Recovery approach

A recovery approach to mental disorder or substance dependence (and/or from being labeled in those terms) emphasizes and supports a person's potential for recovery. Recovery is generally seen in this approach as a personal journey rather than a set outcome, and one that may involve developing hope, a secure base and sense of self, supportive relationships, empowerment, social inclusion, coping skills, and meaning. Other names for the concept are recovery model or recovery-oriented practice.

Originating from the 12-Step Program of Alcoholics Anonymous and the civil rights movement, the use of the concept in mental health emerged as deinstitutionalization resulted in more individuals living in the community. It gained impetus as a social movement due to a perceived failure by services or wider society to adequately support social inclusion, and by studies demonstrating that many people do recover. A recovery approach has now been explicitly adopted as the guiding principle of the mental health or substance dependency policies of a number of countries and states. In many cases practical steps are being taken to base services on a recovery model, although a range of obstacles, concerns and criticisms have been raised both by service providers and by recipients of services. A number of standardized measures have been developed to assess aspects of recovery, although there is some variation between professionalized models and those originating in the psychiatric survivors movement.

History

In general medicine and psychiatry, recovery has long been used to refer to the end of a particular experience or episode of illness. The broader concept of "recovery" as a general philosophy and model was first popularized in regard to recovery from substance abuse/drug addiction, for example within twelve-step programs.

Application of recovery models to psychiatric disorders is comparatively recent. By consensus the main impetus for the development came from the within the consumer/survivor/ex-patient movement, a grassroots self-help and advocacy initiative, particularly within the United States during the late 1980s and early 1990s.^[1] The professional literature, starting with the psychiatric rehabilitation movement in particular, began to incorporate the concept from the early 1990s in the United States, followed by New Zealand and more recently across nearly all countries within the "First World".^[2] Similar approaches developed around the same time, without necessarily using the term recovery, in Italy, the Netherlands and the UK.

Developments were fueled by a number of long term outcome studies of people with "major mental illnesses" in populations from virtually every continent, including landmark cross-national studies by the World Health Organization from the 1970s and 1990s, showing unexpectedly high rates of complete or partial recovery, with exact statistics varying by region and the criteria used. The cumulative impact of personal stories or testimony of recovery has also been a powerful force behind the development of recovery approaches and policies. A key issue became how service consumers could maintain the ownership and authenticity of recovery concepts while also supporting them in professional policy and practice.^[3]

Increasingly, recovery became both a subject of mental health services research and a term emblematic of many of the goals of the Consumer/Survivor/Ex-Patient Movement. The concept of recovery was often defined and applied differently by consumers/survivors and professionals. Specific policy and clinical strategies were developed to implement recovery principles although key questions remained.^[1][4]

Elements of recovery

It has been emphasized that each individual's journey to recovery is a deeply personal process, as well as being related to an individual's community and society.^[5] A number of features or signs of recovery have been proposed as often core elements, however:

Hope

Finding and nurturing hope has been described as a key to recovery. It is said to include not just optimism but a sustainable belief in oneself and a willingness to persevere through uncertainty and setbacks. Hope may start at a certain turning point, or emerge gradually as a small and fragile feeling, and may fluctuate with despair. It is said to involve trusting, and risking disappointment, failure and further hurt.^[5]

Secure base

Appropriate housing, a sufficient income, freedom from violence, and adequate access to health care have also been proposed.^[6] It has been suggested that home is where recovery may begin. Housing services, if required, need to flexibly involve people and to build on individuals' personal visions and strengths, instead of "placing" and potentially "re-institutionalizing" people.^[7]

Self

Recovery of a durable sense of self (if it had been lost or taken away) has been proposed as an important element. A research review suggested that people sometimes achieve this by "positive withdrawal"—regulating social involvement and negotiating public space in order to only move towards others in a way that feels safe yet meaningful; and nurturing personal psychological space that allows room for developing understanding and a broad sense of self, interests, spirituality, etc. It was suggested that the process is usually greatly facilitated by experiences of interpersonal acceptance, mutuality, and a sense of social belonging; and is often challenging in the face of the typical barrage of overt and covert negative messages that come from the broader social context.^[8]

Supportive relationships

A common aspect of recovery is said to be the presence of others who believe in the person's potential to recover, and who stand by them. While mental health professionals can offer a particular limited kind of relationship and help foster hope, relationships with friends, family and the community are said to often be of wider and longer-term importance..^[9] Others who have experienced similar difficulties, who may be on a journey of recovery, can be of particular importance. Those who share the same values and outlooks more generally (not just in the area of mental health) may also be particularly important. It is said that one-way relationships based on being helped can actually be devaluing, and that reciprocal relationships and mutual support networks can be of more value to self-esteem and recovery.^[5]

Empowerment and Inclusion

Empowerment and self-determination are said to be important to recovery, including having self-control. This can mean developing the confidence for independent assertive decision making and help-seeking. Achieving social inclusion may require support and may require challenging stigma and prejudice about mental distress/disorder/difference. It may also require recovering unpracticed social skills or making up for gaps in work history.^[5]

Coping strategies

The development of personal coping strategies (including self-management or self-help) is said to be an important element. This can involve making use of medication or psychotherapy if the consumer is fully informed and listened to, including about adverse effects and about which methods fit with the consumer's life and their journey of recovery. Developing coping and problem solving skills to manage individual traits and problem issues (which may or may not be seen as symptoms of mental disorder) may require a person becoming their own expert, in order to identify key stress points and possible crisis points, and to understand and develop personal ways of responding and coping.^[5]

Being able to move on can mean having to cope with feelings of loss, which may include despair and anger. When an individual is ready, this can mean a process of grieving. It may require accepting past suffering and lost opportunities or lost time.^[5]

Meaning

Developing a sense of meaning and overall purpose is said to be important for sustaining the recovery process. This may involve recovering or developing a social or work role. It may also involve renewing, finding or developing a guiding philosophy, religion, politics or culture.^[5] From a postmodern perspective, this can be seen as developing a narrative.^[10]

Concepts of recovery

Varied definitions

What constitutes 'recovery', or a recovery model, is a matter of ongoing debate both in theory and in practice. In general, professionalized clinical models tend to focus on improvement in particular symptoms and functions, and on the role of treatments, while consumer/survivor models tend to put more emphasis on peer support, empowerment and real-world personal experience.^[11][12][13] Similarly, recovery may be viewed in terms of a social model of disability rather than a medical model of disability, and there may be differences in the acceptance of diagnostic "labels" and treatments.^[5]

A review of research suggested that writers on recovery are rarely explicit about which of the various concepts they are employing. The reviewers classified the approaches they found in to broadly "rehabilitation" perspectives, which they defined as being focused on life and meaning within the context of enduring disability, and "clinical" perspectives which focused on observable remission of symptoms and restoration of functioning.^[14] From a psychiatric rehabilitation perspective, a number of additional qualities of the recovery process have been suggested, including that it: can occur without professional intervention, but requires people who believe in and stand by the person in recovery; does not depend on believing certain theories about the cause of conditions; can be said to occur even if symptoms later re-occur, but does change the frequency and duration of symptoms; requires recovery from the consequences of a psychiatric condition as well as the condition itself; is not linear but does tend to take place as a series of small steps; does not mean the person was never really psychiatrically disabled; focuses on wellness not illness, and on consumer choice.^[15]

A consensus statement on mental health recovery from US agencies, that involved some consumer input, defined 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. Ten fundamental components were elucidated, all assuming that the person continues to be a "consumer" or to have a "mental disability".^[16] Conferences have been held on the importance of the "elusive" concept from the perspectives of consumers and psychiatrists.^[17]

One approach to recovery known as the Tidal Model focuses on the continuous process of change inherent in all people, conveying the meaning of experiences through water metaphors. Crisis is seen as involving opportunity; creativity is valued; and different domains are explored such as sense of security, personal narrative and relationships. Initially developed by mental health nurses along with service users, Tidal is a particular model that has been specifically researched. Based on a discrete set of values (the Ten Commitments), it emphasizes the importance of each person's own voice, resourcefulness and wisdom. Since 1999, projects based on the Tidal Model have been established in several countries.

For many, recovery has a political as well as personal implication—where to recover is to: find meaning; challenge prejudice (including diagnostic "labels" in some cases); perhaps to be a "bad" non-compliant patient and refuse to accept the indoctrination of the system; to reclaim a chosen life and place within society; and to validate the self.^[18] Recovery can thus be viewed as one manifestation of empowerment. Such an empowerment model may emphasize that conditions are not necessarily permanent; that other people have recovered who can be role models and share experiences; and that "symptoms" can be understood as expressions of distress related to emotions and other people. One such model from the US National Empowerment Center proposes a number of principles of how people recover and seeks to identify the characteristics of people in recovery.^[19]

In general, recovery may be seen as more of a philosophy or attitude than a specific model, requiring fundamentally that "we regain personal power and a valued place in our communities. Sometimes we need services to support us to get there".^[20]

Recovery from substance dependence

Particular kinds of recovery models have been adopted in drug rehabilitation services. While interventions in this area have tended to focus on harm reduction, particularly through substitute prescribing (or alternatively requiring total abstinence) recovery approaches have emphasised the need to simultaneously address the whole of people's lives, and to encourage aspirations while promoting equal access and opportunities within society. From the perspective of services the work may include helping people with "developing the skills to prevent relapse into further illegal drug taking, rebuilding broken relationships or forging new ones, actively engaging in meaningful activities and taking steps to build a home and provide for themselves and their families. Milestones could be as simple as gaining weight, re-establishing relationships with friends, or building self-esteem. What is key is that recovery is sustained."^[21]

Concerns

Some concerns have been raised about a recovery approach in theory and in practice. These include suggestions that it: is an old concept; only happens to very few people; represents an irresponsible fad; happens only as a result of active treatment; implies a cure; can only be implemented with new resources; adds to the burden of already stretched providers; is neither reimbursable nor evidence based; devalues the role of professional intervention; and increases providers' exposure to risk and liability.^[22]

Other criticisms focused on practical implementation by service providers include that: the recovery model can be manipulated by officials to serve various political and financial interests including withdrawing services and pushing people out before they're ready; that it is becoming a new orthodoxy or bandwagon that neglects the empowerment aspects and structural problems of societies and primarily represents a middle class experience; that it hides the continued dominance of a medical model; and that it potentially increases social exclusion and marginalizes those who don't fit into a recovery narrative.^[23]

There have been specific tensions between recovery models and "evidence-based practice" models in the transformation of US mental health services based on the recommendations of the New Freedom Commission on Mental Health.^[24] The Commission's emphasis on recovery has been interpreted by some critics as saying that everyone can fully recover through sheer will power and therefore as giving false hope and implicitly blaming those who may be unable to recover.^[25] However, the critics have themselves been charged with undermining consumer rights and failing to recognize that the model is intended to support a person in their personal journey rather than expecting a given outcome, and that it relates to social and political support and empowerment as well as the individual.^[26]

Various stages of resistance to recovery approaches have been identified amongst staff in traditional services, starting with "Our people [first of all, they aren't 'your people'] are much sicker than yours. They won't be able to recover" and ending in "Our doctors will never agree to this". However, ways to harness the energy of this perceived resistance and use it to move forward have been proposed.^[27] In addition, staff training materials have been developed by various organisations, for example by the National Empowerment Center.^{[28][29][30][31]}

Some positives and negatives of recovery models were highlighted in a study of a community mental health service for people diagnosed with schizophrenia. It was concluded that while the approach may be a useful corrective to the usual style of case management - at least when genuinely chosen and shaped by each unique individual on the ground - serious social, institutional and personal difficulties made it essential that there be sufficient ongoing effective support with stress management and coping in daily life. Cultural biases and uncertainties were also noted in the 'North American' model of recovery in practice, reflecting views about the sorts of contributions and lifestyles that should be considered valuable or acceptable.^[32]

Assessment

A number of standardized questionnaires and assessments have been developed to try to assess aspects of an individual's recovery journey. These include the Milestones of Recovery (MOR) Scale, Recovery Enhancing Environment (REE) measure, Recovery Measurement Tool (RMT), Recovery Oriented System Indicators (ROSI) Measure,^[33] Stages of Recovery Instrument (STORI),^[34] and numerous related instruments.^[35]

The data-collection systems and terminology used by services and funders are said to be typically incompatible with recovery frameworks, so methods of adapting them have been developed.^[36] It has also been argued that the Diagnostic and Statistical Manual of Mental Disorders (and to some extent any system of categorical classification of mental disorders) uses definitions and terminology that are inconsistent with a recovery model, leading to suggestions that the next version, the DSM-V, requires: greater sensitivity to cultural issues and gender; to recognize the need for others to change as well as just those singled out for a diagnosis of disorder; and to adopt a dimensional approach to assessment that better captures individuality and does not erroneously imply excess psychopathology or chronicity.^[37]

National policies and implementation

United States and Canada

The New Freedom Commission on Mental Health has proposed to transform the mental health system in the US by shifting the paradigm of care from traditional medical psychiatric treatment toward the concept of recovery, and the American Psychiatric Association has endorsed a recovery model from a psychiatric services perspective.^[38][39]

The US Department of Health and Human Services reports developing national and state initiatives to empower consumers and support recovery, with specific committees planning to launch nationwide pro-recovery, anti-stigma education campaigns; develop and synthesize recovery policies; train consumers in carrying out evaluations of mental health systems; and help further the development of peer-run services.^[40] Mental Health service directors and planners are providing guidance to help state services implement recovery approaches.^[41]

Some US states, such as California (see the California Mental Health Services Act), Wisconsin and Ohio, already report redesigning their mental health systems to stress recovery model values like hope, healing, empowerment, social connectedness, human rights, and recovery-oriented services.^[42] In California, The Village ISA, with its leading psychiatrist and recovery theorist Mark Ragins, has led the way for progress in the recovery approach.

At least some parts of the Canadian Mental Health Association, such as the Ontario region, have adopted recovery as a guiding principle for reforming and developing the mental health system.^[6]

New Zealand and Australia

Since 1998, all mental health services in New Zealand have been required by government policy to use a recovery approach^[43][44] and mental health professionals are expected to demonstrate competence in the recovery model.^[45] Australia's National Mental Health Plan 2003-2008 states that services should adopt a recovery orientation^[46] although there is variation between Australian states and territories in the level of knowledge, commitment and implementation.^[47]

UK and Ireland

In 2005, the National Institute for Mental Health in England (NIMHE) endorsed a recovery model as a possible guiding principle of mental health service provision and public education.^[48] The National Health Service is implementing a recovery approach in at least some regions, and has developed a new professional role of Support Time and Recovery Worker.^[49] Centre for Mental Health issued a 2008 policy paper proposing that the recovery approach is an idea "whose time has come" ^[23][50] and, in partnership with the NHS Confederation Mental Health Network, and support and funding from the Department of Health, manages the Implementing Recovery through Organisational Change (ImROC) nationwide project that aims to put recovery at the heart of mental health services in the UK. ^[51] The Scottish Executive has included the promotion and support of recovery as one of its four key mental health aims and funded a Scottish Recovery Network to facilitate this.^[52] A 2006 review of nursing in Scotland recommended a recovery approach as the model for mental health nursing care and intervention.^[53] The Mental Health Commission of Ireland reports that its guiding documents place the service user at the core and emphasize an individual's personal journey towards recovery.^[54]

See also

References

External links

• NASW Practice Snapshot: The Mental Health Recovery Model
• Recovery as a Journey of the Heart (PDF)
• A Critical Exploration of Social Inequities in the Mental Health Recovery Literature
• National Resource Center on Psychiatric Advance Directives