Recovery Theory (Issue: 3)

The consumer recovery model has had increasing influence on mental health practices in the United States, Western Europe, and several other countries. However, adoption of the model has reflected political decisions rather than empirical evidence of the validity of the model or its value for treatment services. The recovery construct is poorly defined, and until recently there has been no reliable and valid measure with which to base a research program. We have developed an empirical measure that is well-suited for both research and clinical applications: We briefly describe the MARS and present preliminary data demonstrating that recovery is not a simple by-product of traditional outcome do-mains, but seems to be a distinct construct that may have important implications for understanding consumers with serious mental illness and for evaluating the outcome of treatment programs.

Schizophrenia and most other forms of serious mental illness have traditionally been viewed as chronic conditions with poor outcomes. This pessimistic view has begun to change, as a series of long-term outcome studies have demonstrated that the course is more variable both across and within individuals, and that many people meeting strict diagnostic criteria have very good outcomes, often without maintenance medication e.

There are now upwards of 20 contemporary studies of the long-term outcome of schizophrenia. At the same time as these new outcome data have been collected, there is growing recognition that traditional paternalistic mental health services have generated feelings of hopelessness and helplessness among many consumers, promoting dependence, and fostering stigma. In response to the failure of traditional services, consumers and many professionals have promoted a recovery movement, based on a model of recovery and health care that emphasizes hope, respect, and consumer control of their lives and mental health services 5.

Two important reports from the US federal government provided momentum to the recovery movement. Transforming mental health care in America 7. Among other things, the report stated: The principles enunciated in these reports have been adopted by several state mental health systems in the United States, along with Canada, the United Kingdom, Italy, Australia, and New Zealand.

The consumer movement and the associated policy changes are based on the contention that recovery is a process that occurs over time in a non-linear fashion 8. It is a way of living a satisfying, hopeful, and contributing life even with limitations caused by illness.

The SAMHSA definition and dimensions are each elaborated in an accompanying document, but they do not provide an operational definition of recovery. Rather, they comprise diverse dimensions of the recovery model, in- cluding: As SAMHSA is the federal agency charged with developing and implementing national health policies, this conceptualization will likely have important implications for clinical practice and reimbursement in the United States.

CONSUMER-ORIENTED DEFINITIONS OF RECOVERY

However, the recovery components specified by SAMSHA are not well-defined and there are marked redundancies across the items e. Some of the elements refer to individual characteristics e. Overall, the elements are not adequate criteria for research, or for evaluating the effectiveness of clinical programs. No systematic data are available on rates of recovery as defined from the consumer perspective. Anecdotal data and commentaries by the many impressive consumer spokespersons for the recovery model are informative, but it is difficult to extrapolate from these sources of information.

It is clear that the professional and scientific communities have not sufficiently appreciated the subjective experiences of people with severe mental illness, and their ability to recover from the debilitating effects of their illness. Conversely, it is not clear if the experiences of consumer-professionals are characteristic of the broader population of people with severe mental illness or if they represent a distinct good outcome subgroup. If the concept is to have lasting impact, it is essential that it be tied to more objective measures of course of illness and community functioning that are viewed as relevant by scientists, clinicians, family members, and legislators.

Studies are required to understand factors that contribute to consumer-defined recovery and determine its course. For example, consumer definitions generally suggest that recovery is independent of symptoms, but the few studies that have examined this issue report that recovery and symptoms are negatively correlated 14 , A major limitation of the consumer model of recovery is that is it not grounded in established psychological principles, and refers to vague constructs that have not been objectively defined Bandura postulated that people are agents of their experience and not simply passive respondents to a deterministic environment, or automatons who are driven by neurocognitive processes.

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The primary engine through which agency operates is self-efficacy. It also involves both personal agency what people can do on their own and interpersonal agency ability to marshal help from others It has a powerful influence on motivation and goal setting, life choices, and action. The more people are confident in their ability to succeed or cope effectively, the more willing they are to set ambitious goals and take action.

Self-efficacy also influences affect states. High self-efficacy can lead to mastery experiences, self-esteem, and life satisfaction, while low self-efficacy can lead to anticipatory anxiety, a sense of failure regardless of actual performance , helplessness, and depression. Negative experiences and attitudes on the left diminish self-efficacy, which leads to decrements in parameters of recovery, while positive experiences and attitudes on the right enhance self-efficacy and foster recovery.

People with severe mental illness often have histories of personal failure in a host of social role experiences, experience harmful stigma from the public, media, mental health professionals, and sometimes significant others , and often develop self-stigma These experiences can erode self-efficacy for coping with their illness or dealing with a broad range of life demands.

Diminished self-efficacy can lead to hopelessness, lack of self-respect, and lack of feelings of control self-direction or empowerment, which has been shown to happen in people with severe mental illness Conversely, vocational success, effective shared decision making in health care, and other mastery experiences can produce increased self-efficacy and enhance feelings of empowerment, hope, self-respect, and capacity for self-direction.

Recovery from severe mental illness entails developing enhanced efficacy beliefs for key social roles e. The contention that recovery entails adaptation to illness and disability 10 is consistent with the social learning view that efficacy beliefs are specific to situations and that a person can feel efficacious in some domains despite hav- ing difficulty in others. The empirical literature on self-efficacy and agency in severe mental illness is limited, although the concepts have been widely linked 22 , 23 , 24 and several studies support the relationship between efficacy and outcomes in severe mental illness samples.

Personal efficacy has been shown to be related to quality of life and community functioning, including employment, in several studies 23 , 25 , Efficacy was found to have a strong negative relationship with perceived discrimination and self-stigma, and a strong positive relationship with empowerment in an outpatient schizophrenia cohort 27 , and it was inversely related to depression and perceived loss of independence in a schizophrenia spectrum sample While not directly measuring self-efficacy, Grant and Beck 29 examined the related construct of defeatist beliefs: They found that these negative attitudes mediated the relationship between cognitive impairment and both negative symptoms and social and vocational functioning in a sample of people with schizophrenia and schizoaffective disorder.

Another limitation of the current literature on the consumer model is that it is not clear to what extent recovery is mediated or moderated by functional outcome domains, such as work and social relationships: Does progress along the path toward recovery enable improved social relationships, do improved relationships contribute to recovery, or is movement along both dimensions somehow intertwined? We believe it is essential to develop a scientific base for the consumer model and to document that recovery has important practical and conceptual implications that extend beyond the subjective well-being of consumers.

Adverse experiences may diminish efficacy, and prevent or retard recovery, while positive experiences would have the opposite effect. There is also a feedback loop in which enhanced efficacy and progress along the path of recovery motivates and empowers the person to make positive life changes.

Recovery | Mental Health Foundation

Conversely, an increased sense of hope and empowerment may enable the person to seek better housing. Recovery may also be influenced by moderators. Recovery-oriented treatment can exert a positive influence, and paternalistic care can have a negative effect. Some domains, such as substance use, psychiatric symptoms and cognitive impairment, may function as negative moderators only when they are at significant levels. Yet another limitation of the recovery construct is that there are no measures of recovery as defined by SAMHSA and only a handful that are based on other definitions Andersen et al 31 identified only one recovery measure in a search of the published literature.

Campbell-Orde et al 32 surveyed consumer and government organizations as well as the literature and identified eight measures, of which only six actually focus on recovery per se. Results of these surveys reflect the fact that, for the most part, extant recovery instruments have been developed ad hoc by consumer groups and have not been published. They have evolved from small work group or consensus conferences with primary attention to face and consensual validity rather than a systematic psychometric program of scale development. Most are based on unsupported models or definitions of recovery.

Some are too long to be practical, and others are too heterogeneous to be useful as overall outcome variables. In response to this situation we have developed a new measure based on our operationalized version of the SAMHSA recovery domains: The MARS is a item self-report instrument designed to assess recovery status in people with serious mental illness. It was developed using an iterative process by a team of six doctoral level clinical scientists with expertise in serious mental illness and recovery in a series of ten face-to-face meetings, supplemented by structured interviews with six independent experts and a panel of consumers.

Reductions in services cannot be justified on the basis of meeting the goal of being supportive of recovery. The clinical framework underpinning most mental health services locates problems of exclusion largely within the individual. Clinical endeavours, therefore, focus on changing people through treatment therapy, skills training, etc. This requires a framework predicated on a human rights and a social model of exclusion: Participation and inclusion do not involve changing people to fit in, but changing the world: Work, whether it is paid, voluntary or household work, is the major way most people make a contribution to society.

Work supports recovery Self-stigma, anticipated discrimination and discrimination in services and society contribute to these high unemployment rates 41 — 43 , as can deficit-based services with low employment expectations for people with major mental distress, and employers who lack knowledge of good employment practices for this group of people Currently, governments in many Western countries are attempting to reduce the numbers of people receiving welfare benefits or pensions, often with a punitive rather than incentive-based approach.

Advocates who lobby against this approach to welfare have inadvertently created a discourse that focuses on the right to welfare over the right to work for people with mental distress. Punitive welfare reform is not the fundamental injustice; it is the number of people who are out of work. The whole community benefits when it is assumed that people with mental health problems can work, when they have the same rights as others to determine their contribution, and when they have reliable access to welfare if or when they cannot work.

Is recovery just new wine in old bottles 45? In other words, does supporting recovery mean more than just optimal implementation of what we already know is best practice?

However, a systematic review has identified five key recovery processes as connectedness, hope and optimism, identity, meaning and purpose, and empowerment the CHIME framework These recovery processes differ from traditional clinical outcome targets, and interventions targeted at these processes are needed.

We now describe ten empirically supported pro-recovery interventions. Inclusion criteria were interventions that target recovery outcomes such as the CHIME framework, and have emerging or established supportive empirical evidence based on experimental investigation. They are intended as illustrative exemplars rather than a prescriptive list of interventions. The aim is to identify the types of intervention which could be expected to be provided in a recovery-oriented mental health system.

It is based on recovery values of hope, self-determination over one's life, participation in the service, mutuality, and the use of lived experience knowledge to help each other. Informal peer support comes from natural supports such as family and friends. By contrast, formal peer support involves workers who are either employed in autonomous peer-run services outside traditional mental health services, or partner with professionals within a traditional mental health or social service. Peer support workers are individuals with mental illness who identify themselves as such, and who use their lived experience to support others to recover.

Key features of their role are clear 47 , and implementation guidelines are now available A substantial and positive evidence base now exists for peer support services 47 , identifying the experience and benefits of being a peer support worker 49 — 51 , changes in workplace structure made to sustain the delivery of peer support services 52 — 54 , and description of changes initiated by peer support workers 55 , Evidence from seven randomized controlled trials RCTs evaluating the impact of peer support workers found consistent benefits in relation to clinical outcomes engagement, symptomatology, functioning, admission rates , subjective outcomes hope, control, agency, empowerment and social outcomes friendships, community connection RCTs on peer-led self-management interventions in the Netherlands 58 and USA 59 , 60 showed benefits in relation to having a recovery role model, pursuing recovery, hopefulness, self-perceived recovery, symptom scores and quality of life.

A Cochrane review identified eleven randomized trials involving 2, people in three countries Australia, UK, USA , showing equivalent outcomes from peer support workers compared with professionals employed in similar roles People with mental illness are almost by definition vulnerable to experiencing emotional crisis. Recent healthcare technologies support people to remain in control during crisis. For example, an advance directive involves specifying actions to be taken for the person's health if capacity is lost in the future.

Actions may involve treatment or specify a proxy decision-maker. Advance directives have strong empirical support A variant increasingly used in a mental health context is joint crisis plans, which are developed in collaboration with the clinical team. RCT evidence about joint crisis plans in psychosis shows benefits for reduced compulsory treatment 63 , service use 64 and increased control Trials in other clinical populations are underway Self-management of symptoms is a major trend across all chronic disease groups.

The wellness recovery action planning WRAP tools and processes support self-management with a specific focus on recovery-oriented mental health services. WRAP is used to create recovery plans, by guiding individuals and groups of people to reflect on what has assisted them to stay well in the past, and to consider strategies that assisted others with their recovery The focus is on approach motivation defining wellness and supporting goal striving rather than avoidance motivation e. The process relies on peer facilitation, to activate the hope-inducing benefits of authentic role models The illness management and recovery program IMR is an empirically-supported standardized intervention to teach illness self-management strategies to people with a severe mental illness It can be provided in individual or group format, takes five to ten months to complete, and comprises five empirically based strategies: The centrality of medication adherence and psychoeducation about mental illness in IMR can present a barrier to its use by people seeking to support recovery.

Supporting recovery is not incompatible with diagnosis and medication, but a barrier arises when diagnosis and medication are assumed to come first in steps towards recovery 71 see Abuse 3. However, IMR begins with and focuses on self-directed problem definition, problem solving and pursuit of personally meaningful goals, all vital elements of recovery support 72 , RCT evaluations indicate IMR can significantly improve symptomatology, functioning, knowledge and progress towards goals for people in supportive housing 74 , outpatient services 75 , and community rehabilitation centres The manualized intervention 77 is theoretically based 32 , Staff are trained and supported through reflection sessions and supervision to use three working practices.

First, to maximize person-centred care planning, staff discuss the values and treatment preferences of the service user, using conversational, narrative and visual approaches. Second, staff use a standardized assessment 79 to identify the service user's strengths, so that care planning will be focused on amplifying strengths and ability to access community supports, as well as on deficit amelioration. Additionally, the staff-service user relationship is targeted by training staff to use coaching skills.

The strengths model of case management aims to help people with mental health problems to attain goals they set themselves by identifying, securing, and sustaining the range of environmental and personal resources that are needed to live, play, and work in a normally interdependent way in the community It has been used broadly and over decades in social care sectors in the USA, and in clinical services in Japan, Hong Kong and Australia The evidence base comprises four RCTs 85 — 88 and several pre-post evaluations 89 , showing improved psychosocial outcomes especially for symptomatology and social functioning and consumer satisfaction Greater fidelity is associated with more improved consumer outcomes People with psychiatric disabilities have emphasized the importance of education as a tool to assist them in gaining the competencies needed to assume full citizenship Recovery colleges or recovery education programs are an educational approach to supporting the recovery and reintegration of people with psychiatric disabilities.

This model of service provision was pioneered at Boston University in 92 , and is now being introduced in Italy, Ireland and England There is robust supporting evidence for several key features 94 , including co-production 95 and supporting self-management through education College-specific evaluation evidence is positive but limited People who cannot work should have easy access to welfare, and positive incentives to return to work.

But most people with mental health problems want to work 98 , though they need support in choosing, finding and keeping work Individual placement and support is an intervention which provides this support , and has a strong evidence base For example, a six-country European RCT showed that individual placement and support was superior to the local alternative in each site, in terms of helping people find and maintain paid employment Follow-up studies conducted after years confirm that the greater effectiveness of this intervention is sustained over the longer term , , and there is evidence of cost savings through reduced mental health service use and lower reliance on welfare benefits , Safe and secure permanent housing can act as a base from which people with a severe mental illness can achieve numerous recovery goals and improve quality of life , The housing first intervention involves rapid re-housing in independent accommodation.

This approach has an emerging evidence base showing improved outcomes and reduced costs People with a severe mental illness should have access to a range of housing options, with the capability to exercise choice regarding preferences. The active involvement of mental health service users, relatives and friends is essential for the development of recovery-oriented mental health practice and research However, the idea that mental health is everyone's business, regardless of their background and experience, and accepting each other as equally entitled experts, remains a challenge.

What Is Recovery?

Trialogue groups also known as psychosis seminars are an approach to addressing this challenge. A mental health trialogue meeting is a community forum where service users, carers, friends, mental health workers, and others with an interest in mental health participate in an open dialogue. Meetings address different topics, e. In German-speaking countries, well over one hundred trialogue groups are regularly attended by 5, people , and international interest and experiences are growing Trialogues facilitate a discrete and independent form of acquisition and production of knowledge, and drive recovery-oriented changes in communication and structures.

Although the CHIME framework has been shown to apply across those cultures which produced guidelines included in the review , the generalizability of the concept of recovery remains a concern. For example, an important issue is the collectivist versus individualist value paradigm In collectivist cultures, such as Maori the indigenous people of New Zealand and Chinese ones, emphasis is placed on interdependence among family members and relatives over and above the independence that is often promoted in Western cultures Apart from culture, the mental health system and service context are also important considerations.

For example, middle-and low-income countries may not have the infrastructure, such as budget and community-based services, to support basic mental health care , let alone recovery approaches. It is important to investigate how the concept of recovery is interpreted by service users and health professionals within a non-Western cultural context — Can recovery-related assessment and fidelity scales be applied with reliability and validity ?

By investigating factors that facilitate or hinder recovery for individuals from diverse backgrounds, more culturally applicable recovery concepts can be developed which will better address service users' needs and rights. An understanding of how to transform services is emerging.

Recovery Model of Mental Illness: A Complementary Approach to Psychiatric Care

A synthesis of international guidance on supporting recovery identifies four levels of practice: Most interventions reviewed in this paper address the first two of these levels. The Implementing Recovery — Organizational Change ImROC initiative across England addresses the culture of mental health services 93 , using a learning set approach to helping organizations address ten key organizational challenges The final frontier is perhaps reducing and removing the barriers which prevent individuals experiencing full entitlements of citizenship It has been argued that this change of emphasis applies more widely than just support for employment and housing However, the broadest — and most important — challenge is societal change, which will involve professionals and people with lived experience becoming partners and social activists , to challenge stigmatizing assumptions that people with mental illness cannot, or should not, have the same citizenship entitlements as anyone else in their community.

The views expressed in this publication are those of the authors and not necessarily those of any healthcare organization or funding agency. National Center for Biotechnology Information , U. Journal List World Psychiatry v. Published online Feb 4. Author information Copyright and License information Disclaimer. This article has been cited by other articles in PMC. Abstract An understanding of recovery as a personal and subjective experience has emerged within mental health systems. Recovery, mental health services, peer support workers, advance directives, wellness recovery action planning, individual placement and support, supported housing, mental health trialogues, organizational transformation, promoting citizenship.

Advance directives People with mental illness are almost by definition vulnerable to experiencing emotional crisis. Wellness recovery action planning Self-management of symptoms is a major trend across all chronic disease groups. Illness management and recovery The illness management and recovery program IMR is an empirically-supported standardized intervention to teach illness self-management strategies to people with a severe mental illness Strengths model The strengths model of case management aims to help people with mental health problems to attain goals they set themselves by identifying, securing, and sustaining the range of environmental and personal resources that are needed to live, play, and work in a normally interdependent way in the community Recovery colleges or recovery education programs People with psychiatric disabilities have emphasized the importance of education as a tool to assist them in gaining the competencies needed to assume full citizenship Individual placement and support People who cannot work should have easy access to welfare, and positive incentives to return to work.

Mental health trialogues The active involvement of mental health service users, relatives and friends is essential for the development of recovery-oriented mental health practice and research Recovery from mental illness: Department of Health and Ageing. Fourth national mental health plan: Commonwealth of Australia; Mental Health Commission of Canada. Changing directions, changing lives: Mental Health Commission of Canada; New Freedom Commission on Mental Health.

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