Best Practices: Recovery Centers for People With a Mental Illness: an Emerging Best Practice?

In 2003, the New Freedom Commission called for mental health services to become more recovery oriented (1). In response, new interventions to enhance recovery have been created. One innovative intervention has been the development of recovery centers that offer a variety of services and resources that aim to foster various aspects of recovery among people with severe mental illness (2). Some recovery centers are consumer operated and peer run, whereas others are more reliant on professional staff (3).

Recovery centers aim to differentiate themselves from day treatment centers, clubhouses, and other sheltered environments, which often focus on providing a place of refuge and slow adjustment to living with a psychiatric disability (4). These older models, especially day treatment centers, place less emphasis on rapid transition from a service-dependent lifestyle to a full life in the community (5). In contrast, recovery centers represent a newer model that focuses on a renewed notion of recovery by providing recovery-oriented interventions affecting various life domains, including education, employment, wellness management, and housing (6).

Research on recovery centers and other newer models of recovery-oriented interventions is scant. A recent survey found a variety of promising approaches, largely unstudied, that could be classified under the rubric of recovery center (2). One quasi-experimental study that evaluated the impact of a recovery center on consumers found that it developed “readiness for rehabilitation and recovery” by significantly improving empowerment and “recovery attitudes” (7). The center used an educational model that is described in detail elsewhere (6).

This column reports a qualitative evaluation of a nascent recovery center in New York City. The results of the evaluation are consistent with other research that suggests that recovery centers may be an emerging best practice (2,3,6,7). We also explicitly detail the methods used to perform the evaluation because they are consistent with best practice in qualitative research.

Pathways Resource Center

Pathways to Housing, Inc., created a small-scale recovery center named Pathways Resource Center in May 2008 with the aim of providing a variety of recovery-oriented services to its clientele. Pathways implements the Housing First model of supportive housing, which provides permanent independent housing and consumer-driven support services to persons experiencing severe mental illnesses and substance use disorders. One of the defining aspirations of Pathways' programs is that if given the right supports, consumers can maintain independent and meaningful lifestyles with minimal dependence on services (8). The center, created to reflect that philosophy, is dedicated to a notion of recovery that emphasizes the consumer's capacity to move on from a service-dependent lifestyle (1).

The target population for the center is people who are living in supported housing in the New York City area that is provided by a separate arm of Pathways to Housing. All of the residents have a diagnosis of severe mental illness, and many have co-occurring disorders, such as substance abuse, HIV infection, or diabetes.

Very soon after the center's opening, a number of classes started, each running to a strict timetable. A stable pool of clients, approximately 30 per week, began to attend the classes. Between May 2008 and October 2009, the number of classes grew and diversified, and the number of new attendees steadily rose. By October 2009, approximately 50 people per week were using the center.

Most of the classes are led by paid staff or volunteers from the community. A small number are led by consumers. Because living in poverty makes it difficult for members to come to the center, Pathways to Housing provides free travel cards or lunches to those who attend class. These benefits enable the most vulnerable to participate without economic impediment and are highly valued by the clientele. They should be considered part of the best practice for recovery centers.

Classes can be described as addressing matters related to functional recovery or clinical recovery. Functional recovery refers to activities that equip participants with everyday skills and knowledge that can enhance normal functioning in society. The center offers weekly classes in functional activities, including computer education (five hours), GED completion (90 minutes), literacy (90 minutes), employment search assistance (three hours), photography (three hours), art (three hours), communications (two hours), and cooking and nutrition (one hour).

Practical, skills-based functional classes dominate the weekly schedule, although they are augmented by a small number of groups that meet to specifically target clinical recovery. Clinical recovery refers to activities that address the common symptoms of severe mental illnesses and co-occurring substance use disorders. These weekly activities include harm reduction classes (two hours), an anger management group (one hour), a stress release group (one hour), and a recovery group (one hour).

Best practices: qualitative research

The qualitative evaluation was governed by three objectives, namely to track the developmental trajectory of this innovative recovery center, elicit the views of the clientele about the impact of the center, and assess challenges associated with implementation. We strove to use best practices in qualitative research when assessing development and impact of the center. Qualitative research is generally considered more rigorous if the investigation employs more than one method. This technique, known as triangulation, allows researchers to gain varying perspectives on an issue (9). For this reason, we used both participant observation and focus groups as methods of investigation.

The authors conducted five focus groups at regular intervals between July 2008, just after the center opened, to October 2009. All users of the center were invited to attend these focus groups through open advertisement and word of mouth. All focus groups were recorded and transcribed for later analysis. Focus groups were interspersed with regular (generally twice a month) observation of clients by one of the authors from September 2008 to July 2009.

Observation involved going to the center to view activities, participate in classes, or attend social events. In addition, we selected consumers to take for lunch or accompany on walks around the neighborhood to further elicit their perspectives on the center. We enumerated the number of attendees at the classes observed and also consulted sign-in sheets that were used to measure attendance at every class. Unfortunately, because the sign-in sheets were inconsistently administered by class facilitators, they provided only a rough indicator of attendance.

The analysis of results was also consistent with best practice in qualitative research (10). All focus group transcripts and field notes were imported into atlas-ti computer software. We engaged in conventional methods of thematic analysis to answer the research questions. Themes were identified independently and emerging themes were later discussed and a consensus was reached. This form of multiple coding in qualitative research, known to be a strong check and balance of observer bias, is recommended as a way to improve validity. Once the analysis had been completed, the first author returned to the recovery center, in May 2010, to discuss emerging themes with focus group participants, who agreed with our primary conclusions. Again, the process of checking conclusions with study participants adds rigor to qualitative research.

Perceived benefits of the center

Participants at the center spoke very favorably about its impact on their day-to-day lives. They noted that the center was equipping them with skills and abilities that they could use as a springboard to obtain gainful employment, attend accredited educational courses, and access other opportunities in the outside world. One participant called the recovery center “a stepping stone for each and every one of us.” Another noted, “I think in just being here, in every aspect, it's upgrading—you know—your own skills. Because, we are interacting with each other just like in an office.” Another said, “It's a place where you can come and expand your educational abilities.”

When talking about the computer class, one participant stated that, “it is a trade that you learn that will give you a benefit in the future, “cause computer pays well … like, make more money as a computer operator.” These quotes were emblematic of the view reported by many participants that providing education was the most appreciated of the center's functions.

Many classes involved considerable teamwork and peer support, which fostered a strong sense of camaraderie. For example, the nutrition class involved shopping and cooking together, and the art and the photography classes involved working together, sometimes in pairs and as a team. A focus on working as a team and the sense of community it fostered were also perceived as benefits of the center. As one participant said, referring to other participants, “I call them my family. You know … these are my family. When I know that when I'm done, I could come to somebody here. They notice that I don't have a family. I could speak to somebody and I know that they are going to give me the right advice, you know. It made me think about not getting into trouble and for me to do the right thing.” Notably, this consumer regarded this sense of family not only as a benefit in itself but also as a moral corrective by providing a renewed sense of accountability.

The center's challenges

At the conclusion of the research in October 2009, the center had settled into a schedule of staying open from 10 a.m. to 4 p.m. on Monday to Friday. The center had also established strictly enforced rules and regulations as a result of discord during the early months of the center's life. For example, a frequent complaint was that people arrived late for groups, allegedly to benefit from the free travel cards or lunches that were associated with attendance without having to fully participate. Likewise some consumers complained about others who came to the center but did not participate or contribute to the life of the center.

These complaints led to intense debate at the center about acceptable behavior that prompted the consumers themselves to create a set of rules and regulations. These emerging rules stipulated that people could not be at the center if they were not attending a class; that those who arrived more than ten minutes late for a class were denied entry; that the center close for lunch, and that people could be suspended from the center for up to two months. In fact at least one individual was suspended during the research.

A final challenge was the question of whether people should be expected to move on. In line with Pathways philosophy (8), consumers agreed that the center should not become just another day treatment center where people would stagnate indefinitely, becoming so comfortable that they were reluctant to leave. The rules and regulations of Pathways Resource Center reflected that desire. Nevertheless, although many consumers saw the recovery center as a stepping stone, others became comfortable with the sense of camaraderie associated with the center and seemed quite reluctant to move on. For example, one consumer noted, “We embrace each other, support each other, counsel and support each other. … We depend on each other.” This dependency, in some cases declared openly, acted as an impediment to moving on for some consumers.

Discussion and conclusions

The recovery center described by this study took the form of a small educational institution that was designed specifically for people with a severe mental illness. It was similar to a popular and effective recovery center in Boston described by one of the few previous studies of recovery centers (6,7). The distribution of activities suggested that the center's philosophy was strongly oriented toward encouraging clients to meet the benchmark for entering appropriate educational facilities such as community college, to become competitive in the open job market with an eye to finding gainful employment, and to enhance skills such as cooking or anger management that may allow better daily functioning.

A focus on education, employment, and functional improvement overlaps with many of the activities provided by progressive day treatment centers and clubhouses. However, the high proportion of time devoted to such activities and the strict school-like atmosphere make Pathways Resource Center somewhat distinct from these older models. This suggests that the center aligns well with newer incarnations of recovery centers that emphasize the importance of education and functional recovery over and above clinical recovery (2,3,6,7)

In line with other recent research, this study affirmed the feasibility and popularity of recovery centers that focus on educational and functional improvement (2,6,7). However, it provided no information about the center's efficacy and effectiveness. Future research should rigorously evaluate outcomes as well as process to assess overall influence of such centers. Process evaluations can follow the procedures we have outlined, which were consistent with best practice in qualitative research. Outcome evaluations will require quasi-experimental or randomized designs.