive computerized program with quizzes at the end
of each session
Chapter 1: Introduction
Chapter 2: Preparation (Assessing the inpatient practice settings)
Chapter 3: The self-learning program
Chapter 4: The group learning program
Chapter 5: Summary
❖ This format is designed for flexible delivery to in-patient providers through self-
paced learning.

Example –
Group Learning Module 1: Encouraging participation
Mr. A, a 38-year-old man, was admitted two weeks ago to the in-patient ward having taken an
overdose of sleeping tablets, while experiencing recurrent psychotic symptoms. Mr. A spends most of
his time on the ward sleeping. Every morning when it’s time to get up for breakfast, self-care, and
making his bed, Mr. A does not want to do anything. He tells providers that he would like to stay in
bed all day; he does not need to take a shower and get dressed. The ward staff have given him
information about the activities available to him, but he states he is not interested. All he wants is to
be left alone and allowed to go home.
Staff dilemma: If Mr. A doesn’t want to do anything or if he wants

to stay in bed, that’s his choice. However, as a provider, engaging
him is my obligation since it can positively influence his health. I
am not strict but there are some things that he has to do such as
personal care. How can I engage Mr. A in activities to enable his
recovery?

Appreciative Inquiry Approach
1. Discovery: Providers are encouraged to
explore the positive possibilities of recovery-
oriented practice in their current setting.
2. Dreaming: The providers work together to
develop ideas of what the recovery-oriented
practice might be.
3. Designing: The providers work together to
craft detailed plans based on what they have
learned in the discovery and dream phases.
4. Delivery: The energy moves toward action
planning and focuses on the providers’
commitments for change. After the
transformation, the team members reflect on
what has been learned throughout the
process.
Cooperrider, Whitney, & Stavros, 2008

Pilot test of the Recovery Education Program
• A total of 26 participants from 3 Ontario inpatient sites.
✓ 50% of participants were nurses; the other 50% of participants included
administrators, OT, psychologists, social workers, and recreational therapists.
• Results:
✓ Participants who received the self-learning program improved in recovery
knowledge and sense of recovery knowledge application
✓ Participants experience satisfaction and gave positive feedback about the group
learning program
Chen, S-P, Krupa, T., Lysaght R, McCay, E., & Myra, P. (2014). Development of a
recovery education program for inpatient mental health providers. Psychiatric
Rehabilitation Journal, 37(4), 329-332. http://dx.doi.org/10.1037/prj0000082

Summary
• Occupational therapists can use this program as a
valuable resource to lead inter-professional
practice in promoting recovery in the inpatient
context.

Group Discussion
Central question:
“How should we strategically position occupational therapy to
advance the recovery vision in the coming years?”
In small groups:
• Identify your distinct priorities as to where efforts should be targeted
– For each of these priorities, identify possible action plans to move forward

Where to from here?
References (1/4)
Anthony, W. (1993). Recovery from mental illness: The guiding vision of the mental health services system in the 1990's. Psychosocial Rehabilitation Journal, 16(4), 11-23.
Asen, E. (1986). Psychiatry for beginners. London, UK: Unwin Paperbacks.
Baranek, P., Deber, R., & Williams, A. P. (2004). Almost home: Reforming home and community care in Ontario. Toronto, ON: University of Toronto Press.
Canada, Parliament, Senate. (2006). Standing Senate Committee on Social Affairs, Science and Technology. M.J.L. Kirby (Chair) & W.J. Keon (Deputy Chair). Out of the shadows
at last: Transforming mental health, mental illness and addiction services in Canada. 38th Parl., 1st sess., p. 42. Retrieved from
http://www.parl.gc.ca/Content/SEN/Committee/391/soci/rep/rep02may06-e.htm.
Chen, S-P, Krupa, T., Lysaght R, McCay, E., & Myra, P. (2013). The development of recovery competencies for in-patient mental health providers working with people with
serious mental illness. Administration and Policy in Mental Health and Mental Health Services Research, 40, 96-116, DOI: 10.1007/s10488-011-0380-x.
Chen, S-P, Krupa, T., Lysaght R, McCay, E., & Myra, P. (2014). Development of a recovery education program for inpatient mental health providers. Psychiatric Rehabilitation
Journal, 37(4), 329-332. http://dx.doi.org/10.1037/prj0000082
Chen, S-P. & Krupa, T. (in press). Recovery education program for inpatient mental health providers. Ottawa, Ontario: Canadian Association of Occupational Therapists.
Cooperrider, D. L., Whitney, D., & Stavros, J. M. (2008). Appreciative Inquiry Handbook: For leaders of change. San Francisco, CA: Crown Custom Publishing, Inc.
Davidson, Rakfeldt & Strauss (2010). The roots of the recovery movement. West Sussex, UK: Wiley-Blackwell.
Davidson, L., Tondora, J., Lawless, M. S., O'Connell, M. J., & Rowe, M. (2009). A practical guide to recovery-oriented practice: Tools for transforming practice. New York: Oxford
University Press, Inc.
Doroud, N., Fossey, E., & Fortune, T. (2015). Recovery as an occupational journey: A scoping review exploring the links between occupational engagement and recovery for
people with enduring mental health issues. Australian Occupational Therapy Journal, 62(6).

References (2/4)
Edgelow, M., & Krupa, T. (2011). Randomized controlled pilot study of an occupational time-use intervention for people with serious mental illness. American Journal of
Occupational Therapy, 65(3), 267-276.
Kidd, S. A., Herman, Y., Barbic, S., Ganguli, R., George, T. P., Hassan, S., ... & Velligan, D. (2014). Testing a modification of cognitive adaptation training: streamlining the model
for broader implementation. Schizophrenia research, 156(1), 46-50.
Kirby, M., Howlett, M., & Chodos, H. (2009). Towards recovery and well-being: A framework for a mental health strategy for Canada. (Draft. Ottawa, ON: Mental Health
Commission of Canada. Retrieved from http://www.mentalhealthcommission.ca
Kirby, M., & Keon, W. J. (2006). Out of the shadows at last: Transforming mental health, mental illness and addiction services in Canada. Ottawa: Standing Senate Committee
on Social Affairs, Science and Technology.
Kirsh, B., Krupa, T., Cockburn, L., & Gewurtz, R. (2010). A Canadian model of work integration for persons with mental illnesses. Disability and rehabilitation, 32(22), 1833-
1846.
Krupa, T., Kirsh, B., Gewurtz, R., & Cockburn, L. (2005). Improving the employment prospects of people with serious mental illness: Five challenges for a national mental health
strategy. Canadian Public Policy, XXXI (SUPPLEMENT), October 17, 2006-S59-63.
Krupa, T. (2012). The Recovery Model. In B. Schell, Gillen and M. Scaffa. (Eds). Willard and Spackman’s Occupational Therapy, 12 Ed. Philadelphia: Lippincott.
Krupa, T., & Chen, S. P. (2013). Psychiatric/Psychosocial Rehabilitation (PSR) in relation to vocational and educational environments: work and learning. Current Psychiatry
Reviews, 9(3), 195-206.
Krupa, T., & Clark, C. (2009). Using tensions in practice to promote the integration of treatment and rehabilitation in a recovery-oriented system. Canadian Journal of
Community Mental Health, 28, 47-59.
Krupa, T. (2008). Part of the solution...or part of the problem? Addressing the stigma of mental illness in our midst. Canadian Journal of Occupational Therapy, 75(4), 198-205.

References (3/4)
Krupa, T., Edgelow, M., Chen, S., Mieras, C., Almas, A., Perry, A., . . . Bransfield, M. (2010). Action over inertia: Addressing the activity-health needs of individuals with serious
mental illness. Ottawa: CAOT Publications ACE.
Krupa, T., Fossey, E., Anthony, W. A., Brown, C., & Pitts, D. B. (2009). Doing daily life: How occupational therapy can inform psychiatric rehabilitation practice. Psychiatric
Rehabilitation Journal, 32(3), 155-161. doi: 10.2975/32.3.2009.155.161
Lal, S. (2010). Prescribing recovery as the new mantra for mental health: Does one prescription serve all? The Canadian Journal of Occupational Therapy, 77(2), 82-89. doi:
10.1111/j.1365-2850.2007.01185.x
Lloyd, C., Waghorn, G., & Williams, P. L. (2008). Conceptualizing recovery in mental health rehabilitation. British Journal of Occupational Therapy, 71(8), 321-328.
Marshall, C. A., & Lysaght, R. (2016). The Experience of Occupational Transition From Homelessness to Becoming Housed. American Journal of Occupational Therapy,
70(4_Supplement_1), 7011505089p1-7011505089p1.
Mental Health Commission of Canada. (2009). Toward recovery & well-being: A framework for a mental health strategy for Canada. Retrieved
from http://www.mentalhealthcommission.ca.
Mental Health Commission of Canada. (2012). Changing directions, changing lives: The mental health strategy for Canada. Calgary, AB: Author. Retrieved from
http://strategy.mentalhealthcommission.ca/pdf/strategy-text-en.pdf
Mental Health Commission of Canada. (2015). Guidelines for Recovery-Oriented Practice. Calgary, AB: Author. Retrieved from
http://www.mentalhealthcommission.ca/sites/default/files/MHCC_RecoveryGuidelines_ENG_0.pdf
Merryman, M. B., & Riegel, S. K. (2007). The recovery process and people with serious mental illness living in the community: An occupational therapy perspective.
Occupational therapy in Mental Health, 23, 51-73
Nelson, G. (2006). Mental health policy in Canada (pp 245-266), In A. Westhues, Ed., Canadian Social Policy, 4th Edition. Waterloo, ON: Wilfred Laurier University Press.
Poole, J. (2011). Behind the rhetoric: Mental health recovery in Ontario. Halifax, NS: Fernwood Publishing. Chapter: Sifting through the Results: Behind the Rhetoric of Hope.

References (4/4)
Rebeiro Gruhl, K.L. (2011). An exploratory study of the influence of place on access to employment for persons with serious mental illness residing in northeastern Ontario.
Unpublished doctoral dissertation. School of Rural and Northern Health, Laurentian University, Sudbury, ON.
Rebeiro Gruhl, LaCarte & Calixte (2015). Authentic peer support work: challenges and opportunities for an evolving occupation, Journal of Mental Health, DOI:
10.3109/09638237.2015.1057322
Rebeiro Gruhl, K. L. (2005). The recovery paradigm: Should occupational therapists be interested? Canadian Journal of Occupational Therapy, 72(2), 96-102.
Roy, M. J., Lysaght, R., & Krupa, T. M. (2017). Action on the social determinants of health through social enterprise. Canadian Medical Association Journal, 189(11), E440-E441.
Simmons, H.G. (1990). Unbalanced: Mental health policy in Ontario, 1930-1989. Toronto, ON: Wall and Thompson.
Talbot, L., & Walker, R. (2007). Community perspectives on the impact of policy change on linking social capital in a rural community. Health & Place, 13, 482-492.
Trainor, J., Pomeroy, E., & Pape, B. (Eds.). (2004). Building a framework for support: A community development approach to mental health policy. (3rd ed.). Toronto, ON:
Canadian Mental Health Association.
Trainor, J., Shepherd, M., Boydell, K. M., Leff, A., & Crawford, E. (1997). Beyond the service paradigm: The impact and implications of consumer/survivor initiatives. Psychiatric
Rehabilitation Journal, 21(2), 132-140. http://dx.doi.org/10.1037/h0095328
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Laurier University Press.
Wrobleski, T., Walker, A., Jarus-Hakak, I., & Suto, M.J. (2015). Peer support as a catalyst for recovery: A mixed-methods study. Canadian Journal of Occupational Therapy, 82(1),
64-73. DOI: 10.1177/0008417414551784

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Recovery in Mental Health

© Canadian Association of Occupational Therapists / Association canadienne des ergothérapeutes, Ottawa

Round Table and Facilitated Discussions

© Canadian Association of Occupational Therapists / Association canadienne des ergothérapeutes, Ottawa

Additional Comments and Considerations Arising from Discussions

© Canadian Association of Occupational Therapists / Association canadienne des ergothérapeutes, Ottawa

© Canadian Association of Occupational Therapists / Association canadienne des ergothérapeutes, Ottawa

Recovery in Mental Health

CAOT Conference 2017  Friday, June 23, 2017

Canadian Association of Occupational Therapists Association canadienne des ergothérapeutes

• Identify multiple definitions of recovery discussed in our service systems

Canadian Association of Occupational Therapists Association canadienne des ergothérapeutes

“How should we strategically position

Canadian Association of Occupational Therapists Association canadienne des ergothérapeutes

Past, present, and future relevance for occupational therapy

Catherine White, PhD, OTReg (NB, NS)

Canadian Association of Occupational Therapists Association canadienne des ergothérapeutes

…a deeply personal, unique process of changing one’s attitudes, values,

Canadian Association of Occupational Therapists Association canadienne des ergothérapeutes

Recovery as a process? (journey)

Recovery domains? (e.g. clinical, personal, social, functional)

Recovery components? (e.g. hope, self-determination, inclusion)

Canadian Association of Occupational Therapists Association canadienne des ergothérapeutes

• “occupational therapists are uniquely positioned to assume a

Canadian Association of Occupational Therapists Association canadienne des ergothérapeutes

• Krupa, T., et al. (2010). Action over inertia: Addressing the

• Recovery identified as a guiding principle, “placed at the centre of

• 2007 marked an important milestone when the Mental Health

Canadian Association of Occupational Therapists Association canadienne des ergothérapeutes

Toward Recovery and Well-Being: A Framework for a Mental Health

Canadian Association of Occupational Therapists Association canadienne des ergothérapeutes

Canadian Association of Occupational Therapists Association canadienne des ergothérapeutes

Canadian Association of Occupational Therapists Association canadienne des ergothérapeutes

2. They understand that we all live our lives in complex societies

Canadian Association of Occupational Therapists Association canadienne des ergothérapeutes

Canadian Association of Occupational Therapists Association canadienne des ergothérapeutes

• Recovery as an occupational journey: A scoping review

Canadian Association of Occupational Therapists Association canadienne des ergothérapeutes

Karen Rebeiro Gruhl PhD., O.T. Reg (Ont)

Canadian Association of Occupational Therapists Association canadienne des ergothérapeutes

• To understand how social and economic policy further complicates the

• To identify policy gaps and opportunities for occupational therapy

Canadian Association of Occupational Therapists Association canadienne des ergothérapeutes

Canadian Association of Occupational Therapists Association canadienne des ergothérapeutes

(Trainor, Pape, & Pomeroy, 1997)

Canadian Association of Occupational Therapists Association canadienne des ergothérapeutes

Canadian Association of Occupational Therapists Association canadienne des ergothérapeutes

Canadian Association of Occupational Therapists Association canadienne des ergothérapeutes

Canadian Association of Occupational Therapists Association canadienne des ergothérapeutes

Canadian Association of Occupational Therapists Association canadienne des ergothérapeutes

Canadian Association of Occupational Therapists Association canadienne des ergothérapeutes

Canadian Association of Occupational Therapists Association canadienne des ergothérapeutes

Canadian Association of Occupational Therapists Association canadienne des ergothérapeutes

Canadian Association of Occupational Therapists Association canadienne des ergothérapeutes

An opportunity for occupational therapy in Canada

Terry Krupa PhD, Queen’s University

Canadian Association of Occupational Therapists Association canadienne des ergothérapeutes

• Developments in recovery knowledge

• Recovery–related tools and resources

• Efforts to improve recovery-related competencies across the broad

• Advancements in recovery-oriented practice delivery and evaluation

Canadian Association of Occupational Therapists Association canadienne des ergothérapeutes