The concerns listed in the accompanying box have been culled from a series of presentations, discussions, and training sessions conducted over the last several years as the state of Connecticut has moved toward a recovery-oriented system of care (
18 ). As the work of transformation can at times elicit tensions and conflict, the rubric of "top ten concerns"—derived from
Late Night With David Letterman —was chosen to introduce some levity into the situation. Because of space limitations, we cannot take each concern separately but will address, and offer alternatives to, the two most significant challenges that appear common across the specific concerns—namely, those of resources and risk.
Recovery and resources
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. In our training, we have found it useful to discuss the various meanings of recovery as they relate to mental illness (as we did above) but also, and perhaps even more important, to distinguish between recovery, which pertains to the role and responsibility of the person with a serious mental illness, and recovery-oriented care, which pertains to the role and responsibility of mental health providers.
Recovery is a process in which the person engages to figure out how to manage and live with his or her disorder. It is not a fad, an added burden, or a new and as yet unproven practice imposed on already stretched providers. As such, it is neither something providers can do to or for people with mental illness, nor is it something that can be promoted after or separate from treatment and other clinical services. Rather, the New Freedom Commission has argued for recovery to be adopted as the overarching aim of all mental health services (with the exception of forensic services for offenders with mental illness, the primary aim of which may be containment or community safety). It is thus insufficient for mental health providers to agree that they could do more to enhance quality-of-life domains among people with mental illness if they had new or additional resources. Many providers, for example, are happy to open new "recovery programs" or to decrease caseload size if offered the requisite resources. But recovery-oriented care cannot be conceptualized as an add-on to existing services.
Providers who argue that they must provide treatment first and can then perhaps focus on offering rehabilitation (if there is the time or resources), should be asked: If what you are offering is not oriented to promoting recovery, then what is it for? And if there are ways in which what you offer could be more recovery-oriented, and thereby more effective at achieving its aims, would you not want to learn about it and try it?
We are not suggesting that offering recovery-oriented care does not require the expenditure of resources. However, we cannot afford to have a recovery-oriented system grow up parallel to, and distinct from, existing systems of care, conceptualized as an adjunctive or ancillary service. Resources will be needed to fund services and supports and to carry out the staff training and consultation needed to retool the mental health workforce, but these resources will have to be derived, in large part, from the resources currently allocated to fund existing services, supports, and training.
Rather than being contradictory to recovery, this approach is one way in which the current emphasis on evidence-based practices can be used to promote recovery-oriented care. If there is no evidence supporting the effectiveness of a given practice in promoting an individual's ability to manage, overcome, or live with his or her mental illness, then why should scarce resources be used to fund it? Why should those resources not be reallocated to support practices that are more effective in achieving the overarching aim of the system of care? In this respect, it makes no sense to ask whether recovery or recovery-oriented care is "evidence based." There is ample evidence, documented extensively over 30 years, that people can and do learn how to live with and recover from serious mental illness in the various senses described above (
19 ). The question about evidence-based practices is which interventions, provided by whom, are most effective at promoting which of these various forms of recovery under what circumstances. It is true that new or existing resources will need to be devoted to answering this question in the future if transformation is to be optimally effective in achieving its aims.
Recovery and risk
The second commonly expressed concern about recovery involves issues of ethics and risk. How can the idea of recovery be relevant to someone experiencing an acute episode of psychosis or mania? It would seem that such a person would need to get better first before recovery can be discussed or even considered. Similarly, some staff question the ethics of focusing on strengths, hopes, and dreams when a person may be faced with such urgent needs as safety, shelter, and stabilization. Self-determination and client choice are touted as cornerstones of the recovery process. But what sense does it make to afford choices to a population of individuals whose judgment is impaired by the very conditions we are charged with treating? Doesn't honoring the choices of someone with an acute or severe mental illness involve abandoning him or her to the ravages of the illness, often to the streets? Doesn't this amount to leaving a vulnerable population of people "to rot with their rights on" (
20 )? Finally, providers ask, How can you tell us to promote client choice and self-determination on one hand while holding us responsible for adverse events on the other? Doesn't increasing client choice increase provider risk?
Most people who may be described as in recovery from mental illness neither think nor talk about the term "recovery" at all. They talk about getting a job, making friends, having faith, living on their own, and generally getting their lives back. Their engagement in this process is equally relevant to all phases and forms of treatment, although the goals of each phase or form may differ. For example, in terms of acute episodes, recovery doesn't start after the episode resolves, nor can it be put on hold while the person is receiving treatment. From the person's perspective, it is rather that the acute episode has temporarily disrupted his or her ongoing process of recovery (or it may be an anticipated part of the process), and care received during this period can more or less promote or undermine that process.
Recovery requires reframing the treatment enterprise from the professional's perspective to the person's perspective. In this regard, the issue is not what role recovery plays in treatment but what role treatment plays in recovery. This shift has important implications for how we conceptualize and deliver care and the degree to which this care is acceptable to, and effective for, the people we serve. For example, if we accept the premise that mental illness is a condition that many people can learn to live with, our emphases on choice and self-determination become inevitable rather than optional. How else can people learn how to manage their condition in particular, and their life more generally, if they are not allowed to make their own decisions?
But mental illness is different from other illnesses, providers suggest, because of the issue of risk. To this concern we have several responses. First, a majority of people with mental illness pose no risks to the community (
21,
22,
23 ). In fact, surveys have shown consistently that this population is much more likely to be victimized than to victimize others (
24,
25 ). These findings suggest that people with mental illness—like all other American citizens—should be presumed innocent until proven otherwise. In the realm of choice, this presumption means being allowed to make one's own decisions unless and until there are clear and persuasive grounds for imposing restrictions on this most fundamental of our civil rights (
26 ). A core principle of the recovery paradigm is the appropriate application of established constructs of informed consent and permission to treat to a majority of individuals with serious mental illness a majority of the time. Application of this principle means that—as in other forms of medicine—no matter how expert or experienced the provider, it is ideally left up to the person and his or her loved ones to make informed decisions about care. It is not the practitioner's role to make such health care decisions for the person.
But doesn't such an approach result in devaluing or disregarding the knowledge and expertise of the professional? We suggest, to the contrary, that a recovery-oriented approach brings psychiatry closer to other medical specialties in which it is the specialist's role to assess the person's functioning, diagnose his or her condition, educate the person about the costs and benefits of the effective interventions available to treat the condition, and then, with provision of informed consent and permission to treat, competently provide the appropriate interventions. If mental illness is an illness like any other, it should be treated as such, by medical staff as well as by the general public. If this basic tenet is accepted, it is difficult to understand how providers could view their roles as any less important, or as requiring any less skill, than those of other specialists, such as cardiologists or oncologists.
However, given that one of the obligations of public mental health systems is to protect the community, we understand, and insist, that—just as in other forms of medicine—there are exceptions to this rule. These exceptions, as clearly delineated in federal and state statutes, invariably involve a person who poses some degree of risk, either to him- or herself or to others. In these cases, just as in emergency medicine, the issue of informed consent and permission to treat is suspended temporarily to perform life-saving measures. These cases do not contradict recovery but pose important challenges to it—challenges that may in the future be addressed through such mechanisms as psychiatric advance directives or other creative means to enable people to retain control over their lives, even in such extenuating circumstances. In the interim, rather than arguing about whether or not recovery-oriented care increases risk (an issue about which we do not yet have data), we suggest that it is more useful to highlight the ways in which a recovery-oriented approach clarifies and reinforces the need that already exists for appropriate risk assessment and management. Within the context of a recovery-oriented system of care, the competent conduct of risk assessments will be needed precisely in order to identify the rare circumstances in which people cannot be allowed to act in ways that put others or themselves at risk.
By defining the cases or periods of time in which people pose sufficient risk to have others step in and make decisions for them (to protect them and the public), competent risk assessment leads to the additional byproduct of delimiting a domain of behavior and a population of people for whom there is no such need. This byproduct is important, because the recovery vision emphasizes not only the rights of people with mental illness but also the responsibilities they carry associated with community membership. In a majority of circumstances in which people do not pose immediate risks to self or others, it is not only their right to make their own decisions but also their responsibility. As Deegan (
27 ) has suggested, people need to have "the dignity of risk" and "the right to fail" in order to learn from their own mistakes. Given the social climate in which mental health care is currently offered, it will be primarily through the appropriate use of risk assessment and management strategies that this latitude will become possible. For this reason, advocates are neither afraid of nor do they dismiss the scrutiny of risk assessment. They welcome it. But they welcome it on the condition that, in a majority of cases, when people are found not to pose serious or imminent risks to themselves or others, they are allowed to make their own choices and, by necessity, their own mistakes. Thus, although 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.