We are pleased that CC have published many articles on the recovery approach in the last few years and thankfully now the NHS Trusts are beginning to employ the term and develop mechanisms to implement a recovery oriented approach. Service users/survivors should bear in mind as they read on that the most important aspect of the recovery approach to remember is that ‘you own your own recovery’. If you don’t experience that sense of ownership then it’s simply not recovery..
The recovery approach emphasizes and supports an individual’s potential for recovery. Recovery can be seen as a personal journey requiring hope, a secure base, supportive relationships, empowerment, social inclusion, coping skills, and finding meaning.
Originating in programs to overcome drug addiction, the use of the concept in mental health emerged as de-institutionalization resulted in more individuals living in community settings. It gained impetus due to the failure to adequately support social integration, and by studies demonstrating that many people can in fact recover.
The recovery model has now been explicitly adopted as the guiding principle of the mental health systems of a number of countries and states.
In many cases now very practical steps are being taken to base services on the recovery model. A number of standardized measures have been developed to assess aspects of recovery. There is also still some (at times considerable) variation between professionalized recovery models and those originating in the service user/consumer/survivor movement.
By consensus the main impetus for the development of a recovery approach came from the consumer/survivor movement, it was a grassroots self-help and advocacy initiative, particularly seen within the United States during the late 1980s and early 1990s. The professional literature, starting with psychiatric rehabilitation, 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’. Similar approaches developed around the same time, without necessarily using the term recovery, in Italy, the Netherlands and the UK.
Developments were fuelled by a number of long term outcome studies of people with major mental illnesses including populations from virtually every continent, including the landmark World Health Organization cross-national studies from the 1970s and 1990s, showing unexpectedly high rates of what were termed ‘complete’ recovery and ‘social’ recovery.
The cumulative impact of personal stories or testimony of recovery have also been a powerful force behind the development of recovery approaches. 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.
Increasingly, recovery became both a subject of mental health services research and a term symbolic of many of the goals of the user/consumer/survivor 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 some key questions remained. There is some variation within the Recovery Model as professionalized clinical approaches 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.
Recovery can be seen in terms of a social model of disability rather than a medical model and in practice should always incorporate direct payments and individualized funding, there may also be differences in the degree of acceptance of diagnostic labels and psychiatric rehabilitation. The concept of recovery is used primarily to refer to managing symptoms, reducing psychosocial disability, and improving role performance.
A US agency statement on mental health recovery, that involved some consumer input, proposed 10 fundamental components of recovery, which it defined it as a journey of healing and a transformation enabling a person with a mental health issue to live a meaningful life in a community of his or her choice while striving to achieve his or her full potential.
Conferences have been held on the importance of the concept from the perspective of consumers and psychiatrists. From the viewpoint of psychiatric rehabilitation services, a number of qualities of recovery have been suggested:
Recovery can occur without professional intervention; Recovery requires people who believe in and stand by the person in recovery;A recovery vision is not a function of theories about the cause of psychiatric conditions;Recovery can occur even if symptoms reoccur;Recovery changes frequency and duration of symptoms;Recovery from the consequences of a psychiatric condition are often far more difficult than from the symptoms;Recovery is not linear;Recovery takes place as a series of small steps;Recovery does not mean the person was never really psychiatrically disabled; Recovery focuses on wellness not illness; Recovery should focus on consumer choice.For many, recovery has a political as well as personal implication – where to recover is to find meaning, to challenge prejudice (including diagnostic labels and psychiatry itself in some cases), to reclaim a chosen life and place within society, and to validate the self. Recovery can then be viewed as one manifestation of empowerment. An empowerment model of recovery may emphasize that conditions are not necessarily permanent, that other people have recovered who can be role models and share experiences, and symptoms can be understood as expressions of distress related to emotions and other people.One such model from the US National Empowerment Center advances 10 such principles of recovery and framed them within a cognitive-behavioural approach.Some issues have been raised about recovery models, including that recovery that a focus on recovery adds to the burden of already stretched providers (yes, people do say that..), that recovery must involve cure, that recovery happens to very few people, that recovery-oriented care can only be implemented through the addition of new resources, that recovery-oriented care is neither reimbursable nor evidence based, that recovery-oriented care devalues the role of professional intervention, and that recovery-oriented care increases providers exposure to risk and liability.There have also been tensions between recovery models and particular evidence-based practice models in the transformation of mental health services based on the recommendations of the New Freedom Commission in the USA.A number of tools have been developed to try to assess aspects of the recovery journey. These include the Recovery Enhancing Environment (REE) measure, the Recovery Measurement Tool (RMT) and the Recovery Oriented System Indicators (ROSI) measure the Stages of Recovery Instrument (STORI) and numerous related instruments.It should always be emphasized that each individual’s journey to recovery is a deeply personal process, as well as being related to an individuals community and society.A number of features have been proposed as common core elements:Hope has been described as the key to recovery for example.It includes 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 daring to trust in yourself and other people and to risk.A common aspect of recovery is said to be the presence of others who believe in a 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, community will often be of wider and longer-term importance.Others who have experienced similar difficulties, who may be on a journey of recovery themselves, can also be of particular value. Those who share the same values and outlooks more generally (not just in the area of mental health..) may also be particularly important.
Consumers consider that one-way relationships based simply on being helped by an ‘expert’ can actually be devaluing, and that reciprocal relationships and mutual support networks can be of a more long-term value to self-esteem.
Empowerment and self-determination are also said to be vital to recovery, including having control. This can mean developing personal confidence, assertive decision-making and help-seeking.
Achieving Social inclusion may require support and will require challenging stigma and prejudice about mental distress/disorder/difference.
It may also require recovering unpractised social skills or making up for gaps in work history.
The development of personal coping strategies, self-management and self-help is also considered to be an important element.
This can involve making use of and getting more information about which methods fit with a persons life and their own particular 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 a ‘mental disorder’) may require a person becoming their own expert, in order to identify key stress/crisis points, and to understand and develop personal ways of responding and coping. Being able to move on can also mean having to cope with feelings of loss, despair and anger.
When an individual is ready can mean emerging from a process of grieving. It may require accepting past suffering and opportunities ‘lost’, and developing a new sense of meaning and overall purpose – this is essential 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.
Some services report redesigning their mental health systems to stress values like hope, healing, empowerment, social connectedness, human rights, and recovery-oriented services. In the USA 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 are developing.
At least some parts of the Canadian Mental Health Association (Ontario region), have adopted recovery as a guiding principle for reforming and developing the mental health system.
Since 1998, all mental health services in New Zealand have been required by government policy to use a recovery approach, and mental health professionals are expected to demonstrate competence in the recovery model.
Australia’s National Mental Health Plan 2003-2008 states that services should adopt a recovery orientation, although there is variation between Australian states and territories in the level of knowledge, commitment and implementation.
The National Institute for Mental Health in England (NIMHE) has endorsed a recovery model as the guiding principle of mental health service provision and public education. Support Time and Recovery Worker policy has been implemented by the National Health Service and the Scottish Executive has included promoting and supporting recovery as one of its four key mental health aims and funded a Scottish Recovery Network.
A 2006 review of nursing in Scotland recommended a recovery approach as the model for mental health nursing care and intervention.
The Mental Health Commission of Ireland also reports that its guiding documents place the service user at the core and emphasize an individuals personal journey towards recovery.
