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July 1, 2006
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Some experts question whether recovery-oriented care can fulfill its promises

Everywhere you turn, you'll find people in behavioral healthcare talking about recovery. From the halls of a local community mental health center to meeting rooms on Capitol Hill, the push for recovery-based services has become an important force in behavioral healthcare. While provider and consumer buy-in of recovery appears strong, some are expressing concerns about the concept.

To start with, recovery is not a clear-cut idea, and many definitions exist. The federal government relied on more than 110 experts to develop this consensus statement: “Mental health recovery is 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.”1

Complicating the notion of recovery, recovery means different things for different mental health consumers. Larry Davidson, PhD, and colleagues report in the May issue of Psychiatric Services that recovery for one consumer might mean recovering from a mental illness over a long period, while for others recovery is more about having the right to self-determination and community inclusion than clinical or functional status.2

Such ambiguity leads Faith B. Dickerson, PhD, MPH, to consider recovery a “fuzzy concept.” Dr. Dickerson, director of psychology at Sheppard Pratt Health System in Baltimore, says that when consumers hear “recovery,” they often think “cure,” and that is hardly the end result for many patients.“Mental illnesses are highly disabling, and, as recent reviews have emphasized, our science has not come even close to being able to cure or prevent them,” she writes in the May issue of Psychiatric Services.3 One of those reviews was led by Thomas R. Insel, MD, director of the National Institute of Mental Health, who writes with a colleague in Molecular Psychiatry, “Even with optimal care, many patients with mental illness will not recover, where recovery is defined as permanent remission.”4

Although she appreciates the energy and enthusiasm that the concept of recovery has brought to the field, Dr. Dickerson suggests providers would be better advised to rely on evidence-based treatments that have been proven to be effective in relieving symptoms, but which have had limited use because of costs, lack of resources, and so on. While Dr. Dickerson is hardly suggesting that the field scrap the recovery model, she does wonder if recovery interventions might distract attention from research-proven treatments, especially because “From my understanding, recovery hasn't yet been linked with evidence-based practices that are focused exclusively on recovery,” she told Behavioral Healthcare.

Dr. Davidson and colleagues outline some of Dr. Dickerson's and others' concerns in their article in Psychiatric Services. Taking a cue from the Late Show With David Letterman, they list* the top ten concerns about recovery in serious mental illness they have encountered in trying to implement recovery-oriented services:

  1. Recovery is old news. “What's all the hype? We've been doing recovery for decades.”

  2. Recovery-oriented care adds to the burden of mental health professionals who already are stretched thin by demands that exceed their resources. “You mean I not only have to care for and treat people, but now I have to do recovery too?”

  3. Recovery means that the person is cured. “What do you mean your clients are in recovery? Don't you see how disabled they still are? Isn't that a contradiction?”

  4. Recovery happens for very few people with serious mental illness. “You're not talking about the people I see. They're too disabled. Recovery is not possible for them.”

  5. Recovery in mental health is an irresponsible fad. “This is just the latest flavor of the month, and one that also sets people up for failure.”

  6. Recovery only happens after, and as a result of, active treatment and the cultivation of insight. “My patients won't even acknowledge that they're sick. How can I talk to them about recovery when they have no insight about being ill?”

  7. Recovery can be implemented only through the introduction of new services. “Sure, we'll be happy to do recovery, just give us the money it will take to start a (new) recovery program.”

  8. Recovery-oriented services are neither reimbursable nor evidence based. “First it was managed care, then it was evidence-based practice, and now it's recovery. But recovery is neither cost-effective nor evidence based.”

  9. Recovery approaches devalue the role of professional intervention. “Why did I just spend ten years in training if someone else, with no training, is going to make all the decisions?”

  10. Recovery increases providers' exposure to risk and liability. “If recovery is the person's responsibility, then how come I get the blame when things go wrong?”2

Dr. Davidson and colleagues see these concerns in terms of two overarching issues—resources and risk. Regarding resources, they state, “Many of the concerns about recovery derive from a misunderstanding of the nature of the processes involved and who is responsible for which aspects of the recovery process.” They argue that recovery is the role and responsibility of the consumer, while it is the responsibility of the provider to offer recovery-oriented care. And regarding risk, they comment, “[A]lthough a recovery orientation might in fact increase risk, it is primarily the person's access to opportunities for taking risks that needs to be increased, not necessarily the provider's or the community's exposure to risk.”2