Two Birds, One Stone: Unintended Consequences and a Potential Solution for Problems With Recovery in Mental Health

Recovery is the rallying cry of 21st century mental health care reform. Mental health professional organizations are engaged in Recovery to Practice initiatives (1), state mental health authorities and large mental health systems such as the Veterans Health Administration are embracing wholesale recovery transformation (2), and recovery is ever present in academic journals. We argue that sympathetic professionals have stolen the recovery movement from consumer activists and that this well-intentioned theft has produced an ill-fated reform effort with unintended, detrimental results. We summarize the results of the institutionalization and mainstreaming of recovery and suggest a course correction in health care reform: mental health transformation efforts should adopt and augment the language and principles of the patient-centered care movement. Joining the two professional movements would return the recovery movement to consumer advocates and provide a common approach for holistic and comprehensive professional health system reform.

The Theft of Recovery

We trace the recovery movement back to the social justice movements of the 1960s and 1970s, exemplified by expatient/survivor activist groups such as the Insane Liberation Front. These activists, motivated by a shared experience of outrage after distressing encounters with the professional mental health system, sought to develop support networks and a voice independent of professional mental health services. These early efforts were decidedly outside the mainstream, excluded professionals, and were, at their heart, social justice movements that rejected the medical model of care’s emphasis on symptoms and on power imbalances in the relationships between health professionals and care recipients (3).

With success in securing system change, recovery became more mainstream. Researchers and policy makers sought to define and operationalize recovery to pursue the worthy goals of the recovery movement. For example, the Substance Abuse and Mental Health Services Administration convened an expert panel and delineated ten core principles of recovery: person driven, holistic, culturally based, respectful, supported by peers, supported through relationships, addresses trauma, involves strengths and responsibility, occurs via many pathways, and emerges from hope (4). New interventions were created to support recovery (for example, Wellness Recovery Action Planning), existing interventions were freshly retooled to highlight recovery promotion (for example, Illness Management and Recovery), and mental health professionals sought to transform systems to support recovery goals. We call this the “professionalizing of recovery,” and we call the result “professional recovery” to differentiate from the original recovery movement.

Despite positive steps, the professionalizing of recovery had unintended consequences. Recovery could no longer be a radical social justice movement because professionals, who by definition are part of the established system, make changes within the boundaries of the financial, legal, and structural rules of a medical model health care system (5). Professionalizing recovery created dissonance with the original goals of the recovery movement. Initially the recovery movement attacked the very notion of diagnosis as unnecessary labeling; professional recovery maintains diagnoses but uses person-first language to minimize labeling and stigma. Leaders in the early recovery movement rejected professional guidance, learning through trial and error regardless of risk; mainstream service systems minimize risk and maximize safety (6). Further, at least one historical analysis has suggested that professionalized recovery is markedly similar to the values and practices in professional mental health care throughout the last 50 years (7). This well-meaning theft-through-adoption of recovery not only has poorly represented the original goals of the movement but also has overpowered the voices of recovery calling for radical changes to the system.

Unintended Support for Marginalization of Mental Health Care and Services

Although a goal of professional recovery has been the integration of general medical and mental health care, the professionalizing of recovery has unintentionally perpetuated the duality of these systems and helped maintain a second-class status for mental health issues. Researchers, policy makers, and practice entities worldwide have documented the importance of mental health care in overall health promotion (8). Despite this, mental health care is typically treated as separate from and secondary to general medical care in importance, and there are continuing issues with parity, poorer funding, and widespread discrimination and stigma (9-12). When the social justice–focused founders of recovery were gaining their voice, general medical practitioners were developing a new approach to physical health care that has evolved into “patient-centered care.” Enid Balint first differentiated patient-centered medicine from illness-oriented medicine in 1969, starting a new health care movement (13). As we elaborate below, the goals of patient-centered care are much like those of professional recovery: individualization, empowerment, and holistic service provision. Also like the recovery movement, patient-centered care has its own language, articulated frameworks, and practice suggestions. By focusing on professionalized recovery rather than patient-centered care, professionals created a separate but parallel health care transformation movement, inadvertently supporting the mind and body duality.

Given these unintended events and consequences, we believe that mental health professionals should join with general medical partners in a holistic revision of all of health care and return the language of recovery to the social justice and activist arena. Below we explore the parallels between the principles of patient-centered care and those of professionalized recovery as support.

“Recovery” in Physical Health: Patient-Centered Care

Descriptions of patient-centered care and professionalized recovery overlap significantly. The Institute of Medicine defines patient-centered care much as others describe recovery: “providing care that is respectful of and responsive to individual patient preferences, needs, and values and ensuring that patient values guide all clinical decisions” (14). Patient-centered care seeks to empower patients to control their health care goals and the treatments by which these goals are obtained (15), while also seeking to promote collaborative relationships between patients and providers. This includes the fostering of healing relationships through tools such as shared decision making and the provision of services by a coordinated team of health care providers to ensure a holistic approach and increased continuity of care (16).

A One-Stone Solution to the Two-Bird Problem

Patient-centered care may be the stone that allows us to solve the two-bird problem.

Bird One: Social Activism

When recovery was professionalized, activism withered. Adopting patient-centered care provides mental health professionals with a distinct language, permitting individuals with lived experience to reclaim the definition, process, and experience of recovery as their own. In this way, recovery can continue to be the voice of the individual, the voice of peer support, and a more radical movement owned by those who have experienced mental illness.

Bird Two: Duality, Parity, and Language

Historically, treatment of mind and body has been divided, with separate reimbursement and treatment systems. Recent movements in health care seek to either create parity or integrate the two, with a range of services designed to integrate mental health and general medical care. By using recovery language in mental health care reform and patient-centered care language in the reform of general medical care, and by keeping our transformation efforts separate, we are unintentionally reinforcing the division. The language of patient-centered care is consistent with professional recovery. Such language is respectful and responsive to individual preferences, needs, and values; ensures those preferences, needs, and values guide decisions; empowers patients; and elicits shared decision making. If mental health care is to be considered part of health care in general, to have the same lack of stigma thought to be associated with general medical care, and to have parity with general medical care, adopting the broader, positive language and principles of patient-centered care will help with this goal. This is the first step.

The mental health community then will need to take action by joining with larger transformation efforts and inviting patient-centered care advocates in general medical care to partner in one unified health reform movement. In this mutually beneficial relationship, we can help the patient-centered care movement to further evolve by adding those holistic elements that we now associate with recovery, such as the core belief that patients will improve, the importance of hope, and the use of alternatives to the word “patient” to emphasize the care recipients’ active role in the health care relationship. We recognize that, like the professionalized recovery movement, the patient-centered care movement experiences many implementation barriers and that the predominant model remains the medical model. Joining forces and using a shared language of reform may create synergy, help to accelerate all efforts while reducing the duality between physical and mental health, and ultimately decrease stigma and disparity.

Conclusions

We argue that the widespread adoption and acceptance of the recovery movement has, in many ways, had the opposite effect than intended. By professionalizing recovery we have essentially silenced the voice of activism, arguably contributing to further marginalization. We have no way of knowing how consumers’ activism would have shaped and improved mental health care had recovery remained a social justice movement. However, we can decide now to support more consumer advocacy toward improving health care even further.

It is arguable that our solution is more symbolic than substantive. However, all social justice movements, including the recovery movement, have voiced deep-seated beliefs that shifts in language propel shifts in attitudes. Using and adding to the language of patient-centered care is only a first step toward bridging the gap between mental health and physical health care, but speaking the same language is key in facilitating this partnership.

We mental health professionals can and should acknowledge the boundaries of our role in health care transformation. If the goal of modern health care is to have individualized care centered around each person’s goals and values and holistic treatment of mind and body, then we should adopt a unified language of patient-centered care rather than perpetuating, through language and action, a division between physical and mental health. We should give recovery back to those who advocated for it and ultimately defined it so that holistic, consumer-centered health care can continue to be advanced in ways that matter deeply. As professionals, we need consumers’ advocacy to guide us again.