Mental Disorder Aranged by Nathan CowlesPhotographed by Heather Burns
The Model What Is Recovery? A Conceptual Model and Explication Written by Nora Jacobson, Ph.D. 1 Dianne Greenley, M.S.W., J.D. Psychiatric Services 2001 I n our model, the word recovery refers both to internal conditions— the attitudes, experiences, and pro- cesses of change of individuals who are recovering—and external conditions— the circumstances, events, policies, and practices that may facilitate recovery. Together, internal and external condi- tions produce the process called recov- ery. These conditions have a reciprocal effect, and the process of recovery, once realized, can itself become a factor that further transforms bothSpecial thanks to my dear friend Heather Burns for the photography, who without this would not have been possible. internal and external conditions.
Hope T he hope that leads to recovery is, at its most basic level, the indi- vidual’s belief that recovery is pos- psychiatry, psychology, social work, and science cannot account for this phe- nomenon of hope. But those of us who Focusing on strengths rather than on weaknesses sible. The attitudinal components of have recovered know that this grace is or the possibility hope are recognizing and accepting real. We lived it. It is our shared secret”. of failure, looking that there is a problem, committing to The source of this grace is differ- forward rather change, focusing on strengths rather ent for each individual. For one it will be than ruminating than on weaknesses or the possibility the entity he or she knows as God. For on the past of failure, looking forward rather than another, it might be a spiritual connec- ruminating on the past, celebrating tion with nature. Individuals not drawn small steps rather than expecting seis- to spirituality may find their grace in mic shifts in a short time, reordering other sources, such as making art or priorities, and cultivating optimism. contemplating philosophical issues. Gaining hope has about it something Hope sustains, even during periods of of the transcendent. “A tiny, fragile relapse. It creates its own possibilities. 2 3 spark of hope appeared and prom- Hope is a frame of mind that ised that there could be something colors every perception. By expand- more than all of this darkness.… This ing the realm of the possible, hope lays is the mystery. This is the grace.… the groundwork for healing to begin. All of the polemic and technology of In its simplest sense, empow- of meaningful choices. The second is erment may be understood as a cor- courage—a willingness to take risks, rective for the lack of control, sense to speak in one’s own voice, and to of helplessness, and dependency that step outside of safe routines. The many consumers develop after long- third is responsibility, a concept that term interactions with the mental speaks to the consumer’s obligations. health system. A sense of empow- erment emerges from inside one’s In the recovery model, the self—although it may be facilitated by aim is to have consumers assume external conditions—and it has three more and more responsibility for components. The first is autonomy, themselves. Their particular respon- or the ability to act as an indepen- sibilities include developing goals, dent agent. The tools needed to act working with providers and others— autonomously include knowledge, for example, family and friends—to self-confidence, and the availability make plans for reaching these goals.
Healing C onsumers and professionals who accept the dictionary definition of recovery—to regain normal health, The second healing process is control—that is, finding ways to relieve the symptoms of the illness or The external conditions that define recovery poise, or status—may resist the very reduce the social and psychological are human rights, possibility of recovery because they effects of stress. For some consum- “a positive culture see it as an unrealistic expectation. ers, medication is a successful strategy of healing,” and However, it is important to remember for effecting control. Another strat- recovery oriented that recovery is not synonymous with egy is learning to reduce the occur- services. cure. Recovery is distinguished both rence and severity of symptoms and by its endpoint—which is not neces- the effects of stress through self-care sarily a return to “normal” health and practices, such as adopting a wellness functioning—and by its emphasis on lifestyle or using symptom moni- the individual’s active participation toring and response techniques. in self-help activities. The concept4 5 of recovery is better captured by the The word “control” has a notion of healing, a process that has double meaning. In one sense it refers two main components: defining a to the outcome of managing symp- self apart from illness, and control. toms or stress. The second meaning, however, refers to the locus of con- As Estroff has noted, people trol, or who has control. In recovery who have psychiatric disabilities often it is the consumer who has taken find that they lose their “selves” inside control, who has become an active mental illness. Recovery is in part agent in his or her own life. Control the process of “recovering” the self is an important factor in the next by reconceptualizing illness as only a internal condition, empowerment. part of the self, not as a definition of the whole. As consumers reconnect with their selves, they begin to expe- rience a sense of self-esteem and self- respect that allows them to confront and overcome the stigma against persons with mental illness that they may have internalized, thus allow- ing further connection with the self.
Connection An analysis of T o find roles to play in the world. These roles may involve activi- ties, relationship status, or occupa- services provided. It is important to recognize, however, that these three conditions are simply different foci numerous accounts by consumers who describe tion. Many consumers report that the viewed through the same lens. That themselves as most powerful form of connection is, implementation of the principles “being in recovery” is helping others who are also living of human rights in an organization suggests that the with mental illness. For some consum- results in a positive culture of healing, key conditions in ers, this means becoming a mental and recovery-oriented services are ser- thips proccess are health provider or advocate; for others, vices that emerge from such a culture. hope, empowerment, it means bearing witness, or telling healing, and their own stories in public arenas. connection In all of these capacities, consumers increase the general understanding of what it is like to live with a men-6 7 tal illness. They find ways to validate and reconcile their own experiences, and by standing as living exemplars of the possibility of recovery, they serve as role models for others. In yet another sense, connec- tion is the bridge between internal and external conditions, allowing reciprocal action between the two. The external conditions that define recovery are human rights, “a positive culture of healing”, and recov- ery-oriented services. On the surface, these three conditions seem quite dif- ferent. Human rights denotes a broad, societal condition; a positive culture of healing refers to the cultural milieu in which services are offered; and recov- ery-oriented services are the actual
Healing Culture In its broadest sense, a human rights agenda lays out a vision of a F isher has written of the need to “build a coherent social faith and order” as a way to promote recov- matter what his or her current status. This belief must lead them to focus society in which power and resources on the person, not the illness, and are distributed equitably. When ery. He described this new order as on his or her strengths and goals. applied to mental illness, human “a positive culture of healing… a A key component of a posi- rights emphasizes reducing and then culture of inclusion, caring, coopera- tive culture of healing is the develop- eliminating stigma and discrimina- tion, dreaming, humility, empower- ment of collaborative relationships tion against persons with psychiatric ment, hope, humor, dignity, respect, between consumers and providers. disabilities; promoting and protecting trust, and love.” When applied to the In contrast to a hierarchical model of the rights of persons in the service culture of a human services organiza- service provision, the collaborative system; providing equal opportunities tion, this vision of a positive culture of model allows consumers and provid- for consumers in education, employ- healing begins with an environment ers to work together to plan, negoti- 9 ment, and housing; and ensuring that characterized by tolerance, listen- ate, and make decisions about the consumers have access to needed ing, empathy, compassion, respect, services and activities the consumer resources, including those necessary safety, trust, diversity, and cultural will use to support his or her recov-8 for sustaining life (adequate food competence. A healing culture is ery. Collaboration implies that the and shelter) as well as the social and oriented toward human rights for all consumer is an active participant, that health services that can aid recovery individuals and groups. Consumers’ he or she is presented with a range (physical, dental, and mental health rights are incorporated into all deci- of options and given the opportunity services; job training; supported hous- sions, and informed consent is part to choose from among them, and ing; and employment programs). of the bedrock of daily practice. that providers allow the consumer to take some risks with these choices. This human rights agenda In a positive culture of heal- Consumers have the opportunity to allows for different perspectives and ing, professionals as well as consum- make choices other than those the different types of activism. It can be ers are empowered and engaged. For provider might have made for them. used to advocate for the reduction providers, empowerment means first and ultimately the elimination of believing that they can make a differ- Finally, a true collaborative involuntary commitment and other ence and then making a commitment relationship is one in which both forced treatment, which many view as to changing the way they concep- consumer and provider come to see violations of human rights, or it can tualize the course of mental illness each other as human beings. For be used to campaign for parity legisla- and the way they practice. Providers providers, this means learning to see tion and universal health coverage. must embrace the belief that every beyond the diagnostic—or racial, consumer can achieve hope, healing, ethnic, and socioeconomic—catego- empowerment, and connection, no
Recovery Services T he Boston University Center for Psychiatric Rehabilitation has developed a model for designing Examples include advocacy, peer support programs, recovery-oriented services. The model hospitalization delineates four major consequences alternatives, hotlines of severe mental illness—impair- or “warm lines,” ment, dysfunction, disability, and and programming disadvantage. Recovery-oriented that provides services address the range of these opportunities for features and include services directed role modeling at symptom relief, crisis interven- and mentoring. tion, case management, rehabilita- tion, enrichment, rights protection, basic support, and self-help.10 11 A second model, developed by the Ohio Department of Mental Health, describes the best practices to be implemented by consumers, clinicians, and community supports and family involvement, challenging sions about medication are worked size their diverse but complementary at four different stages of the mental stigma and discrimination, reflective out in a partnership between the strengths. Examples include recovery health recovery process. The practices practice and continuous improvement, provider and the consumer, rather education and training, clubhouse encompass clinical care, peer and fam- cultural sensitivity and safety, and than being dictated by the provider. organizations, crisis planning, the ily support, work, power and control, spirituality and personal meaning. Consumer-run services are development of recovery and treat- stigma, community involvement, Each of these models inte- planned, implemented, and provided ment plans, community integration, access to resources, and education. A grates services provided by profes- by consumers for consumers. Exam- and consumer rights education. third model offers practice guidance sionals, services provided by con- ples include advocacy, peer support Although many of these within “a framework for designing, sumers, and services provided in programs, hospitalization alternatives, services may sound similar to services implementing, and evaluating behav- collaboration. Services provided by hotlines or “warm lines,” and pro- currently being offered in many mental ior healthcare services that facilitate professionals include medication, gramming that provides opportunities health systems, it is important to individual recovery and personal out- psychiatric rehabilitation, and tradi- for role modeling and mentoring. recognize that no service is recovery- comes.” Using the overarching meta- tional support services such as therapy Collaborative services are oriented unless it incorporates the phor of “a healing culture,” this model and case management. The recovery provided by and for both consum- attitude that recovery is possible and addresses such issues as language, orientation in these services lies in ers and professionals as well as family has the goal of promoting hope, heal- dignity and respect, empowerment the attitudes of the professionals who members, friends, and members of ing, empowerment, and connection. and personal responsibility, consumer provide them. For example, deci- the larger community and empha-
About the Authors The hope that leads to recovery is, at its most basic level, the individual’s belief that recovery Dr. Jacobson’s work on is possible. HOUSEING STRATGIES USED Number of Percent of the conceptual model and on this programs programs paper was supported by the Wis- consin Coalition for Advocacy. Permanent housing strategies Dr. Jacobson is an associate Develops dedicated 33 77% scientist with the University of Wis- Actively recruit landlords 18 42% consin School of Nursing in Madison, has dedicated section vouchers 17 40%12 K6/316 Clinical Science Center, 600 Highland Avenue, Madison, Wisconsin Operates perminent 6 14% suppotive housing 53792 (e-mail, najacobson@facstaff. wisc.edu). Ms. Greenley is a supervis- Temporary and transition assistance ing attorney at the Wisconsin Coali- Uses resources for short term 43 100% tion for Advocacy and co-principal investigator with the women and men- Uses resources for ongoing rental 37 86% tal health study site at the University of Wisconsin School of Social Work. Offers transitial options 30 70% Uses motels 21 49% Housing search and retention assistance Provides housing advocates 42 98% Offers land lords support 43 100% Offers ongoing support 43 100% Helps consumers apply for housing 38 88% Partnerships Perminent suportive housing 19 44% Public housing authority 13 30%