Abstract
The concept of recovery is now widely promoted as the guiding principle for the provision of mental health services in Australia and overseas. While there is increasing pressure on service providers to ensure that services are recovery oriented, the way in which recovery-based practice is operationalized at the coalface presents a number of challenges. These are discussed in the context of five key questions that address (i) the appropriateness of recovery as a focus for service delivery, (ii) the distinction between recovery as a process and an outcome, (iii) the assessment of recovery initiatives, (iv) the alignment of recovery with current service delivery models, and (v) the risks associated with recovery-based practice. It is argued that these questions provide a framework for a debate that must extend beyond patients and providers of mental health services to the broader public, whose attitudes will ultimately determine the possibilities and limits of recovery-oriented practice.
The current emphasis on recovery that has emerged from the lived experience of people with mental illness suggests that many of these individuals are able to overcome their difficulties to lead satisfying and contributing lives. This clearly challenges the belief that conditions such as schizophrenia follow a course of progressive deterioration. The concept of recovery provides a new approach to the provision of mental health services and is now widely promoted in most developed countries [1], [2]. Indeed, recovery has begun to shape the thinking of mental health professions [3], the policies that underpin mental health services [4], [5], the development of specific approaches to the provision of mental health services [6], and the provision of mental health training [7], [8].
In Australia, recovery has become popular in mental health discourse and currently underpins mental health policy and service delivery initiatives. The National Mental Health Plan 2003–2008 [9] advocates that ‘a recovery orientation should drive service delivery’. There is increasing pressure on service providers to ensure that the services offered to people with mental health problems are recovery oriented. But it is not clear that the concept of recovery is used in a consistent manner or that the implications for service delivery have been thought through in a systematic way. In the USA, where the recovery movement originated, mental health services have identified a range of concerns about using recovery as the guiding framework for service provision [10]. It is therefore timely to step back from the rhetoric of recovery and take a closer look at some of the implications for service providers if recovery is to be used as a guiding vision for mental health service delivery.
Recovery within the mental health context
Although the exact definition of recovery remains ambiguous, there is consensus that recovery does not necessarily imply ‘cure’. Many health professionals (and patients) fail to grasp this distinction and confuse recovering (the process) with recovery/recovered (the outcome) [11]. The current focus on the concept within the mental health context seems to emphasize the process rather than the outcome. This is not to suggest that outcomes such as symptom reduction are irrelevant. What is important is the personal meaning that each individual attaches to the concept. Common themes in patient accounts indicate that recovery involves developing new meaning and purpose in life, taking responsibility for one's illness, renewing a sense of hope, being involved in meaningful activities, managing symptoms, overcoming stigma, and being supported by others [12], [13]. Recovery in the mental health context implies that while individuals with mental illness may continue to experience symptoms and functional disability, they can move beyond the negative consequences of the illness to achieve greater self-confidence and hope for the future [14].
The implication for service providers is that they should seek to leverage their services to promote the components of recovery highlighted by patients. This will require mental health staff to approach service provision with new thinking, refined skills and more positive attitudes [15]. Moving beyond a focus on psychopathology towards helping people foster self-efficacy and pursue their personal goals is seen as a key component of this transition [16]. While this is unlikely to conflict with clinicians’ existing values, it does raise a number of practice issues for service providers. These are discussed here under five key questions.
Is ‘recovery’ an appropriate focus for service delivery or is it a purely personal phenomenon?
Recovery is usually self-defined and each individual's experience of their recovery may be very different. Thus there is no clearly prescribed formula or defined set of service inputs for achieving recovery. Recovery principles [1] and standards [3] are available but these tend to focus on system level issues and provide limited guidance to practising clinicians. The subjective and personal nature of recovery makes it difficult for clinicians to comprehend [10] and thus, operationalize at the service level [17].
Published narratives from the recovery literature seem to suggest that the orientation of ‘traditional’ services impedes recovery [18–20]. Themes from many of the published accounts of recovery include survival in the face of dysfunctional services and the importance of personal qualities and natural supports that are independent of services [15], [21]. Recovery advocates are understandably critical of services that claim to be recovery oriented but continue to focus on goals of maintenance, monitoring, symptom management and relapse prevention [5].
But it is challenging for services to substantially shift their focus away from these service components. Most services for people with severe mental illness operate in a public environment where there is accountability to third parties (ultimately to the general public), whose priorities include individual and community safety and who are likely to have a low tolerance for adventurous services. Moves to standardize treatment through the introduction of clinical pathways in the mental health field may compromise attempts to establish recovery-based practice [22]. To operate within a recovery oriented framework, services need to be able to balance the tension between working with the priorities and goals of patients and addressing the expectations and anxieties of the community, rather than simply responding to one or the other.
This is not to suggest that recovery-oriented services are not achievable. Advocates of recovery oriented services frequently cite the work of Harding et al. and others to demonstrate that people with severe disabilities can recover when a mental health service system adopts a therapeutic approach to service delivery [23], [24]. But the presumption that services can become recovery oriented by virtue of changes in clinician values or the introduction of recovery principles is somewhat naïve. A great deal of work needs to be done to clarify what is meant, operationally, by recovery-oriented services and this needs to involve consultation with third-party stakeholders as well as providers and patients. The challenge for mental health services is to develop strategies that harness the recovery capacities of individuals as they learn new ways of coping with their illness.
Is a recovery orientation in mental health services an end in itself or a means to achieve traditional outcomes such as symptom remission, reduced dependence on services or functional improvement?
There is increasing pressure on the mental health professionals to shift their focus to the process of recovery rather than the traditional outcomes of symptom remission and functional improvement [1], [15]. Indeed, the focus on recovering seems to be an end in itself. As noted by Whitwell, people with mental illness may go on recovering throughout their life and may never achieve complete recovery [25].
Much greater awareness of recovery processes and the lived experience of individuals with mental illness is required. But conventional measures of outcome tend to reflect the priorities of the service provider and not necessarily those of the service user [26]. Traditional outcomes are usually assessed using standardized and objective measures and rarely consider factors important to patients (e.g. hope, empowerment, spirituality, and narratives of the subjective experience). Indeed, recent initiatives to promote the use of routine outcome measures in Australia have been criticized for not focusing on patient concerns [27]. But we think it is important not to confuse the recovery process with functional outcomes and especially important not to assume that the former has superseded the latter. It is possible that the focus on process that is promoted within a recovery-oriented system will lead to better functional outcomes for patients. Although the evidence to support this hypothesis is growing, it is far from conclusive [11].
What kind of measurement is required to determine whether services are contributing to, rather than detracting from, the experience of recovery?
Traditional outcomes of service delivery (readmissions, symptom reduction, improved functioning etc.) are objectively defined and can be subjected to reliable measurement. In contrast, the constructs central to recovery (e.g. personal growth, hope, autonomy, spirituality etc.) are individually defined and much more subjective in their application. Although these factors complicate assessment, a number of authors have attempted to operationally define these constructs. Corrigan and Ralph defined three dimensions of recovery that should be considered in evaluation studies [2]: (i) psychological well-being (how one experiences the present; i.e. satisfaction and limitations with life etc.); (ii) hope (whether one looks towards the future with the promise of continued satisfaction and achievement despite the limitations of the illness); and (iii) spirituality (whether one looks beyond the immediate world for inspiration and guidance).
Others have produced instruments that assess the construct from a number of perspectives. The Recovery Assessment Scale [28] is a useful measure of patient perceptions of their role in the recovery process. The items that make up this measure have been derived from interviews with people in recovery. The 41 items coalesce into five factors: personal confidence and hope; willingness to ask for help; goal orientation; reliance on others; and no domination by symptoms.
The Recovery Attitude Scale [29] and the Recovery Knowledge Inventory [30] are widely used to explore staff perceptions of recovery. Both instruments cover similar domains and tend to focus on the factors highlighted as being of relevance to patient recovery; roles and responsibilities in recovery, the importance of supports, the non-linear process of recovery, risk taking, and decision making. While these have acceptable psychometric properties, external validity is yet to be demonstrated. Further information is required on the extent to which those individuals who demonstrate improvement on these instruments experience recovery principles that are central to the concept.
At the service level it is important to have measures or benchmarks that can be used to evaluate the degree to which a complete service is recovery oriented. In the absence of such a measure, services can simply lay claim to this status in the knowledge that their claim is unlikely to be tested. The Recovery Self-Assessment [31] is gaining popularity as a useful measure of service orientation towards recovery. It enables assessment of services from a number of perspectives (providers, patients and family members) and covers a number of domains: the degree to which staff promote life goals, patient involvement, diversity of treatment options provided, patient choice, and the degree to which the services offered are individually tailored. Although there is preliminary evidence of construct validity, it needs to be demonstrated that the patients of services that rate highly show greater evidence of recovery than those of services that rate poorly.
While further work is needed on formal recovery assessment tools, the developers of these instruments will need to consider the lived experience of recovery in addition to service characteristics. Most of the instruments available are primarily quantitative in their structure and it has been proposed that the evaluation of recovery be broadened to include subjective experiences [12]. Nonetheless, we agree with Deegan that ‘such an approach may steer us toward solutions that are more complex and difficult to prove, but potentially more rewarding’ [12].
To what extent is recovery as a guiding principle compatible with current service models and practices, including involuntary and ‘assertive’ treatment?
Within the modern concept of recovery, control of the recovery process is clearly placed in the hands of the individual in recovery rather than the treating mental health professional [1], [10]. Individuals with mental illness may choose options that place them at risk or are inconsistent with what the evidence suggests is most likely to optimize outcomes. For example, a patient may decide to cease taking medication so as to assess his/her ability to manage their illness without it. The clinician, having reference to the research evidence and previous knowledge of treating the individual, may oppose such a move. This is likely to lead to a struggle between the patient who wishes to exercise self-determination and take control of their illness, and the clinician who is operating from an evidence base and sense of wider accountability.
Anthony points out that mental health organizations (and their employees) will need to accommodate and encourage practice models that enable individuals to take risks [1]. But clinicians may have different views about the degree of risk posed, when to intervene, and under what circumstances [32]. A possible consequence of a rupture between patient choices and clinician-recommended treatments is that individuals may be left to their own devices to become the victims of neglect under a banner of recovery [12]. Under the current system, mental health professionals tend to be risk-aversive because they have to justify their actions when efforts to promote patient empowerment result in negative outcomes [23]. While adequate risk assessment and advance treatment directives may provide some protection, mental health professionals will continue to err on the side of caution until they are assured that the system will support them in times of crisis [10].
Assertive models of case management and especially involuntary treatment of people with mental health problems may compromise patient autonomy. As a result, it has been argued that such an approach is not consistent with recovery-oriented service principles [33]. Anthony suggests that ‘outpatient commitment and forced medication oftentimes are seemingly paired in a naïve and incongruous way with the pursuit of recovery-oriented systems’ [34]. This suggests that services using force or coercion in the treatment of individuals with mental illness cannot claim to be truly recovery-oriented. While Anthony suggests that ‘there is no such thing as forced recovery’, it is difficult to see how force can be eliminated completely from service provision when the well-being and safety of patients, carers and the general public is at stake. Paradoxically, the more health professionals withdraw from assertive and involuntary treatment in the name of recovery, the more likely that police and others operating outside the mental health system will be called on to assume a coercive role.
We think that there is room for debate as to whether coercion in relation to mental health services should be distanced from clinical decision making. It may be that coercion is best placed in the hands of the criminal justice system where it is less likely to be confused with clinical care. Clinicians may resort to coercion because it is expedient rather than necessary [35]. Italian laws and practice norms that have restricted coercion in inpatient settings have not seriously compromised capacity to provide quality clinical care or increased the risk to staff [36]. But we think that it would be naïve to imagine that the shift to recovery-based practice will eliminate the need for coercion. This means that the incongruity between the values of the recovery approach and the use of coercion will need to be addressed because it adds to the confusion surrounding recovery.
What, if any, are the risks associated with adopting a recovery approach?
We think that there are three broad categories of risk associated with a recovery approach. The first is that it becomes a contemporary version of the ‘anti-psychiatry’ movement, discouraging people from accessing professional services that could benefit them. The second is that it could generate unreasonable expectations or disappointments when recovery as a process and lived experience becomes confused with recovery as an objective state. The third is that it could provide a ‘let-out’ that results in clinicians losing focus on their role of assisting patients to achieve functional improvements.
One of the assumptions of recovery is that ‘recovery can occur without professional intervention and that recovery may be facilitated by the patient's own natural support system’ [1]. Although it does not follow that professional services are rendered ineffective, there is risk that some patients and their families will interpret the concept in that way. While acknowledging the benefits of self-help and peer support, the potential contribution of professional help should not be devalued in the rush to a recovery-oriented system. As noted by Deegan, mental health professionals and those in recovery must ‘work together to expand opportunities for recovery’ [12].
Notwithstanding previous research, which suggests that a significant proportion of people with mental health problems can and will recover functional capacity, promoting recovery with patients and their families may create unrealistic expectations or impose pressure to achieve outcomes that are counterproductive. The potential problem is that what has become familiar jargon to practitioners, and short-hand for a very complex construct, may be interpreted in its everyday meaning by patients and families. Patients may form the expectation that this new way of providing care will lead to a quick cure and early return to pre-illness states [37]. Indeed, some individuals with long-standing mental illness may see the focus on recovery as an indication of failure on their part, because they have not or cannot recover. It is clearly important that practitioners develop a capacity to communicate about recovery without just using the term. It may be better not to use the term at all unless it is clear that patients and families already have a clear understanding of its meaning and the difference between this and its everyday usage.
Clinicians have been encouraged to develop a stronger focus on patient outcomes, having reference to both clinical and functional indicators [38]. We think that this is an important development because it introduces accountability both at an individual patient level and a service-wide level. If mental health services focus exclusively on the recovery process there is risk of what has, in another context, been termed ‘the soft bigotry of low expectations’. When professionals lose interest in functional outcomes, the risk for patients is neglect that is masked in some kind of recovery rhetoric [12].
Conclusion
The imperative to implement recovery-oriented services presents a number of challenges for service providers. Although adopting a ‘recovery vision’ has the potential to provide new opportunities and a renewed sense of hope for people with mental illness, without greater clarity and focus there is risk that it develops the quality of an empty aspiration. We have identified five questions that we believe must be addressed if recovery is to be a meaningful framework for service delivery. These questions do not yield to simple answers but rather provide a framework for discussion and debate among patients, service providers and other key stakeholders such as family and carers, policy makers, researchers and the wider public. In the absence of such a debate it is likely that enthusiasm generated by the possibilities inherent in this construct will be replaced by cynicism or confusion regarding its application. It is possible that transition to recovery-oriented services, if implemented in practice (rather than as rhetoric), will be as radical as the transition from institutional to community care. Recovery-oriented practice implies increased patient autonomy and greater willingness among mental health staff to work alongside patients, as distinct from managing care. Like deinsitutionalization, recovery-oriented practice is driven by ethical considerations as much as clinical considerations. Furthermore, it has implications for the community as a whole because it implies a less paternalistic approach to care and consequently an increased exposure of the community to both illness and recovery as a public phenomenon. It follows that the debate around the questions we have raised must not be confined to the clinical service environment but must extend into the broader community. Failure to obtain public understanding of and commitment to the principles of recovery oriented practice will result in a backlash when the consequences impinge directly or indirectly on public experience of mental illness. We agree with Deegan, who suggests that ‘we should remain critical but not cynical’ as we move towards recovery oriented service systems [12].