The President's New Freedom Commission on Mental Health has proposed to
transform the mental health system by shifting the paradigm of care of persons
with serious mental illness from traditional medical psychiatric treatment
toward the concept of "recovery." Although there are many
perceptions and definitions of the term recovery, especially emanating from
the substance abuse field, the cornerstone definition of mental health
recovery was developed by William Anthony, Ph.D., director of the Boston
Center for Psychiatric Rehabilitation.
Anthony, in 1993, identified recovery as "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 illness. Recovery involves the development of new
meaning and purpose in one's life as one grows beyond the catastrophic effects
of mental illness."
The recently adopted APA position statement titled "Use of the
Concept of Recovery" stated, "The concept of recovery has a long
history in medicine, and its principles are important in the management of all
chronic disorders. The concept of recovery enriches and supports medical and
rehabilitation models. By applying the concept of recovery as well as
rehabilitation techniques and by encouraging other mental health professionals
to adopt the concept of recovery, psychiatrists can enhance the care of all
clinical populations served within the community-based and other public-sector
mental health and behavioral health systems."
The concept of recovery has become so important in psychiatry that the
theme selected for APA's 2005 Institute on Psychiatric Services was"
Recovery and Community." You will read more about the meeting,
which was held earlier this month in San Diego, in the next issue of
Psychiatric News. Among those who spoke on the recovery theme were
individuals who have made groundbreaking contributions to the recovery
movement, such as Fred Freese, Ph.D., a leader of the Alliance for the
Mentally Ill; Tony Lehman, M.D., professor and chair of the Department of
Psychiatry at the University of Maryland; and H. Westley Clark, M.D., J.D.,
director of the federal Center for Substance Abuse Treatment.
Several factors are common in the recovery paradigm. These include hope,
medication and other psychiatric treatments, empowerment, support, education,
self-help, spirituality, employment, and meaningful activities.
Hope is the desire that one can get better, accompanied by confidence and
expectations. It is the foundation for ongoing recovery from mental illness.
Psychiatrists create hope as we treat patients. At some point, however,
patients must develop and internalize their own sense of hope.
Most people with severe mental illness say that medications are critical to
their success and provide hope. It is often a complicated and frustrating
collaborative process of doctor and patient to find the right combination of
medications with the right dosing and fewest side effects, and it has to be
understood that the goal is not necessarily to become medication free but to
take the least amount necessary. A long-term trusting relationship with a
psychiatrist and continuity of care built over time are part of this
Empowerment is the belief that one has the power to control one's own life,
including illness. It involves taking responsibility for oneself and
advocating for oneself as well as others.
Support from one's doctor and others on the treatment team, as well from
peers, family, and friends, is essential to recovery. Having multiple sources
of support is especially beneficial. Participation in mutual support groups is
one important tool for recovery. Being able to interact with others who
understand experiences and feelings not only reduces the sense of isolation
but increases social activity in the community.
To maximize recovery, it is important to learn as much as possible about
mental illness, medications, best treatment practices, and available
resources. Early recognition of symptoms that lead to relapse is often the key
to relapse prevention.
The value of professional treatment is enhanced when self-help is also
involved. Self-help can take many forms, including learning to identify
symptoms early and to take actions to counteract them, reading, attending
mutual support groups, and developing a support system to rely on when
For many patients, spirituality also provides hope and solace, peace and
understanding, and is an additional source of support.
And most importantly, employment and meaningful activities increase
self-esteem. Work increases social interactions and provides an opportunity
for patients to regain a positive identity in the face of serious mental
At a recent NIMH conference on mental health services research, Carla
Green, Ph.D., M.P.H., discussed predictors of recovery of persons with severe
and persistent mental illness. Continuity of care and relationships with
clinicians were seen as crucial to recovery. Psychiatrists and other
clinicians contribute to recovery by providing continuity of care, a trusting
relationship (that is, the sense that the doctor really cares), a
collaborative approach with input solicited and accepted from the patient, and
a normal relationship (that is, being able to talk about everyday things and
feelings about everyday issues). Recovery is enhanced by a fit between the
clinician, treatment strategies, and patients' needs. Of course, for many of
us, this is just good quality care that we strive to provide despite the
distractions of funding limits and managed care constraints.
There is a good deal that we as psychiatrists can learn about recovery, and
we have a most critical role in facilitating it. The doctor-patient
relationship plays an essential role, and we must be ever mindful of it.▪