3: Preparing for the journey: Understanding various types of recovery plans and orienting participants to the PCCP process

Module 3: Preparing for the journey: Understanding various types of recovery plans and orienting participants to the PCCP process

Goal

This module introduces the various types of support plans and their roles within mental health service delivery systems. It describes the difference between person-centered care plans developed within service systems and other types of self-directed recovery plans that individuals might develop outside the context of professional treatment. In addition, it stresses the importance of providing PCCP education and “preplanning” activities to the individual and his or her invitees so that all stakeholders will have the necessary confidence and skills to be an active participant in the PCCP process.

Learning Objectives

After completing this module, the learner will be able to:

describe the purpose and function of different types of plans for recovery, such as WRAP plans versus service or treatment plans;
provide, as necessary, basic orientation to the individual and his or her natural supporter invitees regarding the purpose and process of person-centered care planning (PCCP);
describe at least two legal protections that persons in recovery should be aware of as they pursue community-based PCCP goals;
describe the potential role and activities of Peers in supporting the PCCP process;
support individuals in carrying out necessary preplanning activities such as building a Recovery Team;

Learning Assessment

A learning assessment is included at the end of the module. If you are already familiar with the various types of recovery plans and how to prepare participants for their involvement in PCCP, you can go to the end of this module to take the assessment to test your understanding.

What Are the Different Types of Plans?

Different types of plans can be useful in supporting a person’s recovery. Some might be described as self-help plans that can be created alone or with the assistance of family, friends, and other natural supporters. These “recovery” plans are often created outside the context of formal professional services, and the individual may, or may not, choose to share the plan with his or her treatment providers. In contrast, other types of plans (such as the “person-centered care plans, PCCPs” which are the focus of this text) are created within the context of professional services through a formal collaboration with a person’s mental health care providers. The purpose and function of these different types of plans may vary, and an individual may elect to have one, the other, or both! Despite their unique characteristics, recovery and PCCPs share the same vision of helping an individual to move toward achieving his or her personally valued goals and aspirations.

WRAP and other recovery plans

A Wellness Recovery Action Plan™ (WRAP), developed by Mary Ellen Copeland, is one type of a self-directed recovery plan for identifying simple, safe, and effective wellness tools and strategies [1]. A WRAP can help a person to achieve whatever they want out of life, particularly if they want help managing their mental health issues and recovery. A WRAP can be created completely on one’s own, but it may also be developed with the support of a peer-run educational program (see the list for further details regarding the role of a “peer support specialist, PSS”) that aims to help people to S-H-A-P-E their lives through five principles of physical and emotional wellness:

Support
Hope
Advocacy
Personal Responsibility
Education

WRAP was developed through extensive data gathered from consumers of mental health services about the different approaches they had found to help them feel better and stay well. On the basis of that data, several people came together to create a simple system for recovery that has proven to be useful and effective for a wide range of people around the world [1]. For more information and resources regarding the WRAP, visit www.mentalhealthrecovery.com/.

In addition to WRAP, many systems of recovery planning have been created to help people create individualized wellness tools, which support them in accomplishing what they most want out of life. Some examples include:

Pathways to Recovery: A Strengths Recovery Self-Help Workbook [2]
This Is Your Life: Creating Your Self-Directed Life Plan [3]
My Plan for Living Successfully [4]
Personal Medicine [5]

WRAP and recovery plans are important self-help tools that people can create completely alone or with the help of family, friends, and other supportive individuals. What these plans have in common is that they prompt people to create their own personal vision of recovery and enable them to select the methods that they believe will work best for them as they pursue that vision. For many individuals, their recovery journey may include a path through the mental health treatment system. This brings with it the need for a different type of plan, that is, the required service or treatment plan.

Service or treatment plans

Service or treatment plans are documents that mental health professionals develop within the context of professional services in order to inform treatment and to meet system and regulatory obligations. These plans can help guide an individual’s recovery by identifying valued life goals and the services and supports needed to attain those goals. Not only do these plans have clinical utility, but also are often used to meet the system requirements and standards of care. Most medical insurances, for example, reimburse providers and organizations only when there is clear documentation that their services or prescribed treatments are “medically necessary” (see Module 6 for more details regarding this concept) to help an individual to overcome identified problems associated with a mental health or addictive disorder. Treatment plans are also used to support utilization management, to authorize services, and to allocate limited resources.

Like any other complex system, these “requirements” of mental health service funders may be unintentionally counterproductive to the very service system they were originally intended to support. The service or treatment plans are often viewed as paperwork exercises required merely to fulfill regulatory demands but are otherwise of limited value to the consumer or provider. Practitioners openly express the frustration that treatment plans, as currently crafted, are not a meaningful part of the therapeutic work and partnership. In fact, many report that treatment planning actually interferes with their work and partnership given the heavy burden of documentation requirements they operate under (i.e., We feel like we are treating the chart and not the person!) and given the restricted and often negative content that currently dominates most plans (i.e., People don’t get excited about plans that only talk about med compliance and symptom reduction).

In PCCP, however, an alternative vision is proposed where co-created treatment plans become a meaningful tool, for both the provider and the consumer, in shaping the person’s unique recovery journey. PCCPs are fully informed by any personal action or recovery plan (such as a WRAP if the individual has elected to share this with his or her team) given the recovery-based principle of respect for both professional and lived experience. While a self-directed WRAP may only include personal wellness strategies (e.g., meditating, engaging in preferred hobbies, exercising), the PCCP, as discussed within this text, must include professionally delivered clinical and rehabilitative interventions as the PCCP is the “master document” that is meant to reflect a person’s receipt of services within the mental health system. Table 3.1 outlines the key differences between a personal WRAP and a formal PCCP.

Table 3.1 WRAP Versus Person-Centered Care Plans

WRAP Plan	PCC Plan
A WRAP may be completed independent of the mental health system.	A PCC plan is completed within formal mental health services.
A WRAP dominant function is to support an individual’s daily wellness and recovery.	A PCC plan serves an individual’s recovery as well as multiple administrative and fiscal functions (e.g., the PCCP supports billing/payment for professional services rendered).
A WRAP belongs to the person in recovery. A person may, or may not, decide to share it with you as their clinician or provider. Information in a WRAP may be helpful in informing a treatment plan. People can be invited, but should not be required, to share their WRAP.	A PCC plan belongs to the team of people who have worked together to create it, that is, professionals, a service user, and his/her natural supporters. Professional members of the team automatically have access to the PCC plan as it is the formal document used to organize the delivery of mental health services and supports.
A WRAP identifies all the simple, safe, and effective things a person in recovery does to maintain their daily wellness. It also includes identifying things that may signal a crisis and how a person prefers such crisis situations to be handled, that is, who to involve, what services to offer, and so on.	A PCC plan identifies long-term goal(s) that might take months or even years to get to. It then identifies the short-term objective that will bring a person closer to his or her goal over the next 3 or 6 months. It may or may not include a crisis plan or any of daily wellness strategies that a person uses in his/her recovery.
A WRAP can be revised anytime, and the person in recovery decides when and how to use it.	A PCC plan can also be revised at any time. However, PCCPs are generally updated according to a standard schedule (e.g., every 3 months), which is determined by local and/or State regulations.
A WRAP focuses primarily on what the person in recovery will do to keep him- or herself well. While that may include the use of mental health services, the plan focuses on the individual’s personal steps toward wellness.	A PCC plan must include the range of clinical and rehabilitative interventions that are provided to the person in recovery. Quality PCCPs also document self-directed action steps and contributions from natural supporters.

What is the Role of the Person in Recovery in PCCP and What Type of Orientation/Preparation is Helpful?

When developing a PCCP, as when developing a travel itinerary, sufficient attention has to be paid in advance to the planning process so that all those involved will know what to expect and how best to contribute as a member of the team. This advance education and “planning for the plan” increases the probability of long-term success and helps us evaluate whether or not we are satisfied with both the PCCP process and its hoped-for results.

A Cautionary Note Regarding Cultural Preferences and Person-Centered Care Planning

We offer an important cautionary note regarding the need to be attentive to cultural factors that may enter into the dialogue when providing education and preplanning support to individuals involved in PCCP. For those people from cultures or backgrounds where there is a more collectivist orientation, such as in many Latin, Native American, and African cultures, there may be questions and concerns about the individualistic nature of the planning process. These issues should be addressed right away, with the clear message that PCCP is meant to respect personal and cultural preferences for decision making, including when the preference is to defer to family members, elders, professional health care providers, or others. To insist that the individual assume primary responsibility for the process when he or she is not comfortable with that role is to ignore the very preferences the PCCP process is meant to elicit. When a person desires a more collective process, it should be honored in the spirit of tailoring care to his or her own cultural background, values, and priorities. Insisting otherwise can cause a rupture in the relationship and precipitate disengagement in services. Therefore, attending to this issue early and directly is essential.

PCCP is most effective when the individual and his or her natural supporters (e.g., family members, friends, spiritual guides) both understand and actively participate in all steps of plan development and implementation. Some individuals may naturally take the reins and engage in this process. Others may find person-centered planning to be a new or even uncomfortable experience. It is important for providers not to misinterpret this fear or discomfort as apathy, passivity, or a lack of motivation to engage in person-centered planning. An apparent reluctance to participate may, in fact, be due to the learned helplessness that stems from years of having other people take control and assume decision-making authority over one’s life. Just as the process of sharing power and responsibility in treatment planning is a sometimes disconcerting shift in roles among mental health practitioners, many persons with psychiatric disabilities may truly want to exert greater control but feel unprepared to do so. Depending on the degree this contributes to the person’s discomfort with “taking the wheel” in the recovery planning process, he/she might benefit from some “driver’s education” regarding PCCP and how to be a partner within it. A toolkit for this purpose, “Getting into the Driver’s Seat: Preparing for Your Person Centered Plan” [6],¹ has been developed by the authors and used in multiple states to enhance the active involvement of persons in recovery in the PCP process.

This toolkit can be used to provide support and education so that persons in recovery are prepared to participate as much as possible as equal partners in the planning process. Many systems use sections of the toolkit during the intake procedures to orient individuals as to what to expect in treatment planning. In addition, it will be helpful to revisit the material closer to the time of an actual recovery planning meeting, as often people may be distressed or overwhelmed at their initial visit to a clinic or program. The toolkit can be reviewed individually or in the context of a facilitated PCCP preplanning group depending on the preferences of the person served. Finally, the toolkit contains multiple fillable worksheets, practice exercises, and educational handouts that all reinforce the importance of active participation in PCCP and build knowledge and competency in this area. Figure 3.1 provides a sample of one such handout designed as a simple take-home tool for persons in recovery.

c03f001 — **Figure 3.1** PCCP Orientation for People in Recovery

Supporting the person to understand his or her rights

Person-centered planning is based on the fundamental premise that self-direction is, first and foremost, a human rights issue. Community inclusion, the right to exercise choice in where to live, who to love, how to worship, and what job to pursue are not choices that should be offered to someone only after they have achieved recovery (as determined by professional standards). These rights and freedoms are not contingent upon whether an individual is complying with treatment, finishing the day program, or proving abstinence or med compliance. They are inalienable human rights and must be valued as such throughout all phases of service design and delivery—including during the process of PCCP.

People in recovery have long been speaking out against assumptions that “to be mentally ill means to have lost the capacity for sound reasoning” or the capacity to take responsibility for their treatment and other major life decisions.

—Deegan [7]

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