Recovery in Mental Illness: The Roots, Meanings, and ... · 23 Recovery in Mental Illness: The...

23Recovery in Mental Illness:

The Roots, Meanings,and Implementations of a

"New" Services MovementAnn McCranie

The history of the care and treatment of the mentally ill in America for almost four centuriesoffers a sobering example of a cyclical pattern that has alternated between enthusiasticoptimism and fatalistic pessimism. (Gerald Grab, 1997, The Mad Among Us, pp. 309)

INTRODUCTION

Moral treatment, moral hygiene, asylums, psycho-pharmaceuticals, communitymental health, and community support: all have been heralded as positivenew directions for the treatment of severe and chronic mental illness. But thereality of all of these models has fallen short of providing a permanent solutionor even the ideal support for treatment. Some have come to be seen in thelong run as actually harmful with people with serious mental illness. It wasagainst this backdrop of unsatisfactory, incremental, and unintentionalconsequences - what Frank and Glied (2006) called "better but not well" in theUS context - that the movement of "recovery" has taken root modem mentalhealth services.

472 THE SAGE HANDBOOK OF MENTAL HEALTH AND ILLNESS

"Recovery" for in the field of mental health services is actually a complexof ideas - but I propose it can be understood most simply as hope that someone,particularly someone in the throes of suffering acutely from a serious and persis-tent mental health problem, can reclaim their life or create a newly meaningfulone. "Recovery-oriented" systems of care, then, are those that help rather thanhinder that individual in their "recovery." But admittedly, that broad brush failsto captures what the range of meanings that "recovery" in the context of mentalillness means and has meant to different actors - individuals with mental illness,family members, service providers, and policy makers - over time. Hopper offersanother start: "If a provisional consensus may be hazarded, it would readsomething like this: recovery is difficult, idiosyncratic, and requires faith - but itis possible" (2007: 870, emphasis added).

But how do concepts such as "hope" and "faith" fare in a mental health servicesystem? How do these concepts become embodied in the interaction betweenprovider and individual? How do those concepts become institutionalized andembedded in a system of care marked with disappointment, lack of resources,disorganization, and invisibility? What happens if these terms and movementsare co-opted or fail to take root? And what if Grob's historical view of thependulum swings from enthusiastic optimism to fatalistic pessimism provesprophetic - and this is just the moment before the plunge?

The impact of major reform movements in mental health services, such asdeinstitutionalization (Brown, 1985; Jones, 1993), community care in Britain(Rogers and Pilgrim, 2001) and the even the serendipitous origins of psychop-harmacology (Healy, 2002) reveal that shifts in treatment can have profoundeffects at individual, family, institutional, and state levels. The movement toward"recovery" and "recovery-oriented services" has already had some impact on thedirection of recent mental health policy in the United States (Departmentof Health and Human Services, 2003) and England (Department of Health,2001, 2004) and research (Lieberman et aI., 2008). The challenge this concept"recovery" presents to individuals to understand serious mental illnessdifferently is one important matter, but so too is the challenge the idea's promo-tion has had on individual and organizational practices and structures of care ina changing fiscal, policy, and scientific environment.

The focus of this chapter is on the organizational field of mental healthservices. The purpose is not to define "recovery" - as many have attemptedthis already and the definition continues to change and be debated (Bellack,2006; Davidson and Roe, 2007; Hopper, 2007; Jacobson and Greenley,2001; National Consensus Conference on Mental Health Recovery and MentalHealth Systems Transformation, 2004; Noordsy et aI., 2002; Onken et aI., 2007).Instead, it is to argue that recovery is a concept and movement in modemmental health services. To that end, this chapter will present a brief history ofthe concept in the mental health services field, including a set of key (but notuncontested) definitions for recovery. It will also highlight the critiques, largelyfrom within the movement and offer a brief description of the diffusion of

RECOVERY IN MENTAL ILLNESS 473

recovery-oriented services and some of the most relevant social science researchon recovery.

Whether recovery is truly the "guiding vision" (Anthony, 1993), the "heart andsoul of treatment" (Townsend and Glasser, 2003), "old wine in new bottles"(Davidson et al., 2005; Pilgrim, 2008), or it is just another pendulum swing up tothe "enthusiastic optimism" that Grob (1997) warned about, the concept's diffu-sion throughout the field marks an important moment in modern mental healthservices. This movement has different implications for the different cultural andmaterial environments it enters. While this chapter focuses on the US context, itwill also briefly discuss how the concept of recovery has been received in severalother contexts, such as the United Kingdom and Australia.

A BRIEF HISTORY OF "RECOVERY" IN THE MENTALHEALTH SERVICES FIELD

There is nothing new about the term "recovery" for people with mental illness.The term has been used for many years to refer to a remission or reduction ofsymptoms. In 1937, Abraham Low, a psychiatrist working in state mental hospi-tals in Illinois founded a group called "Recovery, Inc." devoted to structuredself-help groups to provide "after-care" for recently discharged hospital patients.Recovery, Inc. focused on reducing "relapses," through social coping skills,goal-setting, and increasing self-confidence. While Low's original organizationfailed to gain acceptance in the larger research and treatment community and wasdissolved, it was reborn as a peer-led group model (Low, [1991] 1943) that stillexists today.

However, the roots of a concept of recovery - if not the term - have been tracedback to over 200 years ago to Philippe Pinel and his traitement moral in Parisasylums (Davidson et al., 2010). And certainly the concept of recovery is familiarfrom the field of addictions treatment (Davidson and White, 2007). Yet, at somepoints in recent history, recovery was, for some seen as impossible. In the case ofschizophrenia, even the clinical definition asserted a declining course and a per-manent state of illness - such as in Emil Kraepelin criteria for "dementia praecox."Remission or recovery was seen as prima fascia evidence that the illness had notbeen dementia praecox. Eugen Bleuler, who challenged this diagnosis andrenamed this condition "schizophrenia" in part to remove the connotation withdementia, also challenged the chronicity of the problems, recognizing that peoplediagnosed with it could get better.

This early dispute is often cited in the literature about recovery (Bellack, 2006;Corrigan et aI., 1999; Jacobson, 2004; Lieberman et al., 2008). In addition, severallongitudinal studies of the outcomes of individuals who had been institutional-ized or diagnosed with schizophrenia suggested that a large percentage, perhapsa large majority, of individuals were improved after a period of time, particularlyin the area of remission of symptoms (Bleuler, 1974; Harding et al., 1987;


Jacobson, 2004; Lieberman et al., 2008; Tsuang et al., 1979). The concept ofrecovery in mental health services is often less concrete and posits a more expan-sive view of the possibilities for individuals than the outcomes investigated inthese studies (e.g., symptom reduction, decreased medication usage, living inde-pendently, working, etc.). However, as studies showed evidence that improvedquality of life in some key life domains was possible, they provided an "evidencebase" of recovery and had a particular meaning to researchers who sought topromote the ideological concept (Jacobson, 2004).

In one of the first and most cited articles about recovery, clinical psychologist,and advocate Patricia Deegan (1988) wrote a first person account of her illnessand recovery experience and argued that recovery is different from psychosocial(or psychiatric) rehabilitation. Rehabilitation, she argued, is about services andtechnologies, but "recovery refers to the lived or real experiences of persons asthey accept and overcome the challenge of the disability" (1988: 7). Early firstperson accounts had a strong influence on the direction researchers went withtheir recovery writing and pushed beyond the traditional concepts of symptomreduction, independent living, treatment utilization, and employment that werehallmarks of psychiatric outcomes work.

Themes that emerge from Deegan's work, and that three other notable firstperson accounts of recovery from mental illness - Marcia Lovejoy (1982), EssoLeete (1989), and Rae Unzicker (1989) - include hope, acceptance, engagementin social life, active coping, and reclaiming a positive sense of self (Ridgway,2001). First person accounts such as these became the basis for establishinga definition of recovery, and even now comprise a large basis of research forrecovery researchers and for seeing recovery as a unique "journey" into findingpurpose in one's life (Davidson, 2003; Deegan, 2003; Mead and Copeland, 2000;Ridgway, 2001; Roe and Lachman, 2005; Wisdom et al., 2008).

It would not be long before researchers and providers were also promoting theconcept of recovery. After publishing a short piece addressing the topic in 1991,William Anthony, a psychologist and director of the Boston University Centerfor Psychiatric Rehabilitation, returned to the topic wrote the recovery "call toarms" in the mental health services literature (1993). In this he outlined both the"vision" of recovery that would guide services in the years to come and what arecovery-oriented system would look like. Recovery is:

a deeply personal, unique process of changing one's attitudes, values, feelings, goals, skills,and/or roles. It is a way of living a satisfying, hopeful, and contributing life even with limita-tions caused by illness. Recovery involves the development of new meaning and purpose inone's life as one grows beyond the catastrophic effects of mental illness. (1993: 527)

Anthony asserts that "(r)ecovery is what people with disabilities do ... Recoveryis a truly unifying human experience" (1993: 527-528). Recovery, according toAnthony, is multi-dimensional, defying simplistic measurement. However, helaid out a set of assumptions to which providers in a recovery-oriented system ofcare should adhere: recovery happens with or without treatment; it requires social


support; it is independent of etiological beliefs about illness; and it can continueeven if symptoms re-occur (i.e., recovery being a "non-linear process"). ForAnthony, recovery is unique to each person, requires that the person have choicesabout their situation, and must also take place in a social context in whichrecovery from the consequences of the illness (such as stigma) can be harder toovercome than the mental health problem. Recovery-oriented services would notjust rely on more traditional activities such as treatment, crisis intervention, casemanagement, and rehabilitation, but would also seek to enrich lives, protectrights, and enable basic support and self-help.

Anthony's work is still highly cited, even though the effort to find a commonlyaccepted definition of recovery has so far been elusive, even by those quite moti-vated to promote and carry it out in services (e.g., Clay et aI., 2005; Davidsonet aI., 2005). Several comprehensive reviews and proposed reformulations havebeen attempted (Bellack, 2006; Corrigan and Ralph, 2005; Jacobson, 2001;Jacobson and Greenley, 2001; Lunt, 2002; Noordsy et aI., 2002; Onken et al.,2007; Ralph, 2000; Roe et al., 2007). But there is broad agreement among thosewho study recovery is that the notion is subject to much "confusion, dialogue,and debate" (Davidson et aI., 2006: 6) and that "(l)ike mental illness itself, thenotion of recovery represents a multidimensional set of phenomena which mayshare nothing more than a Wittgensteinian sense of 'family resemblance'"(Davidson and Roe, 2007: 460).

Two often cited distinctions that appear in the literature are "recovery in" vs."recovery from" (Davidson and Roe, 2007) or to internal vs. external processesin recovery (Jacobson and Greenley, 2001). Davidson and Roe distinguishbetween the meaning of recovery "from" mental illness as a more symptom-based remission type of return to function, whereas recovery "in" mental illnesscan refer to moving ahead with life even as symptoms persist and functions arenot returned. Jacobson and Greenley (2001) refer to the "internal" components ofrecovery, such as hope, attitudes, experiences and processes of individual change,whereas "external" conditions - such as material circumstances, services,policies, practices, can aid or hinder the process. These themes are echoed againand again as researchers attempt to clarify the meaning of recovery.

Recovery in the United States

In the United States, the banner of recovery was seen as an opportunity forcommon ground for individuals with mental illness and providers (Frese, 1998).It was lauded as a goal for individuals and for systems in the 1999 SurgeonGeneral's Report (Department of Health and Human Services, 1999). Two ofthe more influential recent definitions came from high profile public reportson the "transformation" of the mental health systems, one from President GeorgeW. Bush's New Freedom Commission on Mental Health (New FreedomCommission on Mental Health, 2003) and the other from the Substance Abuseand Mental Health Services Administration (SAMHSA),s National Consensus


Statement (2004). In the New Freedom Commission report, recovery was acentral organizing concept:

Recovery refers to the process in which people are able to live, work, learn, and participatefully in their communities. For some individuals, recovery is the ability to live a fulfilling andproductive life despite a disability. For others, recovery implies the reduction or completeremission of symptoms. Science has shown that having hope plays an integral role in anindividual's recovery. (2003: 5)

Shortly after, the US Substance Abuse and Mental Health Services Admin-istration (SAMHSA) produced a "consensus statement" that defined recovery as"a journey of healing and transformation enabling a person with a mental healthproblem to live a meaningful life in a community of his or her choice while striv-ing to achieve his or her full potential." The consensus was reached after a seriesof reports and paper on topics surrounding recovery was commissioned and over100 stakeholders in mental health service providers - individuals with mentalillness, family members, academic researchers, providers, government officials,etc. - worked to find agreement on the meaning. The consensus statement alsoidentifies ten "dimensions" of recovery: self-direction, individualized and person-centred, empowerment, holism, non-linearity, strengths-based, peer support,respect, responsibility, and finally, hope (National Consensus Conference onMental Health Recovery and Mental Health Systems Transformation, 2004).

Critiquing the concept of recovery

Even among supporters for the concept of "recovery" in the mental healthservices field, some have pointed out that studying recovery is a problem forscientists because it can become overly broad and meaningless (Roe et al., 2007).While arguing for understanding that would draw from economist and philoso-pher Amartya Sen's capabilities approach, Hopper described the current state ofaffairs of the concept of recovery a "co-opted, near-toothless gospel of hope"(2007: 877). He noted the lack of contentiousness about the varied meaningsreflect "working misunderstandings" of the meanings and values attached to theconcept (2008: 307). Pilgrim (2008, 2009) makes a similar argument aboutthe "polyvalent concept" of recovery and argues that ethnographic study of theconcept is needed to untangle meanings and enactments lest these misunder-standings continue. Others have argued recovery could be in some instances aveiled attempt to further cut services or to leave behind those in most need in thename of reaching an elusive goal (Dickerson, 2006; Johnson, 2005). Peyser (2001)warned that it could actually harm individuals by interfering with treatment goalsof symptom reduction. As the call for recovery -oriented services was (and still is)happening alongside managed care reforms and calls for the "transformation" ofUS mental health services, Jacobson and Curtis (2000) note that recovery couldbe co-opted as a concept and left without content.

The moving target of the definition, coupled with the difficulty of pinningdown concepts as "hope" and "unique processes," have led to frustration and


scepticism and some suggestion that recovery ought to be rooted in "objectivelymeasureable" functional criteria focused on symptom reduction and remission(Bellack, 2006; Liberman et al., 2002; Roe et al., 2007). This is a direct challengeto the view that recovery is not about symptoms or functional improvement.However, the focus on functional remission may serve as a de facto answer forresearchers frustrated with concepts too difficult to operationalize. Libermanand Kopelowicz (2005), for instance distinguishes between the "process" and"outcome" of recovery. A recent special issue of Schizophrenia Bulletin (seeEssock and Sederer, 2009) published a series of seven reports on measurement of"functional recovery." The focus of this "functional recovery" that it is focusedmore on an individual's ability to be able to perform daily activities (such asself-care and work) and be integrated into social life.

Leiberman et al. (2008) suggests that in order for it to be a useful heuristic,recovery should be qualified with the domain of life in which it is achieved -such as "recovery of vocational function" or "recovery of cognitive function."This account of a way to pull together neuroscience and psychiatry with therecovery movement allows the focus to stay on more traditional issues of symp-tomatology and "acknowledges" but does not address the other issues of living soclose to the recovery movement: "civil rights, stigma, housing, vocational oppor-tunities, and other community issues" (Leiberman et al., 2008: 488). Some withinthe movement have also argued that recovery as a term suggests going or lookingback to a previous, perhaps mythical "state of health," whereas the true goal shouldbe moving forward. Advocate Kathleen Crowley has termed this idea "Procovery"(Crowley, 2000) and has developed a set of trainings for providers and individualsand "Procovery Circles" that function like peer-led support groups.

But the component parts of recovery remain difficult to measure. An effort byEuropean researchers to review the literature for the use of the concept of "hope"found 49 different definitions and 32 different measurement tools (Schrank et al.,2008). In an era of increased interest and demand for evidence-based practices inmental health services, some have questioned (Browne, 2006) whether recoverycan be even be appropriately tied to outcomes, while others have said that it canand should be done (Anthony et al., 2003; Frese et al., 2001). Tanenbaum (2006)identifies the tensions between the tenets of evidence-base practice (EBP), soheavily dependent on randomized control trials and experimental methods andaggregate results, and the tenets of recovery, so focused on individualized andself-determining recovery goals. In short, she argues that recovery demands anew standard for EBP studies, one that involves individuals with mental illnessin the meaning making of research framing and interpretation.

It is important to note where in the mental health services literature rigorousdiscussion has been taking place. Discussion and disagreements about the mean-ing of recovery in the psychiatric/psychosocial rehabilitation and communitymental health journals have been answered with a more muted critique - evensilence - from the larger clinical psychiatric and psychological community. Forinstance, a recent working group of prominent psychiatrists and neuroscientists


considered criteria for remission of schizophrenia and came up with somesignificant changes, but explicitly avoided engaging the criteria for recovery, asthe concept is underspecified and reflects "ongoing multidisciplinary effortsseeking to incorporate the viewpoints of patients, caregivers, and clinicians, aswell as an evolving appreciation for the relationship between improvements insymptoms, cognition, and functionality" (Andreasen et al., 2005: 442). The rela-tively supportive language about the potential for recovery as a concept - if onlyit can be more clearly specified - belies a larger silence by some of the mostprominent journals in the fields of clinical psychiatry (such as the Archives ofGeneral Psychiatry, Journal of Clinical Psychiatry, and the American Journal ofPsychiatry) or clinical psychology (such as Psychological Medicine, or the influ-ential Annual Review of Psychology or Annual Review of Clinical Psychology)about anything other than a functional recovery outcome measure (far more akinto a remission paradigm). One exception to this is the British Journal ofPsychiatry, which has published a number of pieces taking the issue head-on(Dickens, 2009; Dinniss, 2006; Lester and Gask, 2006), perhaps reflecting a dif-ferent national response to the concept (discussed more below). In the UnitedStates, academic discussion has been largely relegated to journals that are focusedon services research (Psychiatric Services, Journal of Psychiatric Rehabilitation,and Community Mental Health Journal) and the more narrowly focused journal,Schizophrenia Bulletin (which, not coincidentally, published some of those earlyfirst-person accounts (Leete, 1989; Lovejoy, 1982) that came to influence theconcept's development.

As George Bernard Shaw wrote, "Silence is the most perfect expression ofscorn" and this quiet could portend a larger battle for this community of serviceresearchers to have the idea of recovery, with its messy multiple constituencies,recognized in larger academic circles. This silence in the broader community,after a 20-year history of writing high profile policy involvement, and the emer-gence of new treatment models, speaks volumes of the "fractiousness that has yetto face the fact" (Hopper, 2007: 307). Sociologists would do well to pay attentionto these cleavages - as they reflect long-standing divisions in the treatment andresearch of mental illness within psychology and psychiatry - between medicaland social understandings of illness.

MARCHING AHEAD: "RECOVERY-ORIENTED SERVICES"IN AN AGE OF "EVIDENCE-BASED PRACTICES"

As recovery has gained currency, so have efforts to tie specific models oftreatment to it. Davidson defined recovery-oriented services as those that empha-size the shared decision making of individual and provider (Davidson et al.,2009). Psychosocial, or psychiatric, rehabilitation models, which emphasize goalsetting, skill-building and community integration were a welcome home forrecovery principles (Lamb, 1994; Stromwall and Hurdle, 2003; Taylor and


Yuen, 2008). One the field's leading journals, Psychiatric Rehabilitation Journal,(founded and edited by Anthony), has become central for publications onrecovery. The connection between the field of rehabilitation and recovery is anearly one with Anthony's involvement and Deegan's warning in 1988 that reha-bilitation was not synonymous with a recovery-oriented approach. The UnitedStates Psychiatric Rehabilitation Association, the field's professional certifica-tion organization, has adopted recovery language in its mission statement andrecovery-oriented services as a center point in its training efforts.

The concept of recovery has focused on new individual service models,practices, types of actors, and the interaction between care providers and thosethey work with. Simultaneously, there has been an interest in developing andimplementing evidence-based practices (analogous to the evidence-based medi-cine movement in general health research). How to square the goals of evidence-based practices with the more subjective terms of recovery has been the subjectof much discussion (Anthony et al., 2003; Bellack, 2006; Farkas et al., 2005;Fisher and Ahern, 2002; O'Connor and Delaney, 2007; Tanenbaum, 2006). Freseet al. (2001) suggests that recovery-based models of treatment (those that empha-size more choice, empowerment, and regaining control of one's life) wouldbe more appropriate when the individual is experiencing less severe symptoms ofillness and is not as highly impaired in their decision-making ability. A moreevidence-based medical model approach could be appropriate when individualsare more impaired. Frese et al. points out that among activists, support for"recovery-oriented services" vs. "evidence-based practices" varies along a con-tinuum of severity of illness for which the activists advocate. This illustrates atension between functional remission (recovery "from") and personal journeysof recovery (recovery "in").

One identified evidence-based practice that is explicitly tied to recovery move-ment and stresses empowerment of individuals is "Illness Management andRecovery" (Mueser et al., 2002; Roe et al., 2009). Illness Management andRecovery is a structured program for providers that encourages them to work inconcert with individual consumers/users to plan for and pursue individual goals.It stresses educating individuals about mental illness, about the "stress vulnera-bility model" and how to reduce their chances of stressful circumstances thatcould lead to relapse. Individuals are also walked through steps to build their ownsocial support networks, counselled about their medication use, and to navigatethe mental health system.

Deegan, in attempting to address some of the problems that individuals facewhen they talk to their providers about their medication use, has introduced"CommonGround" (Deegan et al., 2008). This model offers a web-based soft-ware package to help individuals talk more openly about their psychotropic(and other) medication usage with their doctors. An individual would useCommon Ground, which asks questions about usage, side effects, and otherissues involving medication, before seeing their provider. They would also beprompted to share information with their doctor about their "personal medicine,"


(Deegan, 2005) or non-pharmaceutical techniques, like walking or gardening,they use to gain relief from their problems. This intervention, still in the pilotstage, is one of many efforts to foster collaboration between individuals and theirproviders and to provide a more "recovery-oriented" approach to care.

But the recovery movement has also advanced the creation of a new categoryof professional caregivers - that offered by peers who also have mental illnesswho then are trained to work with others (Clay et al., 2005; Corrigan et aI.,2005). Peer support is nothing particularly new - recall Low's reliance on peersin the late 1930s for his Recovery, Inc. and the emphasis on peer-run supportprograms such as clubhouses and advocacy organizations (Clay et al., 2005).But, the new emphasis on training and certifying peers ("Peer Recovery SupportSpecialists") to provide mental health services to other individuals, has added anew professional category for individuals with mental illness (or their familymembers). Special certification programs (at the Institute for Recovery andCommunity Integration, for instance), special billing codes for services, and anational professional organization (the National Association of Peer Specialists,Inc.) have developed. Certification as a peer specialist depends on an individual'sidentity as someone diagnosed with a mental illness, but other identity-basedprofessional statuses are available. In Florida, for instance, certification isavailable as a "peer," as a "family peer" and as both.

One of the motivations behind peer support as recovery-oriented services hear-kens back to advocate demands for more involvement in the treatment system byindividuals affected with mental illness. But there is also Deegan's concept ofthecontagiousness of hope (1988) - that by modeling recovery, peers can provideinspiration to others to pursue their own goals.

CONCORDANCE AND CONTRASTS: RECOVERYIN NON-US CONTEXTS

The discussion above is not to suggest that recovery is a conceptual product ordiscovery of the United States (indeed, international scholars are engaged in dis-cussions with US scholars cited above). The concept of recovery has a muchlonger history, crossing many eras and national borders (Davidson et aI., 2010).It is perhaps more appropriate to talk about the "rediscovery" of recovery (Ramonet al., 2007). But as others have noted (Allott and Loganathan 2002; Ramonet al., 2007), the influence of some US (and New Zealand) researchers andpolicy makers has been felt in the United Kingdom, particularly through policydocuments, such as those from the Ohio Department of Mental Health, andthrough specific recovery approaches, such as the Wellness Action RecoveryPlan (Copeland, 1997[2002]).

However, the modern recovery movement met a somewhat different set ofcircumstances when it began to be recognized and written about in the UK.It meshed with the political agenda of "social inclusion" in welfare policies since


New Labour came to power in 1997 (Ramon et al., 2007) and with a moregeneral focus on lay-lead self-management of chronic physical and mentalconditions (Davidson et al., 2005). The meaning of that social inclusion rhetorichas been questioned by some (Pilgrim, 2008; Rogers and Pilgrim, 2001), as theynote the concurrent fascination with "risk management" of individuals withmental illness. While social inclusion is a clearly stated goal of many US policydocuments, it is clearly not a central focus of most recovery work - which is farmore focused on individuals. Appealing to Amartya Sen, some US researchers(Hopper, 2007; Ware et al., 2008) have called for a reconceptualization of recov-ery from a capabilities approach and social model of disabilities approach - yetanother example of the border-crossing of ideas.

Similar to the "transformation" effort of the United States, mental healthservices in the UK have also been the subject of a decade of concerted transfor-mation efforts begun in 1999 called the National Services Framework. Thisframework, while ambitious and underfunded, has been focused largely on dein-stitutionalization and a community support model (Department of Health, 2001;Sainsbury Center for Mental Health, 2003). Ramon et al. (2007) declare it alargely unimplemented process, with few clear guidelines for seeing it through.Throughout Britain and Ireland there are varying degrees of implementation.Ireland, for instance, has only recently begun to address recovery in policy docu-ments (Kartalova-O'Doherty and Doherty, 2010), whereas Scotland has alreadydeveloped and begun implementing its own recovery indicator tool - based onone developed in New York State - and has made a concerted effort to train peerrecovery specialists (Scottish Recovery Network, 2005; Slade, 2009).

Australia, as Ramon et al. (2007) points out, might not have been using theterm "recovery" in policy documents until 2003, when it was addressed as a coreconcept in the National Mental Health Service Plan. But as early as 1989, lan-guage that echoed central tenets in most recovery definitions - optimism forimprovement and the importance of involving people with mental illness in theirown treatment planning process - were central toAustralian national policy. There,recovery oriented work is being pushed largely by consumer/service user groups,and is largely housed in a somewhat separate psychosocial rehabilitation systemheavily influenced by consumers/service users. This stands outside the more"clinical" approach of most public mental health clinics (Ramon et al., 2007).

While Anglophone researchers and writers of recovery often refer and evenimport work from other national contexts, the conceptual flexibility can meanimportant differences are lost. This international diffusion of ideas and practicesdeserves attention.

CONSIDERING RECOVERY IN THE SOCIAL SCIENCES

Some sociologists have already begun addressing recovery and recovery-orientedservices and the impact they could have on individuals and mental health systems.


Nora Jacobson's articles (Jacobson, 2001, 2003; Jacobson and Greenley, 2001)and book length treatment on recovery efforts in the state of Wisconsin (2004) isexpansive in its scope and places recovery in the US federalist context. In aneffort to understand the definition, process, and consequences of recovery inmental health services, she (2004) deconstructs the various usages of the termrecovery and identifies five key meanings: evidence, experience, ideology, policy,and politics. These "recovery-as" meanings each operate at different levels andconvey different meanings about what recovery is.

Jacobson parses the various definitions of recovery that mental health stake-holder draw upon. "Recovery-as-evidence" refers particularly to the growingunderstanding by mental health service researchers that individuals with seriousmental illness could, and did, in fact get better over time and see a remission ofsymptoms. "Recovery-as-experience" drew meaning from the lived experiencesand narratives of those with mental illness, and drew more from a politicaland social-disabilities based understanding of the individual embedded within asocial context. "Recovery-as-ideology" drew from the two previous wells ofmeaning and crafted a new stream of research and writing about how providersand services ought to be organized to support recovery. "Recovery-as-policy"developed as policy-setting bodies (like state governments) tried to makesense of this new emphasis to translate it into policy and practice. "Recovery-as-politics" is the ongoing process of how to deal with the consequences ofthe movement in light of other realities, such as constricted finances, morecalls for evidence-based practices, and peer involvement in the provision oftreatment.

Jacobson (2004) poses seminal questions about the consequences of recovery:what will a recovery-oriented system looks like, who benefits, how it will becompatible with other system changes, and how its success or failure will beevaluated? Further, who will have the right to evaluate success? As she notedearlier (Jacobson and Curtis, 2000), the questions start as questions of epistemol-ogy and end with questions of policies and values.

Others find different sets of meanings and interest groups. Pilgrim (2008,2009) cautions that recovery is a "polyvalent concept," and using Britain as acase study, finds it to have at least three distinct and sometimes contradictorymeanings. In one, it refers to a notion that biomedical psychiatric biologicalrecovery from illness is possible - a direct contradiction to the Kraepelin pessi-mism of a declining course. A second meaning, held by those providers offeringa social skills or rehabilitation approach, takes another optimistic view of thecourse of illness from a different philosophy of treatment. A third, what Pilgrimrefers to as the "dissenting service user" approach is a more social model ofrecovery, focused on empowerment and autonomy, sometimes in opposition tothe oppressiveness of treatment regimes. These three meanings, all operating underthe same banner of recovery, can be used simultaneously or individually, butcan mask critical ontological positions and make meaningful policy consensusprecarious or impossible.


Other sociologists have taken interest in recovery - particularly as anoutcome. For instance, one groups of researchers (Link et al., 2001) havetaken a sociological approach to understanding how stigma can impederecovery and found that experienced stigma impacts later self-esteem measures.Relatedly, Markovitz (2001) has approached recovery from the outcomesperspective, and has proposed a recovery model that incorporates symptoms,self-concept, and life satisfaction as all reciprocally related to one another inthe lives of individuals with mental illness. Finding support in his work forboth a social stress/social support argument that social circumstances contributeto illness and to medical/psychiatric view of symptoms causing social distress,Markovitz concludes that that treatment that incorporates both symptommanagement and social and vocation skills training are key to being"recovery -oriented."

Echoing (but not drawing from) Jacobson and Greenley's (2001) distinctionsof "internal" vs. "external" conditions for recovery, Yanos et al. (2007) arguethat sociologists understanding of both structure and agency can be enhancedby paying attention to the ways in which individual choices and constraintsand collective action can reconfigure social structures and enhance or inhibitrecovery for individuals. Individual actions, such as coping and goal-settingcoupled with structural transformation through collective political action,can increase individuals' abilities to recover. Both social structure and individualagency become critical considerations when considering recovery, a taskmade no easier when outcomes for individuals are often considered outsidea structure/agency framework, and rather a function of biology and ofsymptomatology.

With an explicitly political economic take on recovery, Warner (1994) arguesprovocatively that recovery from schizophrenia is tied to socioeconomicconditions. Oppressive economic conditions create stressors for people who thensuffer disproportionately when economic conditions keep them from resumingmeaningful adult social roles (such as employment) or from enjoying basicnecessities (such as secure housing and food). Furthermore, systems of care thatdo not ameliorate stress on caregivers and families leave individuals adrift andsocially isolated, stressed further.

All of these arguments about the nature of recovery, particularly as they impactthe individual are important. However, there is a further set of questions aboutwhat recovery suggests for the future of the mental health service system, andhow it is organized that are only now beginning to be answerable. What, forinstance, does it mean when the meaningful and unique personal journey ofrecovery is a valued concept by researchers and providers, but remains so illusivein definition and measurement? What does this portend for policy choices? Whathappens when "recovery" meets a policy environment interested in enactingperformance-based standards and "transformation" (in the United States). Theliterature on engaging recovery and evidence-based practices begins to suggestthat there is no simple answer.


CONCLUSION: AGENDA FOR THE SOCIOLOGICALSTUDY OF RECOVERY

Brand new technologies and revolutionary ideas can rapidly displace old ways.But the history of mental health treatments reveals that many elements of care forpeople with serious mental illness - such as moral treatment, moral hygiene,asylums, psycho-pharmaceuticals, community mental health, and communitysupport - do not simply appear or disappear, but rather wax and wane in impor-tance, and get reinvented and rediscovered over time. Perhaps the concept ofrecovery will be something similar. While it has increased in prominence in rheto-ric, policy, and services over the last two decades, the concept has a long history.

While it is clear that the rhetoric of recovery has permeated at least one cornerof the modern mental health services field, that of rehabilitation, this materialimpact of this "guiding vision" is still unfolding. Certainly services have beenchallenged, efforts to change attitudes and outlooks are underway, and thediffusion of this idea and language has crossed many borders.

For a field that has been so active and fruitful in discussing the social construc-tion of mental illness, few sociologists of mental health have taken on theflip: the social construction of recovery. It is time and we are well-equipped.For instance, sociology can and should explore further the provocative politicaleconomic research of Warner (1994) and the questions it raised. Sociologistsof mental health have done excellent work in understanding how mental illnessand stress is stratified, but paid less attention to how recovery from thatsame problem is also stratified. If we are to believe Warner, understanding thiscould point us to clear ways in which systems can be strengthened for the mostvulnerable.

In addition, drawing the concept of recovery from the stories of the successfulcan draw on a rich history of the sociology of mental illness of identity research.In addition to the obvious contributions we can offer to understanding the livedexperiences of people with serious mental illness who are recovering or arerecovered, sociologists of mental health should attend to this social movementboth inside and outside of research circles as it develops or withers. Who will winin this nascent dispute over whether outcome or process should come to repre-sent recovery in the academic literature? Will recovery become another fad of themental health services literature and fade away, or will it have staying power asit is ingratiated into treatment models and policy statements? What impact doesthis recovery have on traditional social pressures such as stigma? And finally,who "recovers," and who does not?

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