Recovery: Patients, Families, Communities

October 11-14, 2007; New Orleans, Louisiana

Michael T. Compton, MD, MPH

December 28, 2007

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.

Recovery From the Perspective of Community Mental Health Services

Jacqueline M. Feldman, MD, Patrick A Linton Professor of Psychiatry and Behavioral Neurobiology at the University of Alabama at Birmingham and Vice Chair, Scientific Program Committee, IPS Conference, gave a lecture defining, evaluating, and supporting recovery in the public sector/community mental health setting, entitled "Recovery Is in the Eye of the Beholder."[6] She started by stating that, "when I started working with people with schizophrenia 17 years ago, things were not very hopeful. . .," but now that the field is on the cusp of a real paradigm shift to the recovery model, the picture is quite different. Dr. Feldman suggested that, "if you choose to work with this wonderful patient population, then you are obliged to embrace recovery."

After a brief quiz for the audience to provoke thought about each clinician's own treatment programs (eg, "Do you believe that people with schizophrenia can recover?" and "What do you think needs to be in place for a person to recover?"), Dr. Feldman discussed "recovery in evolution." She contrasted treatment approaches that focus on symptom remission/reduction vs those centered on skills expansion. The former has a deficit focus (eg, isolation, being out of control, noncompliance) that tends to present the patient and his or her illness as hopeless. The symptom remission/reduction model presents the physician as:

  • Being in control;

  • Offering professional support;

  • Managing symptoms; and

  • Being paternalistic.

The skills expansion paradigm, which is inherently recovery-oriented, is strengths-based, focused on social skills, and more interested in the often episodic (rather than chronic and pervasive) nature of schizophrenia.

Dr. Feldman discussed some basic principles of incorporating the recovery model in community mental health settings. She described recovery as:

  • Consumer-empowered -- eg, the patient decides how frequently to follow up;

  • An enhancer of natural supports in managing life; and

  • Inherently consumer-centered.

Recovery, Dr. Feldman said, "is sitting down, being quiet, and asking the patient what he or she wants from treatment."

Remission has been defined as "a state in which patients have experienced an improvement in core signs and symptoms to the extent that any remaining symptoms are of such low intensity that they no longer interfere significantly with behavior and are below the threshold typically utilized in justifying an initial diagnosis of schizophrenia."[7] A number of general definitions and operational definitions for recovery in schizophrenia have been proposed.[8]

Dr. Feldman noted that the President's New Freedom Commission on Mental Health suggested that, "care must focus on increasing consumers' ability to successfully cope with life's challenges. . . ."[9] Important principles of recovery include hope and optimism that one can get better, self-help, wellness, and learning how to keep symptoms from disturbing one's overall sense of well-being. In her presentation, Dr. Feldman commented on the Recovery Oriented Services Evaluation (ROSE), which clinicians and administrators can use to see if their programs are truly recovery-oriented.[10]

Psychoeducation and Recovery

A symposium sponsored by the Therapeutic Education Association focused on the role of psychoeducation in recovery.[11] With regard to psychoeducation, Cynthia C. Bisbee, PhD, Former Clinical Director of the Montgomery Area Mental Health Authority, Montgomery, Alabama, discussed where we have been, where we are now, and where we are going.

Where We Have Been

Dr. Bisbee commented that just 3 decades ago, there was:

  • Great reluctance to give patients information about their diagnoses;

  • Blame and exclusion of families (eg, the schizophrenogenic mother concept);

  • Little mention of psychoeducation prior to 1980 (the term psychoeducation may have been used in the educational sector to refer to teaching children to deal with their feelings);

  • No clear definitions or curricula available for psychoeducation;

  • Only rare discussion of psychiatric illnesses in the media;

  • Virtually no funding available for psychoeducation as a treatment modality. (Education was not on the pharmaceutical industry's agenda.)

However, there was a small body of literature on nurse medication groups, which turned out to be the beginnings of psychiatric patient education. In the 1980s and 1990s, psychoeducation-oriented topics in the literature included:

  • Family education and consultation related to schizophrenia;

  • Psychosocial skills training; and

  • Multiple family groups.

In the more recent decade or so, the literature has demonstrated:

  • Diversification of psychoeducational models;

  • Evaluation of psychoeducational programs;

  • Psychoeducational programming for first-episode psychosis;

  • Evidence-based practices including family psychoeducation and "illness management and recovery";

  • Dissemination of the psychoeducation model; and

  • Policy and system implications of psychoeducation.

Where We Are Now

Sharing information with patients has become routine, and both patients and families are now part of the treatment planning process. Psychoeducation, like recovery, has become an everyday word. There has been a proliferation of psychoeducational materials in multiple media (eg, the Internet). Several states have established funding mechanisms (though still largely under-reimbursed) for psychoeducational activities in the clinical setting. Clinicians now have a plethora of curricula and resources at their disposal, including toolkits, pharmaceutical company products, books, and other materials. SAMHSA has defined evidence-based practices and assembled detailed toolkits to assist programs with implementation (eg, assertive community treatment, supported employment), including family psychoeducation.[12]

Where We Are Going

Dr. Bisbee briefly summarized the future of psychoeducation by mentioning the increasing (but still incomplete) acceptance of models of psychoeducation and implementation of evidence-based practices. Methods are being developed to enhance uptake of this treatment modality, such as through the use of toolkits. She mentioned that further research on dissemination is needed and that funding mechanisms should be broadened.

Recovery and Psychoeducation

After this overview of the past, present, and future of psychoeducation, Patricia L. Scheifler, MSW, Director of Partnership for Recovery, Sylacauga, Alabama, discussed the role of patient psychoeducation in psychiatric recovery. She began by discussing how psychoeducation encompasses 3 overlapping entities:

  • Psychiatric patient education on diagnosis, symptoms, medications, etc;

  • Skills training (eg, assertiveness, daily life skills, problem solving); and

  • Illness management skills training, such as stress management skills, and symptom monitoring.

She then addressed the question of why clinicians should practice psychoeducation, offering such reasons as the fact that psychoeducation:

  • Has been recognized as an evidence-based practice;

  • Focuses on recovery;

  • Includes easy-to-use outcome measures;

  • Can be provided by all members of the treatment team; and

  • Can be taught using tailored materials.

Potential outcomes of psychoeducation include increased knowledge, improved adherence, and reduced relapse rates.

The remainder of Ms. Scheifler's presentation focused on ways to facilitate effective psychoeducation across levels of care, especially given that most staff members are not trained as educators. She also presented her methods for determining competency to provide psychoeducation and teaching clinicians how to be effective psychoeducators.

Other presentations during this symposium included the recounting of a number of moving stories about experiences with psychoeducational support groups for families over the past 25 years by Harriet P. Lefley, PhD, one of the founders of psychoeducation, Professor of the Department of Psychiatry University of Miami School of Medicine, Miami, Florida. Her descriptions of these longitudinal psychoeducational support groups demonstrate that while evidence-based psychoeducation practice usually refers to 9-month standardized curricula, families' needs are often dynamic and change over time. Thus, psychoeducation in the context of recovery is commonly an ongoing, longer-term process.

Karen A. Landwehr, MA, Clinician and Educator at the Comprehensive Mental Health Community Education Partnership, Tacoma, Washington, then discussed the role of community psychoeducation in creating a climate of recovery. Also in this symposium, Dale L. Johnson, PhD, Professor Emeritus of Psychology at University of Houston, Houston, Texas, gave a presentation entitled, "The Global Community: What Can It Teach Us about Recovery and How to Achieve it?"

Conclusions

In addition to many other sessions focused on the recovery theme, additional topics covered at the Institute of Psychiatric Services conference included:

  • Mental health responses to Hurricane Katrina and disaster psychiatry more generally;

  • Smoking cessation for individuals with serious mental illnesses;

  • Psychosocial and pharmacologic treatment modalities for schizophrenia;

  • Psychiatric services for people who are homeless and have a mental illness; and

  • Co-occurring disorders.

The prominent theme of recovery proved refreshing and informative for psychiatrists working in community and public sector settings.

References

  1. Peele R. Potential Impact of the Recovery Model on DSM-V. 2007 CME Syllabus and Proceedings Summary of the 59th Institute on Psychiatric Services; October 11-14, 2007; New Orleans, Louisiana. Workshop 3.

  2. SAMHSA's Partners for Recovery. Mission statement. August 9, 2007. Available at: http://pfr.samhsa.gov/index.html. Accessed November 3, 2007.

  3. SAMHSA's Partners for Recovery. National Summit on Recovery Conference Report. September 28-29, 2005; Washington, DC. Available at: http://pfr.samhsa.gov/docs/Summit-Report.pdf. Accessed November 3, 2007.

  4. Bellack AS. Scientific and consumer models of recovery in schizophrenia: concordance, contrasts, and implications. Schizophr Bull. 2006;32:432-442.

  5. US Department of Health and Human Services. Substance Abuse and Mental Health Services Administration Center for Mental Health Services. National Consensus Statement on Mental Health Recovery. Available at: http://mentalhealth.samhsa.gov/publications/allpubs/sma05-4129/. Accessed November 3, 2007.

  6. Feldman J. Recovery is in the eye of the beholder. 2007 CME Syllabus and Proceedings Summary of the 59th Institute on Psychiatric Services; October 11-14, 2007; New Orleans, Louisiana. Lecture 2.

  7. Andreasen NC, Carpenter WT Jr, Kane JM, Lasser RA, Marder SR, Weinberger DR. Remission in schizophrenia: proposed criteria and rationale for consensus. Am J Psychiatry. 2005;162:441-449.

  8. Liberman RP, Kopelowicz A. Recovery from schizophrenia: a concept in search of research. Psychiatr Serv. 2005;56:735-742.

  9. President's New Freedom Commission on Mental Health. Final Report to the President. May 2003. Available at http://www.mentalhealthcommission.gov/. Accessed November 3, 2007.

  10. AACP ROSE -- Recovery Oriented Survey Evaluation. Available at http://www.comm.psych.pitt.edu/finds/AACPROSEIII.pdf. Accessed November 3, 2007.

  11. Landwehr KA, Baker LS. Creating the environment: the role of psychoeducation in recovery. 2007 CME Syllabus and Proceedings Summary of the 59th Institute on Psychiatric Services; October 11-14, 2007; New Orleans, Louisiana. Symposium 8.

  12. Family Psychoeducation Implementation Resource Kit. Implementation Resource Kit User's Guide. Draft Version 2003. Available at http://download.ncadi.samhsa.gov/ken/pdf/toolkits/family/02.FamPsy_
    Users.pdf. Accessed November 3, 2007.