State University
THE MENTAL HEALTH RECOVERY MOVEMENT AND FAMILY THERAPY, PART I: CONSUMER-LED REFORM OF SERVICES TO PERSONS DIAGNOSED WITH SEVERE
MENTAL ILLNESS
Diane R. Gehart California State University
In 2004, the U.S. Department of Health and Human Services issued a consensus state- ment on mental health recovery based on the New Freedom Commission’s recommenda- tion that public mental health organizations adopt a ‘‘recovery’’ approach to severe and persistent mental illness, including services to those dually diagnosed with mental health and substance abuse issues. By formally adopting and promoting a recovery orientation to severe mental illness, the United States followed suit with other first-world nations that have also adopted this approach based on two decades of research by the World Health Organization. This movement represents a significant paradigm shift in the treatment of severe mental health, a shift that is more closely aligned with the nonpathologizing and strength-based traditions in marriage and family therapy. Furthermore, the recovery movement is the first consumer-led movement to have a transformational effect on profes- sional practice, thus a watershed moment for the field. Part I of this article introduces family therapists to the concept of mental health recovery, providing an overview of its history, key concepts, and practice implications. Part II of this article outlines a collabo- rative, appreciative approach for working in recovery-oriented contexts.
In 2004, the U.S. Department of Health and Human Services recommended that public mental health organizations adopt a ‘‘recovery’’ orientation to severe and persistent mental ill- ness, including those dually diagnosed with mental health and substance abuse issues. Originat- ing as a grassroots movement and supported by two decades of research conducted by the World Health Organization (Ralph, 2000), recovery-oriented models for working with severe mental illness are being rapidly implemented in public agencies across the country. Recovery models represent a significant paradigm shift in the approach to severe mental health, one that is more closely aligned with the nonpathologizing and strength-based traditions in marriage and family therapy (MFT). The recovery paradigm also represents the first time a consumer-led movement has had a significant impact on mental health practice, starting a potentially radical revolution in the field. As a consumer-advocacy movement, the majority of literature on recov- ery addresses improvements in service delivery and targets program administrators and case managers as its primary audience; little, if any, literature describes the practice implications of recovery for therapists. This two-part article serves to bridge this gap.
Part I introduces family therapists to recovery-oriented approaches for working with severe mental illness, including its historical origins, current definitions, key elements, and relation to evidence-based treatments. In addition, the article includes a discussion of the philosophical correlates between recovery and family therapy theories; a four-phase model of adoption; and a brief overview of implications for MFT practice. Part II of this article proposes a collaborative, appreciative approach for recovery-oriented work based on postmodern therapy theories.
Diane R. Gehart, PhD, Professor, Marriage and Family Therapy Program, California State University.
The literature review was supported in part by a grant from the California Board of Behavioral Science that
funded the creation of a bibliography for the new MFT curriculum that is available at http://www.bbs.ca.gov and
http://www.masteringcompetencies.com. Portions of this article were presented at the 2009 American Association for
Family Therapy Annual Convention.
Address correspondence to Diane R. Gehart, Marriage and Family Therapy Program, California State
University, 18111 Nordhoff, Northridge, California 91330; E-mail: [email protected]
Journal of Marital and Family Therapy doi: 10.1111/j.1752-0606.2011.00230.x July 2012, Vol. 38, No. 3, 429–442
July 2012 JOURNAL OF MARITAL AND FAMILY THERAPY 429
HISTORICAL OVERVIEW OF THE RECOVERY MOVEMENT
Begun in the 1930s as a grassroots, consumer-advocacy movement, recovery was not taken seriously by professionals until the 1980s, at which time rehabilitation counselors began explor- ing the concept as it relates to substance abuse (Ralph & Corrigan, 2005). In the 1990s, recov- ery was first explored in mental health arenas, primarily because of the outcome of two decades of research. Cross-national studies conducted by the World Health Organization produced sur- prising findings: 28% of persons diagnosed with severe mental illness reported full recovery (defined as no symptoms) and 52% reported social recovery (defined as needing medication or other services but able to maintain normal work, relationships, and a meaningful life; Davidson, Harding, & Spaniol, 2005; Hopper, Harrison, Janca, & Sartorius, 2007; Ralph, 2000). These findings were consistent in first- and third-world countries, with third-world countries using minimal psychiatric interventions generally reporting better outcomes.
Based on this research, which implies that severe mental illness can be treated more effec- tively and at a reduced cost, many countries began formally adopting the recovery model in the 1990s to treat severe and chronic mental illnesses, with the United Kingdom, Ireland, Australia, and other European countries leading the way. In the United States, it was not until 2002 that the President’s New Freedom Commission (2003) formally recommended that the United States move toward a recovery-oriented approach for mental health services, stating that the current system ‘‘simply manages symptoms and accepts long term disability’’ (USDHHS, 2003, p. 1). In 2004, the U.S. Department of Health and Human Services developed a consensus statement that defined the elements of recovery, which underscored that persons diagnosed with mental illness do not need to be symptom-free in order to participate in their communities, as has his- torically been the case.
States such as Washington and Ohio have been leaders in implementing recovery-based mental health programs. However, California was the first state to create sufficient funding to meaningfully transform its public mental health system. In a 2004 popular referendum, Califor- nians passed Proposition 63, which became known as the Mental Health Services Act, provid- ing $900,000,000 in funding for new, recovery-based mental health programs in 2008 alone. In the summer of 2009, the California legislature also passed a revision to the MFT licensure law that added training in recovery-oriented approaches to the curriculum, thereby expanding their scope of practice and the role of MFTs in public mental health. As exemplified in California, MFTs are quickly becoming part of recovery-oriented mental health programs and are needing to define their role in these systems.
DEFINITIONS OF RECOVERY
The term recovery has conjured debate and been the focus of more academic scrutiny in the field of mental health than it has in the related field of substance abuse, where a person’s level of recovery can be more objectively measured in terms of use (Anthony, 1993; Onken, Craign, Ridgway, Ralph, & Cook, 2007). Initially, some professionals argued that recovery was a misleading concept that should not be applied to mental illness because a person’s symptoms often do not go away entirely, as implied in colloquial use (Whitwell, 1999). However, after the adoption of the term by the Department of Health, recovery has become widely applied in the United States to severe mental illness and dual diagnosis of substance abuse and mental illness.
Most practitioners consider mental health and substance abuse recovery to be more alike than different because they share similar philosophies and practices, including the concept of recovery as a process, e.g., ‘‘being in recovery’’ rather than recovery being a final state, e.g., ‘‘being recovered from’’ (Gagne, White, & Anthony, 2007). The U.S. Department of Health and Human Services (2004) has formally defined mental health recovery as ‘‘a journey of heal- ing and transformation enabling a person with a mental health problem to live a meaningful life in a community of his or her choice while striving to achieve his or her full potential’’ (p. 2).
For most, recovery from severe mental illness means, in the vernacular, ‘‘getting your life back,’’ whether or not you continue to have symptoms and ⁄or use medications or therapy to
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manage symptoms. That said, living a life with meaning while recovering often involves a sig- nificant reduction of symptoms. Thus, although not the primary focus, symptom reduction is typically a by-product of the recovery process (Davidson, Tondora, O’Connell, Lawless, & Rowe, 2009).
Some have taken a more radical approach to defining recovery and strongly discourage referring to mental health diagnoses such as schizophrenia as ‘‘illnesses,’’ arguing that such a framework makes recovery more difficult (Breeding, 2008), an argument heard in family ther- apy for decades (Gergen, Anderson, & Hoffman, 1996; Haley, 1979). Others highlight that recovery is more of a personal journey of discovery than a course of treatment (Roberts & Wolfson, 2004). Consumer (the term preferred to ‘‘client’’ in recovery contexts based on feed- back from consumer groups, sometimes referred to as ‘‘service recipient’’) definitions of recov- ery emphasize that recovery involves regaining a ‘‘normal’’ life and allowing the person diagnosed with severe mental illness to have autonomy in his or her recovery journey (Borg, 2008). More recent debate has raised concerns that the lack of clarity around the meaning of recovery and the political nature of the term may result in its becoming a shibboleth and hol- low of its intended meaning (Davidson, O’Connell, Tondora, Staeheli, & Evans, n.d.).
RECOVERY AS PARADIGM
Although often referred to as a ‘‘model,’’ it is perhaps best for family therapists to concep- tualize recovery as a paradigm. Rather than operating at the level of a therapeutic model, such as structural or narrative therapy, recovery is an alternative to the medical model for conceptu- alizing mental illness. Instead of using the medical paradigm of disease, the recovery paradigm approaches mental ‘‘illness’’ using a social model of disability that emphasizes psychosocial functioning over medical symptomatology. This view of ‘‘mental illness’’ resonates with the his- tory, practices, and tenets of family therapy and thus is a refreshing shift for many MFTs. The recovery paradigm is different from these family therapy approaches in that it originated and is promoted by consumers; no such consumer movement has had such a strong impact on mental health practice. Because of the strong political and financial support, the recovery movement is more likely to transform the current medical delivery system than similar therapy-based approaches have in the past.
However, it is important to note that the recovery paradigm is not ‘‘anti-’’medical model or against interventions such as diagnosis or medication; such medical interventions are valued yet secondary to psychosocial needs, such as autonomy, which are considered primary needs for successful recovery. For example, one woman in recovery did not want to take medications to manage her hallucinations, but she did want to work. Her recovery-oriented therapist did not require that she take medication but instead helped her to focus on the goal that had mean- ing for her: maintaining gainful employment. After working for a couple of months, she found that the hallucinations were a problem and at that point decided to try antipsychotic medica- tion to support her in maintaining employment. Thus, medication was used as a resource when the consumer determined it was most beneficial to help her live a meaningful life.
ELEMENTS OF RECOVERY
Numerous ‘‘models’’ for recovery have been developed by practitioners working in different contexts with different populations. Some of these models have been informed by philosophical theories, whereas others have been developed from grounded theory and similar methods. In their review of existing models, Onken et al. (2007) describe recovery models as having a fundamentally ecological systems framework, which involves viewing a person from an ecological perspective, with an eye toward examining how the individual’s unique characteristics interact with environ- mental elements. An ecological framework is familiar to family therapists through the work of Bateson (1972, 1979, 1991) and Bronfenbrenner’s (1979) ecological systems theories.
In addition to an overarching ecological perspective, Onken et al. (2007) identify the following elements common to most models of recovery: (a) person-centered, (b) re-authoring, (c) exchange-centered, and (d) community-centered elements (see Table 1).
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Person-Centered Elements of Recovery Recovery is typically described as person-centered, which does not refer to Carl Rogers’s
(1961) person-centered therapy. Instead, person-centered is contrasted with problem- or disease- centered treatment (Davidson et al., 2009), much the same way that narrative therapists separate persons from problems (Freedman & Combs, 1996). Reminiscent of postmodern and humanistic therapies, these person-centered elements include the following: (a) hope, (b) sense of agency, (c) self-determination, (d) meaning and purpose, and (e) awareness and potentiality. Person-centered elements require that the therapist help persons diagnosed with a severe mental illness not simply to believe that things can get better but also to impart the will to take responsibility for their recovery and develop the unshakable faith that they are capable of making it happen. Activating these recovery elements often involves drawing upon the person’s spiritual and religious resources because for many consumers, faith is required to do the seemingly impossible task of recovery. The therapist has the challenging role of seeing hope when few others do and to inspire not only the consumer but often a network of professionals, family, and friends who have witnessed seri- ous, ongoing problems. Of all the elements of recovery, these are the most difficult, the most dependent on the therapist’s personal development, and the least teachable.
Re-Authoring Elements of Recovery Recovery-oriented practice focuses on re-authoring consumers’ identity and illness narra-
tives as well as reducing the impact of problematic dominant discourses about mental illness (Onken et al., 2007), using elements of postmodern, collaborative, narrative, and cognitive therapies familiar to family therapists. Re-authoring is a ‘‘pivotal task in the recovery process, perhaps the primary mechanism of personal growth’’ (Onken et al., 2007, p. 13). When work- ing with narratives from a recovery perspective, therapists use a strength-based approach to thicken descriptions in the consumers’ lives around experiences of (a) coping, (b) healing, (c) wellness, and (d) thriving to reduce their sense of being a ‘‘deviant other.’’ This process serves to reinterpret the person’s experience of mental illness as a part of a much larger life narra- tive, one that also involves heroic moments of coping, a complex process of healing, and movement toward wellness. Consistent with current narrative practices, re-storying does not involve a ‘‘story-ectomy’’ (Gehart, 2010) in which the problem narrative is ignored or mini- mized in a Pollyanna manner, but rather the problem story is recontextualized and reinter- preted within a richer and more comprehensive depiction of the person’s lived experience. When promoting wellness, therapists can draw upon positive psychology research (Peterson & Seligman, 2004; Seligman, 2002) that identifies specific beliefs and behaviors that are corre- lated with well-being and lasting happiness, even with those diagnosed with severe and chronic illnesses.
Exchange-Centered Elements of Recovery Exchange-centered elements of recovery refer to examining the nature of the exchange
between the individual and larger community and society, addressing issues of (a) social function- ing, (b) power, and (c) choice among meaningful options. These elements address the need for an individual to have a meaningful role in society, which often takes the form of work in supported or traditional employment settings, serving as a peer advocate for others with mental illness, or similar contribution. When consumers expand their social role beyond that of being a ‘‘patient,’’ they experience a sense of greater social power and a renewed sense of having choice and owner- ship in their lives. Of particular interest, researchers have found that employment, which repre- sents a more equitable exchange between the individual and society, is correlated with more successful and sustainable recovery from severe mental illness (Anthony, Brown, Rogers, & Derringer, 1999; Eklund, Hansson, & Ahlqvist, 2004; Linhorst, 2005). In addition, recovery pro- grams often include peer advocates—persons in recovery helping those starting the journey of recovery—to provide hope and role models for those beginning the process while simultaneously helping the advocates expand their social role to include mentoring and leadership. Furthermore, a recent report on recovery-oriented services released by the Substance Abuse and Mental Health Services Administration emphasizes the importance of consumer choice in sequencing and select- ing services to support their recovery (Sheedy & Whitter, 2009).
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Community-Centered Elements of Recovery The final elements of recovery involve providing community support: (a) social connections
and relationships, (b) social circumstances and opportunities, and (c) integration into a commu- nity. Central to the recovery process, human connections and social inclusion for persons with severe mental illness may involve partners, family, peers, friends, roommates, pets, social service workers, professionals, and ⁄or support groups (Repper & Perkins, 2006). Recovery-oriented work requires helping consumers to rebuild or strengthen these connections to increase intimacy and social support, a goal that is at the heart of family therapy.
In addition, recovery-oriented practice also addresses consumers’ social circumstances and opportunities, which may involve helping them access social services and resources to ensure basic needs are met, including housing, food, medical care, and legal assistance, a practice com- monly referred to as case management. In recovery-oriented practice, case management is seam- lessly integrated with what is often separately referred to as ‘‘treatment,’’ thus expanding the role for clinicians. Although case management has not been emphasized in MFT literature, case management was readily identified as one of the MFT Core Competencies (Nelson et al., 2007).
RECOVERY, STIGMA, AND SOCIAL JUSTICE
In contextualizing recovery-oriented models, professionals should remain cognizant that they stem first and foremost from social justice movements that promote consumer rights for persons diagnosed with a mental illness and aim to reduce the stigma associated with these diagnoses (Davidson et al., 2009). Recovery-based practices respond to consumer demands to be treated with dignity, have a strong voice in their treatment, and exercise their autonomy to make decisions even when they choose to go against medical advice. In many cases, consumers’ autonomy and rights are restricted ostensibly ‘‘for their own good,’’ to prevent potential harm to themselves or others, and ⁄or to reduce their symptoms, as in a hospitalization owing to active psychosis. Recovery advocates argue that unless there is clear evidence of imminent harm to self or others, routine hospitalization of severe symptoms is oppressive, unnecessary, and potentially counterproductive and serves the need for professionals to reduce their legal liability rather than help those they claim to serve (Davidson et al., 2009). Thus, recovery advocates state that recovery inherently implies more risk than professionals and the public have been willing to allow persons diagnosed with severe mental illness. The legal and ethical implications of increasing consumer autonomy have yet to be adequately defined.
Furthermore, in recovery-oriented work, practitioners actively address prejudice experi- enced by those diagnosed with mental illness that may be attributed to their illness, disability
Table 1 Overview of Elements of Recovery and Theoretical Correlates
Person-centered elements
Re-authoring elements
Exchange-centered elements
Community-centered elements
Elements of recovery
Hope Agency Self-determination Meaning Awareness
Coping Healing Wellness Thriving
Social Functioning Power Choice
Relationships Opportunities Integration
Marriage and family therapy theoretical correlates
Solution-based Narrative Collaborative Existential
Narrative Collaborative Cognitive Positive psychology
Systems Structural Narrative Cognitive
Systems Case management Cognitive-behavioral
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status, socioeconomic status, ethnicity, race, religion, sexual orientation, or other factors. In many cases, consumers need professionals to assist in actively advocating on their behalf when they encounter injustice, especially when they are interacting with large social service and government agencies.
RECOVERY AND EVIDENCE-BASED THERAPIES
Recovery approaches have been developing momentum during the same period that evi- dence-based therapies have become increasingly valued in treating severe mental illness. Farkas, Gagne, Anthony, and Chamberlin (2005) argue that evidence-based therapies vary greatly in their compatibility with recovery-based values, such as person (vs. illness) orientation, quality of consumer involvement, emphasis on consumer self-determination, and promotion of growth potential. They recommend that programs implementing evidence-based treatments evaluate these in relation to recovery values, such as autonomy and choice. Thus, the goal should be to incorporate recovery-based principles into evidence-based treatments and practices to provide effective treatments that address the needs of the whole person, including promoting his or her sense of dignity, independence, and resilience.
RECOVERY AND FAMILY THERAPY
Outside of social justice–based therapies, such as the narrative-based Just Therapy (Waldegrave, 2005; Waldegrave & Tamasese, 1994), family therapists have not been actively involved in the consumer-led recovery movement. Nonetheless, family therapy has a long his- tory of professionals advocating for the same issues championed in recovery; for this reason, family therapists have often been considered radicals and heretics by other mental health pro- fessionals. As early as 1965, Richard Fisch published an article in a leading journal of psychia- try entitled ‘‘Resistance to Change in the Psychiatric Community’’ in which he enumerates abuses in the treatment of those diagnosed with severe mental illness. He challenges psychia- trists to critically examine their practices and provocatively suggests that psychoanalytic prac- tices might actually create the chronicity of mental illness: ‘‘One wonders how often patients who have achieved marked relief and ego enhancement in the early stages of treatment are sub- sequently convinced [by their therapist] of the ‘illusory’ nature of their improvement and seduced into lengthy if not interminable treatment’’ (Fisch, 1965 ⁄ 2009, p. 3). He recommends decreasing hospitalizations, exploring alternatives to psychoanalysis, using multidisciplinary teams, increasing outcomes research, and adopting a more sociological approach: all of these are suggested by recovery advocates.
Similarly, Don Jackson’s (1967a/2009a) seminal article, ‘‘The Myth of Normality,’’ is one of the earliest professional statements to provide support for current recovery-oriented practices that define health as leading a meaningful life rather than the absence of pathology. As eluded to in the title, he argues that psychiatry does not have a meaningful or reliable means for defin- ing or measuring ‘‘normality’’ and launches a harsh critique of psychiatric diagnostic practices. In another article advocating for consumer rights, Jackson argues that consumers have the ‘‘right’’ to not be treated, including refusing medications and choosing to experience the univer- sal forms of struggle and life difficulty that ‘‘can lead to character growth insofar as it stimu- lates seeking for solutions to improve the[ir] condition’’ (Jackson, 1967b ⁄ 2009b, p. 226).
Although not at the center of the recovery movement, in contexts where they have been active in public mental health, family therapists have made significant contributions. The work of Jaakko Seikkula (2002) and his Finish colleagues (Haarakangas, Seikkula, Alakare, & Aaltonen, 2007) is a prime example of the potential for family therapy practice in recovery- oriented contexts. Using the collaborative therapies of Anderson and Goolishian (1992; Ander- son, 1997) and Andersen (1991), Seikkula and his colleagues developed the Open Dialogue approach to working with psychosis, which they implemented and refined in the public psychi- atric hospital for the Lapland region of Finland over the past 20 years. They currently report outcomes in which 83% of diagnosed persons return to work and 77% report no symptoms after 2 years of services (Haarakangas et al., 2007). Even more impressive, after using their
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Open Dialogue approach for over two decades, they report that they rarely have chronic cases of psychosis, such as schizophrenia, in the Lapland region of Finland. Their work provides precedent for eradicating chronic mental illness, having profound implications for the field, government agencies, and society at large.
Similarly, McFarlane’s (2004) evidence-based multifamily psychoeducational groups for families with a member diagnosed with severe mental illness is a cognitive-behavioral family therapy approach that has demonstrated impressive reductions in relapse while promoting recovery across a wide range of functioning, including psychiatric symptoms, employment, social skills, medical health, and overall well-being. Multifamily psychoeducation groups have been found to be more effective than offering the same education to individual families, espe- cially with families experiencing severe mental illness for the first time (McFarlane, Dixon, Lukens, & Lucksted, 2003). These findings were replicated in several international contexts, including China, Britain, Scandinavia, and Spain.
PHILOSOPHICAL CORRELATES OF RECOVERY
As a grassroots consumer movement, the recovery model does not have formal philosophi- cal foundations. Nonetheless, as the recovery movement has entered the professional realm, it is important to identify the underlying epistemological and ontological foundations, which can be readily correlated with common philosophical foundations of family therapy: namely, sys- temic, social constructionist, and humanistic epistemologies.
Systemic Correlates Systemic family therapy resonates with the ecological framework and social functioning
aspects of recovery-oriented practices (Onken et al., 2007). Arguably, systems theorists, such as Don Jackson, Rich Fisch, Paul Watzlawick, John Weakland, Jay Haley, Salvador Minuchin, Virginia Satir, Carl Whitaker, Nathan Ackerman, and Milton Erickson, developed the first recovery-oriented therapies for severe mental illness, primarily in their pioneering work with families in which a member was diagnosed with schizophrenia. These systemic founders revolu- tionized the field of mental health by exploring how a person’s broader social system and com- munication patterns affected those diagnosed with mental illness.
Focusing on the individual’s interactions in the family and social environment, these pioneers worked with severe mental illness assuming that full recovery was possible, mavericks in psychological and psychiatric circles where mental illness was assumed to be a lifelong sen- tence (Haley, 1979, 1990; Ray, 2009; Watzlawick, Bavelas, & Jackson, 1967; Watzlawick, Weakland, & Fisch, 1974). Family therapists emphasized that the expression of an individual’s symptoms and therefore the process of recovery are inherently part of larger interactional exchanges with family, social, professional, and community systems.
For decades, therapists such as Jay Haley (1979, 1990) have encouraged a ‘‘benevolent’’ approach to working with severe mental illness where the therapist works with consumers and their symptoms by employing interventions aimed at changing the context rather than the person or symptom (e.g., joining the consumer in speaking word salad rather than trying to get the person to use conventional speech). Foundational to systemic approaches is the assumption that ‘‘all behavior makes sense in context’’ (Ray & Watzlawick, 2005 ⁄ 2009, p. 186), informing a more respectful and curious approach to understanding the challenging symptoms associated with these diagnoses. Decades ahead of current recovery models, systemic therapies employ a non-normative approach that instead focuses the therapist’s attention on consumers’ personal goals and mobilizing their existing abilities to reach these goals (Ray & Watzlawick, 2005 ⁄ 2009). Additionally, systemic therapists relate to severe mental illness in a nonreactive, curious, and often playful manner that is unique in mental health, thus providing a useful framework for working from a recovery-oriented approach (Ray & Watzlawick, 2005 ⁄ 2009).
Recovery-oriented models do not discuss ‘‘systemic’’ principles in the same language or in as much detail as is customary in family therapy: there is no discussion of homeostasis, feedback loops, or metacommunication. However, the two approaches share the following assumptions:
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• Intimate relationships are integral to personal well-being (Davidson et al., 2005). • The expression of mental health symptoms arises in and from the interactions between the person and his or her environment (Onken et al., 2007).
• Mental health practices should target relational functioning as a primary goal (Davidson et al., 2008; Onken et al., 2007).
Although these assumptions have been part of family therapy practice for decades, they are new and still revolutionary when considered in the context of traditional public mental health.
Postmodern and Social Constructionist Correlates Of all of the psycho- and family therapies, recovery models are most closely aligned with post-
modern and social constructionist approaches. Using a postmodern lens, recovery models focus on the sociopolitical impact of diagnostic discourses and how they inform and constrain an indi- vidual’s identity narrative, limiting a person’s perceived possibilities and opportunities (Kirkpa- trick, 2008; Roberts, 2000). In fact, the crux of the recovery paradigm shift is to illuminate the impact of societal discourses around the concept of ‘‘mental illness’’ and how these constrain the options, behaviors, and relationships of persons who bear this label as well as shape the daily interactions between professionals and persons diagnosed with mental illness. By deconstructing discourses on mental illness, strengths, resources, and opportunities can be more readily identified and acted upon, creating a foundation of hope for more positive outcomes and possibilities.
Postmodern therapists have been active in recovery-based program development. At the request of and with the active involvement of local consumers, Michael White and his colleagues at Dulwich Centre began developing narrative-based recovery programs for those diagnosed with severe mental illness in 1997 (Dulwich Centre, 1997; Freedman & Combs, 2009). Influenced by White’s work, Waldegrave and Tamasese (1994) have been leaders in integrating social justice issues into professional practice. In Europe, Jaakko Seikkula (2002) and his team have had impressive outcomes using a collaborative approach with persons diag- nosed with psychosis. Similarly, Griffith and Griffith (2002) describe a collaborative, dialogic approach for using spirituality and religion in working with severe mental illness, a resource that is typically underutilized, particularly with psychosis.
Postmodern approaches and recovery share the following assumptions:
• A person’s experience of ‘‘mental illness,’’ including his or her sense of autonomy and personal identity, is informed by broader societal discourses, which must be questioned and reexamined in the process of recovery (Kirkpatrick, 2008; Roberts, 2000).
• ‘‘Recovery’’ involves developing identity narratives in which persons diagnosed with a mental illness feel a sense of agency, hope, and possibility that enables them to create a life that is personally meaningful and fulfilling (Kirkpatrick, 2008; Roberts, 2000).
• One of the primary tasks of the therapist is to identify strengths and resources and pro- mote a hopeful vision of their future (Davidson et al., 2009).
• Social justice and stigma are key issues in recovery, and therapists are responsible for doing their part to promote positive community and social change (Davidson et al., 2009).
These assumptions help practitioners view the symptoms of mental illness and the mental illness itself as part of a larger societal process that defines acceptable and unacceptable behav- ior, health and illness, and normality and abnormality. The journey of recovery involves exam- ining the cultural source of these constructs and helping consumers redefine themselves in relation to these discourses in new and more personally useful ways.
Humanistic Foundations Humanistic and related existential principles are readily apparent in recovery models. Most
notably, the primary goal of recovery is to help a person diagnosed with a mental illness to cre- ate a life that has meaning (USDHHS, 2004), a goal that was first articulated by existential therapists (Frankl, 1959 ⁄ 1984), and allows them to fulfill their human potential (USDHHS, 2004), the aim of humanistic approaches (Rogers, 1961). The recovery journey entails creating
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a meaningful life, which typically requires a unique struggle to make sense of one’s symptoms, the potential causes, and ultimately, one’s responsibility for creating a ‘‘good’’ life given the cir- cumstances. Thus, the journey of recovery puts the burden of responsibility for recovery squarely on the shoulders of the consumer, not the professional. The professional’s role is to support this journey in whatever way is necessary at a given moment, including coach, advo- cate, consultant, resource seeker, or fellow human being.
Undetermined Role of Particular Traditional Practices Recovery-oriented approaches are potentially at odds with several assumptions common in
psychotherapy and family therapy practices, most notably cognitive-behavioral and psycho- dynamic-oriented therapies as well as certain humanistic practices (Davidson et al., 2009). First, the recovery approach does not privilege the therapist with ‘‘expert’’ knowledge whose role is to identify irrational beliefs, dysfunctional dynamics, or other areas of pathology. Recovery ori- entation does not encourage therapists to ‘‘reeducate’’ consumers unless they specifically request and show interest in such information. Similarly, the analysis of past relational dynamics is rarely a focus in recovery-oriented care; again, such an approach would be used only in cases when consumers themselves request it. Furthermore, the recovery model does not encourage a strong affective focus, including emotional expression and affective confrontation, as is common in many humanistic approaches, such as symbolic experiential or person-centered. In particular, emotional expression is generally moderated and reduced in families with members experiencing psychotic symptoms (Kymalainen & Weisman de Mamani, 2008). Thus, therapists must recon- figure traditional practices that are based on the therapist’s unilateral determination of pathol- ogy to be used more collaboratively with consumers.
FOUR-PHASE MODEL FOR ADOPTING A RECOVERY ORIENTATION
Most therapists have been introduced to recovery concepts from outside of the professional dialogue, e.g., through their agency’s administrative policy, licensing laws, and ⁄or federal pro- gram requirements. As recovery is entering disciplinary dialogue from external sources that use foreign terminology and frames of reference, family therapists often experience confusion and resistance when first introduced to the concepts. The four-phase model describes a common pattern of how family therapists’ and other mental health professionals’ understanding unfolds and develops. This model is not necessarily linear, and each phase may not be experienced by all therapists (in fact, the purpose of this article is to reduce time spent in phase one).
Phase One: Horror, Outrage, and Righteous Indignation When MFT educators and practitioners in California first heard that the ‘‘recovery model’’
was being added to the MFT curriculum, they frequently responded with horror and indigna- tion. Many felt they themselves were in need of recovery from exposure to the recovery model. The outrage came primarily from the sense that the state licensing board was ‘‘forcing’’ or ‘‘favoring’’ one theoretical model above others, those rejected ‘‘others’’ being traditional MFT theories. Few, if any, had heard or even read about a ‘‘recovery model’’ or ‘‘recovery orienta- tion’’ outside of substance abuse literature. Psychologists had similar reactions in public agen- cies that were flush with funding for recovery-based programs (L. Woods, personal communication, April 15, 2009).
The key insight during this phase comes when therapists realize that the recovery orienta- tion is in dialogue with the medical model, not psycho- or family therapy models. Most thera- pists have a strong connection to their therapeutic model and are suspicious of attempts to get them to change. In fact, it would be foolish to expect skilled clinicians to somehow altogether ‘‘stop using’’ the theories in which they have been trained; such attempts are bound to fail. Instead, therapists should be encouraged to identify ways to use the broader recovery paradigm to draw upon the skills they already possess to help persons diagnosed with severe mental illness achieve better outcomes. That said, all therapists will need to modify and expand their current practices; the degree to which depends on how closely aligned their current practices are to recovery principles.
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Phase Two: Overconfidence Once family therapists understand what recovery is about, many begin to feel that a recov-
ery orientation is more closely aligned with MFT models than the behavioral medical model favored by third-party payers. The emphasis on social functioning—maintaining meaningful relationships, a job, social life, and personal life—is more congruent with most psychotherapy and family therapy theories than a focus on observable medical and psychiatric symptoms. This sense of familiarity often results in a sense of overconfidence: ‘‘we are already doing that’’ or ‘‘we’ve been doing that for years.’’ During this phase, it is important to identify the aspects of recovery that are familiar and already part of one’s practice. However, it is unrealistic to believe that ‘‘you are already doing it’’ because it is a new and evolving approach that, in fact, few, if any, are doing or have mastered. As demonstrated in Finland, successfully implementing recovery should ideally lead to approximately 80% of consumers diagnosed with severe mental illness achieving full or social recovery after 2 years of services. Thus, a high bar has been set for claiming to be ‘‘recovery oriented.’’
Phase Three: Integration and Balance The third phase, and arguably final phase for most, is integration and balance. This is the
only phase in this model that is necessary for effectively working from a recovery-oriented approach. In this phase, practitioners learn how to integrate the broader recovery paradigm into their work in a way that transforms it yet also utilizes what the practitioner has already been doing. The recovery paradigm then becomes fully integrated into their work.
Because recovery is a paradigm, once integrated into one’s approach, it transforms work with both mild and severe mental health issues as well as work in private practice and larger agency settings. For example, the paradigm of recovery has had a subtle yet profound shift in my private practice, where I see a broad range of clients. Some have mild parent–child rela- tional issues, whereas others have chronic and severe mental health issues. In cases of mild or even ‘‘normal’’ transitional issues, the recovery paradigm has shifted my focus to a broader question: is this client ⁄ family living a meaningful, rich, fulfilling life? Similarly, when working with persons diagnosed with severe and chronic mental health issues, my attention and our conversations more frequently address their quality of life and fullness of who they are. The focus on wellness, whether working with mild or severe consumers, often results in goals that are broader and interventions that are more creative and ‘‘outside the box’’ than traditional therapy.
Phase Four: Creative Implementation The final phase that some may experience is creative implementation of recovery concepts
in their work. This final phase is optional in that it represents a creative development of new recovery-oriented practices. In this phase, practitioners, educators, and researchers explore the yet-to-be-discovered possibilities of using recovery principles; developing new approaches, strategies, formats, research designs, etc. This creative engagement will mostly be seen by those on the frontlines with those working primarily with severe mental illness, but those in private practice, training centers, and research centers also have numerous opportunities to expand the practice of marriage and family therapy based on recovery principles. This phase is characterized by high energy and excitement combined with the spirit of exploration and discovery.
INITIAL IMPLICATIONS FOR THE FIELD
Funding One of the most motivating factors for learning about mental health recovery is funding.
The federal adoption of recovery has led to significant funding for recovery-based research and programs. For example, in the state of California, over $900,000,000 per year has been raised through a special tax for new recovery-oriented programs. Similarly, National Institutes of Mental Health, Substance Abuse and Mental Health Services Administration, and other federal sources of funding favor recovery-oriented programs because they fit with the national agenda
438 JOURNAL OF MARITAL AND FAMILY THERAPY July 2012
set by the U.S. Department of Health and Human Services. In the years ahead, both research and service programs are likely to increasingly require a recovery orientation combined with evidence-based practices for funding.
Scope of Practice Recovery-oriented practice expands the skills necessary to effectively function within the
MFT scope of practice, requiring greater expertise in case management, occupational function- ing, social functioning, wellness, systems of care, community mental health, severe mental illness, and psychopharmacology. As recovery-oriented approaches increasingly become stan- dard practice, MFTs will need to effectively implement this model, which requires knowledge of areas formerly considered outside the scope of practice. The holistic approach of recovery requires MFTs to directly intervene on issues of occupational and social functioning in order to help individuals function better in their intimate relationships.
Practice Contexts As recovery-oriented work becomes more common, the contexts in which MFTs work will
also change. In the past few decades, MFTs have already witnessed a shift with a larger per- centage working in employment settings, such as community mental health agencies, and fewer MFTs in private practice (Northey, 2009). While this trend is likely to continue, it is also likely that increasingly MFTs will be working in different contexts as well, such as in-home therapy, school settings, and community settings. Therapy may also occur in unexpected places, such as parks, outdoor cafés, and malls: contexts that often make a person with severe mental illness feel safer. Ironically, most therapists think of their office as providing ultimate protection and safety; this is true primarily in the areas of confidentiality and anonymity. However, if a person has felt victimized by the service delivery system and medical profession, the ‘‘professional’’ context can be a significant barrier to feeling safe and therefore to positive outcomes. Recov- ery-oriented principles therefore allow for greater flexibility in service contexts.
Ethics The ethical implications of recovery-oriented practice for therapists are yet to be deter-
mined and have not been fully explored. In short, we are entering uncharted waters that are not likely to be mapped anytime soon. In fact, it is possible that we will never be able to create the type of ethical maps (or guidelines) we have historically. Rather than follow clear and consistently applied ethical guidelines, therapists will most likely have to rely on ethical decision-making practices that enable them to vary and ‘‘customize’’ ethical practices far more than has historically been the case. More decisions will be left to individual judgment, which is likely to result in numerous challenges for practitioners as well as ethics review boards. Supervision in ethical decision making is likely to play a much greater and significant role in training.
Boundaries Of all the ethical challenges, therapist–consumer boundaries are likely to require the most
attention and adaptation. In public mental health recovery-based programs, the therapist’s role typically also includes case manager, advocate, mentor, and at times even friend; interactions occur in the consumer’s home, a coffee shop, social service waiting rooms, the therapist’s car, and other unpredictable contexts. The overall tenor of the relationship changes to be more casual and down-to-earth. To practice ethically across all of these situations, therapists must closely monitor what does harm, what helps, and what does not with an individual consumer rather than apply a one-size-fits-all approach. As we move forward, boundaries in recovery- oriented practice are likely to be a frequently debated topic.
CLOSING REFLECTIONS
Family therapists are well prepared for working in recovery-oriented contexts and mean- ingfully contributing to the quickly emerging field of mental health recovery. In many ways, the
July 2012 JOURNAL OF MARITAL AND FAMILY THERAPY 439
principles of recovery return MFTs to their roots, a nonpathologizing, down-to-earth, and hopeful approach to working with families with a member diagnosed with severe mental illness. The recovery approach also opens the possibility for getting outside the limitations of a closed office and 50-min session to work in everyday contexts and the community. Working from a recovery perspective also requires broadening the purpose of therapy, shifting the goal from symptom resolution to wellness in its fullest sense, and creating a life well lived, including inti- mate relationships, career, and community inclusion. However, the recovery paradigm brings with it challenges, requiring therapists to reexamine their boundaries, assumptions about mental illness, and expert position. At a more profound level, the very notion of ‘‘therapy’’ is called into question, perhaps opening the door to a radical redefinition of our work. Whether one finds these changes welcome or not, recovery is the paradigm for public mental health in the years ahead. Family therapists must either choose to define their role in recovery-oriented systems or they will find their role defined for them.
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