Recovery Enhancing Environment Scale (REE)

Abstract

The Recovery Enhancing Environment Scale (REE), also known in its developmental phase as the Developing Recovery Enhancing Environment Measure (DREEM), is a comprehensive, consumer-driven instrument designed to assess the degree to which mental health programs and services align with recovery-oriented principles. Developed by Priscilla Ridgway and Ann Press, the scale captures consumer perceptions regarding the organizational climate, the quality of service delivery, and the presence of elements essential for personal recovery. It is widely used for program evaluation and organizational self-assessment to facilitate the transformation of traditional mental health services toward models centered on hope, self-determination, and empowerment.

Keywords

Recovery Enhancing Environment Scale, REE, DREEM, mental health recovery, psychiatric disability, consumer empowerment, program evaluation, organizational fidelity.

Authors

Priscilla Ridgway, Ann Press, David Anderson, Patricia E. Deegan, S. Ratzlaff, L. Davidson, C.A. Rapp

Purpose

The primary purpose of the REE is twofold: first, to provide a standardized, reliable method for consumers (individuals receiving services for psychiatric disability) to evaluate their service environment; and second, to serve as a practical guide for mental health organizations seeking to measure and implement recovery-oriented practices. The scale helps identify specific program strengths and weaknesses across critical domains, thereby creating a blueprint for systemic and clinical improvements necessary to support individual recovery journeys.

The instrument is designed to move beyond traditional symptom-reduction metrics by focusing on the consumer’s experience of agency support, self-determination, and quality of life. By measuring both the perceived importance of recovery elements and the program’s performance in supporting those elements, the REE facilitates data-driven decision-making aimed at organizational transformation.

Construct

The REE measures the multi-dimensional construct of the Recovery Enhancing Environment. This construct is based on the philosophy that clinical environments must actively promote conditions necessary for individuals to achieve personal recovery from psychiatric disability. The scale components cover a broad range of factors, including interpersonal staff relations, availability of resources (housing, income), opportunities for skill building, and recognition of the individual beyond their diagnosis.

The scale is structured around several core dimensions of recovery, such as hope, identity, meaning, and empowerment. It also includes sections that assess the organizational climate and specific recovery outcomes (Recovery Markers), ensuring a holistic evaluation of the environment’s impact on the consumer’s progress toward personal goals.

Validity

The validity of the REE has been established through extensive field testing conducted across various state mental health systems, including detailed field tests in Massachusetts and Michigan (leading to the REE-MI version). Content validity was ensured by deriving items directly from established principles of recovery and through collaboration with consumer experts and advocates.

Construct validity is supported by demonstrating that the scale components align logically with theoretical models of recovery and resilience. Field testing reports, such as those published by the University of Kansas School of Social Welfare, confirm that the subscales effectively measure distinct yet related aspects of the recovery environment and correlate appropriately with positive consumer outcomes (Recovery Markers).

Reliability

Reliability studies for the REE, particularly during the DREEM and subsequent REE-MI field tests, focused primarily on internal consistency across the various subscales. Measures of internal consistency, typically calculated using Cronbach’s Alpha, demonstrate that items within clusters—such as the Elements of Recovery and the Organizational Climate sections—cohere reliably to measure the intended underlying factor.

The consistency of consumer responses across different program elements suggests that the instrument provides a stable and dependable measure of the recovery orientation of mental health programs. The repeated use and revision of the scale (2004, 2011) further indicate ongoing efforts to optimize reliability and applicability across diverse service settings.

Factor Analysis

Factor analysis of the REE generally supports a multi-factor model reflecting the structural components of the instrument. The results typically differentiate between several key domains:

• Consumer Perceived Importance: Measuring how important various elements are to the individual’s recovery.

• Program Performance/Fidelity: Assessing the extent to which the organization delivers services consistent with recovery principles.

• Organizational Climate: Evaluating the overall atmosphere of hope, respect, and support within the program.

• Recovery Markers: Capturing current consumer status regarding practical and personal outcomes (e.g., housing, employment, hopefulness).

This multi-factor structure underscores the instrument’s ability to provide nuanced feedback, distinguishing between the consumer’s personal values concerning recovery and their objective evaluation of the program’s supportive capacity.

Instrument

Test Type: Program Evaluation Scale, Consumer Self-Report Questionnaire

Format: Multi-section questionnaire utilizing demographic questions, a stage-of-recovery assessment, and Likert-type scales (typically SA, A, D, SD, or SA, A, N, D, SD) for assessment of importance and performance/fidelity. It also includes open-ended consumer feedback questions.

Language Available: English (Primary)

Population Group: Consumers of community mental health services and psychiatric rehabilitation programs.

Age Group: Adults (typically 18 years and older).

Population Details: Individuals living with psychiatric disability, often in community mental health settings. The instrument includes specific sections addressing the needs of minority groups, parents, individuals with dual diagnoses (substance abuse), and survivors of trauma/abuse, indicating suitability for diverse populations.

Test Methodology: Quantitative survey methodology administered either as a paper-and-pencil test or electronically, designed to capture subjective consumer experience and objective program characteristics.

Keywords

Program assessment, mental health services, DREEM, consumer feedback, psychiatric recovery, system transformation, organizational fidelity, empowerment.

Authors

Author ORCID Identifier: N/A

Affiliation Email addresses: [email protected]

Correspondence Address: N/A (Contact authors via email for current affiliation details.)

Permissions & Fee and Test Year

The REE was first published and field-tested starting in 2003, with significant revisions and documentation produced in 2004 and 2011 (e.g., the REE-MI version). Usage permissions and any associated fees should be sought directly from the primary authors (Priscilla Ridgway or Ann Press) or their affiliated organizations, such as Pat Deegan & Associates, who were involved in early field testing. The scale is frequently employed by state agencies for mandated quality improvement initiatives.

Reference’s

The original PDF reports for the instrument can be downloaded here: REE_Final_Report_5-5-11_364022_7.pdf and here: DREEM total dft4 no tc.pdf.

• Ridgway, P. (2003, May 28). The Recovery Enhancing Environment Measure (REE): Using measurement tools to understand and shape recovery-oriented practice. Plenary paper presentation. Washington, DC: The 2003 Joint National Conference on Mental Health Block Grants and National Conference on Mental Health Statistics.

• Ridgway, P., Press, A., Anderson, D. & Deegan, P.E. (2004). Field testing the Recovery Enhancing Environment Measure: The Massachusetts experience. Byfield, MA: Pat Deegan & Associates.

• Ridgway, P.A., & Press, A.N. (2004, June 3). An instrument to assess the recovery and resiliency orientation of community mental health programs: The Recovery Enhancing Environment Measure (REE). Conference presentation. Washington, DC: The 2004 Joint National Conference on Mental Health Block Grants and Mental Health Statistics.

• Ridgway, P., & Press, A. (2004). Assessing the recovery-orientation of your mental health program: A user’s guide for the Recovery-Enhancing Environment scale (REE). Version 1. Lawrence, Kansas: University of Kansas, School of Social Welfare, Office of Mental Health Training and Research.

• Ridgway, P.A., Press, A.N., Ratzlaff, S., Davidson, L. & Rapp, C.A. (2003). Report on field testing the Recovery Enhancing Environment Measure. Lawrence, KS: University of Kansas School of Social Welfare Office of Mental Health Research and Training.

Items of the Recovery Enhancing Environment Scale (REE)

RECOVERY ENHANCING ENVIRONMENT – Michigan (REE-MI)

I. A FEW QUESTIONS ABOUT YOU

1. What age group are you in (Check your current age group)?
   • ___18‐25
   • ___26‐35
   • ___36‐45
   • ___46‐55
   • ___56‐65
   • ___66‐75
   • ___76 or older
2. What is your gender?
   • ___Male
   • ___Female
3. What is your racial or ethnic background?
   • ___White
   • ___ Black or African American
   • ___ Hispanic or Latino
   • ___ American Indian or Alaskan Native
   • ___ Asian
   • ___ Native Hawaiian or other Pacific Islander
   • ___ Arab‐Chaldean
   • ___ Other Category:
4. In total, how long have you received any form of mental health services?
   • ___Less than one year
   • ___One year or more but less than 5 years
   • ___Between 5 and 10 years
   • ___More than 10 years
5. Do you currently receive any community mental health services from programs other than this one?
   • __ Yes
   • __ No

II. YOUR INVOLVEMENT IN THE RECOVERY PROCESS

Which of the following statements is most true for you? (Check only one)

• __ I have never heard of, or thought about, recovery from psychiatric disability.
• __ I do not believe I have any need to recover from psychiatric problems.
• __ I have not had the time to really consider mental health recovery.
• __ I’ve been thinking about recovery, but haven’t decided to move on it yet.
• __ I am committed to my recovery, and am making plans to take action very soon.
• __ I am actively involved in the process of recovery from psychiatric disability.
• __ I was actively moving toward recovery, but now I’m not because: ________________________________________________________
• __ I feel that I am fully recovered; I just have to maintain my gains.
• __Other (specify) _____________________________________________

III. ELEMENTS OF RECOVERY AND RECOVERY-ENHANCING

For each of the following questions you should circle one of these answers:

• SA ‐‐If you strongly agree with the statement.
• A ‐‐If you agree with the statement
• D ‐‐If you disagree with the statement.
• SD ‐‐If you strongly disagree with the statement.

1. having a positive sense of personal identity beyond my psychiatric disorder is important to my recovery. SA, A, D, SD
   1. Staff view me as more than a “case” or a diagnosis; they want to know me as a person. SA, A, D, SD
   2. The program offers individualized services to meet my unique needs. SA, A, D, SD
   3. Staff treat me as a whole person with a body, mind, emotions, important relationships and spirit. SA, A, D, SD
2. having a sense of meaning in life is important to my recovery. SA, A, D, SD
   1. Staff help me make sense out of what is happening in my life. SA, A, D, SD
   2. Staff ask me what is meaningful to me. SA, A, D, SD
   3. This program encourages me do things that give my life meaning. SA, A, D, SD
3. having hope is important to my recovery. SA, A, D, SD
   1. Staff believe I have a positive future. SA, A, D, SD
   2. Staff encourage me to feel hopeful again when I’m discouraged or have a setback. SA, A, D, SD
   3. Staff tell me most people do recover from psychiatric problems over time. SA, A, D, SD
4. Being able to self-manage symptoms and avoid relapse is important to my recovery. SA, A, D, SD
   1. This program helps me identify and monitor triggers/early signs of relapse. SA, A, D, SD
   2. This program helps me develop personalized coping skills so I can manage stress well. SA, A, D, SD
   3. This program teaches me ways to self-monitor and self-control psychiatric symptoms. SA, A, D, SD
5. Improving my general health and wellness is important to my recovery. SA, A, D, SD
   1. Staff pay careful attention to my physical health. SA, A, D, SD
   2. This program encourages me to achieve a higher level of wellness. SA, A, D, SD
   3. This program offers wellness programming such as nutrition, movement, relaxation. SA, A, D, SD
6. having my rights respected and upheld is important to my recovery. SA, A, D, SD
   1. Staff inform me of my rights. SA, A, D, SD
   2. There is a clear grievance policy if any of my rights are violated. SA, A, D, SD
   3. Staff uphold my rights. SA, A, D, SD
7. having positive relationships is important to my recovery. SA, A, D, SD
   1. Staff assist me in having positive relationships with my peers. SA, A, D, SD
   2. Staff support me in building or rebuilding positive relationships with family members. SA, A, D, SD
   3. Staff assist me in forming friendships with people outside the mental health system. SA, A, D, SD
8. having my basic needs met is important to my recovery. SA, A, D, SD
   1. This program assists me to get a basic income and/or benefits. SA, A, D, SD
   2. This program helps me get decent, affordable housing and/or rent subsidies. SA, A, D, SD
   3. This program helps me gain access to health care. SA, A, D, SD
9. having a sense of control over my life and feeling empowered is important to my recovery. SA, A, D, SD
   1. Staff encourage and support my sense of empowerment. SA, A, D, SD
   2. Staff assist me to gain or maintain control over important decisions in my life. SA, A, D, SD
   3. Staff do not try to maintain power and control over me. SA, A, D, SD
10. Taking on new challenges and moving out of my comfort zone is important to my recovery. SA, A, D, SD
    1. Staff encourage me to take on new challenges. SA, A, D, SD
    2. I feel supported when I try new things that seemed out of my reach before. SA, A, D, SD
    3. Staff encourage me to stretch myself and grow. SA, A, D, SD

IV. SPECIAL NEEDS

The next five questions relate only to specific groups of people. If you are NOT a member of the specific group being asked about, answer “no” and go onto the next question.

1. Are you are a member of an ethnic, racial or cultural minority group?
   • Yes (Please answer questions a‐c, below)
   • No (Go to question 2)

   having my ethnic & cultural background respected is important to my recovery SA, A, D, SD

   1. Staff here are respectful to me as a person of a racial, ethnic, or cultural minority SA, A, D, SD
   2. This program understands and supports my cultural values/language/customs. SA, A, D, SD
   3. Staff are aware of, and sensitive to my cultural heritage and needs. SA, A, D, SD
2. Do you have a substance abuse problem?
   • Yes (Please answer questions a‐c, below)
   • No (Go to question 3)

   having help with alcohol or drug problems is important to my recovery. SA, A, D, SD

   1. This program has resources to help me with both alcohol and psychiatric problems. SA, A, D, SD
   2. This program has resources to help me with both drug and psychiatric problems. SA, A, D, SD
   3. This program links me to self-help groups that deal with dual diagnoses/ substance abuse. SA, A, D, SD
3. Do you have a history of trauma or abuse?
   • Yes (Please answer questions a‐c, below)
   • No (Go to question 4)

   Healing from trauma, including sexual abuse and/or physical abuse, is important to my recovery. SA, A, D, SD

   1. This program has resources to help me heal from abuse and/or trauma. SA, A, D, SD
   2. It feels safe to open up about abuse or trauma in this program. SA, A, D, SD
   3. Staff deal effectively with abuse and trauma. SA, A, D, SD
4. Are you a lesbian, gay, bi-sexual or transgendered person?
   • Yes (Please answer questions a‐c, below)
   • No (Go to question 5)

   having support for my sexual orientation is important to my recovery. SA, A, D, SD

   1. Staff of this program are not homophobic (very negative about gay, lesbian, bi-sexual or transgendered people). SA, A, D, SD
   2. Staff of the program are respectful to me as a lesbian, gay, bi-sexual or transgendered person. SA, A, D, SD
   3. Staff deal effectively with issues of sexual orientation. SA, A, D, SD
5. Are you a parent?
   • Yes (Please answer questions a‐c, below)
   • No (Go to next section)

   having support as a parent is important to my recovery. SA, A, D, SD

   1. Staff support me in my role as parent. SA, A, D, SD
   2. Staff assist me to be an effective parent. SA, A, D, SD
   3. Staff help me uphold my rights in custody disputes. SA, A, D, SD

V. RECOVERY MARKERS –Revised (RM-R)

For each of the following questions, circle the one answer that is most true for you right now.

1. My living situation feels like a safe home to me. SA, A, D, SD
2. I have people I trust whom I can turn to for help. SA, A, D, SD
3. I have at least one close mutual (give-and-take) relationship. SA, A, D, SD
4. I am involved in activities I find meaningful. SA, A, D, SD
5. My psychiatric symptoms are under control. SA, A, D, SD
6. I have enough income to meet my needs. SA, A, D, SD
7. I am learning new things that are important to me. SA, A, D, SD
8. I am in good physical health. SA, A, D, SD
9. I have a positive spiritual life/connection to a higher power. SA, A, D, SD
10. I like and respect myself. SA, A, D, SD
11. I’m using my personal strengths, skills or talents. SA, A, D, SD
12. I have goals I’m working to achieve. SA, A, D, SD
13. I have reasons to get out of bed in the morning. SA, A, D, SD
14. I have more good days than bad. SA, A, D, SD
15. I have a decent quality of life. SA, A, D, SD
16. I control the important decisions in my life. SA, A, D, SD
17. I contribute to my community. SA, A, D, SD
18. I am growing as a person. SA, A, D, SD
19. I have a sense of belonging. SA, A, D, SD
20. I feel alert and alive. SA, A, D, SD
21. I feel hopeful about my future. SA, A, D, SD
22. I am able to deal with stress. SA, A, D, SD
23. I believe I can make positive changes in my life. SA, A, D, SD

True False

24. I’m not working, but see myself working within 6 months. True False
25. I am working part time (less than 35 hours a week). True False
26. I am working full time (35 or more hours per week). True False
27. I am in school. True False