Recovery model

The recovery model, recovery approach or psychological recovery is an approach to

William Anthony,[2] Director of the Boston Centre for Psychiatric Rehabilitation developed a cornerstone definition of mental health recovery in 1993. "Recovery is a deeply personal, unique process of changing one's attitudes, values, feelings, goals, skills and/or roles. It is a way of living a satisfying, hopeful, and contributing life even with limitations caused by the illness. Recovery involves the development of new meaning and purpose in one's life as one grows beyond the catastrophic effects of mental illness."^[3][4]

The concept of recovery in

According to a study, a combined social and physical environment intervention has the potential to enhance the need for recovery. However, the study's focus on a general healthy and well-functioning population posed challenges in achieving significant impact. The researchers suggested implementing the intervention among a population with higher baseline values on the need for recovery and providing opportunities for physical activity, such as organizing lunchtime walking or yoga classes at work. Additionally, they recommended strategically integrating a social media platform with incentives for regular use, linking it to other platforms like Facebook, and considering more drastic physical interventions, such as restructuring an entire department floor, to enhance the intervention's effectiveness. The study concluded that relatively simple environment modifications, such as placing signs to promote stair use, did not lead to changes in the need for recovery.[5]

In

Mental health recovery emerged in Geel, Belgium in the 13th century. Saint Dymphna—the patron saint of mental illness—was martyred there by her father in the 7th century. The Church of Saint Dymphna (built in 1349) became a pilgrimage destination for those seeking help with their psychiatric conditions. By the late 1400s, so many pilgrims were coming to Geel that the townspeople began hosting them as guests in their homes. This tradition of community recovery continues to this day. ^[6][7][8]

More widespread application of recovery models to psychiatric disorders is comparatively recent. The concept of recovery can be traced back as far as 1840, when John Thomas Perceval, son of Prime Minister Spencer Perceval, wrote of his personal recovery from the psychosis that he experienced from 1830 until 1832, a recovery that he obtained despite the "treatment" he received from the "lunatic" doctors who attended him.^[9] But by consensus the main impetus for the development came from within the consumer/survivor/ex-patient movement, a grassroots self-help and advocacy initiative, particularly within the United States during the late 1980s and early 1990s.^[10] The professional literature, starting with the psychiatric rehabilitation movement in particular, 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".^[11] Similar approaches developed around the same time, without necessarily using the term recovery, in Italy, the Netherlands and the UK.

Developments were fueled by a number of long-term outcome studies of people with "major mental illnesses" in populations from virtually every continent, including landmark cross-national studies by the World Health Organization from the 1970s and 1990s, showing unexpectedly high rates of complete or partial recovery, with exact statistics varying by region and the criteria used. The cumulative impact of personal stories or testimony of recovery has also been a powerful force behind the development of recovery approaches and policies. 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.^[12]

Increasingly, recovery became both a subject of mental health services research and a term emblematic of many of the goals of the

It has been emphasized that each individual's journey to recovery is a deeply personal process, as well as being related to an individual's community and society.[14] A number of features or signs of recovery have been proposed as often core elements^[15] and comprehensively they have been categorized under the concept of CHIME.^[16] CHIME is a mnemonic of connectedness, hope & optimism, identity, meaning & purpose and empowerment.^[17]

A common aspect of recovery is said to be the presence of others who believe in the person's potential to recover^[18][19] and who stand by them. According to Relational Cultural Theory as developed by Jean Baker Miller, recovery requires mutuality and empathy in relationships.^[18] The theory states this requires relationships that embody respect, authenticity, and emotional availability.^[18][20] Supportive relationships can also be made safer through predictability and avoiding shaming and violence.^[20][18][21] While mental health professionals can offer a particular limited kind of relationship and help foster hope, relationships with friends, family and the community are said to often be of wider and longer-term importance.^[22] Case managers can play the role of connecting recovering persons to services that the recovering person may have limited access to, such as food stamps and medical care.^[23][24] Others who have experienced similar difficulties and are on a journey of recovery can also play a role in establishing community and combating a recovering person's feelings of isolation.^[18] An example of a recovery approach that fosters a sense of community to combat feelings of isolation is the safe house or transitional housing model of rehabilitation. This approach supports victims of trauma through a community-centered, transitional housing method that provides social services, healthcare, and psychological support to navigate through and past experiences. Safe houses aim to support survivors on account of their individual needs and can effectively rehabilitate those recovering from issues such as sexual violence and drug addiction without criminalization.^[25] Additionally, safe houses provide a comfortable space where survivors can be listened to and uplifted through compassion.^[26] In practice, this can be accomplished through one on one interviews with other recovering persons,^[18] engaging in communal story circles,^[18] or peer-led support groups.^[27] Those who share the same values and outlooks more generally (not just in the area of mental health) may also be particularly important. It is said that one-way relationships based on being helped can actually be devaluing and potentially re-traumatizing,^[21] and that reciprocal relationships and mutual support networks can be of more value to self-esteem and recovery.^{[14][18][20][19]}

Finding and nurturing hope has been described as a key to recovery. It is said to include 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 trusting, and risking disappointment, failure and further hurt.^[14]

Recovery of a durable sense of self (if it had been lost or taken away) has been proposed as an important element. A research review suggested that people sometimes achieve this by "positive withdrawal"—regulating social involvement and negotiating public space in order to only move towards others in a way that feels safe yet meaningful; and nurturing personal psychological space that allows room for developing understanding and a broad sense of self, interests, spirituality, etc. It was suggested that the process is usually greatly facilitated by experiences of interpersonal acceptance, mutuality, and a sense of social belonging; and is often challenging in the face of the typical barrage of overt and covert negative messages that come from the broader social context.^[28] Being able to move on can mean having to cope with feelings of loss, which may include despair and anger. When an individual is ready for change, a process of grieving is initiated. It may require accepting past suffering and lost opportunities or lost time.^[14]

The development of personal

What constitutes 'recovery', or a recovery model, is a matter of ongoing debate both in theory and in practice. In general, professionalized clinical models 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.^[33][34][35] "Recovery from", the medical approach, is defined by a dwindling of symptoms, whereas "recovery in", the peer approach, may still involve symptoms, but the person feels they are gaining more control over their life.^[36] Similarly, recovery may be viewed in terms of a social model of disability rather than a medical model of disability, and there may be differences in the acceptance of diagnostic "labels" and treatments.^[14]

A review of research suggested that writers on recovery are rarely explicit about which of the various concepts they are employing. The reviewers classified the approaches they found in to broadly "rehabilitation" perspectives, which they defined as being focused on life and meaning within the context of enduring disability, and "clinical" perspectives which focused on observable remission of symptoms and restoration of functioning.

A consensus statement on mental health recovery from US agencies, that involved some consumer input, defined recovery as a journey of healing and transformation enabling a person with a mental health problem to live a meaningful life in a community of his or her choice while striving to achieve his or her full potential. Ten fundamental components were elucidated, all assuming that the person continues to be a "consumer" or to have a "mental disability".[39] Conferences have been held on the importance of the "elusive" concept from the perspectives of consumers and psychiatrists.^[40]

One approach to recovery known as the

For many, recovery has a political as well as personal implication—where to recover is to: find meaning; challenge prejudice (including diagnostic "labels" in some cases); perhaps to be a "bad" non-compliant patient and refuse to accept the indoctrination of the system; to reclaim a chosen life and place within society; and to validate the self.^[41] Recovery can thus be viewed as one manifestation of empowerment. Such an empowerment model may emphasize that conditions are not necessarily permanent; that other people have recovered who can be role models and share experiences; and that "symptoms" can be understood as expressions of distress related to emotions and other people. One such model from the US National Empowerment Center proposes a number of principles of how people recover and seeks to identify the characteristics of people in recovery.^[42]

In general, recovery may be seen as more of a philosophy or attitude than a specific model, requiring fundamentally that "we regain personal power and a valued place in our communities. Sometimes we need services to support us to get there".^[43]

Particular kinds of recovery models have been adopted in

Trauma-Informed care is a philosophy for recovery that combines the conditions and needs of people recovering from mental illness and/or substance abuse into one framework. This framework combines all of the elements of the Recovery Approach and adds an awareness of trauma. Advocates of trauma-informed care argue the principles and strategies should be applied to individuals experiencing mental illness, substance dependence, and trauma as these three often occur simultaneously or as result of each other.[47]^{[19][23][21][27]} The paradigms surrounding trauma-informed care began to shift in 1998 and 1999. In 1998, the Center for Mental Health Services, the Center for Substance Abuse Treatment, and the Center for Substance Abuse Prevention collaborated to fund 14 sites to develop integrated services in order to address the interrelated effects of violence, mental health, and substance abuse.^[47] In 1999, the National Association of State Mental Health Program Directors passed a resolution recognizing the impact of violence and trauma^[47] and developed a toolkit of resources for the implementation of trauma services in state mental health agencies.^[19] Trauma-informed care has been supported in academia as well. Scholars claim that neglecting the role of trauma in a person's story can interfere with recovery in the form of misdiagnosis, inaccurate treatment, or retraumatization.^{[23][21][18][27][47][20]} Some principles of trauma-informed care include validating survivor experiences and resiliency, aiming to increase a survivor's control over her/his/their recovery, creating atmospheres for recovery that embody consistency and confidentiality, minimizing the possibilities of triggering past trauma, and integrating survivors/recovering persons in service evaluation.^{[27][19][18][21]} In practice, trauma-informed care has shown to be most effective when every participant in a service providing context to be committed to following these principles.^[23][21] In addition, these principles can apply to all steps of the recovery process within a service providing context, including outreach and engagement, screening, advocacy, crisis intervention, and resource coordination.^{[19][27][18][20][21]} The overall goal in trauma-informed care is facilitating healing and empowerment using strengths-based empowerment practices and a comprehensive array of services that integrate co-occurring disorders and the multitude of needs a recovering person might have, such as drug treatment, housing, relationship building, and parenting support.^[23][21][27]

These approaches are in contrast to traditional care systems. Advocates of trauma-informed care critique traditional service delivery systems, such as standard hospitals, for failing to understand the role of trauma in a patient's life.^[47] Traditional service delivery systems are also critiqued for isolating the conditions of a recovering person and not addressing conditions such as substance abuse and mental illness simultaneously as part of one source.^[23][47] Specific practices in traditional service delivery systems, such as unnecessary procedures, undressing for examinations, involuntary hospitalizations, crowded emergency rooms, and limited time for providers to meet with patients, have all been critiqued as insensitive to persons recovering from trauma and consequential mental illness or substance abuse.^[21][20][47] Limited resources and time in the United States healthcare system can make the implementation of trauma-informed care difficult.^[20]

There are other challenges to trauma-informed care besides limits in the United States healthcare system that can make trauma-informed care ineffective for treating persons recovering from mental illness or substance dependence. Advocates of trauma-informed care argue implementation requires a strong commitment from leadership in an agency to train staff members to be trauma-aware, but this training can be costly and time-consuming.^[47][27][19] "Trauma-informed care" and "trauma" also have contested definitions and can be hard to measure in a real world service setting.^[19] Another barrier to trauma-informed care is the necessity of screening for histories of trauma.^{[19][21][20][47][27]} While agencies need to screen for histories of trauma in order to give the best care, there can be feelings of shame and fear of being invalidated that can prevent a recovering person from disclosing their personal experiences.^[20]

Some concerns have been raised about a recovery approach in theory and in practice. These include suggestions that it: is an old concept; only happens to very few people; represents an irresponsible fad; happens only as a result of active treatment; implies a cure; can only be implemented with new resources; adds to the burden of already stretched providers; is neither reimbursable nor evidence based; devalues the role of professional intervention; and increases providers' exposure to risk and liability.^[48]

Other criticisms focused on practical implementation by service providers include that: the recovery model can be manipulated by officials to serve various political and financial interests including withdrawing services and pushing people out before they're ready; that it is becoming a new orthodoxy or bandwagon that neglects the empowerment aspects and structural problems of societies and primarily represents a middle class experience; that it hides the continued dominance of a medical model; and that it potentially increases social exclusion and marginalizes those who don't fit into a recovery narrative.^[49]

There have been specific tensions between recovery models and "evidence-based practice" models in the transformation of US mental health services based on the recommendations of the New Freedom Commission on Mental Health.^[50] The commission's emphasis on recovery has been interpreted by some critics as saying that everyone can fully recover through sheer will power and therefore as giving false hope and implicitly blaming those who may be unable to recover.^[51] However, the critics have themselves been charged with undermining consumer rights and failing to recognize that the model is intended to support a person in their personal journey rather than expecting a given outcome, and that it relates to social and political support and empowerment as well as the individual.^[52]

Various stages of resistance to recovery approaches have been identified amongst staff in traditional services, starting with "Our people are much sicker than yours. They won't be able to recover" and ending in "Our doctors will never agree to this". However, ways to harness the energy of this perceived resistance and use it to move forward have been proposed.^[53] In addition, staff training materials have been developed by various organisations, for example by the National Empowerment Center.^{[54][55][56][57]}

Some positives and negatives of recovery models were highlighted in a study of a

A number of standardized questionnaires and assessments have been developed to try to assess aspects of an individual's recovery journey. These include the Milestones of Recovery (MOR) Scale, Recovery Enhancing Environment (REE) measure, Recovery Measurement Tool (RMT), Recovery Oriented System Indicators (ROSI) Measure,[59] Stages of Recovery Instrument (STORI),^[60] and numerous related instruments.^[61]

The data-collection systems and terminology used by services and funders are said to be typically incompatible with recovery frameworks, so methods of adapting them have been developed.^[62] It has also been argued that the Diagnostic and Statistical Manual of Mental Disorders (and to some extent any system of categorical classification of mental disorders) uses definitions and terminology that are inconsistent with a recovery model, leading to suggestions that the next version, the DSM-V, requires: greater sensitivity to cultural issues and gender; to recognize the need for others to change as well as just those singled out for a diagnosis of disorder; and to adopt a dimensional approach to assessment that better captures individuality and does not erroneously imply excess psychopathology or chronicity.^[63]

The New Freedom Commission on Mental Health has proposed to transform the mental health system in the US by shifting the paradigm of care from traditional medical psychiatric treatment toward the concept of recovery, and the American Psychiatric Association has endorsed a recovery model from a psychiatric services perspective.^[64][65]

The

Some US states, such as California (see the California Mental Health Services Act), Wisconsin and Ohio, already report redesigning their mental health systems to stress recovery model values like hope, healing, empowerment, social connectedness, human rights, and recovery-oriented services.^[68]

At least some parts of the Canadian Mental Health Association, such as the Ontario region, have adopted recovery as a guiding principle for reforming and developing the mental health system.^[69]

Since 1998, all mental health services in New Zealand have been required by government policy to use a recovery approach^[70][71] and mental health professionals are expected to demonstrate competence in the recovery model.^[72] Australia's National Mental Health Plan 2003-2008 states that services should adopt a recovery orientation^[73] although there is variation between Australian states and territories in the level of knowledge, commitment and implementation.^[74]

In 2005, the