This module introduces the key concepts in mental health recovery and recovery-oriented practice. It reviews the history and development of “person-centered” care planning and places it within the broader context of recovery-oriented efforts that are transforming the mental health system as a whole.

After completing this module, you will be better able to:

• define mental health recovery;
  
• describe the difference between traditional practices and recovery-oriented approaches;
  
• define person-centered care planning;
  
• understand how person-centered planning differs from past practice.

A learning assessment is included at the end of the module. If you are already familiar with mental health recovery and its implications for care planning, you can go to the end of this module to take the assessment section to test your understanding.

Recovery is about living a fulfilling and rewarding life in the context of mental health challenges. While some people recover in the sense that they no longer experience psychiatric symptoms, recovery is not necessarily about becoming symptom- or problem-free. A large part of recovery for many people is moving beyond being labeled as a “mental patient,” “client,” or even “consumer” to find new meaning, purpose, and possibility in life. For many people, recovery means [1]:

• No longer defining oneself by the experience of mental illness.
  
• Being a full participant in the community with valued roles such as worker, parent, student, neighbor, friend, artist, tenant, lover, and citizen.
  
• Running one’s own life and making one’s own decisions.
  
• Having a rich network of personal and social support outside of the mental health system.
  
• Celebrating the newfound strength and skills gained from living with, and recovering from, mental illness.
  
• Having hope and optimism for the future.

All around the world people have been demonstrating the possibility, and reality, of mental health recovery. Their stories of lived experience are supported by a mounting evidence base that suggests that recovery is more the norm than the exception in serious mental illness. Beginning with the World Health Organization’s (WHO) International Pilot Study of Schizophrenia launched in 1967, there have been a series of long-term, longitudinal studies conducted that have produced a consistent picture of broad heterogeneity in outcome for persons with serious mental illnesses. For example, with respect to schizophrenia, the WHO study documented partial to full recovery in between 45% and 65% of each sample, even when recovery was defined in a clinical fashion as a remission in symptoms, while an even larger percentage of people were able to live independently despite continued symptoms [3].

Similarly, the Vermont Longitudinal Study conducted by Courtney Harding and colleagues found recovery or significant improvement in 62%–68% of the people studied—a finding that was all the more important given that the research was carried out on individuals discharged from a state hospital who were considered to have the most severe and persistent of conditions [4]. Since then, eight more long-term studies (e.g., 22–37 years) have been completed around the world, yielding comparable—and at times, better—results [5].

A variety of self-help and 12-step programs in the addictions arena has influenced the recovery movement and the value it places on mutual support and shared experience. However, there are some unique differences between the actual experience of recovery in mental illness as compared to recovery from addiction. For example, there are core differences related to issues of power. A common requirement in 12-step programs is to admit powerlessness and turn one’s self and life over to a “Higher Power.” While respecting the importance spirituality plays in many people’s lives, mental health recovery emphasizes empowerment and self-determination as well; helping individuals to find their own voice and to take personal responsibility for their own lives. This is based on the belief that people need to reclaim, not turn over, their power as one of the first steps of recovery.

This distinction between mental health and addiction recovery impacts both the process of self-identification and the use of preferred language and terms. For example, traditional 12-step programs encourage individuals to introduce themselves as: “My name is X and I am an alcoholic.” This is consistent with the 12-step focus on acknowledging one’s powerlessness over a substance, and self-identification in this manner is respected as a part of the individual’s unique recovery process. In contrast, in the mental health recovery community, there is an emphasis on helping individuals to move beyond the diagnostic labels that have been applied to them by others. Therefore, individuals are encouraged to use “person-first” language and thereby NOT to identify themselves, or allow themselves to be identified by others, in any way that makes a psychiatric diagnosis their most salient or defining characteristic: for example, “My name is X and I am schizophrenic.” In both the addiction and mental health contexts, it is important to note that individual preferences around language and self-identification vary widely, and additional guidance on this topic is offered in Module 2.

Despite these differences in the process of recovery in mental illness and addiction, there are numerous areas of overlap and commonality [10]. The important thing to remember is that no matter what an individual’s particular label or diagnosis, people with mental illnesses and addictions are first and foremost people, and people who know best what kind of life they will find worth living in the wake of a behavioral health condition. This is the hallmark of the recovery movement in both mental health and addiction.

A number of prominent reports reflect the emergence of recovery and recovery-oriented care as the driving force behind mental health systems across the globe. For example, a 2012 issue of the International Review of Psychiatry contained papers outlining the current stage of recovery research and practice from Austria, Australia, Canada, England, Hong Kong, Israel, New Zealand, Scotland, and the United States [11], while a 2011 review of policy developments identified 30 government documents mandating recovery-oriented care from English-speaking countries around the globe [12]. The following are a few examples from these English-speaking nations:

Achieving the Promise: Transforming Mental Health Care in America, US Department of Health and Human Services [13]. This report called for recovery to be the “common, recognized outcome of mental health services” and recommended “fundamentally reforming how mental health care is delivered in America” to be reoriented to the goal of recovery. This report strongly criticized the nation’s current mental health system as one that, too often, “simply manages symptoms and accepts long-term disability.”

Improving the Quality of Health Care for Mental and Substance Use Conditions, Institute of Medicine [14]. This report speaks specifically of the decision-making abilities of individuals who have a mental illness as well as those who do not. One harmful stereotype that is referenced in the report is “incompetent decision making.” One key recommendation notes that “to promote patient-centered care, all parties involved in health care for mental or substance use conditions should support the decision-making abilities and preferences for treatment and recovery of persons with mental and substance use problems and illnesses.”

No Health without Mental Health, UK Department of Health [15]. This national policy framework for England identifies six priorities for the mental health system, including “more people will have good mental health,” “more people with mental health problems will recover,” and “fewer people will experience stigma and discrimination.” One national initiative being carried out as part of this policy is the Implementing Recovery–Organisational Change (ImROC) program, which is working with 33 of the 55 mental health trusts (provider organizations) in England to support their transformation to a recovery orientation [16]. This initiative includes the recommendation that the mental health workforce comprise 50% people with lived experience of mental illness [17] and introduce Recovery Colleges to provide support to people with mental illnesses through an educational approach [18].

Changing Directions, Changing Lives, Mental Health Commission of Canada [19]. An emerging vehicle of change in several countries has been the establishment of influential Mental Health Commissions. The Canadian commission was established in 2007, and in developing its national mental health strategy, it has taken testimony from thousands of people living with mental health conditions. An important stepping stone was the 2009 discussion document Toward Recovery and Well-Being [20], which defined mental health as “a state of well-being in which the individual realizes his or her own potential, can cope with the normal stresses of life, can work productively and fruitfully, and is able to make a contribution to her or his own community.” In this report, a mental health framework is developed as a blueprint for change, with the strategic direction to “foster recovery and well-being for people of all ages living with mental health problems and illnesses, and to uphold their rights.” The emphasis on well-being in the context of mental illness is consistent with empirical research [21] and the links between well-being research and recovery are becoming clearer [22].

A Recovery Approach within the Irish Mental Health Services—A Framework for Development, Mental Health Commission of Ireland [23]. The Mental Health Commission in Ireland has created a framework for developing services across the island of Ireland, which involves a focus on the strengths and opportunities rather than the limitations and symptoms of illness. The contribution of mental health systems is understood to involve “enabling and empowering the person to access their inner strengths and resources to build a meaningful, valued, and satisfying life.” One transformation component that is highlighted is that of dynamic leadership because “if the predominant ethos is one of benign paternalism and illness orientation, or one that ignores the input of service users at management and service development level, then a culture that ignores the principles of recovery is likely to be fostered throughout the organization. Equally, without a stated commitment to the principle of individualism and choice, people may simply re-title current practice as recovery-oriented.” This focus on the role of organizational commitment is consistent with best practices internationally [11].

Blueprint II: Improving Mental Health and Well-Being for All New Zealanders, Mental Health Commission of New Zealand [24]. In 1998, New Zealand developed the first national blueprint for transformation toward recovery. In 2012, it issued a new 10-year national strategy based on the learning from Blueprint I, and addressed specifically the impact of the global economic downturn. It adopted the “Triple Aim” model as a framework for sustainable service development: 1) improving quality, safety, and experience of care; 2) improving health and equity for all populations; and 3) ensuring the best value in public health system resources. In identifying eight priority areas for service development, a shift from Blueprint 1 was evident, involving a greater focus on well-being and a more explicit reference to issues of risk and safety.

Framework for Recovery-Oriented Practice, Department of Health, Victoria [25]. Although a state-based policy rather than a national policy, this framework draws on the best available evidence internationally to identify the key domains of recovery-oriented practice: promoting a culture of hope; encouraging autonomy and self-determination; fostering collaborative partnerships and meaningful engagement; focusing on strengths; striving for holistic and personalized care; involving family, carers, supporting people, and significant others; maximizing community participation and citizenship; showing responsiveness to diversity; and committing to ongoing reflection and learning. For each domain, the key capabilities and examples of both good practice and good leadership are provided. This is a brief and easily accessible document that informs the development of a recovery orientation as mandated in the fourth National Mental Health Plan (2009–2014) in Australia.