Recovery: Patients, Families, Communities

October 11-14, 2007; New Orleans, Louisiana

Michael T. Compton, MD, MPH

Disclosures

December 28, 2007

In This Article

Introduction

The theme of the 2007 Institute on Psychiatric Services annual conference was "Recovery: Patients, Families, Communities." In this conference report, a workshop, a lecture, and a symposium are summarized, each highlighting the increasingly discussed topic of recovery -- a subject that originated from the field of addictions and has taken hold in many areas of psychiatry. As applied to other areas of mental health (and illness), the recovery paradigm expands considerably from a simpler concept of remission of symptoms and change in behaviors.

 

The Recovery Model and Diagnostic and Statistical Manual of Mental Disorders, 5th Edition
(DSM-V)

Roger Peele, MD, Distinguished Life Fellow of the American Psychiatric Association (APA), Arlington, Virginia, and Chief Psychiatrist of the Montgomery County Department of Health and Human Services, Montgomery County, Maryland, led a workshop entitled "The Potential Impact of the Recovery Model on DSM-V."[1] Dr. Peele hosted this session in conjunction with 3 psychiatry residents (Sheela Kadalar, MD; Samantha Shlakman, MD, MPH; and Anjali Dsouza, MD). In introducing the workshop, Dr. Peele mentioned that the recovery model began in addictions and spread to other areas of psychiatry, and that given that the DSM-V is due out in around 2011, we must consider the ways in which the emerging recovery paradigm, developed subsequent to the publication of DSM-IV, could influence the development of DSM-V.

Introduction

The Recovery Model and Diagnostic and Statistical Manual of Mental Disorders, 5th Edition (DSM-V)

Roger Peele, MD, Distinguished Life Fellow of the American Psychiatric Association (APA), Arlington, Virginia, and Chief Psychiatrist of the Montgomery County Department of Health and Human Services, Montgomery County, Maryland, led a workshop entitled "The Potential Impact of the Recovery Model on DSM-V."[1] Dr. Peele hosted this session in conjunction with 3 psychiatry residents (Sheela Kadalar, MD; Samantha Shlakman, MD, MPH; and Anjali Dsouza, MD). In introducing the workshop, Dr. Peele mentioned that the recovery model began in addictions and spread to other areas of psychiatry, and that given that the DSM-V is due out in around 2011, we must consider the ways in which the emerging recovery paradigm, developed subsequent to the publication of DSM-IV, could influence the development of DSM-V.

Background: Addictions Recovery

Dr. Kadekar discussed recovery as a concept in the field of addictions. She presented definitions of recovery based on Partners for Recovery, an initiative sponsored by the Substance Abuse and Mental Health Services Administration (SAMHSA),[2] and the 2005 National Summit on Recovery,[3] where the working definition of recovery was as follows: "Recovery from alcohol and drug problems is a process of change through which an individual achieves abstinence and improved health, wellness and quality of life."

Dr. Kadekar pointed out that recovery:

  • Has many pathways;

  • Is often seen as self-directed and empowering, based on a personal recognition of the need for change;

  • Tends to be more holistic than the traditional medical model;

  • Takes into account cultural dimensions; and

  • Is based on a continuum of health and wellness.

She described how hope, gratitude, healing, and self-redefinition are integral to the recovery concept, relying in part on support from peers and allies, in a spirit of rejoining/rebuilding the community. The recovery model addresses discrimination and stigma.

Clearly, the recovery paradigm that is taking hold in the context of serious mental illnesses, based on the recovery approach to addictions, diverges considerably from the more unidimensional approaches of remission or symptom reduction.

Recovery in Schizophrenia and Other Serious Psychiatric Illnesses

Dr. Shlakman then presented an overview of recovery in the context of serious psychiatric illnesses, reviewing the literature on 2 types of definitions of recovery:

  • Social; and

  • Scientific.

Social definitions of recovery emphasize how the patient conceptualizes his or her illness and how the patient fits into society; scientific definitions focus on measurable outcomes such as the number of months being symptom free or thresholds on clinical research rating scales.[4] Thus, the latter are thought of more as an outcome, whereas social definitions emphasize the process.

In 2004, the National Consensus Statement on Mental Health Recovery stated that "mental health recovery is a journey of healing 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."[5] Recovery is a process, not an end point; it does not necessarily mean symptom-free; and recovery is part of a larger social movement of empowerment and self-determination. The shift toward a recovery orientation is reflected in a change in conceptualization of the one seeking care as a consumer rather than patient.

After Dr. Shlakman described the recovery model in relation to a serious mental illness such as schizophrenia, Dr. Peele speculated that in the DSM-V, poor prognosis (eg, the ≥ 6-month duration criterion for schizophrenia) may not be part of the illness definition. Such reconceptualizations exemplify how the field could consider changing the criteria for serious mental illnesses to provide for a culture in psychiatry in which people can improve and recover.

Recovery in Personality Disorders

Next, Dr. Dsouza discussed recovery in the context of personality disorders. She suggested that current DSM criteria may not be consistent with the concept of recovery. Personality disorders, by definition, are:

  • Pervasive;

  • Permanent; and

  • Enduring.

But, Dr. Dsouza questioned whether personality disorders are that much more pervasive and chronic than Axis I disorders. Current criteria suggest to patients, families, mental health providers, and insurance companies that personality disorders are untreatable and pervasive; however, diagnostic criteria for personality disorders often fail to adequately describe the patient and add to a sense of bewilderment regarding this group of disorders. By contrast, many dimensional models highlight common psychopathological processes, as exemplified by the relationship between:

Some have suggested eliminating the word "personality" from the name of psychiatric disorders, replacing "personality disorder" with something like "interpersonal disorder" or "emotional dysregulation disorder."

Recovery and DSM-V

After the 3 overviews of the recovery paradigm in addictive disorders, serious mental disorders, and personality disorders were discussed, Dr. Peele presented some thoughts on how the recovery paradigm could be incorporated into DSM-V. First, he presented 6 major foci that are already clear from the preliminary work of the DSM-V Task Force:

  • Life span development as it affects diagnosis;

  • Medical interface as it affects the boundaries of psychiatry with the rest of medicine;

  • Greater sensitivity to cultural and gender factors;

  • Careful considerations of spectra or continua in conceptualizing the relationships among psychiatric disorders;

  • Exploration of relational disorders as a category; and

  • Consideration of supplementing or replacing the categorical approach with a dimensional approach to psychiatric diagnosis.

Dr. Peele discussed how the third, fifth, and sixth of these represent possible areas for DSM-V to move closer to the values of the recovery model:

  • Greater sensitivity to cultural issues and gender should facilitate the aim of the recovery paradigm to stay close to patients' goals;

  • Development of relational disorders has considerable ability to reach recovery values as it points to the need for others, not just the patient, to change; and

  • A dimensional approach to diagnosis would allow for much greater individualization of psychiatric diagnosis and imply less of a separation between the well and the ill.

Thus, as Dr. Peele stated in his handout to the audience, "the dimensional approach should free the clinician to capture the patient's individuality and not imply any psychopathology beyond what the patient has," which would be welcomed by those championing the values of the recovery paradigm.

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