The New Freedom Commission on Mental Health called for a "fundamental
transformation of the nation's approach to mental health care" in its
report to President George W. Bush in July 2003, recommending a focus on"
promoting recovery and building resilience."
Members of Yale University's Department of Psychiatry who are based at the
Connecticut Mental Health Center (CMHC) had already begun work with
Connecticut's Department of Mental Health and Addiction Services (DMHAS) to
help bring about those
Thomas Kirk, Ph.D. (seated), is joined by advocates and Connecticut
state officials as he signs the Commissioner's Policy on Recovery in
State of Connecticut, Department of Mental Health and Addiction
The 2000 appointment of Thomas Kirk, Ph.D., as DMHAS commissioner was a
major impetus for what ultimately became a statewide effort to promote the"
recovery model" in public mental health services and the founding
of the Recovery Education and Training Institute.
Kirk told Psychiatric News that the current focus on promoting
recovery represents a "real culture change." One element of this
change is acceptance of the idea that recovery is an "individual
journey" that will not produce the same outcome for everyone with a
serious mental illness.
Kirk calls DMHAS a "health care service agency," a term that
emphasizes the idea that mental illness is like other serious illnesses in
that the individual should be able to expect help in managing an illness and
achieving the "highest quality of life for which he or she is
capable." The individual, however, should also accept responsibility for
bringing about change.
Larry Davidson, Ph.D., DMHAS's policy director, helped Kirk implement the
recovery concepts. Davidson, an associate professor of psychiatry at Yale
based at CMHC, has researched and written about the recovery idea for nearly a
Davidson acknowledged confusion in the mental health services field about a
definition of recovery and takes seriously the consequences of that
In "Recovery in Serious Mental Illness: Paradigm Shift or
Shibboleth?," a paper published on the DMHAS Web site, Davidson wrote
that "clarity and consensus must be achieved in relation to this
important concept" for progress to be made in achieving implementation
Recovery, according to Davidson, has been used to denote amelioration of
symptoms and a reduction in other deficits associated with serious mental
illness. That approach underlaid research, begun in 1967, of the World Health
Organization's International Pilot Study of Schizophrenia, which found"
full to partial recovery" in 25 percent to 65 percent of each
But, Davidson wrote, those who have experienced serious mental illness and
call themselves "consumers" or "survivors" often view
recovery in a different way. Rather than remission of symptoms, people focus
on overcoming the "[pernicious] effects of being a mental
patient—including rejection from society, poverty, substandard housing,
social isolation, unemployment, loss of valued social roles and identity, and
loss of sense of self and purpose in life—in order to retain or resume
some degree of control over their own lives."
In an interview with Psychiatric News, Davidson noted parallels
between the disability-rights movement and the consumer movement. Society
provides various accommodations for individuals with disabilities, such as
people who are deaf, that enable them to participate meaningfully in community
Accommodations such as supported housing and clubhouses provide similar
kinds of opportunities for people with mental illness. An adequate response to
serious mental illness requires treatment for the individual and appropriate
changes to the environment in which he or she functions, Davidson
Kirk used funds that became available because of the closure of state
psychiatric hospitals to involve consumer advocates in an effort to articulate"
core values" associated with recovery.
In 2002 Kirk issued a policy statement, "Promoting a
Recovery-Oriented Service System," which designated recovery as the"
overarching goal" of the agency and defined recovery as "a
process of restoring or developing a positive and meaningful sense of identity
apart from one's condition and then rebuilding one's life despite or within
the limitations imposed by that condition."
The statement offers several examples of recovery, including"
managing one's illness such that the person can live independently and
have meaningful employment and healthy social relationships."
The DMHAS worked with Davidson and other CMHC-Yale psychiatry faculty
members to establish the Recovery Education and Training Institute.
Luis Bedregal, Ph.D., Maria O'Connell, Ph.D., and Davidson developed the
Recovery Knowledge Inventory (REI) to help assess the knowledge and attitudes
of staff providing public mental health services about recovery to determine
training needs. The REI measures knowledge and attitudes in four broad areas:
roles and responsibilities of mental health professionals and consumers in
recovery, nonlinearity of the recovery process, roles of self-definition and
peers in recovery, and expectations of recovery.
Nearly 5,000 people have received training, which is free and voluntary.
Results so far suggest that staff have the most difficulty in establishing
expectations for their patients and understanding that recovery is a nonlinear
process that does not always involve absence of symptoms.
Davidson recognizes the importance of finding ways of measuring the
ultimate impact of the training on recipients of mental health services, as
well as on participating staff.
Agencies providing public mental health services can apply to the DMHAS to
become a Center of Excellence or a Practice Improvement Initiative site, where
recovery-oriented practices will be developed and refined.
The National Institutes of Health recently awarded the DMHAS a five-year
grant to study culturally responsive, person-centered care in large, urban
mental health systems. The project targets the needs of persons of color who
are living with psychosis and will involve peer-support services and
self-directed wellness strategies that are associated with the recovery
"Recovery in Serious Mental Illness: Paradigm Shift or
Shibboleth?" is posted at<www.dmhas.state.ct.us/recovery/paradigmshift.pdf>.▪