Letter

Recovery and the Medical Model in Institutional Care: Reply

In Reply: We appreciate the opportunity to clarify the goals of our study and to respond to Dr. Davidson's comments. First, we agree that community-based, deinstitutionalized systems of care are preferable, but the reality is that the majority of mental health care in Europe is currently delivered within and from institutions ( 1 ). Given this fact, the purpose of our study (and that of the European Commission members who funded it) was to develop a toolkit to assess the quality of care that these facilities deliver, with a particular focus on human rights. We were not asking in this study about alternatives to institutions.

Second, the definition of "institution" in our study included both psychiatric and social care units and was concerned with community-based as well as hospital-based facilities. Indeed, four of the ten countries that took part had no hospital wards providing psychiatric care. Stakeholders with expertise in both of these settings were sought to participate in the Delphi exercise. Thus Davidson's assumption that all participating units had segregated and supervised patients is incorrect.

Third, we do not agree with the belief that institutional care settings necessarily compromise successful rehabilitation of individuals. This view denies hope to people with complex mental health problems whose disabilities are such that they are unable to return home directly from an acute hospital admission. Promotion of autonomy and social inclusion is key to psychosocial rehabilitation, and our findings demonstrate that recovery principles such as these, together with hope, a strengths-based approach, negotiated treatment choices, and rediscovery of a positive sense of self-identity, are as relevant to institutional care (whether hospital or group home) as they are to other settings. In fact, our study found evidence of the importance of many of the same aspects of care for recovery that Davidson and colleagues ( 2 ) have cited as critical in a previous publication: being supported by family, friends, or professionals; taking medications; being involved in meaningful activities; managing symptoms; taking responsibility; and exercising citizenship.

Finally, the purpose of the Delphi exercise was to provide collated, qualitative evidence of the consensus opinions of four stakeholder groups in ten countries about the most important components of care in promoting recovery for people in facilities that provide long-term care. The four groups comprised service users, advocates, caregivers, and mental health professionals. The countries were chosen by virtue of their different stages of deinstitutionalization. These results were then triangulated with findings from a systematic literature review of effective components of care in use in institutions and with care standards for these types of facilities in the ten countries. We chose this approach specifically to ensure that there was no bias in identifying the components of care most important to recovery through a single evidence source only. Our task was to report our findings accurately—including the fact that the most highly rated domain across countries was "treatment and interventions." Nowhere did we suggest that this means that "less value" should be given to such principles as autonomy and dignity; rather, our intent was to emphasize that this important domain should not be neglected in considerations of the recovery approach, which often highlights other aspects of care.