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CLINICAL CARE (Current Status)







Cannot identify personal needs;

Uninformed of resource opportunities;

May be angry, anxious, distrustful, and unmotivated;

May not accept diagnosis;

Symptoms, treatment, and stigma may interfere with motivation;

May experience shame & stigma concerning illness;

May lack experience in developing trusting relationships.

Depends on professional care;

Aware of illness;

Aware of services & choices available within system;

May not feel empowered to make choices;

May not be interested or desire to make appropriate choices;

May begin to set basic recovery goals.

Takes responsibility for managing his/her life and illness;

Aware of choices of services, treatment and other resources;

Makes choices independently;

Reasonably self- confident and values personal worth;

Chooses level of involvement with family/significant others, peer groups and community activities;

Works toward achieving previously developed recovery goals .

Accepts responsibility & involves him/herself in community;

Views service providers & personal support system as partners and peers;

Works collaboratively with service providers & personal support system to make choices;

Feels he/she has an opportunity to contribute to others and to society;

May move out of public system for attainment of employment and private benefits.


Demonstrates hope and achievement when interacting with consumer;

Promotes acceptance as first step to recovery;

Explains illness, symptoms, courses of treatment and hope for the future and begins to reach consumer about the use and benefits of a personal Relapse Prevention Plan and Advance Directives;

Informs consumer of benefits of active treatment;

Engages family/significant others and refers them to available community supports and education.

Ensures consumer and family/significant others are educated about the choices/resources available to them;

Provides activities that will increase consumer’s readiness to make choices in selecting life roles, environment, and goals;

Educates consumer about mental illness & recovery;

Continues hope- instilling strategies;

Involves consumer in designing his/her Recovery Management Plans (including medication and side effects), Relapse Prevention Plan and Advance Directives.

Works with consumer to define and achieve preferred life roles & goals;

Continues instilling hope strategies;

Encourages input from family/significant others as appropriate;

Encourages development of individualized coping strategies to deal with persistent symptoms;

Continues to support consumers with medication management;

Encourages consumer to use personal Recovery Management Plan, Relapse Prevention Plan and Advance Directives as necessary.

Works with consumer & consumer chosen support system to enhance/support chosen life roles;

Provides information and contracts to consumer to help locate other community resources & supports;

Provides consumer ongoing continued support;

Supports consumer in his/her interdependent role in community and society.


Makes available family and consumer peer support, consumer enrichment and engagement activities;

Makes available, especially to families and consumers, information and education concerning mental illness.

Makes available educational opportunities for consumers and their families/significant others that focus on mental illness, recovery process and strategies that facilitate recovery;

Provides support and information to overcome stigma and enhance community inclusion (e.g., via churches, community organizations);

Continues to make available consumer peer support.

Community resources address treatment, life goals, chosen roles, goals & social needs;

Promotes & supports anti-stigma campaigns;

Actively seeks and supports consumer & family/significant other involvement in community mental health programs.

Makes available for consumer collaborative support as needed to remain in chosen life role;

Continues to seek respect & value consumer & family/significant other involvement in community activities & organizations;

Continues to support consumer & family/significant others.

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CLINICAL CARE (Best Practices)







Identifies information about mental illness, recovery process, stigma, self-esteem, and building self confidence;

Gains awareness of illness through symptom reduction & education;

Develops self trust by living through traumatic events with support (e.g. hospitalization, family problems, incarceration);

Begins to develop trusting relationships with clinician and others.

Gains awareness of cyclical or episodic nature of illness & that recovery is not a linear process;

Begins to set recovery goals;

Uses available resources;

Accepts illness & treatment;

Participates in peer support activities;

Reshapes identity;

Begins to make more appropriate choices/decisions;

Participates in prescribed treatment;

Keeps appointments with doctors & therapists;

Attends & participates in self-help group meetings;

Seeks alternative treatment (e.g. vitamins/herbs, social interactions instead of groups).

Seeks out information from providers & other resources;

Participates in structured activities;

Monitors illness & medications & reports needs to clinician/ physician;

Develops & achieves recovery goals;

Develops & uses own personal coping skills for dealing with residual of recurring symptoms & personal support system;

May keep journal that focuses on feelings; expectations, & life roles;

Begins to be involved in both personal & group advocacy activities.

Reviews personal Recovery Management Plan to update & note accomplishments;

Reviews journal to determine progress;

Takes an active part in peer & advocacy efforts;

Works with other consumers to achieve personal life goals;

Uses mental health services on an "as necessary" basis;

May choose to use private system based upon employment benefits received.


Builds relationship with consumer by listening, valuing & accepting him/ her as a worthwhile person;

Continues using hope- instilling strategies;

Develops collaboratively with consumer, family/ others and physicians on Recovery Plan;

Collaborates with consumer in managing illness with proper medication by providing information about mediation, strategies for effective management.

Develops rapport & positive relationships with consumer’s family/ significant others;

Assists consumer in setting & reaching goals, thus increasing personal control & self-esteem;

Links consumer to appropriate services, benefits and entitlements;

Connects consumer with successful role models.

May involve consumer in groups designed to target issues related to transitioning back to community, goal setting and building relapse prevention strategies and Advance Directives;

Refers family/significant others to psycho-education classes;

Provides (as appropriate) printed information on diagnosis & available resources;

Continues to use hope- instilling strategies;

Helps consumer learn coping skills;

Keeps current on research & treatment to assist consumer in gaining mastery over symptoms;

Assists consumer in developing goals that are shaped by external ideals;

Develops with consumer his/her Relapse Prevention Plan and Advance Directives.

Assists consumer in connecting with community services based upon his/her needs;

Works with consumer to review & monitor status of his/her goals;

Works with consumer to define Recovery Support Plan, Relapse Prevention Plan and Advance Directives;

Assists consumer in contacting agencies & services that will help him/her achieve life goals & support recovery-enhancing activities (i.e., GED, BVR, recovery groups, housing options, volunteer opportunities);

Refers to Social Security to learn about how to use work incentives;

Supports & assists consumer in developing personal coping skills;

Assists consumer in developing a personal emergency support system including peers, friends, significant others.

Monitors with consumer Recovery Management Plan;

Provides support and assistance in maintaining recovery;

Advocates use of community resources;

Encourages & supports consumer in becoming more involved in community activities;

Keep consumer and family current about new medications.


Conducts depression screenings, stress tests, etc. at Health Fairs;

Provides educational products, programs, opportunities that meet the needs of the consumer;

Makes psycho-education & peer support groups available to families/significant others;

Provides & supports Drop-In Centers.

Continues providing psycho-education;

Designs inclusive support activities for consumer & family/significant others;

Continues to make available peer support groups for consumers and their families/significant others;

Provides education that focuses on overcoming stigma.

Supports & provides opportunities for volunteer work, paid employment, GED, vocational training, technical training and college opportunities;

Provides housing options including independent housing and home ownership;

Provides opportunities for consumer to be included in cultural, social, physical & entertainment activities;

Includes consumer & his/her family/significant others in planning, providing, & evaluating mental health & support services;

Provides advocacy training for both consumer & his/her family/significant others.

Expands community support;

Increases opportunities for consumer to become involved in community;

Continues anti-stigma public education.

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