The Theory of Recovery Psychology/The Recovery Model/Chapter Four

Lawrence Kohlberg's Theory on the developmental phases of ethics and how this relates to the evolution of the mental health system

Lawrence Kohlberg developed the concept of the stages of moral development moral development where he describes a human beings mental capacities for moral reasoning and establishment of ethical values through stages of progressing growth. The view in the recovery movement is that society as well as the mental health system is not unlike a child maturing to an awakening of adult responsibility.

• Preconventional Morality
• Stage 1-Punishment and Obedience Orientation (Might makes right orientation)
• Stage 2-Instrumental purpose and exchange
• Conventional Morality
• Stage 3-Approval of Others
• Stage 4 Social System and Conscience
• Post-Conventional Morality
• Stage 5 Morality of Contract, individual rights and democratically accepted law
• Stage 6 Universal Principles

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Essay Question: Where would you place the practitioners of mental health throughout history if you were to apply them to Kohlberg's theory of Moral Development?: 1. 500 years ago 2. Moral therapy era 3. 200 years ago 4. Sixty years ago 5.at the dawn of the deinstutionalization movement 6. Now

The Recovery Movement and Transformation of the mental health system

The establishment of Fountain House in the 1940's seeded the development of the recovery concept and is considered by some to be the birthplace for the recovery movement. Many psychosocial rehabilitation centers, services and programs followed, many of which were founded by ex-patients. They were formed with the common purpose of improving the quality of life for individuals with mental illness. The consumer movement was fueled by righteous anger (that is, anger not associated with shame.) Beginning in the late 1950's with the invention of psychotropic medications, large numbers of persons were discharged from state psychiatric institutions. Many former patients were forced to fend for themselves on the street with virtually no support. This spurred the funding and development of community mental health centers (CMHC’s), and the development of services for this deinstitutionalized population.

The Olmstead Decision

For people with psychiatric disabilities, the U.S. Supreme Court's 1999 Olmstead v. L.C. decision is a monumental desegregation order. In the same way that the 1954 Brown v. Board of Education decision called on states to stop segregating schools by race, the Olmstead decision calls upon the states to stop unnecessarily segregating people with disabilities while providing services. The Olmstead case began when two women, Lois Curtis and Elaine Wilson, living in Georgia institutions sued the state, saying that their doctors had determined that community-based treatment would be more appropriate, but that, since no opportunities for community treatment existed, they were unjustly required to stay in the institution. They based their case on the Americans with Disabilities Act (ADA), which prohibits discrimination based on disability. When the case reached the U.S. Supreme Court, it ruled in favor of the two women. Noting that "unjustified isolation" in institutions is a form of discrimination prohibited by the ADA, the Court ruled that a state is required to provide community-based treatment to a person if: (1) it is appropriate; (2) the person does not oppose it; and (3) the state has the resources to provide it. The Court also noted that a state could defend a lawsuit by showing that it had a "comprehensive plan" for placing people in community-based treatment.Unfortunately, changes following on the case have not developed rapidly. Just as desegregation was slow in the wake of the Brown decision, many disability advocates believe that the community integration required by Olmstead is not advancing quickly enough. Many states have failed to develop plans that meet advocates' approval, with most plans lacking the specific timelines and budgets needed to ensure community placements. Even as it took a dedicated civil rights movement to end segregation, it is up to people with psychiatric disabilities and mental health advocates to stay involved in the Olmstead planning process to ensure that the needs of people with psychiatric disabilities are being met. In many cases, advocates play a role in educating the states about the types of community-based services and supports that meet people's needs. Because the Olmstead ruling contains some exceptions, some advocates are involved in demonstrating that those exceptions do not apply in most cases. They argue that community-based care is appropriate even for people who have been institutionalized on a long-term basis, that people will community-based care if they are allowed to see and test their options, and that states can fund community-based care by shifting funding away from institutions.

Americans with Disability Act

Fundamental to the definition of community integration is the expectation that people with psychiatric disabilities can have the same opportunity to live in the community as everyone else. To live in the community requires the ability to seek employment, housing, education and to pursue leisure and civic activities of one's own choice. The passage of a landmark federal law and the Supreme Court's interpretation of that law have established community integration as a legal right for people with psychiatric disabilities. Congress laid the foundation for a federal community integration mandate in 1990, when it passed the Americans with Disabilities Act (ADA). The ADA is part of a greater movement toward social change initiated by the Civil Rights Act and the Fair Housing Act of the 1960s. Although the earlier laws did not include people with disabilities, their approach to social justice set the groundwork for later laws that did, such as the Rehabilitation Act of 1973 and the ADA of 1990. The ADA was the result of grassroots organizing by people with many types of disabilities nationwide. Definition of Disability: According to the U.S Equal Employment Opportunity Commission and U.S. Department of Justice Civil Right Division's Americans with Disabilities Act: Questions and Answers: An individual is considered to have a disability if s/he has a physical or mental impairment that substantially limits one or more major life activities, has a record of such an impairment, or is regarded as having such an impairment. Various 'titles,' or parts, of the ADA outlaw discrimination against people with disabilities in several major areas, including:

Employment: An employer is not allowed to discriminate in hiring, firing, promotion, or other aspects of the job, and must make 'reasonable accommodations' that allow a person with a disability to perform a job. Reasonable accommodations are modifications or adjustments to a workplace environment that will give a qualified applicant who has a disability the ability to apply and will enable an employee with a disability to perform essential job functions. It is necessary for employers to accommodate only known disabilities of a qualified applicant or employee. Accommodations should also be individualized, because disabilities and job requirements vary. Employers are not required to make accommodations that would pose "undue hardships" to their business i.e. an "action requiring significant difficulty or expense."

Smaller employers can receive a special tax credit for complying with accommodations of the ADA. The employment provision applies to private employers, State and local governments, employment agencies, and labor unions. Employers with 25 or more employees were covered as of July 26, 1992. Employers with 15 or more employees were covered two years later, beginning July 26, 1994. (Title I.) The ADA bars discrimination in all employment practices including: job application procedures, hiring and firing, advancement, compensation, training, recruitment, advertising, tenure, layoff, leave, fringe benefits, and all other employment-related activities

Government services: Local and state governments must make their services accessible to people with disabilities and must not discriminate in providing services. . Every public entity program is covered by the ADA, including the activities of State legislatures and courts, town meetings, police and fire departments, motor vehicle licensing, and employment. (Titles II.)

Businesses: Private businesses and non-profits that serve the public, called ?places of public accommodation? by the ADA, and ?commercial facilities? (other businesses), are required to make their facilities accessible to people with disabilities and must not discriminate based on disability. Some examples of places of public accommodation include: restaurants, hotels, theaters, doctors' offices, pharmacies, retail stores, museums, libraries, parks, private schools, and day care centers. (Title III.) How are these provisions enforced?

Employment complaints about actions that occurred after July 26, 1992 can be filed with the Equal Employment Opportunity Commission or certain State human rights agencies. Possible remedies include: hiring, reinstatement, promotion, back pay, front pay, restored benefits, reasonable accommodation, attorneys' fees, expert witness fees, and court costs.

The provisions of the ADA's State and local governments are enforced through private lawsuits. Complaints can also be filed with eight designated Federal agencies, including the Department of Justice. Public accommodations provisions can be enforced through private lawsuits in which a court order can be obtained to stop the discrimination that is occurring. Complaints can also be filed with the Attorney General. Other titles cover topics including telecommunications and miscellaneous matters, but the titles relating to employment and government services are particularly significant to community integration. Individuals who experience discrimination and prejudice in the workplace and in the provision of support services find themselves with diminished choices in their ability to care for themselves and to participate in the everyday activities of life choices -- where to live and where to work. Despite certain limits, the ADA requires major changes from businesses and governments, and Congress was aware that businesses and governments would need guidance in making those changes. To help provide that guidance, Congress specified in the ADA that certain federal agencies, like the Equal Employment Opportunity Commission (EEOC) and the Department of Justice (DOJ), would put together some more specific regulations on how to comply with the ADA. The Equal Employment Opportunity Commission enforces Title I's prohibition against discrimination and has issued many regulations based on Title I. However, defining a reasonable accommodation in response to psychiatric symptoms can often be more challenging than designing accommodations of physical or sensory disabilities. ADA regulations disallow employers from asking disability-related questions during the application process, unless the applicant asks for reasonable accommodation during the process of hiring. Under most cases, employers must keep all information about their employees' medical conditions confidential (supervisors and managers can be told about needed accommodations; first aid and safety personnel can be informed if the person with a disability may require emergency treatment; and government officials assessing ADA compliance should be given information on request).

Some reasonable accommodations for people with psychiatric abilities include: time off from work, a modified work schedule (some medications cause morning grogginess and a modified work schedule can combat this problem), physical changes in the workplace, such as dividers or partitions (to help people with disability-related concentration problems, making exceptions in work policy, the adjusting of supervisory methods, providing a job coach, and others. The federally funded Job Accommodation Network (JAN) offers free consultation services to employers and employees. One set of regulations issued by the Department of Justice in response to Title II of the ADA has proven to be particularly significant for people with psychiatric disabilities and formed the basis of a landmark Supreme Court ruling. DOJ's 'integration regulation' states: A public entity shall administer services, programs, and activities in the most integrated setting appropriate to the needs of qualified individuals with disabilities, [meaning] a setting that enables individuals with disabilities to interact with non-disabled persons to the fullest extent possible. (28 C.F.R., part 35, section 130 and Appendix A.) This regulation, which offers many people with psychiatric disabilities a chance to live in the community rather than in institutions, won the approval of the U.S. Supreme Court in the Olmstead v. L.C. decision.

Respect for Diversity

To better serve the clients of mental health services, practitioners need to develop better cultural competency. Staff are expected to develop a competency in their awareness of their own assumptions, values, and beliefs about others who may be different from themselves. The staff must be willing to modify and correct any biases or stereotypes that they have to better understand those they serve. The practitioner must have a knowledge regarding traditional theories and principles concerning human behavior, development, psychopathology, therapy and rehabilitation and the relevence to the needs of various ethnic-cultural group members. A working knowledge of institutional, class, cultural and language barriers which prevent members of various cultures from getting the appropriate services. The skills necessary to work in a multicultural population include the ability to identify behavior in the terms of culture and to identify the needs of the individual and the neccesary process of seeking out the compatible resources for that individuals culture.

Developmental Stages of Cultural Competency

Cultural Destructiveness:

Cultural Incapacity:

Cultural Blindness:

Culturally open:

Culturally competent:

Culturally procient: