A scientific agenda for the concept of recovery as it applies to schizophrenia
Introduction
With publication of the Surgeon General's Report on Mental Health (Department of Health and Human Services, 1999) and the President's New Freedom Commission on Mental Health's Final Report (2003), the concept of “recovery,” which had evolved through the consumer advocacy movement since the first half of the 20th century (Frese, 1998, Tomes, 2006), became a significant consideration for treatment providers and policy makers. Recovery is now routinely a subject of presentations and publications by consumers, clinicians, administrators, researchers, and policy makers, and many states are developing plans to transform their mental health systems in accordance with recovery-oriented care, as recommended by the reports noted above and other publications. At the same time that the groundswell of advocacy for recovery-oriented care continues to increase, however, it has been noted that there is still a lack of a consensual definition of what recovery is or involves. Indeed, as Davidson, O'Connell, Tondora, Straeheli, and Evans (2005) noted, “the only thing about which most involved parties seem to be able to agree is that the notion of recovery has become the focus of a considerable amount of confusion, dialogue and debate between and among various constituencies within the mental health community” (p. 6). Davidson et al. (2005) further noted that as a result of the variety of uses of the word, recovery is in danger of becoming the latest in a line of terms that are used frequently to connote insider status in the mental health community, but without having any meaningful content or implications. Similarly, Liberman and Kopelowicz (2005) noted that lack of agreement on how to define recovery may lead to its loss of credibility as a meaningful construct, a concern also voiced by Roe, Rudnick, and Gill (2007). Jacobson and Greenly (2001) also noted that without consensual agreement on what recovery is, it is likely that currently available treatments and delivery systems will be repackaged in non-significant ways, with the claim that they are now recovery-oriented. Finally, Davidson et al. (2005) argued that the elusive nature of the concept has led to an inconsistency in the degree to which recovery principles are translated into actual practice, and the degree to which the extent that this is occurring can even be assessed. All of these scenarios imply that, despite the current enthusiasm regarding transforming mental health care in a more recovery-oriented direction, unless agreement can be reached on one or more ways to understand recovery in terms that can be measured and studied, there will ultimately be a less than desired impact on the types of services and supports that are made available to consumers of mental health services. These issues are in addition to the complex set of issues that have been raised involving implementation of a recovery model even after agreement on concepts has occurred at the local level (Davidson, O'Connell, Tondora, Styron, & Kangas, 2006).
As a remedy for this situation, Bellack (2006), Liberman and Kopelowicz (2005), and Slade and Hayward (2007) called for efforts to ground the concept of recovery in a scientific base. This would include operational definitions of recovery, reliable measurement of phenomena considered to be core features of recovery, the generation of research data on factors that facilitate or impede attainment of recovery criteria sets, and factors related to the effectiveness of recovery-oriented care. As Liberman (2002) pointed out, in addition to accelerating our understandings of recovery and of how to help people recover, such research can also help improve the differentiation of schizophrenia as a heterogeneous set of disabilities rather than a unitary disease.
In this paper, we review what we believe to be the major research questions facing the field of schizophrenia treatment with regards to the various uses of the concept of recovery. We also note the data, where available, that led us to formulate what we see as the major questions and issues. While we acknowledge at the outset that many more questions are asked than answered in this paper, our hope is that the questions asked, and the rationale behind their generation, will serve to organize research efforts on recovery so that it moves from being an often ambiguous term to one that has concrete meaning and benefit for people suffering from the effects of schizophrenia. We should also note that while our narrower focus is on schizophrenia, much of the discussion has broader applicability to people with serious mental illness in general. We have chosen to focus on schizophrenia, however, because this condition has traditionally been associated with the poorest outcomes, and because response to even recovery-oriented interventions such as supported employment is often poorest among people with this diagnosis (see below, section on interventions). Therefore, we believe it is important to raise the issues of the extent to which current discourse around recovery applies to this population, and the practical issues that a recovery orientation raises for the treatment and lives of this heterogeneous group of people.
Section snippets
Defining recovery
The concept of recovery has been defined in multiple ways. These different definitions can be roughly organized into two types: those that reflect recovery as an outcome based on whether operationally defined criteria in one or more domains are met, and those that reflect recovery as an ongoing process of identity change including a broadening of self concept wherein the role of consumer of psychiatric services becomes less pronounced. As Bellack (2006) noted, the former type of definition
Defining a research agenda for recovery
Answering the key definitional questions posed above will allow for a more productive focus on other questions relevant to recovery that are in need of further study. These research questions include: 1) how are the outcome and process aspects of recovery related, and to what extent do these relationships vary across individuals? 2) what research designs are most appropriate to study the type of long-term change implied by the process-oriented concept of recovery? 3) how does the recovery
Conceptual issues related to recovery-oriented treatment
In this final section, we address some remaining issues that are relevant to both conceptualization and treatment, and therefore to research as well. One of these involves what can be seen as an apparent incompatibility between evidence-based practices (EBPs) and recovery-oriented care. Some authors have raised concerns about a fundamental incompatibility between these approaches (Essock et al., 2003), while others have demonstrated that the approaches are compatible (Bond et al., 2004, Tracy,
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