From Medscape Psychiatry & Mental Health

Mental Illness in 2010: Putting the Recovery Model Into Practice

 

The Refocus on Recovery 2010 conference, held in London, United Kingdom on September 20 th to 22 nd, provided a multitude of insights for clinicians interested in applying the recovery paradigm to clinical psychiatric practice. After a brief overview of the recovery model, which has been developed primarily in public-sector psychiatric settings caring for individuals with serious mental illnesses, I will summarize some ways that this approach can be put into practice.

As noted by Dr. Patricia Deegan in 1996, the concept of recovery is "rooted in the simple yet profound realization that people who have been diagnosed with mental illness are human beings." [1] Davidson and Strauss [2] noted that recovery represents "rediscovery and reconstruction of an enduring sense of the self as an active and responsible agent," even in the midst of symptoms and dysfunction. For many practitioners, however, the recovery paradigm has remained largely theoretical -- a well-intentioned model of working with clients, though with unclear ramifications in terms of translating this approach to routine clinical practice.

What Are the Core Elements of the Recovery Paradigm?

As described by Marianne Farkas, PhD, from the Center for Psychiatric Rehabilitation at Boston University, at the Refocus on Recovery 2010 conference, although each individual's definition of recovery varies, recovery can be defined generally as the deeply personal and unique development of new meaning and purpose as one grows beyond the catastrophe of mental illness. [3] As such, recovery involves, at its most basic, reclaiming a meaningful life. Thus, it is a process owned by the client, not the service, though mental health practitioners can be helpful during the process. Recovery is a long-term journey with many dimensions; it includes re-engaging in life, finding a niche or major role, developing secondary roles, reawakening hope, developing a sense of purpose, and living despite having a disability. [4]

Dr. Farkas noted that examples of recovery outcomes include [5]:

  1. Gaining or regaining the role of student, worker, community member, or tenant;
  2. Experiencing increased success and satisfaction in these roles;
  3. Reducing/controlling symptoms;
  4. Increasing a sense of empowerment;
  5. Enhancing feelings of well-being;
  6. Increasing the number or quality of interpersonal connections;
  7. Improving measures of physical health; and
  8. Increasing a sense of self-esteem.

Similarly, Victoria Bird, researcher and PhD student with the Health Service and Population Research department at the Institute of Psychiatry (King's College London), discussed at the conference a conceptual framework for personal recovery, which includes key elements of connectedness, identity, meaning and purpose, empowerment, and hope and optimism.

Social inclusion of individuals with mental illnesses, as well as broader issues pertaining to social justice, is frequently discussed in relation to the recovery model. As summarized by Dr. Lynne Friedli at the conference, themes of the recovery paradigm include self-determination and self-management, hope, social inclusion and valued social roles, and personal responsibility, as well as personalization, choice, agency, and control within mental health services. Along these lines, the phrase "nothing about us without us" is a slogan of the consumer movement (and a basic principle of social justice and human rights) that is particularly relevant to the recovery paradigm.

Some of the characteristics of a recovery-oriented organization include ongoing reconfiguration of the program's or health system's mission, policies, procedures, activities, record keeping, and organizational culture toward a recovery approach; working in true partnership with clients; and including people with lived experiences (eg, peer specialists) in the delivery of services. As noted by Dr. Farkas at the conference, recovery is the overall aim of the integrated service system; recovery does not get housed in a particular program component; it is not an intervention per se (like the manualized evidence-based practices that have been proven through randomized, controlled trials); and it is not just a philosophy or political movement.

How Can Practicing Psychiatrists Apply the Recovery Model to Practice?

Dr. Farkas noted that the stage has been clearly set for the adoption of recovery, given that recovery has been known in the literature for more than 30 years. [6] A number of countries, including the United States, United Kingdom, and Australia have declared the importance of the recovery approach at a national level. In the United States, this is exemplified by the New Freedom Commission on Mental Health. [7] Yet, Dr. Farkas noted that in the United States, more than 70% of individuals with serious mental illnesses remain unemployed and only about one quarter have a college degree. In light of these persistently dismal outcomes for many people with serious mental illnesses, largely driven by "a distracted, fragmented and often unavailable system," mental health professionals should work to transform systems by changing the paradigm within which services are conducted.

The American Association of Community Psychiatrists (AACP) has provided guidelines -- in the domains of administration, treatment, and supports -- for transforming behavioral health services into recovery-oriented services. [8] The AACP notes that recovery-oriented services should replace paternalistic, illness-oriented perspectives with collaborative, autonomy-enhancing approaches, which represents a major cultural shift in service delivery. Specifically, the AACP recommends that recovery (defined as "a personal process of growth and change, which typically embraces hope, autonomy, and affiliation as elements of establishing satisfying and productive lives in spite of disabling conditions or experiences") be incorporated through such methods as enlisting consumer and family members to participate in decisions regarding resource allocation and service development; developing an array of vocational services, such as the individualized placement and support model of supported employment; and ensuring access to housing options that support independence, choice, and progression. [8]

Back at the Refocus on Recovery 2010 conference, Clair Le Boutillier, researcher and PhD student also from the Health Service and Population Research department at the Institute of Psychiatry, described key elements of recovery-oriented practices based on a qualitative thematic analysis of 31 international practice guidelines, which revealed 4 key domains of recovery-oriented practices:

  1. The socio-political environment, which includes human rights (basic material needs, stigma and discrimination, advocacy), social inclusion (community participation, social networks), and daily occupations (meaningful activity, valued life roles);
  2. Workplace environment/organizational commitment to recovery, encompassing workplace support structures, quality improvement, care pathways, and workforce planning;
  3. Practice-environment interaction, including working in partnership and inspiring hope; and
  4. Practice approach/an approach that supports a personally defined recovery, which includes informed choice, peer support, a strengths focus, and a holistic approach.

Clearly, psychiatrists can play a major role in promoting the recovery paradigm in any or all of these 4 domains, ranging from adopting a recovery-oriented practice approach to advocating within the socio-political environment.

Dr. Farkas noted a number of practical steps -- too many to be enumerated here -- that can help clinicians move toward an embrace of the recovery paradigm. For example, mental health professionals and program leaders can stop: (1) organizing activities around diagnostic labels and using the role of "patient" in such activities; (2) reserving medical charts primarily for the documentation of failures rather than strengths and accomplishments; (3) segregating clinicians' and consumers' bathrooms, coat racks, and coffee services; and (4) utilizing a system in which only professionals conduct hiring interviews. They can start doing such things as: (1) involving clients in their team planning and review meetings; (2) inviting program graduates to speak at activities; (3) decorating facilities based on input from the individuals who are served; and (4) hiring in a way that considers lived experience as a "value added."

Conclusion

In summary, the recovery paradigm is now widely accepted as the contemporary approach to tailoring mental health service provision for individuals with serious mental illnesses. In addition to clinicians gaining an in-depth understanding of the tenets of the recovery model, they can take steps to put recovery into practice by re-orienting services in a number of ways, ranging from referral policies, to charting procedures, to ways of interacting with clients.

References

  1. Deegan P. Recovery as a journey of the heart. Psychiatric Rehabilitation Journal. 1996;19:91–97.
  2. Davidson L, Strauss JS. Sense of self in recovery from severe mental illness. British Journal of Medical Psychology. 1992;65:131–145.
  3. Anthony WA. Recovery from mental illness: The guiding vision of the mental health service system in the 1990s. Psychosocial Rehabilitation Journal. 1993;16:11–23.
  4. Ridgway P. Restorying psychiatric disability: Learning from first person recovery narratives. Psychiatric Rehabilitation Journal. 2001;24:335–343.
  5. Farkas M, Gagne C, Anthony W, Chamberlin J. Implementing recovery oriented evidence based programs: Identifying the critical dimensions. Community Mental Health Journal . 2005;41:141–158.
  6. Farkas M. The vision of recovery today: What it is and what it means for services. World Psychiatry. 2007;6:68–74.
  7. New Freedom Commission on Mental Health: Achieving the Promise: Transforming Mental Health Care in America.Final Report. Department of Health and Human Services Pub. No. SMA-03-3832. Rockville, MD: 2003.
  8. Sowers W. Transforming systems of care: The American Association of Community Psychiatrists guidelines for recovery oriented services. Community Mental Health Journal. 2005;41:757–774.

Authors and Disclosures

Michael T. Compton, MD, MPH, Associate Professor, Emory University School of Medicine, Department of Psychiatry and Behavioral Sciences, Atlanta, Georgia. Dr. Compton has disclosed no relevant financial relationships.

-From “Mental Illness in 2010: Putting the Recovery Model Into Practice”, by Michael T. Compton, MD, MPH, http://www.medscape.com/viewarticle/730233_4, posted 10/15/2010, retrieved 10/20/10.

 

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