Recovery Model Will Strengthen Psychiatrist-Patient Relationship

The President's New Freedom Commission on Mental Health has proposed to transform the mental health system by shifting the paradigm of care of persons with serious mental illness from traditional medical psychiatric treatment toward the concept of “recovery.” Although there are many perceptions and definitions of the term recovery, especially emanating from the substance abuse field, the cornerstone definition of mental health recovery was developed by William Anthony, Ph.D., director of the Boston Center for Psychiatric Rehabilitation.

Anthony, in 1993, identified recovery as “a deeply personal, unique process of changing one's attitudes, values, feelings, goals, skills, and/or roles. It is a way of living a satisfying, hopeful, and contributing life even with limitations caused by illness. Recovery involves the development of new meaning and purpose in one's life as one grows beyond the catastrophic effects of mental illness.”

The recently adopted APA position statement titled “Use of the Concept of Recovery” stated, “The concept of recovery has a long history in medicine, and its principles are important in the management of all chronic disorders. The concept of recovery enriches and supports medical and rehabilitation models. By applying the concept of recovery as well as rehabilitation techniques and by encouraging other mental health professionals to adopt the concept of recovery, psychiatrists can enhance the care of all clinical populations served within the community-based and other public-sector mental health and behavioral health systems.”

The concept of recovery has become so important in psychiatry that the theme selected for APA's 2005 Institute on Psychiatric Services was“ Recovery and Community.” You will read more about the meeting, which was held earlier this month in San Diego, in the next issue of Psychiatric News. Among those who spoke on the recovery theme were individuals who have made groundbreaking contributions to the recovery movement, such as Fred Freese, Ph.D., a leader of the Alliance for the Mentally Ill; Tony Lehman, M.D., professor and chair of the Department of Psychiatry at the University of Maryland; and H. Westley Clark, M.D., J.D., director of the federal Center for Substance Abuse Treatment.

Several factors are common in the recovery paradigm. These include hope, medication and other psychiatric treatments, empowerment, support, education, self-help, spirituality, employment, and meaningful activities.

Hope is the desire that one can get better, accompanied by confidence and expectations. It is the foundation for ongoing recovery from mental illness. Psychiatrists create hope as we treat patients. At some point, however, patients must develop and internalize their own sense of hope.

Most people with severe mental illness say that medications are critical to their success and provide hope. It is often a complicated and frustrating collaborative process of doctor and patient to find the right combination of medications with the right dosing and fewest side effects, and it has to be understood that the goal is not necessarily to become medication free but to take the least amount necessary. A long-term trusting relationship with a psychiatrist and continuity of care built over time are part of this process.

Empowerment is the belief that one has the power to control one's own life, including illness. It involves taking responsibility for oneself and advocating for oneself as well as others.

Support from one's doctor and others on the treatment team, as well from peers, family, and friends, is essential to recovery. Having multiple sources of support is especially beneficial. Participation in mutual support groups is one important tool for recovery. Being able to interact with others who understand experiences and feelings not only reduces the sense of isolation but increases social activity in the community.

To maximize recovery, it is important to learn as much as possible about mental illness, medications, best treatment practices, and available resources. Early recognition of symptoms that lead to relapse is often the key to relapse prevention.

The value of professional treatment is enhanced when self-help is also involved. Self-help can take many forms, including learning to identify symptoms early and to take actions to counteract them, reading, attending mutual support groups, and developing a support system to rely on when necessary.

For many patients, spirituality also provides hope and solace, peace and understanding, and is an additional source of support.

And most importantly, employment and meaningful activities increase self-esteem. Work increases social interactions and provides an opportunity for patients to regain a positive identity in the face of serious mental illness.

At a recent NIMH conference on mental health services research, Carla Green, Ph.D., M.P.H., discussed predictors of recovery of persons with severe and persistent mental illness. Continuity of care and relationships with clinicians were seen as crucial to recovery. Psychiatrists and other clinicians contribute to recovery by providing continuity of care, a trusting relationship (that is, the sense that the doctor really cares), a collaborative approach with input solicited and accepted from the patient, and a normal relationship (that is, being able to talk about everyday things and feelings about everyday issues). Recovery is enhanced by a fit between the clinician, treatment strategies, and patients' needs. Of course, for many of us, this is just good quality care that we strive to provide despite the distractions of funding limits and managed care constraints.

There is a good deal that we as psychiatrists can learn about recovery, and we have a most critical role in facilitating it. The doctor-patient relationship plays an essential role, and we must be ever mindful of it.▪