Creating a recovery-oriented society: Research and action

Mental health recovery recasts serious mental illness (SMI) from a chronic, degenerative and stigmatizing condition to a challenging individual journey of growth in pursuit of a self-determined and fulfilling life (Ashcraft and Anthony, 2006; Deegan, 1996; Ridgway, 2001). Definitions of recovery typically include both objective (e.g. symptom reduction, improved functioning) and subjective (e.g. increased agency, hope) outcomes, yet typically place consumers’ inherent strengths and resilience in the foreground of the recovery process (Whitley and Drake, 2010). This understanding of recovery, which is consistent with a Euro-American cultural context that is informed by notions of rugged individualism (Adeponle et al., 2012), risks missing larger environmental and societal factors that also determine a person’s well-being and that contribute to one’s ‘recovery potential’ (Draine et al., 2002). Although there has been an increasing focus on what constitutes a recovery-oriented mental health system (Davidson et al., 2009), less attention has been paid to what would constitute a recovery-oriented society.

Fundamental to a recovery-oriented society is legislation and judicial decision-making that prohibits discrimination based on psychiatric disability. Examples within the United States include the Americans with Disabilities Act of 1990 (Americans with Disabilities Act (ADA), 1990), which extends civil rights protection for persons with a mental illness, and the landmark Olmstead Supreme Court ruling (Olmstead v LC, 1999), which prohibits institutionalized treatment when there is the possibility of community-based alternatives. These anti-discrimination measures are critical yet often undermined. Lack of enforcement of existing laws is one problem. Over a decade after the Olmstead decision, the US Department of Justice is now beginning to address that many people residing in psychiatric hospitals continue to be institutionalized when alternatives do, or should, exist (US Department of Justice, 2011). A second issue is the enactment and enforcement of other legislation that runs counter to anti-discrimination measures. For example, many countries have laws that prevent the legal immigration of people with a mental illness (Thornicroft, 2006). Enforcement of existing laws and efforts to reconcile policies that are incompatible with anti-discrimination efforts are needed to promote a recovery-oriented society.

The provision of tangible public goods such as affordable housing and public transportation also plays a key role for a recovery-oriented society. Increased homelessness across Western countries speaks to larger economic disparities that disproportionately affect individuals with serious mental illness. Policies and programs that increase overall affordable housing have been lacking, although more recent attention has been paid to permanent supportive housing models designated specifically for those with psychiatric disabilities. This has been largely motivated by cost savings (Stanhope and Dunn, 2011). Investment in public transportation, however, cannot readily target particular populations using cost-savings arguments but are similarly critical to promote recovery. In fact, as Yanos (2007) has noted, the provision of affordable housing for persons with serious mental illness is increasingly located in remote areas as urban renewal continues. Given the limited access to resources, including car ownership, the lack of public transportation alternatives results in isolation and limited community integration. The allocation of public goods and the purposive design of the built environment can offer a corrective mechanism for marginalized and vulnerable populations that supports a recovery-oriented society.

Of course, societal attitudes remain the key to this larger recovery enterprise. Large-scale as well as targeted anti-stigma campaigns are currently being planned or are underway in several countries with promising, albeit preliminary, results (Henderson et al., 2012). With decreased stigma and the recovery movement’s emphasis on ‘peer’ services as a valuable (and valued) resource, important questions about the viability of positive mental health communities are now being raised (Mandiberg, 2012). Assumptions that ideal community integration consists of ‘mainstreaming’ and normalization may preclude conversation about a positive mental health subculture. An ongoing culture of stigma will inhibit these self-identified communities of the strength that could denote a recovery-oriented society.

The points raised above have briefly considered how a recovery orientation can be considered beyond the mental health system and include society’s rules and laws, allocation of resources, tangible and intangible public goods, and wider community attitudes. In its current form, recovery is about more than ‘simply’ overcoming a mental illness and includes addressing larger issues of increasing social and economic inequalities that exist in most countries. From a Maslovian perspective, the meeting of more basic needs is a prerequisite for self-actualization (Maslow, 1943). Moving up the pyramid towards self-actualization for persons with SMI will require alternative approaches to thinking about the recovery process that considers poverty, economic development, and social welfare more generally (Hopper, 2007). Recovered individuals may be the goal but the process of recovery depends on societal context.