Recovery has been defined in numerous ways. The definition the author proposes has been developed, in part, by a consensus-building process involving professionals, family members, and people with mental illnesses in Connecticut (Davidson, Tondora, & O’Connell, 2007). They describe recovery as being connected to your community in meaningful ways; having an identity separate from one’s condition; and having a life that is satisfying, fulfilling, and contributing to others despite of or within the limitations imposed by that condition.

A recovery-oriented program is one that provides the knowledge, skills, support, and resources to facilitate the achievement of each individual’s recovery. Giving a program a new recovery title or adding a new recovery policy statement will not work unless there is a clear understanding and implementation of the current research, professional practice, family experience, and consumer experienced-based components of a recovery-oriented program. This paper will pull this varied information together and present it in terms of guidelines for what constitutes a recovery-oriented program with examples of program policy statements supporting the components. And of course, it will be necessary to periodically review and update these guidelines as our knowledge grows. Not all components need to be in the same program, but they need to be an active part of the local helping community and readily accessible to all members of the “recovery community.”

Recovery  Program Components

Hope is a combination of empathy with respect to the person’s present life (i.e., what is) and also with respect to the person’s capacity (i.e., what can be). Both of these aspects of hope need to be communicated to the person and can be parallel processes. If the helper focuses solely on capacity, the person may experience him or her as a “cheer leader” who can not adequately acknowledge his or her full experience. The present, or “what is,” is often painful and sometimes terrorizing because of the illness, symptoms, past history, prejudice, or discrimination. These experiences need to be validated and integrated in order for the person to rebuild his or her life. Helping a person focus on their aspirations and goals represents respect for the person’s capacity, and gives the person hope. It is a way of saying “I assume you have aspirations and goals and I expect you to be able to achieve them.”

Mutuality means that each person brings something important to the interaction. Hope, for example is often described as something the provider holds for the person with the mental illness. While this may be initially true, the bearer of the hope can shift. There are many instances where the provider may feel frustrated or even hopeless concerning the person they are helping and then the person they are helping may do or say something which shifts the provider back to a hopeful place. Relationships that are mutual are respectful. Each person is open to giving to and learning from the other. A mutual relationship can generate many wonderful surprises for each person (Eldridge, Surrey, Rosen, Baker Miller, 2003).

Policy example: Providers will empathize with the person’s situation in life and help each person to identify aspirations and goals and provide the knowledge, skills, support, and resources to achieve them.

Participation: People need to be involved in all aspects of their treatment and recovery processes. The 2003 President’s New Freedom Commission on Mental Health report stated that: “Nearly every consumer of mental health services…expressed the need to fully participate in his or her plan for recovery” It must be assumed that people are able to participate even when it doesn’t look like they can. Encouraging participation may take persistence and patience on the part of the helper. Participation can grow over time as people develop confidence in their ability to act in their own interest.

Self-determination/choice: People have the right to be in the center of decisions that affect their lives. Choice empowers people because it gives them some control over their lives. Choice, even when it involves failure, builds a sense of possibility rather than a sense of impossibility. In the Report of the 2004 Consumer Direction Initiative Summit, Transforming Behavioral Health Care to Self-Direction (SAMHSA, 2004), the term “self-directed care” was defined as a system that is “intended to allow informed consumers to assess their own needs . . . determine how and by whom these needs should be met, and monitor the quality of services they receive” (Dougherty, 2003). A general   principle is that self-determination is essential to everyone’s mental health and well being and is often regarded as a basic human right (Adams, Grieder, Nerney, 2005).

Empowerment: Empowerment means the person is able to say “I can” rather than “I can’t.” Empowerment is built through achieving success in life’s many tasks, even small ones. As successful experiences accumulate, peoples’ sense of empowerment gradually grows. Loss of power is a loss of one’s ability to act in one’s own interest—this is a loss of belief in oneself. Loss of power is also the loss of one’s sense of agency and vitality—the inability to experience oneself as an active and vital agent. People with psychiatric disabilities often experience themselves as having no power, no real choices. Power is further lost through the severing of our connections. When our connections are broken, we feel powerless and despairing (Lifton, 1996). There are a variety of forms of power. The power that is healing, that is more than oneself, that can move another person, is acquired through our relationships. It is power with people not over people. It is a power acquired through reconnecting with oneself, others, our environments, and meanings in life.  It is a power acquired through a deepening of our capacity to experience life fully and directly without being overwhelmed or intimidated. It is a power acquired by coming alive (Mack, 1994).

Growth potential: It is important to see people’s growth potential regardless of current difficulties or disabilities. Their growth potential may appear small at any given moment but it needs to be seen as an important opportunity for developing confidence and empowerment. Getting hope from others and having others show confidence in you is reported by many people with mental illnesses as an important turning point in their lives. Hope can be contagious and can plant a seed of promise, a new potential perspective, in a person who is distraught and despairing (Deegan, 1995).

Community focus:  Providers need to facilitate integration into community life by providing opportunities for the development of multiple roles to discover and create an identity that is separate from and greater than the illness such as a student, worker, volunteer, neighbor, friend, and one who can enjoy life. The identity of “patient” is very debilitating and needs to be actively countered by providing opportunities for new identities through acquiring the ordinary roles in life.

Whole person/family centered: People need to be treated as whole human beings, with natural responses to a profound trauma, and with a deeply felt connection to their family regardless of their current relationship. People with mental illnesses and their family members are not to be diminished or dehumanized in any way by their need for help.

Recovery as an expectation:  It is clear from the research and many personal accounts by people with mental illnesses that most people with serious mental illnesses recover. By recover we mean that people can work, have a social life, have an intimate relationship, live in housing of their choice, have an identity separate from the illness, and contribute to their community. We also know that there are many factors that enhance the recovery process—and some that inhibit it (Davidson, Harding, & Spaniol, 2006; Davidson, Harding, & Spaniol, 2005; Whitty, 2008). We can not promise people that they will recover but we can say that most people have recovered and that with assistance they have a good chance of having a life that is satisfying, fulfilling, and contributing. Because we currently have no way of accurately predicting who will recover it is important to assume that the person we are helping has the potential for recovery.

Policy example: Providers will affirm in their practice the above recovery values essential to a recovery-oriented program.

Policy example: The program will make available, assist in developing, or connect to in the community, the above essential elements of acute and ongoing psychiatric care.

Availability of Primary Health Care
Consumers of mental health services die an average of 25 years earlier than the general public (Everett, Mahler, Biblin, Ganguli, & Mauer, 2007).  Unfortunately, many medical problems of people with mental illnesses go undetected or untreated (Druss, et al., 2008). And their health is further complicated by lack of attention, ignorance, poverty, and neglect. As Lauren Spiro Director of Public Policy, National Coalition of Mental Health Consumer/Survivor Organizations has said in a recent presentation at the 2007 National Wellness Summit for People with Mental Illness (Spiro, 2007):

Each individual’s life depends on the society they live in and the services and supports that are available to them.  To frame the co-morbidity and early mortality rate as simply a medical issue is not only inaccurate but an injustice to everyone.  The problem of co-morbidity and early mortality is an indicator of a broken system within a broken society.  The coalition was formed because the survival of our brothers and sisters is being threatened by the oppressive policies, services and attitudes of the system and of society. We die young because we have no hope.  We die young because our dreams have been crushed.  We die young because our voice is neither heard nor understood.  We die young because many of us live in poverty, and some of us live on the streets.  We die young because our physical health needs are routinely ignored, often because any problems we have are attributed to our mental illnesses. 

Clearly, attention to basic health needs is critical in a recovery-oriented program as well as attention to other aspects of the person’s life that threaten their health and wellness.

Policy example: The program will make available, assist in developing, or connect to in the community, the above essential elements of acute and ongoing medical care.

People have to live with the daily impact of prejudice and discrimination.

They often live with hopelessness and despair.  People live with the perceived impossibility of recovery.

They quickly lose faith in the mental health system.

They are believed and come to believe that they are unable to have normal roles such as student or worker,

There is often a long-period of recuperation that may last several years.

People experience plateaus with the appearance of no progress followed by periods of integration and consolidation.

Their normal developmental phases are interrupted.

Thus, many of the distresses people feel do not come from the illnesses but from the reoccurring traumas of living with a mental illness in our society. Interventions such as peer support groups, therapy, education, skill building, goal setting, and patience on the part of providers and families are required that support and understand the often extreme emotional responses to living with a significant and potentially long-term illness.

Policy example: Practitioners will be responsive to the ongoing psychosocial impact of the illness on the person and the person’s family members.

People, in their recovery process, tend to experience some variability in growth within the various developmental dimensions i.e., vocational, social, educational, physical, and emotional.  People will show variability from others and within themselves over time. This variability can be a function of barriers or facilitators to growth such as quality of personal contact, opportunities, treatment interventions, resources, personal drive, resilience, personal successes, and other factors. It is interesting to note that level of achievement on the various developmental dimensions is not solely or simply related to level of symptoms but also involves successfully engaging a wide variety of barriers and facilitators to recovery. People can have symptoms that they are managing or struggling to manage successfully and still be growing in their recovery.

Policy example: Practitioners will be responsive to the developmental needs, priorities, and choices made by their clients.

Others: Provide interpersonal skills and opportunities for developing sustaining friendships and intimacy. Loneliness is a major problem for people with mental illnesses. Foster an atmosphere of a recovery community.

Broader environment: Provides opportunities for social programs, volunteering, and work that help people feel a part of the community and connected to others.

Meaning and purpose: While developing larger meaning and purpose is helpful (e.g., spirituality), people also need to identify their own personal purpose in life. A personal purpose often involves activities or relationships which make people feel useful and valued.

Policy example: Practitioners will be responsive to the connectedness needs of their clients.

Policy example: Practitioners will encourage clients to be involved in all decisions that affect their lives.

Policy example: Practitioners will encourage clients to set goals and provide the knowledge, skills, and supports to achieve those goals.

Policy example: Practitioners will educate clients about the value of family involvement and encourage signing of appropriate confidentiality release forms. They will encourage clients to involve family members as part of their treatment and rehabilitation team.

Policy example: Programs will educate staff about the value of peer support and actively and assertively involve peers who are in recovery in working for and volunteering for the program.

Providers need to understand that untreated substance abuse is a major barrier to recovery and that people in recovery from dual disorders are a very important part of any treatment team. People with dual disorders often need ongoing interventions for substance abuse related symptoms—which usually begin prior to or after the onset of the mental illnesses. Substance abuse often leads to further trauma, particularly from prejudice, discrimination, and violent victimization, which are common among people with severe mental illnesses.

Policy example: The program will provide integrated dual disorder services including regular substance abuse assessments to new clients.

Providers need to educate people with mental illnesses about intimacy and human sexuality. Help people learn the social skills necessary to find and maintain intimacy. Close personal relationships are important for recovery. Sexually transmitted diseases, especially HIV infection, are a high risk factor for people with mental illnesses.

Providers need to train people with mental illnesses in writing a Relapse Management Plan and an Advanced Directive Plan with a clearly designated surrogate decision maker. The Wellness Recovery Action Plan (WRAP, Mary Ellen Copeland) is an effective course for helping people identify and self-monitor symptoms of the illness and of stress. The WRAP is also effective for developing new beliefs and ways of thinking and challenging self-defeating thoughts. An Advanced Directive Plan gives people choices when they may be unable to make them themselves. The plan identifies how you want to be treated; what place you want to be treated at; who you want to be treated by; what medications you want to receive; and who will be making the decisions for you. The designated surrogate decision maker is the person, identified by the person with the mental illness, who will have final say over all treatment decisions. This is an important role to have someone take when we are unable to make our own decisions. So, the choice should be carefully thought through and put in writing in the plan.  Unfortunately, Advanced Directive Plans are not always followed faithfully by psychiatric staff so the designated surrogate decision maker needs to be particularly one who could be actively involved during crises (Srebnik & Russo, 2007).

Policy example: The program will provide comprehensive and ongoing wellness and fitness training and activities to clients.

Policy example: The program will provide a long-term commitment to clients and adopt a no-fail policy.

Policy example: The program will provide ongoing opportunities for clients to contribute within the program and within the community.

All parties need knowledge about recovery basics, hope, expectation for recovery, choice, listening, whole-person orientation, collaboration, supporting one another, encouraging self-care, knowledge of the illnesses, medications, side effects, and available resources. And, they also need the skills and positive attitudes to support the knowledge.

Policy example: The program will provide ongoing continuing education for providers, family members, people with mental illnesses, and the community.

Policy example: The program will provide ongoing advocacy to improve the daily lives of people with mental illnesses, their families, and providers.

Conclusions
People with mental illnesses can recover and build a self-determined life for themselves in communities of their choice. If the basic components of a recovery-oriented program are in place, their hopes for a fuller life can be more likely realized. It is hoped that by providing this brief summary of a recovery-oriented program providers, family members, and people with mental illnesses can better evaluate the closeness of their programs to what is now known that works.

Adams, N., Grieder, D., & Nerney, T. (2005). Models, Principles and Values of Person /Family-Centered Planning. National Consensus Initiative on Person/Family-Centered Planning. Chicago, IL: UIC National Research and Training Center on Psychiatric Disability.

Bogart, T., & Solomon, P. (1999). Procedures to share treatment information among mental health providers, consumers, and families. Psychiatric Services, 50, 1321–1329.

Corrigan, P. W., Barr, L., Driscoll, H., & Boyle, M. G. (2008). The educational goals of people with psychiatric disabilities. Psychiatric Rehabilitation Journal, 32(1), 67–70.

Davidson, L., Tondora, J., & O’Connell, M. J. 2007. Creating a recovery-oriented system of behavioral healthcare: Moving from concept to reality. Psychiatric Rehabilitation Journal, 31(1), 23–31.

Davidson, L., Harding, C. M., & Spaniol, L. (2006, vol. 2). Recovery from severe mental illnesses: Research evidence and implications for practice, Volume II. Boston, MA: Center for Psychiatric Rehabilitation.

Davidson, L., & Stayner, D. (1997). Loss, loneliness, and the desire for love: Perspectives on the social lives of people with schizophrenia. Psychiatric Rehabilitation Journal, 20(3), 3–12.

Davidson, L., Harding, C. M., & Spaniol, L. (2005, Vol. 1). Recovery from severe mental illnesses: Research evidence and implications for practice, Volume I. Boston, MA: Center for Psychiatric Rehabilitation.

Deegan, P. (1995). Recovery from psychiatric disability.  Presentation at NAMI of Massachusetts Curriculum and Training Committee Conference, Boston State House, Boston, MA.

Dougherty, R. H. (2003, June). Consumer-directed healthcare: The next trend? Behavioral Healthcare Tomorrow, 12, 21.

Doyle-Pita, D., & Spaniol, L. (2002). A comprehensive guide for integrated treatment of people with co-occurring disorders. Boston, MA: Center for Psychiatric Rehabilitation.

Druss, B. G., Marcus, S. C., Campbell, J., Cuffel, B., Harnett, J., Inoglia, C., & Mauer, B. (2008). Medical services for clients in community mental health center: Results fro a national survey. Psychiatric Services, 59(8), 917–920.

Everett, A., Mahler, J., Biblin, J., Ganguli, R., & Mauer, B. (2007). Improving the Health of Mental Health Consumers. Substance Abuse Mental Health Services Administration/Center for Mental Health Services, National Wellness Summit to Reduce Co-morbidity and Early Mortality of People with Mental Illness, Rockville, Maryland, September 17-18, 2007 

Fischer, E. P., McSweeney, J. C., Pyne, J. M., Williams, D. K., Naylor, A. J., Blow, F. C., & Owen, R. R. (2008). Influence of family involvement and substance use on sustained utilization of services for schizophrenia. Psychiatric Services, 59, 902–908.

Hutchinson, D. S., Skrinar, G. S., & Cross, C. (1999). The role of improved physical fitness in rehabilitation and recovery. Psychiatric Rehabilitation Journal, 22(4), 355–359.

 Lifton, R. J. (1996). The broken connection: On death and the continuity of life. Washington, DD: American Psychiatric Press.

Mack, J. E. (1994). Power, powerlessness, and empowerment in psychotherapy. Psychiatry, 57, 178–198.

Magliano, L., Fiorillo, A., Malangone, C., Del Vecchio, H., & Maj. M. (2008). Views of persons with schizophrenia on their own disorder: An Italian participatory study. Psychiatric Services, 59(7), 795–799.

Russinova, Z., Wewiorski, N., Lyass, A., Rogers, E. S. (2003). Correlates of vocational recovery for persons with schizophrenia. International Review of Psychiatry, 14(4), 303–311

SAMHSA. (2004). nmhicstore.samhsa.gov/consumersurvivor/publications_sdc.aspx

Srebnik, D. S., & Russo, J. (2007). Consistency of psychiatric crisis care with advance directive instructions. Psychiatric Services, 58, 1157–1163.

Whitty, P., Clarke, M., McTigue, O., Browne, S., Kamali, M., Kinsella, A., Larkin, C., & O'Callaghan, E. (2008). Predictors of outcome in first-episode schizophrenia over the first 4 years of illness. Psychological Medicine, 38, 1141–1146.