Recovery: a paradigm shift in patient care

William A. Anthony, Ph.D., professor emeritus at Boston University and former executive director for its Center for Psychiatric Rehabilitation, dubbed the 1990s the “decade of recovery.” The subsequent 20 years brought some change to mental health care. But, according to Anthony, recovery still remains just a vision.

Basically, Anthony defines recovery as “the development of new meaning and purpose as one grows beyond the catastrophe of a severe mental illness.” In order to truly implement this definition, the profession needs to adjust its way of thinking. “There has to be a whole system approach, not just the same way we were practicing – put the person in the hospital. When symptoms are suppressed, release them with no regard to follow up in the community,” Anthony says. “We’ve built our system based on the fact that people don’t recover.”

Anthony says that listening is the key component to foster recovery. “We have to engage and involve the person. We’ve done ‘to’ the person, rather than ‘with’ the person,” he says. “We’ve changed how we talk, but not the way we do things. You will some find great individual programs, but we have not changed what we do on a large scale.”

One of the programs Anthony applauds is Alternatives Unlimited, Inc. in Whitinsville, Mass. “The program is working creatively toward recovery. They have tried to make the vision work,” he says.

Michael Seibold, director of community services for Alternatives, explains that Alternatives aims to become a bridging organization, i.e., an agency with an outward focus on integration in the community. He says, “At the heart of recovery is the philosophy to achieve a new life purpose. It’s absolutely critical to find meaningful roles in the community, which is totally linked to success. Recovery is based on hopes, dreams, preferences that help develop meaning in lives. It starts where the person is and what they want to do.”

In addition to listening, employment and independent living form a basis for recovery. “A job gives us meaning. The critical piece is finding work that matches the interests and talents of the client,” Seibold notes.

In the community, Alternatives provides individualized care for 200 people living in community residences and 600 who dwell in their own apartments. “They all receive different level of care hours. We check in on some weekly and give medication reminders to others twice per day. We provide as much or as little support as their needs require and change. Constant communication is important to maintaining the appropriate level of care and support.”

Larry Davidson, Ph.D., professor of psychology in the department of psychiatry at Yale University, director of the Program for Recovery and Community Health at the Yale University School of Medicine and director of Recovery to Practice for the Substance Abuse and Mental Health Services Administration (SAMHSA), calls recovery a “paradigm shift,” and points to the emergence of peer support services and a focus on hope as major steps in the right direction. “In 1992, there were no peer supports. Now they number in the tens of thousands,” he says. “Peers have concrete evidence that anyone can recover. They have transformative power to walk into a setting and help others. They have proven to be very effective change agents.”

Those who serve as peer supports must have had a personal experience of recovery they can draw on, learn from and share with others. “The person’s values and personal identification come into the picture. You have to work with the mental health system as you advocate for changes in the system. You have to be willing to disclose personal experience and need to be patient,” Davidson says.

Peer support works hand-in-hand with clubhouses, whose vision has changed and is now more goal-oriented. “Connecticut has 23 clubhouses that have moved to peer-run programs,” Davidson notes. “In New Jersey, they have a network of 23 to 33 peer run programs. All their clubhouses closed or converted to peer run programs.”

While recovery services are typically associated with adults, children can also benefit from this philosophy. Ellen B. Braaten, Ph.D., associate director of The Clay Center for Young Healthy Minds at Massachusetts General Hospital, director of the Learning and Emotional Assessment Program, track director of the Child Psychology Training Program at MGH/Harvard Medical School (HMS) and assistant professor of psychology at HMS, says that the Clay Center has embraced the concept, but that putting it into practice poses some challenges. “There are no studies in child psychology about recovery, although there is a lot of theory,” she says.

When it comes to children, the main focus is to foster resiliency, Braaten explains. To build resiliency that leads to recovery, psychologists need to involve parents in the process. Age makes a difference so the listening component may apply more to a parent when the client is a young child. She emphasizes that clinicians need to discern parents’ dreams for their young children and involve them [parents] in the recovery process. “Treatment for children at the age of four is much more about empowering the parents to help their child. It’s more of a collaboration,” Braaten says.

Like adults, children function in a number of different settings so recovery requires a holistic approach, which has to involve family, school, community, social networks, sports and other activities and interests, according to Braaten. “Children don’t come in isolation. They are connected to all these entities,” she says. Educating teachers, family and the community helps to build a support system that fosters recovery, she adds.

Adopting a recovery approach is more feasible when it comes to adolescents and teens. “With older kids, we help them make the transition to taking on more responsibility. The job of adolescence is to become empowered and learn self responsibility,” Braaten says.

Davidson believes psychologists have an important role to play in the shift to recovery. “Much of the research on recovery has been done by psychologists,” he says. “We need to take more control in this practice area.”