Recovery model

The Recovery Model is an approach to mental disorder or substance dependence that emphasizes and supports an individual's potential for recovery. Recovery can be seen within the model 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 deinstitutionalization resulted in more individuals living in community settings. It gained impetus due to a perceived failure to adequately support integration, and by studies demonstrating that many can 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 practical steps are being taken to base services on the recovery model, although there are a variety of obstacles and concerns raised. A number of standardized measures have been developed to assess aspects of recovery. There is some variation between professionalized recovery models and those originating in the consumer/survivor movement.

History
In general medicine or psychiatry, recovery has long been used to refer to the end of a particular experience or episode of illness. The broader concept of 'recovery' as a general philosophy and model was first popularised in regard to recovery from substance abuse/drug addiction, for example within twelve-step programs.

Application of recovery model concepts to psychiatric disorders is comparatively recent. By consensus the main impetus for the development came from the consumer/survivor movement, a grassroots self-help and advocacy initiative, particularly within the United States during the late 1980s and early 1990s. The professional literature, starting with psychiatric rehabilitation 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". 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 including populations from virtually every continent, including the landmark World Health Organization crossnational studies from the 1970s and 1990s, showing unexpectedly high rates of where were termed ‘complete recovery’ (20 to 25%) and 'social recovery' (40–45%). The cumulative impact of personal stories or testimony of recovery have 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.

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

Concepts of recovery
There is some variation within the Recovery Model. Professionalized clinical approaches tend to focus on improvement in particular symptoms and functions, and on the role of treatments; 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 of disability, and there may be differences in the degree of acceptance of diagnostic "labels" and treatments. In psychiatric rehabilitation, the concept of recovery may be used to refer primarily 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 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. Conferences have been held on the importance of the concept from the perspective of consumers and psychiatrists.

From the perspective 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" in some cases), to reclaim a chosen life and place within society, and to validate the self. Recovery can thus 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 framed them within a cognitive-behavioral approach.

Some concerns have been raised about recovery models, including that recovery is an old concept, that a focus on recovery adds to the burden of already stretched providers, that recovery must involve cure, that recovery happens to very few people, that recovery represents an irresponsible fad, that recovery happens only after and as a result of active treatment, 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 US mental health services based on the recommendations of the New Freedom Commission.

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 and the Stages of Recovery Instrument (STORI) and numerous related instruments.

Elements of recovery
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. A number of features have been proposed as common core elements:

Hope
Finding and nurturing hope has been described as the 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 daring to trust in yourself and other people and to risk disappointment, failure and further hurt.

Secure base
Appropriate housing, a sufficient income, freedom from violence, and adequate access to healthcare have also been proposed as foundations to recovery.

Supportive relationships
A common aspect of recovery is said to be the presence of others who believe in the 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 and the community are said to often be of wider and longer-term importance. Others who have experienced similar difficulties, who may be on a journey of recovery, can be of particular importance. 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 that reciprocal relationships and mutual support networks can be of more value to self-esteem and recovery.

Empowerment and Inclusion
Empowerment and self-determination are said to be important to recovery, including having control. This can mean developing the confidence for independent assertive decision-making and help-seeking. Achieving Social inclusion may require support and may require challenging stigma and prejudice about mental distress/disorder/difference. It may also require recovering unpracticed social skills or making up for gaps in work history.

Coping strategies
The development of personal coping strategies (including self-management or self-help) is said to be an important element. This can involve making use of medication or psychotherapy if the consumer is fully informed and listened to, including about adverse effects and about which methods fit with the consumer's life and their 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 mental disorder) may require a person becoming their own expert, in order to identify key stress points and possible crisis points, and to understand and develop personal ways of responding and coping.

Coping with loss
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, this can mean a process of greiving. It may require accepting past suffering and lost opportunities or lost time.

Meaning
Developing a sense of meaning and overall purpose is said to be important 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, religion, politics or culture.

United States and Canada
Some US states, such as Wisconsin and Ohio, report redesigning their mental health systems to stress values like hope, healing, empowerment, social connectedness, human rights, and recovery-oriented services. The US Department of Health and Human Sciences reports developing 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. Mental Health service directors and planners are providing guidance to help state services implement recovery approaches

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.

New Zealand and Australia
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.

UK & Ireland
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. A new role of Support Time and Recovery Worker has been implemented by the National Health Service. The Scottish Executive has included promoting and supporting recovery as one of its four key mental health aims and funded a Scottish Recovery Network to facilitate this. 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 reports that its guiding documents place the service user at the core and emphasize an individual’s personal journey towards recovery.