Kathleen Crowley, a member of the Blue Ribbon Commission, wrote this section.

(From the 1997 Report of the Wisconsin Blue Ribbon Commission on Mental Health)

B.  IMPLEMENTING THE CONCEPT OF RECOVERY

Implementing the concept of recovery will change the delivery of mental health services in the 1990s and beyond as significantly as did the concept of “de-institutionalization” in the 1960s and 1970s. As part of the Commission’s examination of the current mental health system, much was learned about the concept of recovery.

1.  Background

Individuals diagnosed with mental disorders and served within the public mental health system are traditionally inefficient users of the system.  This is in large part because the system has been designed in such a way as to serve these individuals as passive recipients rather than active participants.  This inefficiency translates into high levels of non-compliance and poor therapeutic and economic outcomes.

In addition, extremely low expectations have been held for the quality of life for persons with mental disorders.  And there are strong disincentives for them to rebuild their lives, because a distinct show of capability and increase in health could result in a loss of benefits such as Supplemental Security Income (SSI) or Medicaid coverage  and a discontinuation of the very service that may have substantially contributed to their success.

Further, consumers and professionals alike often measure success against an ultimate goal of recovery, defined by Taber’s Medical Dictionary[1] as the process “regaining a former state of health.”   Recovery in this sense is often not an option.

2.  The Vision of Recovery

For many individuals it can be  a better expenditure of time and resources for both consumers and professionals to focus on the successful integration of a mental disorder into a consumer’s life. The goal of attaining a productive and fulfilling life regardless of the level of health assumed attainable has been called procovery and is a powerful vision in this regard.  Regardless of whether this concept is referred to as procovery or recovery, the fundamental focus is one of letting go of what was and rebuilding new dreams.  Accepting the realities of illness, while focusing on LIFE.  William Anthony, Ph.D., Executive Director of the Center for Psychiatric Rehabilitation at Boston University[2] has said “For service providers, recovery from mental illness is a vision commensurate with researchers’ vision of curing and preventing mental illness.  Recovery is a simple yet powerful vision.” Anthony describes 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.”

3.  The Focus of a Recovery-Oriented Mental Health System Makes Financial and Therapeutic Sense 

A recovery-oriented mental health system reaches beyond the critical issues of assuring personal safety and managing symptoms and focuses on the rebuilding of full, productive lives despite a mental disorder.  Living with a long-term mental disorder carries distinct challenges, but learnable skills exist to do this. This can be clearly seen in the area of physical disability: a person with a spinal cord injury can lead a productive and meaningful life in spite of the fact that the spinal cord cannot be mended.  Additionally, much can be learned from the focus of chronic pain management clinics, which work daily with those individuals for whom no relief for chronic physical pain is known.  The focus becomes not the elimination of pain, but a reduction in the bothersomeness of it.  While this sounds inconceivable, it is possible, and it is a concept we should build upon in any new design of mental health services.

This all sounds well and good, some say.  But the mental health system may be experiencing cut backs. How can we possibly afford to offer the resources necessary for individuals with a chronic illness to recover?  In truth, at a time when cost control is critical, how can we not?  Recovery is an everybody wins scenario.  In a recovery-oriented system, mental health consumers rebuild meaningful lives while decreasing their dependence on the system.  From both a therapeutic standpoint as well as an economic standpoint there should be little confusion in this regard.  Rather than creating long term users of a system that fosters dependence, individuals will receive services that will enable them to recover and decrease their dependence on the system.

4.  Principles of a Recovery-Oriented System

A recovery-oriented system of service delivery must include services that are focused on psychiatric rehabilitation and not only on the traditional mental health outpatient/inpatient and medication management services. Recovery-oriented psychiatric rehabilitation services increase role performance in the areas of living, learning, and working and are critical to the eventual independence of individuals diagnosed with mental disorders. 

Basic recovery-oriented principles need to be incorporated into all aspects of service delivery, including:

• Recovery is possible: i.e., a meaningful life is possible despite catastrophic illness, and despite limitations of systems and symptoms.  Services are delivered with a hopeful attitude toward the experience of illness, and “triggers”-- multiple sources and methods of providing motivation and hope -- must be present at every level of the mental health system.
  

• Mental health consumers must be welcomed as partners in their care, in assuming a significant degree of control in the development of their treatment plan, and in determining the goals toward which they choose to work.  Consumer choice must exist!  William Anthony, Ph.D., has said, “Critical to recovery is regaining the belief that there are options from which one can choose -- a belief perhaps even more important to recovery than the particular option one initially chooses.” [3]
  

• A “Just Start Anywhere” mode of consumer action must  be fostered. Recovery does not have one starting point, or one destination. Whether it’s number one, number five, or number thirty on the task list, the goal is to just start moving forward in any area, in any increment.  Both staff and consumers must recognize that there are as many paths to healing as there are paths to illness.
  

• A broad range of consumer run services is promoted. These must be fostered and funded as the critical services they are. Not only are consumer run services a cost and therapeutically effective part of the service milieu, but they provide an atmosphere in which consumers can be recognized and paid for their expertise. Consumers in various stages of recovery can substantially aid the  recovery process of others.  It can be motivating to interact with others further along the road; it can be validating  to interact with others who are somewhat in the same place; and it can be rewarding and serve as a critical reminder as to how far one has come to interact with others just beginning the process.
  

• Meaningful work/educational activities are valued and worked toward.  Meaningful work as defined by the consumer in the case of adult mental health consumers; the furthering of one’s schooling, education and hobbies in ways that are meaningful to the individual in the case of children and adolescents; and fulfilling social and intellectual options in the case of retired persons.  Meaningful work is work that increases self efficacy. Mental health consumers have a long history of being required or pressured to perform demeaning, humiliating work (or in the case of children diagnosed with severe emotional disturbance, segregated into ineffective special education classes) that not only does not build their self-efficacy but shatters it. 
  

• Service providers must encourage and facilitate an increase in consumers’ abilities to self manage disorders in ways that are meaningful to the individual consumer. Consumers can significantly benefit from learning low-cost self-care skills to supplement and in some cases replace conventional medical approaches. Routine development of relapse prevention strategies, individual crisis plans, and advance directives are other ways to self-manage and control a disorder. 
  

• Use of community resources should be encouraged.  Much exists within the community that can help one move towards recovery.  Whether it is volunteer work, community classes, the Sierra club, organized sports or church involvement, community involvement can be motivating, therapeutic, and cost effective. Assessing community resources is an excellent and low-cost way to develop highly individualized services that truly meet the goals and interest of the consumer. 
  

• Staff must be empowered and encouraged to be flexible in the delivery of services.  While managed care in the acute setting tends to utilize strict models, decision trees and mandates, etc.,  in the mental health setting outcomes will be dramatically improved if we recognize that the recovery process is a highly individual one. It is important that staff are not seen as automated deliverers of recovery-oriented services, but as valued partners with expertise and needs of their own. Staff members that are not respected and empowered will have a difficult time empowering others. One must be empowered in order to empower others.

5.  Summary

Recovery must not be used as a buzz word for cutting critical services. Such cutting will only increase the long-term usage and costs of the mental health system.  Rather it must be recognized that (1)  as with chronic physical health issues, treatment requires the availability of an effective complement of “medical” and “rehabilitative” services, and (2) all services must be delivered  in a new manner with a focus on the basic principles of recovery.

In essence, the elements critical to bringing about  recovery on a large scale are not costly or complex. Teilhard de Chardin said, “The focus is not to do remarkable things but to do ordinary things with the conviction of their immense importance.” Mental health consumers want what  everybody else wants. They want a home, and loved ones, and to continue to grow as they age.  They want their lives to have meaning. They do not want to die, never having lived.

A recovery-oriented mental health system moves beyond the focus of surviving, and develops the focus of thriving.  A mental health system must adopt a recovery-oriented delivery of services.  It cannot afford to do otherwise, therapeutically, economically or societally.