CALIFORNIA STATE UNIVERSITY, NORTHRIDGE
A Public Service Announcement About the Recovery Model
A graduate project submitted in partial fulfillment of the requirements
For the Degree of Master of Science in Counseling, Marriage and Family Therapy
by
Melissa Lyn Zaday
May 2015
The graduate project of Melissa L. Zaday is approved:
______________________________
Professor Eric Lyden
________________
Date
______________________________
Dr. Susan Swim
_________________
Date
______________________________
Professor Shari Tarver-Behring
_________________
Date
______________________________
Professor Luis Rubalcava, Chair
__________________
Date
California State University, Northridge
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Acknowledgements
I would like to acknowledge the following individuals for all of their help and support
with this project; My professors and mentors - Professor Luis Rubalcava, Professor Eric
Lyden, Dr. Susan Swim, Dr. Merril Simon, Diana Pantaleo, Cecile Schwedes, and Jon
Amador. I would also like to acknowledge the support of my family, especially my
grandmother Louise Regan and my partner William Grant Stromberg.
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Dedication
This project is dedicated to my grandmother Louise Regan and to my daughter Betty
Louise. Thank you grams for always inspiring me, encouraging me, loving me and
believing in me.
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Table of Contents
Signature Page…………………………………………………………………………….ii
Acknowledgements ............................................................................................................ iii
Dedication .......................................................................................................................... iv
List of Figures ................................................................................................................... vii
Abstract ............................................................................................................................ viii
Chapter 1: A Public Service Announcement About the Recovery Model ...........................1
Introduction and Statement of Need ....................................................................................1
What is Mental Health Care? .........................................................................................1
Why is Mental Health Care Important? .........................................................................3
Barriers to Mental Health Care ......................................................................................4
Purpose.................................................................................................................................5
Significance..........................................................................................................................6
Bridge ................................................................................................................................11
Chapter 2: Literature Review .............................................................................................15
Introduction ........................................................................................................................15
Common Factors Research ..........................................................................................15
Client factors. ........................................................................................................ 16
Therapeutic alliance. ............................................................................................. 17
Placebo factors: hope, expectancy, and allegiance. .............................................. 18
Models and techniques. ......................................................................................... 18
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Why the Medical Model in the First Place?.................................................................20
Problems with a Medical Model Philosophy ...............................................................21
Roots of Recovery........................................................................................................25
Why the Recovery Model Works ................................................................................29
As Professionals ...........................................................................................................34
Support for PSAs .........................................................................................................35
Indications ..........................................................................................................................39
Education About Recovery Model...............................................................................42
Public Service Announcements ...................................................................................43
Chapter 3: Project Audience and Implementation Factors ................................................46
Introduction ........................................................................................................................46
Development of the Project .........................................................................................46
Intended Audience .......................................................................................................49
Personal Qualifications ................................................................................................49
Environment and Equipment .......................................................................................50
Project Outline .............................................................................................................50
Chapter 4: Project ..............................................................................................................51
Chapter 5: Conclusion........................................................................................................52
Summary ............................................................................................................................52
Evaluation ..........................................................................................................................53
Future Work/Research .................................................................................................57
References .........................................................................................................................59
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List of Figures
Figure 1.Radio Script Format ............................................................................................41
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Abstract
A Public Service Announcement About the Recovery Model
By
Melissa L. Zaday
Master of Science in Counseling, Marriage and Family Therapy
With the passing of the Patient Protection and Affordable care act affording more
Americans access to mental health care services, it is necessary to inform the general
public about the new direction in mental health services, the recovery model.
Unfortunately resources letting the general public know about the recovery model are
scarce. Public service announcements are an easy, cost effective way to disseminate
knowledge to a large group of people, therefore it made sense to craft a PSA with the
purpose of bringing awareness of the recovery model to the general population. The
literature review examines the reasoning behind the switch from the medical model to the
recovery model, common factors research and details the structure and efficacy of public
service announcements. Evaluation of the project and future directions are also discussed.
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Chapter 1: A Public Service Announcement About the Recovery Model
Introduction and Statement of Need
With the implementation of the Patient Protection and Affordable care act
affording more Americans access to mental health care services, this project is necessary
to inform the general public about the new direction in mental health services, the
recovery model. The U.S. Government’s embracement of the recovery model is helping
to remove the stigma from mental illness, which is also increasing the amount of people
accessing mental health services. Studies are showing how important mental wellbeing is
to overall health so an increase in people accessing mental health services is a step in the
right direction for a healthy America. This project will help to further reduce stigma,
educate the public about their options when it comes to their mental health needs and
services and encourage people to access mental health care services.
What is Mental Health Care?
Mental health is more than just the absence of a mental disorder. Mental health
includes our psychological, emotional and social well-being; it effects our thoughts, our
feelings and our actions and helps to determine how we make choices, relate to others
and handle stress (Sturgeon, 2006). Other definitions of mental health focus on the
concept of resilience, or the ability to deal with adversity (Nygren, Aléx, Jonsén,
Gustafson, Norberg, & Lundman, 2005). Culturally these definitions of mental health
will differ, but basically have the same underlying principles (Gehart, 2012b). Mental
health is influenced by biological factors such as genes, physical illnesses, injury, and
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brain chemistry. Mental health can also be influenced by life experiences such as trauma
or abuse. Common mental health struggles include depression, anxiety, stress, addiction,
relationship problems, grief, learning disabilities, and mood or personality disorders.
Treatment for mental health issues varies depending upon the individual. Popular
treatments include medication or therapy, and in most cases a combination of both.
Taking care of mental health concerns is important at every age, and for every person
regardless of race, religion, or income. The World Health Organization (WHO) defines
mental health as "a state of well-being in which an individual realizes his or her own
abilities, can cope with the normal stressors of life, can work productively and is able to
make a contribution to his or her community" (WHO, 2014, p.1)
Mental health issues are common; according to the National Alliance on Mental
Illness (NAMI) (2013), one in four adults experiences a mental health issue every year,
and one in 17 live with a serious mental health challenge such as bipolar disorder,
schizophrenia, or major depression. The Substance Abuse and Mental Health Services
Administration's (SAMHSA) (2001) basic “Facts About Mental Health Sheet” states that
mental 'illnesses' are more common than cancer, diabetes, or heart disease. Both men and
women and people of all ages, ethnicities, religions and socioeconomic statuses can
suffer from mental health issues. The WHO (2014) states that depression is the leading
cause of disability worldwide and will be the largest burden on health care by 2020.
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Why is Mental Health Care Important?
Mental health care plays an important role in overall health. The WHO (2014)
states that "there is no health without mental health". The US government recognizes the
seriousness of need for mental health services. In 2008 the United States government
passed the Paul Wellstone and Pete Domenici Mental Health Parity and Addiction Equity
Act of 2008, more commonly known as the federal parity law, which requires health
plans and insurers that offer mental health and substance use benefits to provide coverage
that is equitable to coverage for general medical care. Parity laws do not require
insurance plans to offer coverage for mental health or substance use disorders. However,
the passing of the Patient Protection and Affordable Care Act (2010) means that
beginning in 2014, all new small group and individual market plans are required to cover
mental health and substance use disorder services and to cover them at parity (Beronio,
Glied, Po, & Skopec, 2014). Expectations that mental health care would improve have
risen since The Affordable Care Act prohibits health insurance companies from denying
coverage to people with pre-existing conditions; this benefits people who suffer with
mental health issues who were denied coverage in the past because of their diagnoses.
Through the affordable care act, it is estimated that 32.1 million people with mental
health issues will have access to treatment through Medicaid expansion, subsidized
private insurance and mandatory health insurance through employers ("Effects of the",
2013). In further attempts to make mental health care accessible, in January of 2014, the
US Department of Health and Human Services made $50 million available from the
Affordable Care Act funding to help community health centers across the country
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establish or expand mental and behavioral health services (Feldman, 2014). These funds
are provided so health centers can hire new mental health professionals and expand
services.
Barriers to Mental Health Care
Aside from lack of insurance, the main reason many people do not seek mental health
services because of the stigma surrounding mental health. Stigma is the shame and
disgrace attached to something that is deemed socially unacceptable. Over 100 scholarly
peer-reviewed articles have been published that support some aspect of mental health
stigma serving as a barrier to accessing mental health services (Clement, Schauman,
Graham, Maggioni, Evans-Lacko, Bezborodovs, ... & Thornicroft, 2015). A study by
Wahl (2012) found that mental health stigma contributes to social isolation; once mental
health issues were made public, friends phoned less, invitations to social events decreased
and problems navigating both platonic and sexual relationships increased. Wahl also
found that people with mental health issues experience what he called indirect stigma.
Indirect stigma consists of statements and depictions that convey negative attitudes
towards individuals dealing with mental health issues. Examples of indirect stigma
include characters on television and in films who are portrayed as villainous, ridiculous
or odd and are addressed as ‘psychos’, ‘crazies’, and ‘nuts’. These direct and indirect
prejudices against people dealing with mental health issues often prevent people from
seeking treatment; people naturally attempt to distance themselves from taking on
stigmatizing labels that will exclude them socially. At the opposite end, stigma also leads
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people to believe that what they are going through is not that bad and that only people
who are seriously ‘mentally ill’ seek mental health support services. Stigma directly
affects individuals struggling with mental health issues as well as their support system.
The antidote to stigma is knowledge; the effects of stigma are combated by mental health
literacy and actively engaging in treatment. Mental health literacy is a big component in
mitigating stigmas adverse impact on seeking services. Mental health providers must
promote mental health literacy, help clients enhance their support systems, and encourage
cultural competence among their peers in order to help diminish mental health stigma
(Corrigan, Druss, & Perlick, 2014). This project creating a public service announcement
about the recovery model supports such efforts in educating people, reducing stigma and
promoting mental health care.
Purpose
The purpose of this project is to create a radio broadcast public service
announcement informing the general public about the new direction in mental health
care, the recovery model. The project also addresses the de-stigmatization of mental
health care and the efficacy of the recovery model while persuading individuals to seek
help if they are dealing with a mental health issue.
Knowledge is power; consumers deserve understanding of how mental health services
work. People are more likely to utilize something if they understand how it works
(Hassenzahl, 2005). Recovery is a process that is highly personal and highly
individualized; mental health care providers need to support this process and help educate
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consumers on their different options. Since recovery is so personalized, consumers of
mental health services need to educate themselves about the recovery process so that they
can be more proactive on their journey to recovery.
A study by Silver, Bricker, Schuster, Pancoe, & Pesta (2011) examined the outcomes
of providing recovery training to both individuals experiencing severe mental health
issues and their community members. They found that the individuals suffering with
mental health issues had fewer days and instances of hospitalization nine months after
finishing the training than those who did not receive the recovery training. Additionally,
participants in the recovery training reported feeling more empowered. The community
members who received the recovery training reported that their attitudes and beliefs about
individuals suffering from severe mental health issues had changed for the positive after
interacting with them. This shows how education can lead to de-stigmatization of mental
health issues and how once de-stigmatized, more individuals will be willing to seek help
for their issues.
Significance
This project will contribute a basic understanding about the current direction and
future direction of the mental health service industry and the improvement in these
methods to people seeking mental health services. As a project on file with the university
it will be accessible to all students (as a script and an MP3) and ideally I would like to
broadcast on KCSN as a way to reach the general public. Eventually I hope it will serve
as a tool which could be used on a broader or more national scope.
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Public education about the recovery model in plain terms is practically non-existent.
NAMI (2015) has a small section that discusses mental health recovery on their website.
In 2004 SAMHSA published the national consensus statement on mental health recovery,
a two-page flyer discussing the 10 main components of recovery and how embracing the
recovery model will make for a stronger and healthier America. Additionally, SAMHSA
published the working definition of recovery, a short pamphlet explaining the recovery
model to mental health consumers in 2012. Both resources are available via their website,
but a consumer has to know what they are looking for in order to find it and also needs
the capability to download and view .PDF files. SAMHSA also has their BRSS TACS
(2011) training webinars available to the public but as discussed later, these are geared
more towards clinicians.
Regionally, there are different trainings for mental health care practitioners to
participate in to learn about the recovery model and how to implement recovery oriented
care, but not many for consumers to participate in. In Long Beach, California, Mental
Health America Los Angeles, a recovery oriented community mental health center, runs
week-long immersion training workshops to educate both consumers and practitioners
about the recovery model on an on-going basis (Mental Health America Los Angeles
(MHALA), 2015). They have expanded this immersion training and the same training is
now being offered through Momentum for Mental Health, based in San Jose, CA
(Connors, 2009). This set of trainings are the only trainings available to consumers as
well as clinicians that came up during the research process.
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Even though some education exists, individuals must be connected to the mental
health care system in some way already to access it. If broadcast on the radio, this project
will reach a multitude of people including individuals who may have been hesitant to
seek mental health care because of the stigma surrounding receiving mental health care.
Additionally, to the date of this project, there was no existence of an advertising budget
regarding U.S. mental health found during this research process. Therefore, presenting
this information via public service announcement makes sense because it is low cost to
make, free to air and can reach a wide audience repeatedly
Terminology
Mental health care: Mental health includes our emotional, psychological,
and social well-being and mental health care are any service accessed in order to
address needs in these areas of an individual’s life. Mental health care workers
include therapists, counselors, social workers, psychologists, psychiatrists and
psychiatric nurses. Additionally peer mentors, recovery coaches, and
other various staff members within community mental health centers are
considered mental health workers. Even general practitioners and nurse
practitioners have been receiving more mental health training. General
practitioners are also participants in the mental health care system; they often
provide referrals to psychiatrists and behavioral health specialists. Mental health
services are accessed through private individual services or community mental
health clinics. Services are provided in individual (one-on-one) or group formats
and can include psycho-educational workshops and life skills training. With the
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recovery model, this now also includes peer specialists - "individuals who selfidentify as persons in recovery from mental health issues and are trained to work
with fellow consumers by providing education, advocacy and support" (Frost,
Heinz, & Bach, 2011; p.1) .
Medical model: The medical model of mental health care theorizes that
mental health issues are 'illnesses' that have determinable causes and should be
treated with specific treatments. This model focuses on physical and
cognitive symptoms that may be causing issues in an individual’s life and
attempts to treat the biological and behavioral causes. It is an analogue to the
medical model of medicine, as opposed to a literal adaption; in medicine it is
possible to have a treatment that is purely biochemical (for instance insulin for
diabetes), whereas with the mental health medical model and therapy it is not
possible, even with the discovery of psychotropic medication. The general
structure of the medical model is linear; and follows the path of complaint,
gathering of history, examination/observation, testing, diagnosis, treatment, and
prognosis with and without treatment (Wampold, 2001). Because of its linear,
cause and effect nature, the medical model focuses on evidence-based
practices. Shah and Mountain (2007) defined the medical model as “a process
whereby doctors advise on, coordinate or deliver health-improving interventions
informed by the best available evidence”.
Recovery model: Although coined recovery model, it's less of a model of
treatment and more of a philosophy (Reisner, 2005); it is non-linear and should be
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seen as a process and not an end result. One's attitudes, values, feelings, goals,
skills and/or roles often change during the process of recovery (Anthony, 1993).
Clinical psychologist and advocate Patricia Deegan (1988) wrote an
autobiographical account of her experiences with illness and recovery. Deegan
argued that recovery is different from psychiatric rehabilitation because
rehabilitation is about technologies and services while recovery is the experiences
of people as they overcome the challenges of ‘mental illness’. Unlike the medical
model, the recovery model focuses on psychosocial functioning, individualized
coping skills and deemphasizes diagnostic labeling and medical symptoms. The
National Consensus Statement on Mental Health Recovery published
by SAMHSA (2004) has defined mental health recovery as “a journey of healing
and transformation enabling a person with a mental health problem to live a
meaningful life in a community of his or her choice while striving to achieve his
or her full potential” (p.2). SAMHSA's working definition of recovery pamphlet
identifies the 4 main dimensions that are at the foundation of recovery; health,
home, purpose and community. Additionally the pamphlet establishes the 10
essential components of mental health recovery; Self-direction, Individualized
and person-centered, Empowerment, Holistic, Non-linear, Strengths based, Peer
support, Respect, Responsibility and Hope.
Public service announcement (PSA) – A public service announcement is a
message disseminated to the public via mass media
(print/television/radio/internet) that are very similar to an advertisement. They are
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aired in the same spaces commercials are and run for about the same amount of
time. The difference between advertisements and public service announcements is
that public service announcements are broadcast free of charge, and they aim to
educate, bring awareness to or change public behavior or attitudes towards a
particular issue instead of selling a product or service.
Bridge
Traditionally in the United States, the medical model of mental health services has
focused on the defect within the consumer, deemed the professional the expert and
expected the consumer to be a passive recipient treatment with little say in their treatment
planning. This model has created expensive, long-term mental health care with mixed
results and a shortage of mental health workers (Hoge, Morris, Stuart, Huey, Bergeson, et
al., 2009). Because of these issues, the United States began examining mental health care
services and called for a full transformation of the mental health services system
(Chinman, Weingarten, Stayner, & Davidson, 2001; New Freedom Commission on
Mental Health, 2003; SAMHSA, 2004). The U.S. government’s largest endorsement of
the recovery model is the 2003 President’s New Freedom Commission final report,
successful transformation rests on services and treatments that are consumer- and familycentered with real and meaningful choices and care that is focused “on increasing
consumers’ ability to successfully cope with life’s challenges, on facilitating recovery
and on building resilience, not just on managing symptoms.... An opportunity for the
consumers and their families to gain control over their lives is a necessary component in
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recovery" (New Freedom Commission on Mental Health, 2003, p.27). The New Freedom
Commission on mental health also states "clinical practices and supports for individuals
and their families must project hope, communicate the expectation of recovery, and
empower people to exercise choice and control over their lives." It also directs clinicians
to “develop positive, caring relationships with persons served by listening with respect,
accepting the individual as a unique person, and valuing his/her strengths, abilities, and
dreams." Keeping the concept in mind that recovery is a lifelong, life changing process, it
is of highest importance that consumers of mental health services be active participants in
their recovery process. In fact, without the consumer being actively engaged in their
recovery process it is highly unlikely that recovery as an outcome will even occur. This is
precisely why education about the recovery process and the consumer’s crucial role in it
is so important.
In response to the U.S. governments push for recovery oriented systems of care the
American Psychological Association (APA) (2014) launched a 5 year initiative entitled
"Recovery to Practice" which addresses the goal of integrating mental health recovery
into all branches of psychology including academic institutions, training providers and
practicing clinicians. The APA is also in the process of publishing training modules that
will bring knowledge of the recovery model across multiple disciplines of care (Carr,
Bhagwat, Miller, & Ponce, 2014). This means that the new generation of mental health
workers that are recovery trained begins now.
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Becoming recovery focused as a nation does not mean abandoning medical
knowledge. On the contrary, long term studies on schizophrenia show when physicians
promote the real possibility of recovery as a long-term outcome, elements of recoveryfocused care inherently appear (Barber, 2012). Medication and regular physical checkups are also a part of helping a person build skills, strengths and encourage the lifestyle
change the recovery process brings. Clinicians need to encourage consumers to undertake
roles and missions in life other than being “in treatment” such as romantic relationships,
parenthood, school or a career, hobbies, and so on so that they will have a rich life to as
symptoms abate. Just like for individuals who do not struggle with mental illness work,
volunteering, and other activities provide a focus and a purpose and also help to reduce
negative thoughts and worries, and can even minimize psychotic symptoms (Deegan,
2005). Doctors will need to come to terms with the fact that sometimes their patients will
be feeling well enough to take breaks in treatment – this means lowering or stopping
medication and reducing number of visits to the yearly recommended for sex and age. If
or when the person decides they need treatment again, it should be considered a sign of
strength to know treatment is needed and to be able to obtain it (Barber, 2012).
By examining both the pitfalls of the medical model and the advantages of a recovery
oriented system, it is easy to see why the United States has called for an overhaul of the
mental health services system. Each pillar of the infrastructure has been set to work in
harmony; the government supports the delivery method (healthcare reform, mental health
worker trainings, and collaboration between doctors, psychiatrists and therapists) and the
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delivery method supports a healthier society (healthier individuals and a more supportive
and informed community). The method is so effective because the recovery model is a
more accurate representation of what actually happens in therapy than its medical model
predecessor and is still consistent with common factors research without being beholden
to the scientific and medical industries. It is versatile and adaptable just like its
consumers. Additionally, utilizing the recovery model is helping to destigmatize mental
health issues and encourage people to reach out to and educate their communities about
challenges that one in four adults will face in their lifetime.
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Chapter 2: Literature Review
Introduction
This chapter will review the common factors research for effective mental health
care and explain and critique the medical model and its shortcomings. Also included in
this chapter is a more in-depth discussion of the recovery model; the history of its origins
and the efficacy of the recovery model and suggestions for clinicians are included. The
efficacy of public service announcements for use in the mental health field are also
touched upon. Last, this chapter looks at the development and implementation of the
PSA.
Common Factors Research
Since the 1980's it has been established that psychotherapy and counseling are helpful
in the treatment of mental health issues (Lambert & Bergin, 1994; Wampold,
2001). Despite their widespread use, medications have proven only to be slightly more
effective than placebo and psychotherapy has been shown to outperform medication
(Duncan, Miller, & Sparks, 2000; Elkin et al., 1989; Shea et al., 1992). Currently the
question the scientific community is trying to answer is why - why is it so effective? Is it
the due to specific treatments or factors that are common among all forms of therapy?
Many studies have attempted to prove their superiority over another and researcher after
researcher has tried to determine the best way of doing therapy for a specifically
identified problem (Duncan, Miller, & Sparks, 2004). Since the U.S. has used a medical
model of treatment for mental health issues over the last 70 years, it makes sense
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scientifically that research would utilize resources identifying a key ingredient
responsible for the change and use those key ingredients as the basis for treatment
planning. Wampold (2001) concluded in his analysis of the literature, ‘‘decades of
psychotherapy research have failed to find a scintilla of evidence that any specific
ingredient is necessary for therapeutic change’’ (p. 204). Consistently research has shown
that there is no difference in effectiveness between treatments (Luborsky, Singer,
& Luborsky, 1975). Time and time again this finding has been replicated with similar
results (Elkin et al., 1989; Conners, DiClemente, Carroll, Longabaugh, & Donovan,
1997; Brown, Dreis, & Nace, 1999; Dennis et al., 2004). This of course has led
researchers to examine the common factors across all types and disciplines of
therapy. According to Asay and Lambert (1999) and Tilsen and Nylund (2008), there are
4 major common factors among all major psychotherapeutic approaches: client factors,
quality of the therapeutic relationship, hope/placebo factors, and the model or technique
being utilized.
Client factors.
Client factors, which were originally termed extratherapeutic factors by Lambert
(1992), are the ‘‘single most potent contributor to outcome in psychotherapy’’ (Duncan et
al., 2004, p. 34). Client factors are made up of everything that does not have to do with
therapy itself: personal characteristics, client resources/support systems, chance events,
contextual issues and religious/spiritual beliefs and practices. According to Asay and
Lambert (1999), 40% of improvement during psychotherapy can be attributed to client
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factors. Wampold (2001) attributes 87% of improvement during therapy to client factors.
These findings are surprising considering most people characterize mental health
consumers as ill, incapable, and in need of expert intervention (Tilsen & Nylund,
2008). As Duncan et al. (2004) stated, ‘‘Rarely is the client cast in the role of the chief
agent of change or even mentioned in advertisements announcing the newest line of
fashions in the therapy boutique of techniques’’ (p. 34). These findings support the
recovery model’s emphasis for treatment to be client-directed, and its emphasis on
community supports. The research also suggests that the recovery model’s focus on
empowerment has received empirical validation from the scientific community (Tilsen &
Nylund, 2008).
Therapeutic alliance.
In many studies the therapeutic relationship has been found to be strongly related
to outcome, even when measured early in therapy (Horvath & Symonds, 1991; Martin,
Garske, & Davis, 2000; Wampold, 2001). After client factors, therapeutic alliance is the
next most significant contributing factor to improvement during the therapeutic process.
Lambert (1992) states that therapeutic alliance accounts for 30% of improvement during
therapy and more recently Wampold’s (2001) meta-analysis attributes the alliance as
being 54% of the improvement during therapy. Many researchers have studied the
therapeutic alliance factor (Bachelor, 1995; Bachelor & Horvath, 1999; Krupnick et al.,
1996); Among the most pertinent and repeated findings from these studies that inform
clinicians is that the client’s perception of the alliance and not the therapist’s perception
17
is what predicts the outcome (Bachelor & Horvath, 1999). Duncan et al. (2004) pointed
out the implications of this finding, stating, ‘‘from the client’s perspective, there is no
single, invariably facilitative, type of relationship’’ (p. 35) that leads directly to a
positive outcome. This means that clinicians need to embrace the client’s preferences in
order to achieve a successful outcome. The recovery model utilizes a client as expert and
clinician as collaborator that this research supports.
Placebo factors: hope, expectancy, and allegiance.
According to Lambert (1992) expectancy, hope, and allegiance or 'placebo
factors' account for 15% of the influence on improvement during therapy. Placebo
factors have to do with a client’s expectation that change will occur, the instillation of
hope from the therapist, and the client’s belief in the therapist’s credibility (Tilsen &
Nylund, 2008). A study by Frank and Frank (1991) concluded that even if the client
assumes that therapy will be helpful, it will contribute to a positive outcome. Wampold
(2001) also noted that the therapist's allegiance to their own models (confidence in their
modality) indicates that hope must be held by both client and clinician to produce a
positive outcome. As stated earlier, hope is one of the main tenets of the recovery model
philosophy.
Models and techniques.
Interestingly, research by Lambert (1992) found that 15% of improvement during
therapy can be attributed to the model or technique utilized by the clinician, the same
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percentage that placebo factors account for. Wampold’s (2001) meta-analysis of common
factors found percentages lower than Lambert (1992); Wampold concludes that only 8%
of improvement during therapy is due to model effects. This however does not diminish
the importance of adherence to a specific model as models lend structure to the work
and provide the proverbial toolbox from which to choose tools to address an array of
concerns. This is particularly important because the field of mental health care has had
a heavy emphasis on theories, models, and more recently been pushing for evidence
based practices (EBPs), which seems to lend itself more to the medical model of mental
health care services (Tilsen &Nylund, 2008). EBPs with their medical model nature make
it easy to impose an approach on a client without any regard for individual preferences or
contextual factors, which goes against both client factors research and therapeutic
alliance research. It also goes against one of the main tenants of the recovery model, selfdirection. The recovery model calls for ‘culturally relevant services’ and ‘culturally
competent practitioners’ (Anthony, 2000) as part of a focused shift away from traditional
medical model concepts of therapy to more modern recovery oriented ones.
In light of these common factors, it makes perfect sense as to why the U.S.
government is pushing for a change to recovery oriented services. The medical model of
psychotherapy is not the proper framework for dealing with mental health issues.
Recovery oriented practices are the future of mental health care.
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Why the Medical Model in the First Place?
The medical model philosophy of mental health care can be traced back to 1920
with Sigmund Freud and his "talk therapy" work with "hysterics". His theory of psychoanalytics fit perfectly within the framework of the medical model. His method was very
linear -disorder (hysteria), scientific explanation for disorder (repressed trauma),
mechanism of change (insight to unconscious), and specific therapeutic actions (free
association). In fact it was Freud's work that gave a concrete definition of "mental
illness."
Behavioral theory also contributed to the instillation of the medical model philosophy
to the mental health care system. Wolpe's (1961) systematic desensitization was also a
scientific, linear method - disorder (phobic anxiety), scientific explanation for the
disorder (classical conditioning), mechanism of change (desensitization), and specific
therapeutic action (systematic desensitization). Even to this day, cognitive behavioral
therapy (CBT) and certain desensitization treatments, which are direct therapeutic
descendants of behaviorism, are considered by health insurance companies as Evidence
Based Practices (EBP) and doctors who utilize these treatments are reimbursed through
medical insurance (Elkins, 2009). Evidence based practices and empirically supported
treatments, phrases suggesting a combination of science and medicine, are the newest
terms in the long history of the medical model philosophy of psychotherapy that spans
from Freud's work with "hysterics" to the present day.
20
Problems with a Medical Model Philosophy
The medical model of psychotherapy is in essence is a framework taken from the field
of medicine and superimposed onto the practice of psychotherapy. The framework and its
components including terminology has worked beautifully in the medical field for
decades. However, it does not work as well when utilized for psychotherapy, it is actually
problematic in some respects. The medical model philosophy has 3 serious limitations:
(1) The medical model fails to describe accurately what actually happens in
therapy; psychotherapy is primarily an interpersonal process and not a medical treatment
or procedure (Wampold, 2001); (2) the medical model is still in place not because of its
accuracy but because of its deep connections in the medical, science and health insurance
industries (Elkin, 2009) and (3) the medical model philosophy labels and stigmatizes
people, which actually leads to under-utilization of mental health services and poor
therapeutic outcomes (Corrigan et al., 2000).
From the beginning the medical model philosophy was problematic because the
majority of what was called “mental illness” was not the same as physical illness. First
and foremost, Wampold (2001) pointed out that talking about one's physical illness has
no effect but when people talk about their "mental illness" they start to heal. Additionally,
physical illness has a distinguishable cause such as a pathogen whereas "mental illness"
is usually a result of personal or interpersonal challenges which can be difficult to
pinpoint. Additionally, there is no evidence that treatments can be paired to clients on the
basis of pathology and that adherence to a manual is unrelated to positive outcomes
(Wampold, 2001).This leads to the huge contradiction between the medical model’s
21
philosophy for delivering therapy and what actually happens during therapy. For
example, it is hard to call listening to a woman grieve for her spouse and offering her
words of support as a "medical treatment" or referring to comforting an old man in the
lonely end-stage of his life as a "medical procedure". When mental health issues are seen
as a disease that a professional needs to "treat" and "cure" and there is no concrete "cure"
for these "illnesses", often times individuals can feel hopeless which is actually
counterproductive to reaching therapeutic goals and can lead to exacerbation of
symptoms and increased difficulties (Corrigan et al., 2000). Additionally, the medical
model does not address the fact that people seek therapy for personal growth or relational
issues and not explicitly for treating a "mental illness" (Wampold, 2001).
The ties to medicine and science, two of the most powerful and respected systems in
the United States, has a huge effect on the medical model of psychotherapy and its hold
on mental health care (Elkins, 2009). When terms such as symptoms, illness, diagnosis,
patient and doctor are used it intrinsically aligns psychotherapy with medicine, one of the
most respected systems in U.S. culture. Similarly, when terms like evidence based
practice and empirically supported treatments are used it aligns psychotherapy
with science, the highest ranking and most respected system in our culture; everything
from what kinds of foods humans should consume to the best way to keep humans safe in
automobiles is decided by science. Hence by characterizing psychotherapy in medical
and scientific terms, it creates an air of power and respectability that is borrowed from
these two dominant systems (Elkins, 2009). Stated simply, the ties to medicine and
science are what have been keeping the medical model philosophy of psychotherapy as
22
the dominant contender, not the efficacy of it. In fact, because of the way health
insurance works, most non-psychiatric therapists do not get reimbursed for services; the
insurance companies often require a diagnosis of significant impairment such as major
depressive disorder when the client's issues may be caused by something relational such
as marital distress. This requires practitioners to "up" the diagnosis in order
to receive payment for their services. In turn, their treatment plans and progress notes
must reflect medical necessity. In this manner the medical model forces marriage and
family therapists and other non-psychiatric mental health workers to practice a form of
therapy that is non-relational and goes against their systemic training (Wampold,
2001). This can be a disservice to a client who may be stigmatized or barred from certain
activities such as military duty or police training once a severe diagnosis is on
record. This example in particular shows how the medical model has managed to get its
roots deep into the mental health care system. Elkins (2009) brings up a valid point in his
article “The Medical Model in Psychotherapy- Its Limitations and Failures.” He
states, "We must ask ourselves about the ethical implications of 'playing the medical
model game' and 'pushing the diagnostic envelope' by giving clients diagnoses whose
treatments are reimbursable by medical insurance if we know in our hearts that those
clients are just as sane and normal as we are" (p.14). Is it right to continue subjecting
people to this model of therapy when it has the potential to harm?
As was just pointed out, the medical model philosophy of therapy leads to individuals
being labeled and stigmatized. Research suggests that people who are given a "mental
illness" diagnosis are stigmatized more severely than those with physical health
23
conditions (Corrigan et al., 2000; Weiner, Magnusson, & Perry, 1988). Studies also
suggest that individuals with more severe "psychotic disorders" are discriminated against
more severely than individuals dealing with anxiety or depression diagnoses
(Pescosolido, Monahan, Link, Stueve, & Kikuzawa, 1999). People can obtain labels from
others (a therapist diagnoses someone as schizophrenic) or labels can be obtained by
association (a person seen walking out of a mental health clinic might be assumed to be
"mentally ill"). Controlled research studies have shown that when people
feel stigmatized, they are less likely to seek help for their mental health issues (Cooper,
Corrigan, & Watson, 2003). Research suggests that individuals labeled with a mental
illness believe they are less valued in society because of their diagnosis (Link, 1987; Link
& Phelan, 2001). Studies show when people experience demoralization and low selfefficacy, they fail to pursue opportunities that even despite dealing with ‘mental illness’
they would be able to succeed in doing (Link, 1982, 1987). This in turn has an effect on
goal accomplishment and quality of life. Research has shown a significant relationship
between feeling stigmatized and avoiding treatment (Elkins, 2009). Corrigan and Penn
(1999) identified education as a key factor in diminishing the stigma experienced by
people labeled with mental illness. Education provides information so that the public can
make more informed decisions about how best to deal with mental health issues.
Additionally when members of the general public are in close contact with people dealing
with mental health issues who are able to participate fully in life, having a job and being
productive members of the community, stigma is greatly reduced (Corrigan, Edwards,
Green, Diwan, & Penn, 2001; Corrigan et al., 2002; Pinfold et al., 2003).
24
Roots of Recovery
The evolution of the recovery model began in 1930's as a grassroots consumer
advocacy movement (Gehart, 2012a) that also tied into the deinstitutionalization
movement (LaJueunesse, 2002). Ironically one of the main reasons behind
the deinstitutionalization movement was the increased use of psychiatric medication,
specifically Thorazine, coupled with the idea that it was possible to care for ‘mentally ill’
patients in the community (LaJeunesse, 2002; Ridenour, 1961; Simmons, 1990; Turner,
2004; Whitaker, 2002). Beginning in the 1950's, Thorazine was used for pain relief
because it produced tranquilizing effects which altered a patient’s mood, thought
patterns, and behaviors (LaJeunesse, 2002). By the late 1950's Thorazine was regarded as
the drug that would provide “humane outcomes” for patients and it began to be used
rapidly throughout American mental institutions (Healy, 1997; LaJeunesse, 2002; Scull,
1977). In the United States there were many studies done that pointed out how the use of
neuroleptics such as Thorazine led to the decline in the number of patients in mental
hospitals because it produced a stabilizing effect on their behaviors (LaJeunesse, 2002;
Mechanic and Rochefort, 1990; Scull, 1977; Whitaker, 2002). With this new tool in the
box, the government began to advocate for outpatient treatment facilities and community
resources to replace the role that mental institutions had been cast in for decades
(Whitaker, 2002). It has also been suggested that the deinstitutionalization movement
was a result of the humanitarian shift in society and society’s realization of the horrid
treatment patients were receiving in mental institutions. Unfortunately this good
intentioned set of humanitarian ideals were not coupled with a structure of community
25
resources that should have been necessary to implement before patients were released
from mental hospitals (Simmons, 1990; Scull, 1977). By examining the psychiatric
services that were offered to ex-patients in the community, Geller (2000) concluded that
clinicians were too focused on the scientific efficacy of treatment when they should have
been focused on being humane and providing a higher quality of care. To reduce
hospitalization and increase functioning in the community, Hope (2005) stressed the
importance of collaborative decision-making that involves a team of professionals which
originally excluded the patient. Without considering the client's voice and direction and
without providing proper support within the community, these ex-patients were more
likely to regress and end up homeless, re-hospitalized, or incarcerated (Dear & Wolch,
1987). These movements with no societal framework in place to support them, led to the
“revolving-door syndrome” in which patients were hospitalized, medicated, discharged
and abandoned, and then re-hospitalized at very high rates (LaJeunesse, 2002).
From the deinstitutionalization movement sprang the mental patients’ liberation
movement in the late 1960s and early 1970s. Sparked by the civil rights movement,
individuals who had been labeled ‘mentally ill’ or had been institutionalized began to
organize their own movement to assert and protect their rights as both patients and
people. Not only were people being oppressed by the power dynamic between mental
health clinicians and themselves, but also by the medical model philosophy
itself (Chamberlin, 1990). Individuals that had been labeled as ‘mentally ill’ claimed they
were victims of ‘mentalism’ – the fear of and prejudice against people with mental illness
(Chamberlin, 1978). The mental health liberation movement had 2 distinct factions; the
26
individuals who lobbied through the established medical model system for a more
collaborative approach and referred to themselves as consumers rather than clients or
patients and the group who called themselves survivors who dedicated themselves to
developing alternatives to the medical model of mental health care (McLean, 2000).
Although the factions had these fundamental differences, they were united in the idea that
individuals struggling with mental illness should not be beholden to psychiatric control
(Van Tosh, 2006).
Hand in hand with the mental patients’ liberation movement there was a group of
professionals that believed that psychiatry was making people worse, not better (McLean,
2000). These individuals were the cornerstone for the anti-psychiatry movement in the
sixties and seventies (Ridenour, 1961; Turner, 2004). This anti-psychiatry movement was
made up of intellectuals, not patients, and they participated along with other movements
of the 1960s that challenged the establishment (Rissmiller & Rissmiller, 2006).
As a result of these movements, the mental health care system began to shift from
custodial care to publicly funded community care (Mechanic and Rochefort, 1990; Rose,
1979; Scull, 1977). This shift began to focus on the idea that there was nothing inherently
wrong within an individual and instead the real issues stemmed from environmental and
societal barriers that kept individuals with mental health issues from fully participating
within their communities (Oliver, 1990a; Oliver, 1990b; Scull, 1977; Whitaker, 2002).
Additionally a shift in society’s thinking about mental illness began as they became more
aware of the control mental hospitals and psychiatrists had over patients’ lives (Lewis et
al., 1991).
27
With the rise of humanistic psychology the “therapeutic culture” of the 1960s shifted
from "curing mental illness" to helping people with personal growth, self-awareness,
improved relationships, and cultivating more effective interpersonal skills (Rogers,
1970). Humanistic psychologists have been critical of the medical models use from the
beginning, labeling the model as part of what was wrong with the psychology of the day.
Carl Rogers (1951) played an active role in humanizing therapy; he referred to patients as
clients and opposed diagnostic labels and psychological testing designed to discover
pathology. In summary, Rogers rejected the medical model and its pitfalls to pursue a
model of therapy that was described as "an interpersonal process characterized by
empathy, unconditional caring, and therapist congruence" (Elkins, 2009).
Recovery as a model for mental health care sparked professional interest in the 1980s
because of its efficacy in dealing with substance abuse. In 1985 a national conference
called Alternatives was held to start the first ever nationwide consumer organization
(McLean, 2000). Alternatives is now an annual event, and is the largest national group of
consumers in America. SAMHSA supported the early organizational efforts of
Alternatives (McLean, 2000) and the ongoing role of this agency has increased as the
U.S. has begun its transformation towards a recovery oriented system.
In the 1990s the recovery model was examined for the implications in the mental
health field. Anthony (1993) from Boson University gave the first formal definition of
recovery:
Recovery is 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
28
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. (1993: 527)
Shortly thereafter the U.S. Surgeon General published a report on mental illness
promoting recovery from mental illness as a possibility and advocating for the mental
health care industry to begin moving in a recovery oriented direction. The report also
asserted that the existing mental health care field would need extensive overhauls to meet
the end goal of a recovery model system (Office of the Surgeon General, 1999). The
United States began promoting the use of the recovery model in 2003; the President’s
New Freedom Commission formally endorsed the recovery model as the new approach
for mental health services. In 2004 the U.S. Department of Health and Human Services
SAMHSA defined the elements of recovery. Paramount being that people with severe
diagnoses did not mean to be symptom-free in order to live meaningful and productive
lives.
Why the Recovery Model Works
In interest of keeping psychotherapy’s respectable ties to science, it is important to
examine the empirical evidence of recovery oriented practices. There have been several
interventions and practices that are a direct product of the recovery movement that have
shown that recovery is a step in the right direction. Examples include helping consumers
develop a valued social role through working or volunteering which is directly related to
higher self-esteem, higher social functioning, a higher quality of life and a reduction in
29
the severity or prevalence of symptoms (Marwaha & Johnson, 2004); developing a
community of support (Kaiser, 2000); helping individuals to obtain adequate and
affordable housing which has a direct impact on mental health and quality of life
(Carlsson, Frederiksen, & Gottfries, 2002; Kirkpatrick, Younger, Links, & Saunders,
1996; Shu, Lung, Lu, Chase, & Pan, 2001); peer supports, which research has found
contributes to decreased symptoms, provide larger social networks, and increases quality
of life (Davidson et al., 1999); educational, empowerment-based and personal goal
recovery groups which have been shown to increase the chances of reaching personal
recovery goals and higher levels of self-awareness (Hasson-Ohayon, Roe, & Kravetz,
2007); peer-led groups which promote self-efficacy, self-empowerment, and
determination in achieving recovery (Cook et al., 2009); and the utilization of cognitivebehavioral therapy for managing psychotic symptoms (Rector & Beck, 2001).
One of the first interventions noted above, the act of promoting a valued social
role such as having a job or volunteer position within the consumer’s community is a key
component of an effective recovery plan. Research suggests that having employment,
which symbolizes an even exchange between the consumer and society, during the
recovery process is correlated with more successful and sustained recovery outcomes
(Anthony, Brown, Rogers, & Derringer, 1999; Eklund, Hansson, & Ahlqvist, 2004;
Linhorst, 2005). There is qualitative evidence that suggest individuals who are dealing
with severe mental health issues view having employment as being central to their
recovery (Killeen & O’Day, 2004; Krupa, 2004; Provencher, Greg, Mead, & Mueser,
2002) and gain several benefits from working, including increased self-esteem, decreased
30
social isolation, and improved quality of life (Salyers, Becker, Drake, Torrey, & Wyzik,
2004). Individuals who work during the recovery process have also shown to have more
financial stability, report higher rates of personal growth and gains, personal growth, and
improved mental health (Honey, 2004; Marwaha & Johnson, 2004; Strong, 1998).
Research also shows that employment is a source of self-esteem and self-agency as well
as a source of pride and a facilitator of coping (Strong, 1998; Honey, 2004; Marwaha &
Johnson, 2004; Salyers et al., 2004; Provencher et al., 2002; Salzer & Shear, 2002).
Finally, there is evidence that also suggests that when individuals are more motivated to
work, the higher the likelihood is of obtaining employment. (Mueser et.al., 2001).
Tying into the idea of promoting a valued social role is the aspect of having a
community of support, which includes peer supports. In fact, community is one of the
basic elements in the recovery process. Many consumers define the final stage of
recovery as being the reclaiming of one's place in the community and establishing a new,
preferred identity. Being a member of a community increases an individuals’ long-term
stability, and helps provide access to resources such as housing, employment, and social
support. At the forefront of a consumer’s community of support is generally family and
close friends. Studies have shown family support to be a key determinant of a person’s
commitment and adherence to recovery goals. Peer supports are a crucial component of a
recovery oriented practice (New Freedom Commission, 2003; Office of the Surgeon
General, 1999). Informal peer supports have been part of mental health care since the
1970’s (Chamberlin, 1978), but it has only been with the last twenty years that they have
been completely integrated into the system with the implementation of peer-operated
31
organizations sometimes called ‘consumer run centers’ and extensive peer training
programs (Ostrow & Adams, 2012).
Another key component of the recovery model that is backed by empirical evidence is
the concept of being person centered and helping to facilitate the consumer’s
empowerment. Research shows that having a sense of self-agency is crucial for
individuals to be able to direct and manage their own care. Studies have also shown that
when given options in their treatment choices instead of being forced into one modality,
individuals are more likely to stay committed to their treatment plans and goals
(Morgenstern, Labourvie, McCrady, Kahler, & Frey, 1997). This is why it is important to
remain person centered and focus on what a consumer feels they need on their journey to
recovery. Motivational interviewing is a specific intervention that helps to facilitate a
consumer centered recovery treatment plan (Hettema, Steele, & Miller, 2005). It is
extremely effective because it acknowledges the consumer’s personal responsibility and
freedom of choice. With motivational interviewing, the consumer must accept that a
problem exists and be willing to take steps to address it (Joe, Simpson, & Broome,
1999).
Despite the research mentioned above, there are no studies that focus on the recovery
model as a whole. This is due to the fact that most studies on recovery oriented services
focus on recovery as an outcome and not a process (Campbell-Orde et al., 2005). A huge
challenge in studying the recovery model as a process is that the scientific community is
accustomed to studying outcomes; it is hard to pick apart the components of the recovery
model to claim any one particular piece is the mechanism that makes the recovery model
32
work (Wallcraft, Shrank & Amering, 2009). This is why it is important to examine
common factors research and utilize the components within the recovery model
philosophy. Despite the lack of research on recovery as a process, the U.S. government
has issued multiple reports promoting recovery-orientated systems (Ostrow & Adams,
2012).
Despite the absence of studies examining recovery as a process, it is obvious that
recovery does work when we look at the changes that occur after recovery oriented
systems of mental health care are put into place. States that have implemented recoveryoriented systems of care have significantly positive clinical, social and financial
outcomes. The state of New York who began utilizing a recovery oriented system in 2004
noted improved clinical outcomes for individuals accessing mental health services after
only 1 year. Consumers had decreased emergency room visits, spent less days in medical
and psychiatric hospitals, had fewer suicide attempts, less incidences of physical harm to
others, substance abuse issues, arrests and incarcerations. This helped to reduce public
spending on state and county hospitals and jails. Consumers of the Western New York
Care Coordination program also reported increases in positive activities such as having a
job, going to school, and volunteering (Western New York Care Coordination Program,
2005). The Connecticut Department of Mental Health and Addiction Services (DMHSA)
found that by implementing a recovery oriented system they reduced the number of acute
psychiatric hospitalizations and were able to serve more people by providing more
tailored services (Connecticut Department of Mental Health and Addiction Services,
2009).
33
In Pennsylvania, the city of Philadelphia also transformed their existing mental
health care system into a recovery oriented one. White (2007) examined the changes in
the system and found improvements in the following areas: higher consumer engagement,
more thorough assessment, higher retention rates, a more centralized role of the
consumer, better service relationship between clinicians and consumers, more effective
clinical care, diminished service appointments and duration, more service delivery sites,
higher access to post treatment checkups and support, and more positive attitudes toward
readmission.
Jacobson and Curtis (2000) outlined how the concept of recovery will be
implemented in several State mental health systems policies and practices. States that are
poised to have recovery oriented systems of mental health care include Wisconsin, Ohio,
Vermont, and Nebraska.
As Professionals
As professionals, we need to keep in mind that recovery is often facilitated outside of
our offices and clinics. Recovery can be achieved through a variety of means such as
family and friends, church or support groups, and opportunities education or meaningful
employment. Our main goal as professionals is to instill a sense of hope and be a genuine
support to the as the consumer as they navigate the journey to recovery (Anthony, 1993).
Another thing we need to be cognizant of as we work with consumers is that they are
the expert in their lives and we are there as active participants, not authoritative
overlords. When clinicians function in a position of authority in a consumer’s life, the
34
consumer is at higher risk of developing an unnecessary dependency on the clinician.
Mental health care workers should look at their relationships with consumers as a journey
where both parties are bringing knowledge and skills on the adventure and not only teach
but learn from their clients as well.
Furthermore, we should also keep in mind that people dealing with mental health
issues are not objects that need to be fixed. This idea completely robs the consumer of
strengths and the possibility of self-actualization. It also perpetuates the myth that people
who struggle with mental health issues should have no culpability for their actions,
decisions or choices and puts responsibility in the wrong place. Therefore, clinicians
should be trained in a more holistic, person centered fashion that reflects the individual’s
personal needs and provides a higher quality of care which in turn would assist in
ensuring that individuals' success in the community and in recovery.
Support for PSAs
Since the implementation of the PSA, they have been effectively used to
promote the topic of health, particularly mental health and substance abuse. Part of the
reason that PSAs are so effective is that they are memorable (Corrigan, 2012). In
1987 the Partnership for a Drug-Free America produced one of the most iconic and
effective PSAs ever, "This is your brain on drugs." This iconic PSA uses an egg and a
frying pan to illustrate the effects drugs have on the human body. It opens with a shot of a
middle aged man standing in a kitchen asking “is there anyone out there who still isn’t
clear about what doing drugs does?” He proceeds to walk over to the stove where there
35
are eggs and a hot frying pan ready for cooking. He picks up an egg and states “this is
your brain.” As he cracks it into the hot pan he says “this is drugs.” At this point he picks
up the hot pan for the viewer to see the egg frying away and says “this is your brain on
drugs.” The ad finishes with the actor tossing the pan aside and harshly asking “any
questions?” Entertainment Weekly (1997) named it top 8 commercial of all time and
Time Magazine (2000) listed it as one of the top 10 PSAs ever produced. The ad,
recognized by marketing experts and society as one of the most influential in history,
spawned a number of spoofs and has been referenced in a number of television shows,
movies and even sampled by musicians (Koeske, 2010; Whosampled.com, 2015). The
PSA was so effective that the Partnership for a Drug Free America produced a disturbing
sequel in 1997 starring actress Rachael Leigh Cook that focused specifically on heroin
and how it not only destroys your body, but your relationships and life as well. The PSA
shows Rachel Leigh Cook wrecking the entire kitchen with a frying pan as a metaphor
for what doing heroin does to your life.
In the past decade, more professional groups (such as the American Psychological
Association), advocacy groups (for example National Alliance on Mental Illness),
government agencies (i.e. National Institute of Mental Health and SAMHSA) and even
pharmaceutical companies like Glaxo-Smith-Kline have poured energy and resources
into campaigns aimed at reducing the stigma of mental health issues (Corrigan, 2012).
This of course includes the utilization of public service announcements. These campaigns
are generally educational in nature and encourage contact with people suffering with
mental health issues; this is because information, education, and exposure are the best
36
ways to combat discrimination and prejudice (Corrigan & Penn, 1999; Corrigan, River,
and Lundin, et al, 2001). Research shows that when individuals struggling with mental
health issues are able to keep their job and be a good neighbor within the community they
are less stigmatized (Corrigan, Edwards, Green, Diwan, & Penn, 2001; Corrigan et al.,
2002; Pinfold et al., 2003). Additionally, studies found that anti-stigma programs where
individuals with mental health issues interact with the members of their community have
a positive impact on reducing stigma; community members exhibit less discriminatory
behavior and demonstrate prejudicial attitudes (Corrigan, Rowan, Green, et al.,2002).
Based on this research, the best PSA combines education with contact, for example a
PSA that features someone struggling with mental health issues telling their story - in the
process the audience learns important facts about mental health and more specifically
about whatever issue the consumer happen to be struggling with.
Research has also pointed out that most of the PSAs developed to help diminish the
harmful impact of the stigma of mental health issues are often PSAs that present mental
health issues as treatable diseases (Corrigan & Penn, 1999). Unfortunately there are some
unintended consequences when framing mental health issues as treatable diseases
(Cooper et al. 2003; Corrigan and Fong 2013). By approaching mental health from a
medical model standpoint (issue as illness), it can exacerbate the sense of differentness
between people who struggle with mental health issues and the rest of their community. It
can also perpetuate the idea that individuals facing mental health challenges are somehow
broken, and this can worsen stereotypes and increase discrimination (Corrigan, River, and
Lundin, et al, 2001). Examining these studies produces mixed results; some studies show
37
that PSAs have a good population penetration (i.e., people recognize the PSA when
questioned), but the level of impact (the change in stigmatizing attitudes and behaviors) is
less clearly defined (Corrigan, 2012). Additionally, video based approaches to tackling
stigma (including video PSAs) have been shown to have the most significant impact on
reducing stigmatizing attitudes (Corrigan et al., 2012). Unfortunately, there is no real
system for tracking or evaluating the total effectiveness of PSAs.
Since PSAs are so difficult to assess for effectiveness, it makes sense to look at
similar types of dissemination of information. Used very often by the pharmaceutical
companies, Direct to Consumer Advertising (DTCA) also has been found to have an
impact on the stigma of mental health issues. Since it has been studied more in-depth than
PSAs, and since psychiatric DTCAs are similar in structure to PSAs, looking at the
research might be able to tell us what people are getting out of PSAs. Overall, social
scientists have found that DTCAs have decreased the stigma of mental health issues
(Smardon 2008). Research has shown that viewing DTCA leads to greater awareness of
medications (Beltramini 2006; Singh and Smith, 2005) and more doctor – patient
collaboration (Mintzes et al.. 2003). Physicians are also more likely to prescribe some
kind of drug therapy as a result of increased collaboration (Kravitz et al., 2005; Lipsky
and Taylor 1997).
38
Indications
Advertising professionals and non-profit specialists (Bell, 2010; Biddle, 2011;
Goodwill, 2007) propose the following steps and specifications for structuring an
effective public service announcement:
1. Choose a topic that is important. Make sure it is narrow and to the point. Properly
research your topic. Make sure to include statistics and references.
2. Consider the target audience. Think about needs, preferences, and ideas that may
offend or turn off the audience. Remember reason for creating the PSA is to
change the target audience’s behavior.
3. Make sure the message of your PSA is clear while still being creative; use
emotional responses or humor as attention getters
4. Script your PSA. A thirty second PSA requires 5 to 7 concise assertions. Make
sure to highlight major and minor points and that all information presented is
accurate and from up-to-date research. Radio script 60 seconds = 150 words.
5. Run your PSA script and music ideas through a test audience. Request feedback,
analyze feedback, and make appropriate changes.
6. Record your PSA.
a. Technical specs – master file in either.mp3, .wav or .CDA with a
sampling frequency of 44.1 kHz and a bit rate of 390 kB per second
b. title audio track appropriately
c. burn to disc and check master
39
7. Package your radio PSA for distribution
a. flex mailer with CD, live script card, and business reply card
40
SCRIPT FORMAT
The top of the sheet should list:

how long the PSA should run (i.e., "FOR USE: November 18 - December 20" or
"Immediate: TFN" [til further notice])

length of the PSA

what agency or group the PSA is for, and

title of the PSA.
Don't use hyphenations or abbreviations. Spell out web addresses, specifically the 'dot
com' portion.
The bottom of the sheet should be marked with "###", the standard ending used in
releases to the media to let the media outlet know there are no further pages to the script
or story.
Your script can be sent as "live copy"-- a simple script that's ready to be read by a live
on-air announcer -- or as a pre-recorded tape. While live copy is inexpensive and is used
extensively in radio, television stations rarely use live copy scripts.
(University of Kansas Work Group for Community Health and Development, 2014)
Figure 1.1
41
Education About Recovery Model
In 2011 The Substance Abuse and Mental Health Services Administration has created
an online program to help train clinicians in the recovery model. This program, Bringing
Recovery Supports to Scale Technical Assistance Centers Strategy or BRSS TACS for
short, produces webinars designed to highlight new research, showcase cutting edge
programs, and help clinicians have a better understanding of the recovery model. Topics
include recovery coaches, serving veterans, structuring a recovery oriented practice,
ethical considerations, peer leaders, and how the affordable care act affects substance
abuse and mental health recovery communities ("Bringing recovery supports," 2011).
Many of the webinars last for at least 90 minutes, and many of them are in workshop
format where several 90 minute webinars are viewed in succession to achieve the full
scope and understanding of the topic. While the webinars are extremely helpful and free
to access on the substance abuse and mental health services administration website, they
are definitely geared towards clinicians and not new consumers. Additionally, the
webinars are presented through Adobe connect, a complicated, web conferencing
interface. Being that it is made to be more for clinicians than consumers and it is
complicated to access requiring knowledge of web conferencing software, it offers little
of that knowledge to the general public.
More easily accessible and consumer friendly educational materials are not as in-depth
as the BRSS TACS seminars. The U.S. Department of Health and Human Services
released the 2 sided handout entitled National Consensus on Mental Health Recovery in
2004 which is available to download from their website. The document briefly describes
42
the ten fundamental components of recovery in plain language. In 2012, the department
released SAMHSA's Working Definition of Recovery pamphlet which just expanded on
the original Consensus handout's ten fundamental components of recovery. This
pamphlet is also available via download from the SAMHSA website. Additionally the
National Alliance on Mental Illness (2015) has a small section about mental health
recovery on their website that provides some education about how the recovery model
works that is in plain language for consumers.
Public Service Announcements
The US Department of Health and Human Services produced several mental health
PSAs starring various celebrities to reduce stigma, but none specifically about how
recovery model works. The series is called "Stories of Hope and Recovery" and consists
of 7 high profile individuals in various professions. The first PSA features singer Demi
Lovato. Her PSA is more of an actual testament that individuals can overcome and
recover from their mental health issues. In the video, Demi Lovato discusses what it is
like to be a young adult dealing with mental health issues such as self-harm and a list
of co-morbid diagnoses including bipolar disorder, anorexia, and bulimia. She also urges
people to reach out to trustworthy individuals and seek help for any mental health
struggles they may be experiencing (U.S. Department of Health and Human Services,
Stories of Hope and Recovery: Demi Lovato, 2013 ).
Entertainer Cher is the spokeswoman in the second Stories of Hope and Recovery
PSA. Her video focuses on de-stigmatizing mental health disorders. Cher stresses that
43
mental illness should be discussed out in the open like any other health issue. This PSA
also promotes "appropriate and accessible services for those in need" but doesn't address
how the mental health system has changed in response to the new theories in treating
mental health issues (U.S. Department of Health and Human Services, Stories of Hope
and Recovery: Cher, 2013).
Actress Glenn Close also participated in the Stories of Hope and Recovery Series. In
the video Glen Close discusses her experience of having family members who suffer
with mental health issues. She makes the important point that mental illness affects
everybody in the family and asserts how important it is to have a informed family support
during the recovery process. At over 3 minutes, it is one of the longer PSAs; she goes on
to discuss the importance of education about mental health issues in order to destigmatize them. The PSA closes with Glenn urging all Americans to talk about mental
health issues openly and publicly in hopes that people will seek appropriate services. U.S.
Department of Health and Human Services, Stories of Hope and Recovery: Glenn Close,
2013).
Senator Gordon Smith's PSA for the US Department of Health and Human Services is
also a personal testimonial of dealing with a family member who is affected by mental
health issues. It is a particularly touching PSA because Senator Smith lost his son Garret
to suicide after a lengthy battle with bipolar disorder/ major depression. Senator Smith's
focus in this PSA is to bring the issue of mental health "out from the shadows of society"
in order to prevent untreated mental health issues from affecting other families (U.S.
44
Department of Health and Human Services, Stories of Hope and Recovery: Senator
Gordon Smith, 2013).
Sports journalist John Saunders PSA in his Stories of Hope and Recovery piece
discusses the prevalence of mental health issues in our society. He addresses the fact that
people who suffer with mental health issues often times do not receive the appropriate
empathy and are horribly ashamed. He compares mental illnesses to physical illnesses
using the simile "asking a person who is suffering to move on is like asking a person with
a broken leg to run a marathon". His plea is for people who are suffering with mental
health issues to get professional help and for family members to step in and help those
individuals who may be in need of treatment (U.S. Department of Health and Human
Services, Stories of Hope and Recovery: John Saunders, 2013).
The final PSA in the Stories of Hope and Recovery series comes from University of
Southern California (USC) law professor Elyn Saks. Elyn shares her story of being
affected by chronic severe schizophrenia. In it she endorses the recovery model as the
only acceptable form of treatment for schizophrenic symptoms. She states that through
the recovery model she has been able to live a full and productive life; she is a professor
of law at USC, has a husband and a wonderful community of support (U.S. Department
of Health and Human Services, Stories of Hope and Recovery: Elyn Saks, 2013).
45
Chapter 3: Project Audience and Implementation Factors
Introduction
Thanks to the Patient Protection and Affordable care act, more Americans will
have access to mental health care services. Therefore this project is necessary to inform
the general public about the new direction in mental health services, the recovery model.
With the full endorsement and backing of the US Government, the recovery model is
helping to remove the stigma from mental illness, which is also increasing the amount of
people accessing mental health services. With studies showing how important mental
wellbeing is to overall health and the new influx of consumers of mental health care a
system, making sure the model is consumer friendly and effective is necessary. This
project will help to further reduce stigma, educate the public about their options when it
comes to their mental health needs and services and encourage people to access mental
health care services. This chapter focuses on the development of the project, the intended
audience for the project and how the project can be accessed.
Development of the Project
The development of the project all started in 2012 with my introduction to the
recovery model during my first semester in the graduate program at California
State University, Northridge. As part of the Community Mental Health class we had
guest speaker Christian Moldanado from Mental Health America's The Village program
give a presentation detailing what receiving recovery oriented therapy was like at his
facility. Towards the end of the presentation he showed a video of what it was like day to
46
day at the Village and how consumers were engaged in the act of mental health recovery.
The testimonials were astounding; I could not believe how well a program worked to
treat people who had been dealing with significant psychiatric difficulties. These
individuals spoke about their repeated hospitalizations and how they had
been labeled things like "chronic", "treatment resistant" and even "treatment failures"
before becoming involved with a recovery model of care. Experiencing their testimonials
I decided I wanted to be a part of movement that could create such drastic and long
lasting change for the better in people's lives. I also decided that more people needed to
know about this recovery oriented model of mental health care. I was a first year graduate
student and considered myself an academic who was up to date in the profession I had
chosen and I had not heard about the recovery model. My ideas about recovery at that
point were all centered on Alcoholics Anonymous which are not exactly the same as
mental health recovery. I assumed the general public probably had similar thoughts or
were not even aware of the concept of recovery when dealing with substance abuse.
So I knew I wanted my thesis project to involve educating the general public about the
new direction in mental health care, the recovery model. Having a background in radio,
television and film production I thought it would make sense to produce some sort of
educational media that could be accessed either through broadcast or via the Internet.
Once I thought about education and advocacy from a media standpoint it made perfect
sense to create a PSA - they promote pro-social behaviors, are free to air and can reach a
wide audience repeatedly.
47
Once I decided that I wanted to do a PSA, I had to decide on the medium - should it be
a video that could play on national television spots or be uploaded to Youtube.com to be
accessed anytime by anyone? Would it be better to produce a script for live radio, or
make an audio recording that a DJ could pop in between hit songs? I considered the
possibility of making the recording available for free on iTunes or the online community
could access it for re-distribution through a medium such as Soundcloud.com. My heavy
background in the audio side of production coupled with the advantages of radio
broadcast led me to settle on producing a radio script that can be live announced on a
radio station at any time. This will cut down on technical difficulties (faulty mp3,
scratched disc, etc.) and ensure that the message would reach at least a portion of the
general public. With iTunes and Soundcloud.com people would have to specifically
search for the PSA whereas if it is kept a script read over live broadcast it will reach
different people at different times of the day. As a project on file with California State
University, Northridge there will be a recorded audio file so people can experience the
full effect of the announcement in the event that a radio station never acquiesces to my
requests to add it into the station programming.
After the concept was complete in my mind, I began to make it more concrete. I began
researching PSAs and their efficacy in the health field. I watched numerous video PSAs
and read articles on how to structure effective PSAs. Once all the information was in
place I produced a script. I read the script aloud to both colleagues and friends who had
no ties to mental health care for feedback. Prompted by feedback I made a few small
changes to the script and began writing the literature review and other chapters necessary
48
to turn the script into a fully-fledged thesis project. The final step in the process was the
mp3 recording and upload submission to the CSUN ETD website.
Intended Audience
The intended audience for this project is English speaking individuals old enough to
comprehend what mental health and mental health services are who also live in the
immediate Los Angeles area (broadcast range). Sex and socio-economic status are of no
importance; this message is for men, women, rich and poor alike. The PSA does not
contain anything graphic or inappropriate so small children can listen to the PSA but they
may not comprehend the ideas being expressed. This project could easily be modified and
translated into a variety of different languages in order to reach an even wider audience.
Personal Qualifications
Radio broadcasters need to have a hard copy of the script, professional announcing
skills and the equipment necessary for broadcast; consumers wishing to listen to the PSA
will need an AM/FM receiver with speakers. Someone wanting to view the PSA will
need either a hard copy or access to the university's copy of the thesis project. No prior
knowledge of the recovery model is necessary. Individuals accessing as a project on file
with the university will need Internet access, a computer media program such as iTunes
or Windows Media Player and speakers or headphones. For the most part, individuals
living in the greater Los Angeles Area have access to all of the things necessary to get the
most out of this PSA.
49
Environment and Equipment
Consumers will need access to the media (either radio broadcast or university
file Internet download) and either an AM/FM receiver with speakers for the radio
broadcast or a computer with a media player and speakers. Consumers should listen in a
place where they have the ability to hear clearly and can pay attention to the message
Project Outline
The project is a simple, 60 second script for a PSA. It was worded in accordance
to research by major advertising and broadcast industry aficionados. The script follows
the structure and formatting set forth in the University of Kansas (2014) PSA radio script
curriculum. Included is also an audio recording for reference.
50
Chapter 4: Project
LIVE COPY
FOR USE: "Immediate : TFN"
LENGTH: 1 minute, 00:01:00
AGENCY: Substance Abuse and Mental Health Services Administration (SAMHSA)
TITLE: New Directions in Mental Health Care: Recovery
One in four adults in America experience mental health issues every year. That's 25
percent of Americans. More if you take into consideration those who have let the stigma
of diagnosis prevent them from seeking help. If you or one of your family members have
been reluctant to seek help, you don't have to suffer any longer. Mental health care has a
new focus: recovery. No longer are people being defined by a diagnosis. Recovery is not
about sickness and managing symptoms; it is about empowerment and defining you as a
person. It is about support and community and connection. It is about having a home and
a purpose. Recovery trained mental health workers will connect you with resources,
provide education and give you the hope and support you need on your journey to
wellness. Discover your strengths, your path and your purpose. Visit a
recovery mental health specialist today. For more information about mental health
recovery visit S-A-M-H-S-A dot gov slash recovery
###
51
Chapter 5: Conclusion
Summary
The purpose of this project was to create a public service announcement
informing the general public about the recovery model. In the first chapter, the basic
components of the mental health care system are discussed as well as the barriers
individuals face when trying to access mental health care. It also discusses the purpose
and significance of the public service announcement – currently there is no public
advertising that informs the general public about the transformation from a medical
model philosophy of psychotherapy to a recovery oriented philosophy. It also defines the
main terms discussed in the literature review; mental health care, medical model,
recovery model, and public service announcement. The chapter closes out with a
discussion about why the United States is transitioning from a medical model of mental
health care to a recovery model system.
Chapter 2 is comprised of a literature review. This chapter discussed the common
factors research for effective mental health care and explained and critiqued the medical
model and its shortcomings. Also included in chapter 2 is a more in-depth discussion
of the recovery model; the history of its origins and the efficacy of the recovery model
and suggestions for clinicians are included. The efficacy of public service announcements
for use in the mental health field are also touched upon. Finally chapter 2 looks at the
development and implementation of the PSA.
52
Chapter 3 restates the statement of need for the public service
announcement to be produced. It also focuses on the development of the project, the
intended audience for the project and how the project can be accessed. Chapter 4 is the
radio script of the PSA. This chapter will summarize and evaluate the project and also
examines implications for future use or research.
Evaluation
Since the aim of this project is to expose the general public to the recovery model, I
thought the best way to evaluate it was to run a test audience. I ran three separate test
runs; one for friends and family, one for my peers at the community mental health center
I did my traineeship at and one for my radio and audio production professors that
mentored me through my Associates Degree in radio, television and film production at
College of the Canyons. By going about it in this manner, I managed to get feedback
from a more general audience, a clinical audience familiar with recovery model concepts,
and media production professionals familiar with radio, advertising and public service
announcements.
I received mixed reactions from my general audience of friends and family. The most
interesting reaction came from my grandmother who lived through the era of
electroshock therapy, lobotomies and hiding away family members who suffered with
mental health issues. It was an odd mix of being happy that people were no longer being
treated so inhumanely but also scared that people who do suffer with mental health issues
do live among us in our communities. I thought it really spoke to society’s propensity to
53
stereotype and stigmatize people who experience severe psychotic symptoms and need
access to mental health services. On a more positive note it also speaks to our abilities as
humans to look at others struggles and have both compassion and empathy for people
going through challenges that we may not ever be able to comprehend. My mother who
has been in recovery from substance abuse issues for 6 years thought it conveyed her
experiences pretty accurately; to her having a community of support and linkages to
support services were crucial in the beginning stages of her recovery. She said it was her
NA sponsor who helped her get her certified nursing assistant degree and her sober living
house manager who helped her get her finances in order to be able to pay her bills and
save for a new car. She claims the family therapist was essential in getting our
relationship to a good place. Now she teaches CNA classes for a private Career College
and has a great relationship with me and my daughter. None of that would have been
possible without the recovery model. My friends, several of which have struggled with
mental health issues themselves had different feedback. Some of them were surprised the
U.S. government would be pushing a psychosocial model at all considering the amount of
financial and political clout the pharmaceutical companies have in the health care
industry. 3 out of 5 of them had been given anti-depressants by their general practitioner
and had never seen a psychiatrist. One had been to an in-patient community mental health
clinic and said that the PSA sounded a lot like the things the staff members of the clinic
tried to get him involved in. He said it was the low income housing and help with job
placement that really helped him through his psychosis. He is currently employed for a
large IT company just outside of San Francisco and is “entertaining the idea of a
54
girlfriend” for the first time in years. Probably the best thing I noticed that came out of
this test run of my PSA was that it got people talking about their experiences with
recovery and mental health. This is exactly the thing that will lead to the further destigmatization of mental health care and will help promote education on the subject.
When I ran the PSA by my colleagues, they had very different things to say. Their
responses were more geared towards accuracy of content and that it is an accurate
description of what we do as recovery oriented professionals. They all agreed that the
PSA included the main recovery model “buzz words” with the exception of the word
consumer. They also thought that it may be important to tell people about the recovery
model having more relaxed boundaries than traditional models; I decided against
including this in the PSA because in my opinion yes, technically the boundaries are more
relaxed in recovery oriented practices but to phrase it in that manner implies a sort of
allegiance to a medical model hierarchical structured system in which there is an expert
and a non-expert and the reverence of the expert must be preserved. My colleagues also
suggested that I stress how recovery oriented services have an air of casualness about
them. I also decided against this mainly because as stated during the literature review,
one of the strongholds the medical model has over the recovery model is the backing of
the scientific and medical communities. Since this is the kind of backing the recovery
movement is going to eventually need I thought it would be best to not emphasize
anything that made it seem less legitimate to society as a whole. Overall they thought that
55
the PSA did a good job of simply explaining what is happening differently in mental
health care and accurately reflected the definition of a recovery oriented service system.
My final test run consisted of 3 audio broadcast professionals from College of the
Canyons in Santa Clarita, California. Their suggestions were purely technical in nature
and actually the only feedback I used to make changes in the script. First and foremost,
they pointed me in the right direction as far as where to obtain professional references for
crafting a PSA through the University of Kansas. This was really critical considering all I
had were my old practice scripts to base the structure on; the problem with practice
scripts is that they do not include the entire header that states the agency, length, name,
etc. that is necessary when you are trying to solicit to a specific radio station. Secondly
they gave me a refresher in announcing 101 which went over how announcers read off
the page. This means spelling out symbols like ‘percent’ and web addresses, specifically
the ‘dot com’ portion of them. They said that SAMHSA needed to have dashes between
the letters to let the DJ know that it is an acronym that needs to be spelled also. Finally
they gave me some pointers on communication and persuasion which led to me
rephrasing the line where I offer the idea that “you don’t have to suffer any longer” which
was originally “don’t suffer any longer” – people are more likely to take a suggestion
than follow a command. Also they suggested they change my cadences to sets of 3
(meaning list 3 things at a time) which I also did. This is apparently related to the content
being more convincing and memorable.
56
I believe between the academic research studied concerning the recovery model and
crafting an effective PSA and the feedback from my test audiences that this project will
be a useful tool in promoting access to mental health care. From an educational
standpoint, I believe that the information is legitimate and accurately reflects what the
new system of mental health care looks like. I also think it will encourage more open
discussions about mental health in general which will help to decrease stigma over time.
Future Work/Research
The next step for my project is to approach CSUN’s radio station KCSN and see if
they are interested in running it for a specific length of time. I will need to research how
(if it is even possible) to be able to collect data on actual audiences reached and
impact/efficacy. After KCSN I might try to take it to other local stations such as Santa
Clarita’s KHTS where some of my former colleagues work or a station that has a more
broad range of broadcast such as National Public Radio. After national broadcast and
success, it could be translated into a number of foreign languages considering that
America has always been a melting pot of different cultures. If it really takes off there is
always the possibility of storyboarding and adapting a video version of the PSA that
could be played on local or national television or be uploaded to youtube.com for global
access.
On the video PSA note, I did come across some research that points to how this PSA
could be more effective if it was used in conjunction with a different medium. Studies
found that if there is a greater synergy, there is a greater persuasion effect (Chang &
57
Thornson, 2004). This could be achieved by pairing my PSA with a website, video PSA
or other mediums. For example if my PSA was released and used in conjunction with
SAMHSA existing stories of hope and recovery, it may have a greater impact on getting
people to utilize mental health care. Research has indicated that using combinations of
internet advertising (SAMHSA’s stories of hope and recovery PSAs) and advertising in
traditional media (radio broadcast) as campaign results in more positive consumer
responses than using only one medium (Chang & Thorson, 2004; Havlena, Cardarelli, &
Montigny, 2007).
58
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