Pathways of recovery: 4As framework for preventing further episodes of mental illness

Examples of current models and approaches that support implementation

Page last updated: 2006

Implementation of the 4As Framework has begun in all States and Territories. It is being progressed through a large and diverse range of programs that are currently underway or being developed and evaluated at all levels—national, jurisdictional and local. However, very few communities could claim to have all the elements of the 4As Framework in place, and many models and approaches are not widely available throughout Australia.

Below is listed a small sample of the many innovative developments occurring across Australia or in particular jurisdictions that aim to improve the continuing care segment of the spectrum of interventions for mental health. Please be aware that the models and approaches briefly described here do not give a comprehensive account of innovations in the area. These few models and approaches are described to show how elements of the Framework can be applied in practice. The Australian Network for Promotion, Prevention and Early Intervention for Mental Health and Suicide Prevention (Auseinet) is collating other examples and interested readers are directed to its website for a broader range of initiatives and to keep updated (see Auseinet website (

To support Awareness
To support Anticipation
To support Alternatives
To improve Access

To support Awareness

There is a large and growing self-help literature to support people who have been seriously affected by mental illness across all of the 4As. A particularly well-developed set of resources is available through the Wellness Recovery Action Plan.16 These resources cover the entire range of issues for self-management. Importantly, they can be adopted on an individual level or through a peer support approach, such as that being implemented by Ruah Community Services in Western Australia.

Consumer support networks and carer support networks are available nationally and in all States and Territories.

SANE Australia8 is a national charity whose mission is to help people who have experienced mental illness through campaigns, education and research. Of special relevance is the SANE StigmaWatch program, which monitors the Australian media to encourage accurate and respectful representation of mental illness. SANE also provides resources to improve understanding of mental illness such as fact sheets on mental illness, including information on early warning signs for psychosis.

The Headroom17 website has mental health resources developed by young people for young people, which can help young people to be more aware of their mental health status. A resource entitled 'Keeping yourself well after mental health problems' specifically relates to relapse prevention for young people. The website provides information about Amigos, which is a community support group for young people aged between 16 and 25 years who have experienced mental illness. The website also has information for parents and family members to increase their understanding of young people's mental health.
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The AIMhi18 project addresses mental health care issues for Aboriginal and Torres Strait Islander peoples in the Top End and far north Queensland. Key interventions planned over the next five years are educating people who have experienced mental illness, their family members and carers, and health professionals about mental illness, and remodelling service delivery to provide culturally sensitive assessment and relapse prevention, covering risk factors and early warning signs, in appropriate language and format and with ongoing review by the Indigenous Reference Group.

The Cultural Awareness Tool19 has been developed by the Western Australian Transcultural Mental Health Centre to help primary care service providers to be more culturally sensitive. It provides tools that help practitioners to better understand the explanatory models their clients use when they present to services with a problem.

COPES (Carers Offering Peers Early Support)20 is a program run by Carers ACT and patterned on one at Maroondah Hospital in Victoria recognising that carers in mental health need support when they first encounter the mental health system. The program trains people who have experience as carers to work as support workers in the mental health system to provide support to new carers. Similar initiatives are available in other jurisdictions such as Western Australia.

To support Anticipation

Collaborative Therapy21 is a comprehensive therapeutic framework that applies across the 4As Framework. It is a tool for empowering consumers by enhancing communication between consumers, family and carers, clinicians, and other service providers. The recovery of the consumer is the shared priority as all partners work systematically and collaboratively toward optimal mental health outcomes. An important component is the Collaborative Treatment Journal, which is a small pocket journal held by the consumer that can be used to chart stressors, early warning signs, supports, and other factors that influence the course and management of their mental health. The journal places the consumer at the centre of their recovery by facilitating communication with the other people and services involved in their continuing care. Randomised controlled trials of Collaborative Therapy are currently taking place in Victoria, ACT and South Australia. Early results suggest that Collaborative Therapy provides a comprehensive model for implementing most elements of the Framework.

A Collaborative Recovery Model22 has been developed to train service providers in evidence-based ways to provide collaborative and integrated care to support the recovery processes of people with recurring mental illness. The model identifies key skills, including needs assessment, motivation enhancement to encourage behavioural change, goal planning and homework tasks. Skills are presented through modularised competences that are relevant to case managers and providers of psychosocial rehabilitation. Importantly, the model emphasises recognition of consumers' subjective experience of recovery. The effectiveness of the model is currently being evaluated within several government and non-government agencies in Eastern Australia. Notably, a rural stream focuses on selected rural and regional towns in Queensland and develops and examines interventions to reduce relapses and improve physical health behaviours in people with recurring mental illness.

Advance Agreements23 are written agreements made when a person is well that outline preferred choices for treatment and care when they are unwell. They are an important component of a crisis plan and are usually developed in agreement with a person's clinical manager, community worker, psychiatrist, GP, and support persons. Advanced Agreements promise to offer best practice and agreed treatment and care in an emergency or crisis.

Carer Recognition Bill 2004 (WA)24 is the first legislation passed in Australia that aims to recognise the role of carers in the community and provide a mechanism for the involvement of carers in the provision of services that impact on carers and the role of carers. The Act applies to the Department of Health, public hospitals and the Disability Services Commission and to all agencies funded by them, which need to comply with a Western Australian Carers Charter.

The Bouverie Centre25 is a Victorian state-wide integrated clinical, academic and consultation agency specialising in family approaches in mental health service provision. The Bouverie Centre provides a range of programs to individuals and family members, service providers and agencies. It promotes the idea of Family Sensitive Practice as a way of encouraging the routine involvement of families in client care.
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MH-OAT26 is a NSW state-wide project to strengthen the mental health assessment skills of clinical staff in mental health. The project coordinates the implementation of mental health assessment training, uniform assessment protocols and outcomes and casemix measures throughout NSW. One of the MH-OAT modules is the recovery plan for adults or response plan for children and adolescents, which are designed by consumers. These are completed by the consumer as part of the care-planning process. The recovery plan/response plan provides a supportive structure to assist the consumer in identifying: what helps them stay well; early warning signs; social supports available to them; potential triggers for relapse; and planning strategies to be followed in case of relapse.

To support Alternatives

VICSERV 27 is the peak body for Psychiatric Disability Rehabilitation Services (PDRS) in Victoria. PDRS services provide support to consumers and carers through programs such as home-based outreach, psychosocial rehabilitation day programs, mutual support and self-help, respite and advocacy. VICSERV provides a range of supports to its members that increase the capacity of this sector to provide continuing care to people who have experienced mental illness. Member services include: sector co-ordination, support and advocacy; training and professional development; policy; and information services.

CRS Australia 28 has a number of initiatives related to employment, including the Journey to Recovery Mental Health Kit, which is a package written and designed to give helpful information to people who have a mental health condition and may benefit from vocational rehabilitation. Its aim is to help people on their journey to recovery by offering advice and tools for keeping, or returning to, employment.

The Midas Programme 29 is an initiative of the South Western Sydney Area Health Service that aims to: support, promote and implement programmes and projects targetting the needs of people with comorbid mental and drug related problems, their carers and other significant people in their lives; raise awareness of the prevalence of comorbidity amongst clients for alcohol and other drug (AOD) workers, mental health teams and other health professionals; foster closer relationships and integration of programmes offered by AOD and mental health teams; and promote research, public awareness and information services to benefit people affected by mental illness and problematic substance use.

The Medication Alliance Program 30 has been developed to provide clinicians with strategies that help consumers to have the confidence, competence and desire to use medications as prescribed. It has been adapted from its original development in the United Kingdom to be applicable within Australian contexts. The program recognises the importance of the quality use of medication in continuing care for many people who have been seriously affected by mental illness, as ineffective medication use is a major risk factor for relapse. The program trains clinicians in how best to support people who require medication to use it successfully to maximise their wellbeing.

The Reachout 31 website has a wide range of mental health information for young people. Notably, it has fact sheets specifically addressing the risk and protective factors for illness and staying healthy.

Incorporations of the Clubhouse model are available in some areas, for example the Stepping Stone Clubhouse in Brisbane.32 Clubhouses provide a non-institutional setting where adults with a mental illness provide support to each other as they work to rebuild their confidence, self-esteem, social and vocational skills.

GROW 33 is a community mental health movement with the primary aim of helping fellow sufferers of mental illness or emotional distress recover their mental health and wellbeing through self-activation and friendly mutual help. GROW does this through weekly meetings of small groups of people who have experienced depression, anxiety or other mental or emotional distress, who come together to help each other deal with the challenges of life.

Mental Health Pathways Project is a partnership between Mental Health and the Office of Housing under the Victorian Homelessness Strategy to support the recovery of people with a serious mental illness and complex needs who are at risk of homelessness. The program is currently being evaluated but anecdotal evidence suggests that the bringing together of resources in this cross government program greatly improves consumer outcomes. There is also a pilot supporting people from the Forensic Mental Health Service.
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The Mental Health Association of Central Australia 34 is a non-government organisation that provides a recovery focused rehabilitation service for individuals and families affected by mental health problems or mental illness. The service utilises collaborative interagency approaches and intersectoral linkages to promote recovery. Through the Pathways Program, people are assisted to develop individualised recovery programs using the existing community resource base to effect community reintegration. An integral component is networking with mainstream services and providing support to ensure a positive experience for the consumer and agency. The program increases the consumer's capacity to reintegrate into the community through employment and educational opportunities.

Advocacy Tasmania is an independent, non-profit organisation working to assist older people and people with disabilities to protect and promote their rights and interests. Mental Health Advocacy is for people with a mental health disorder, as well as their family and carers. The advocate supports young people and adults who are in hospital, living in the community, in correctional facilities, or in rural and remote areas to exercise their rights to be safe from harm including abuse, neglect and suicide and to ensure they have access to shelter, freedom and liberty, and fundamental health and wellbeing.

The Tobacco and Mental Illness Project 35 aims to reduce the rate of tobacco smoking amongst people with mental illness. The project has three main objectives: to increase knowledge about smoking and mental illness throughout mental health services, community health services, GPs, people with mental illness, carers and the general community; to identify issues important in managing tobacco addiction within hospital and community based mental health services, and make recommendations about effective management and implementation; and to ensure appropriate smoking cessation/reduction programs are made available to all people with mental illness who want to quit.

To improve Access

Collaborative Therapy, described earlier, is an approach that can improve access to a range of services, both clinical and non-clinical, by ensuring that care pathways are negotiated and agreed between the consumer and the identified service providers.

The Better Outcomes in Mental Health Care Initiative 13 aims to improve access to psychiatric support for primary care providers. Enhanced Primary Care MBS items for consultant physicians support psychiatrists to participate in case conferencing and to provide consultancy advice to GPs in emergency situations. Access to allied health services is enhanced by enabling GPs registered with the initiative to access focussed psychological strategies from allied health professionals to support their patients with mental health problems.

The MindMatters Plus GP Initiative 36 brings schools and general practice together to develop better referral pathways and networks of care for young people with high support needs for mental health and wellbeing.

The Transcultural Mental Health Centre 37 was established in 1993 as a NSW state-wide service to promote access to mental health services for people of non-English speaking background. The Centre also works with consumers, carers, health professionals and the community to encourage positive attitudes to mental health. The Centre recognises people's cultural and linguistic differences in their understanding of mental health. It seeks to support mental health policies, programs and services that ensure access and equity of service, while respecting cultural traditions and sensitivities.

The Primary Mental Health Care Australian Resource Centre (PARC) 38 provides knowledge management, research and information services to support primary mental health care in Australia. PARC was established to enable future work to be better informed by the large body of experience that has accumulated in the area of primary mental health care.