CARe (Comprehensive Approach to Rehabilitation) is a model based on the principles of recovery and psychosocial rehabilitation. It is used nowadays by thousands of professionals in more than 10 countries. It was developed by Jean Pierre Wilken and Dirk den Hollander (see: Den Hollander & Wilken, 2015). The CARe Network is offering training programmes in this model.
CARe –the Comprehensive Approach to Rehabilitation and Recovery– has been around for more than twenty-five years now and is used by thousands of professionals. CARe comprises theories, a basic vision, a practical working method and tools. Though its core essence has remained unchanged over the years – supporting people in achieving their desired level of quality of life – the methodology has evolved over time under the influence of new scientific understanding and social movements. Furthermore, specific applications have been developed, e.g. for the purposes of reintegration to work. CARe is used in assisted living facilities, within wards of mental health care institutions, homeless shelters, in ACT and FACT teams, in supported housing, in geriatric care, youth care, forensic care, and in the treatment of addiction. It is used in supporting clients with an intellectual disability and clients with an autism spectrum disorder.
CARe is intended to enable the provision of effective support for people who are at a given moment unable to cope on their own in society and who have been referred for professional help and guidance. Sometimes this will be for a limited period in their lives, and sometimes it will be for the long term. Their need of this guidance and care may occasionally be complex, mostly due to the concurrence of multiple factors, such as a psychiatric disorder, unemployment and social isolation. An intellectual disability or behavioural problems may also be an issue. In short, their efforts to lead a normal life may be blighted by all sorts of troublesome and unusual factors.
Clients' stories of their recovery show that recovery is possible for everyone. By recovery we mean a unique personal process during which the individual regains his self-confidence, learns to cope better with his vulnerability and starts to play roles in society once more. Many people are resilient beyond their own expectations. Although the recovery process is a personal one, it does necessitate the contribution of others. These others could be people who have experienced similar issues, family or friends, and care workers. Our knowledge regarding the kinds of support that genuinely help people in their recovery process is continuously improving. CARe is intended to harmonize the support provided by care workers with the wishes and needs of people engaged in a recovery process in a manner that is purposive and effective. The model is based on the ideas of recovery, presence and empowerment.
Quality of life and recovery
CARe is focused on the quality of life of people who are mentally and socially in a vulnerable situation. The methodology is a tool for professional care workers to support clients in achieving their desired quality of life. In cases where somebody has experienced serious, traumatic events, such as a psychosis, then recovery is geared towards the disorder itself and resuming 'normal life', a life that the client perceives to be meaningful by being meaningful to himself and others.
We make a distinction between personal and social recovery. Personal recovery pertains to working through what has happened and learning to cope with the vulnerability, and finding one's bearings again in relation to the present and the future. Social recovery pertains to participation: reintegration into society. The term ‘participation’ is key, because clients do want to be part of society and, just as everyone does, be a human being among human beings. Nobody wishes to be a patient or a client, an unwanted status earned when you are forced to seek professional health care. Everyone wants to be regarded as a person who is no less valuable than any other person and who has the same rights and entitlements. Anyone who has spent a protracted period in care will often have to find their way back into society once more. He wishes to go from being a client to a citizen again. Consequently, recovery also implies recovery of one's status as a citizen. This is not just a matter of what the individual does to reintegrate. It also requires a great deal from society, such as acceptance and empathy. For that reason, CARe focuses not only on the individual but also on the individual's environment.
CARe entails a broad approach to rehabilitation and recovery, central to which is the client regarded holistically as a human being, without neglecting to consider his living environment and social network. In view of the fact that all manner of life spheres are interconnected, support is offered in multiple areas to improve the client's quality of life. Comprehensive also implies the attention we wish to devote to all kinds of social factors that affect one's quality of life, such as safety, legislation and regulations, and employment opportunities.
Another aspect of integration is that within CARe we work with the client in three areas:
• Fulfilling wishes and goals relating to quality of life.
• Dealing with vulnerability and reinforcing strengths.
• Gaining access to desired environments and maximizing the quality of life of living environments and social networks.
This pertains to places where the client resides, works, learns or spends his free time (or would like to do so) as well as the social networks of which the client is a part (or would like to be). We pay attention to all these areas in conjunction with one another. The emphasis may vary, but there is always a link between a client's wishes, possibilities and limitations, and the quality of his environment.
The presence approach was developed by Andries Baart (2001). It entails the care worker's fundamental attitude towards the client being one of 'being there'. By ‘being there’ we mean dovetailing with and fine-tuning things to the client and how he perceives and experiences the world in his quest to feel meaningful and significant. Within the compass of CARe we refer to this as working within the relationship dimension. This entails getting to know one another and building a bond of equivalence. Over the past decade, the presence approach has evolved to become a movement counterbalancing the professionalization that is rife within health care, restoring attention to people who are deemed 'socially superfluous'.
Strengths-based work stems from theories of empowerment. We discovered an excellent elaboration of the empowerment philosophy for rehabilitation and recovery in the Strengths Model developed in Kansas in the USA by Charlie Rapp and colleagues (Rapp and Goscha, 2006). Within this approach, empowerment-based working occupies centre stage. The approach places marked emphasis on the principle of the client maintaining control over everything. This forces the care worker to always think from the client's perspective. Another plus point is that priority is given not only to the person's possibilities and options but also to the possibilities and opportunities present in the community.
Within the compass of CARe, qualify of life pertains to personal domains and living domains. Personal domains are: self-care, health, safety and social relationships. Self-care concerns all activities required to enable you to look after yourself properly, such as day-to-day physical and domestic care. However, it is also about social skills, such as asserting oneself and keeping in touch with others. Managing your finances is also something that falls under the rubric of self-care. The health domain pertains to both physical and mental health.
Safety concerns both aspects of emotional safety and physical safety. Feeling safe is of utmost importance for everybody. First and all it is about the basic security we need to be recognized and valued as a unique human being, that we can be who we are. Physical safety includes being protected from threats, physical aggression and (domestic) violence). Social relationships encompass the aggregate of interaction with other people. Naturally these spheres are inter-related. Thus it is common to find meaningfulness by being able to mean something to others within your social relationships. As a red thread meaningfulness passes through all the domains. Meaningfulness is associated with everything which generates personal value. This can be your work, your passion or your religion. You experience meaningfulness by meaning something to others in social relationships.
Life spans all kinds of spheres. On the one hand, it spans the public sphere, the space we share with all our fellow citizens, including streets, squares, shops, parks and public transport. On the other hand, there are the places we live and work. Furthermore, we have places to which we go to learn, such as a school or educational centre, as well as places for leisure activities, such as a sports club. We refer to these as living domains.
Research carried out into recovery factors shows that these can be clustered into several categories (Wilken, 2010). We call these the five pillars of a recovery process. These pillars are:
1. Motivation: driving strengths for recovery, such as hope, wishes and aspirations.
2. Identity: development of personal identity, including by means of constructing one's own life story and discovering personal strengths.
3. Knowledge and skills, including competencies enabling one to cope with one's disability and to develop increased autonomy.
4. Status and creating meaning: developing meaningful activities, valued social roles and positive relationships.
5. Social and material support, including contacts with those who have experienced similar things, housing accommodation, work, professional care and support.
CARe is geared towards maintaining strengths and possibilities that are present and, if need be, bolstering pillars. As such, this could be strengthening on the client's side or strengthening on the side of the environment.
Phases, activities and dimensions
CARe as a guide for the professional comprises the following six phases and activities:
• building and maintaining an ‘effective’ relationship;
• garnering information and drawing up a Personal Strength Profile in conjunction with the client;
• helping the person to formulate wishes, make decisions and set goals;
• helping the person to draw up a Personal Plan (including Support Plan);
• helping the person to implement the plan;
• following the process; learning, evaluating and adjusting.