To the Editor: The March issue included an article by Turton and colleagues (1) describing a process that assessed stakeholder views on the most important treatment components in promoting recovery of people receiving institutional care in the European Union. The authors expressed surprise that aspects of care that were ranked as being most important were "therapeutic interventions" and other domains of "a more conventional" medical model. They contrasted these domains to ones that they considered more reflective of a "recovery" orientation—such as "autonomy and self-management, social inclusion, dignity, hope"—and inferred from these findings that the recovery vision might need to be tempered a bit by giving more importance to medical aspects of care and less value to such "broader recovery principles" as autonomy and dignity. Given that the study was limited to asking stakeholders about institutional care and that participants were chosen based on their belief that "the institutional setting [is] an environment that supports people in moving back into the community," the only thing that surprised me was that the authors were surprised by this largely tautologous finding. Thus I find the conclusions they draw from their findings concerning.
Turton and colleagues readily acknowledge that these findings might be due to the fact that therapeutic interventions and medical care "form the very basis and raison d'être of health care." What they perhaps have not taken fully into account is that therapeutic interventions and medical care form the very justification for institutional care in particular. The question they asked participants was, "In your view, what most helps recovery for people with long-term mental health problems in institutional care?" It would be hard to argue that autonomy or social inclusion are the most helpful aspects of care for people in institutions when these are the same aspects of care that are most compromised in institutional settings. In fact, how could institutional care promote autonomy or social inclusion when by its very function it serves to supervise and segregate? A very different answer to this question could have been "What would most help recovery is for these people to be discharged to community-based care in natural settings." It does not seem that this answer was considered as a possibility.
Rather than interpreting these data to suggest that the recovery orientation needs to be counterbalanced by the medical model, I take these findings, along with the focus of the study on institutional care, to indicate the stage at which the participating countries are at this time in history. It is hard to move beyond the authors' acknowledgment that their results "inevitably reflect[ed] the selected orientation and affiliations of our participants." The results would likely have been different had they recruited stakeholders with experiences of systems that no longer use institutional care. It is worth noting, for example, that advocates and service users in Italy, where institutional care has been prohibited since 1978, did not endorse this "medical" domain at all. What the results suggest to me, therefore, is that many stakeholders remain tied to a predominantly medical model of care carried out within institutional settings. But this is precisely why a transformation of mental health care is needed to begin with.
Dr. Davidson is affiliated with the Department of Psychiatry, Yale University, New Haven, Connecticut.
1.Turton P, Wright C, White S, et al: Promoting recovery in long-term institutional mental health care: an international Delphi study. Psychiatric Services 61:293–299, 2010