Recovery and the psychiatrist

Purpose

The Royal Australian and New Zealand College of Psychiatrists (RANZCP) acknowledges the transformative potential of recovery for all people with mental illness and the importance of adopting recovery-oriented practices for all providers of mental health care. This statement, prepared by the RANZCP Community Collaboration Committee, a constituent committee of the RANZCP Practice, Policy and Partnerships Committee, provides a reference point for members and the public in understanding this potential, and actions the College is committed to in realising this potential.

Background

The RANZCP acknowledges there is no single definition of the concept of ‘recovery’ in mental health. Broad cultural differences across Australia and New Zealand enrich this discussion further. Central to all descriptions of recovery, however, are hope, self-determination, self-management, empowerment, and advocacy (Australian Health Ministers Advisory Council, 2013).

The most commonly-quoted description is from Deegan’s seminal 1996 lecture on the topic:

• Recovery does not refer to an end product or result. It does not mean that one is ‘cured’. In fact, recovery is marked by an ever-deepening acceptance of our limitations. But now, rather than being an occasion for despair, we find that our personal limitations are the ground from which spring our own unique possibilities. This is the paradox of recovery, i.e., that in accepting what we cannot do or be, we begin to discover who we can be and what we can do. Thus, recovery is a process (Deegan, 1996).

The concept of recovery has become a mainstream principle of mental health care, applicable beyond its origins as a social movement of people severely affected by mental illness. A core goal of recovery is that – however a person identifies as having personal experience of mental illness or are Tangata motuhake (people with experience of mental illness or distress) – they are entitled to live with hope, and to undertake a journey of recovery. This journey will take them towards a meaningful and contributing life in the community including workplaces, where a person with experience of mental illness is accepted, valued, and appreciated. The person not only survives, but thrives (Australian Health Ministers Advisory Council, 2013). These goals are shared by the RANZCP and its members.

The RANZCP recognises the importance of recovery by its presence within the assessment of a number of Entrustable Professional Activities in the RANZCP Competency-based Fellowship program. This position statement aims to promote a more consistent understanding of what recovery means for psychiatrists and their practice. It is intended to reinforce the College’s commitment to promoting recovery and recovery-oriented mental health practice, and to encourage reflection by members regarding how practical application of the concept can improve outcomes for people with mental illness (as well as their own professional satisfaction), irrespective of practice mode or setting.

Definition

The meaning of recovery

The concept of recovery originated in the 1970s as a social movement aimed at improving the human rights and community inclusion of people affected by mental illness. Since 1998, governments, internationally, have adopted recovery-oriented policies for delivery of mental health services. Descriptions of recovery vary, with different emphases on physical, social, emotional, and spiritual wellbeing, for example. While acknowledging these differences, the RANZCP recognises that the broad recovery paradigm applies to all people affected by mental illness, including those who are psychiatrists.

While the concepts of clinical recovery, which focuses upon objective improvements in symptoms and function, and personal recovery differ, they are closely interrelated, and there is continuing and fruitful debate about their interaction. In this document, where the term ‘recovery’ is used by itself it is referring primarily to ‘personal recovery’.

The RANZCP Mental Health for the Community: Principles to underpin effective mental health service delivery to the community defines personal recovery as ‘looking beyond clinical recovery, and measuring the effectiveness of treatments and interventions in terms of the impact of these on the things that matter to individuals as they try to find new meaning and purpose in their lives’ (RANZCP, 2012).

In Australia and New Zealand, understanding of the recovery concept is broadly similar, while definitions, awareness, and practice vary according to cultural and policy differences. Personal recovery is defined within the Australian National Framework for Recovery-oriented Mental Health Services as ‘being able to create and live a meaningful and contributing life in a community of choice with or without the presence of mental health issues’ (Australian Health Ministers Advisory Council, 2013). In New Zealand, personal recovery is defined as ‘the ability to live well in the presence or absence of one’s mental illness (or whatever people choose to name their experience). Each person with mental illness needs to define for themselves what ‘living well’ means to them (Mental Health Commission, 2001).

Recovery-oriented Practice

Recovery-oriented practice supports the personal recovery of mental health consumers. It does not negate the skills and principles underlying the evidence-based biopsychosocial approach to psychiatry and may indeed encourage and empower psychiatrists to apply them together in a holistic way, despite any service constraints. Where communities of psychiatrists have closely engaged with the concept of recovery, it has been described as transformative (Jhan and Jhan, 2012; Barber, 2012; Roberts and Boardman, 2014). The spirit of this transformation is best expressed in the following statement:

• We believe that Recovery is probably the most important new direction for mental health services. It represents the convergence of a number of ideas (empowerment, self-management, disability rights, social inclusion, and rehabilitation) under a single heading that signals a new direction for mental health services which is supported by service users, authoritative professional bodies, mental health policy and key leaders in mental health around the world (South London and Maudsley NHS Foundation Trust and South West London and St George’s Mental Health NHS Trust, 2010).

The Australian National Framework for Recovery-oriented Mental Health Services (Australian Health Ministers Advisory Council, 2013) states that markers of recovery-oriented practice include:

• a focus on the needs of people who use services rather than on organisational priorities
• use of language that reflects hope, optimism, recovery, and improvement
• finding personal resonance with each person, which allows you to develop more meaningful conversations
• engaging people with a lived experience in decisions about diagnosis and treatment
• engaging with the person, his/her carers, families and significant others
• supporting the person in recovery to work across all social determinants of health (including housing, social contacts, diet and exercise, work).

Recovery-oriented practice has similarities with Person-Centred Care (PCC), but differs in the overt intention to maximise the role of the person living with mental illness in decision-making and goal-setting regarding their care, with the psychiatrist providing expert support, advice, and assistance. Recovery-oriented goals may overlap significantly with clinical goals, as used in PCC, but may also be very personal and attainable without clinical improvement.

Evidence

The Australian Report Cards (National Mental Health Commission, 2012; 2013) and Report on Mental Health Programmes and Services (National Mental Health Commission, 2014), and the New Zealand Blueprint II (Mental Health Commission, 2012) detail recovery-oriented mental health services and what they means in practice. They call for mental health reform and investment in recovery-oriented services. Considerable work has been already undertaken on recovery-oriented support and care at a planning, competency, and skills level nationally. In Australian mental health policy, this recovery approach is enshrined in government policy. Australia's National Mental Health Plan 2003-2008 (Department of Health, 2003) was the first clear statement that services should adopt a recovery orientation. This was later reinforced, in 2013, when the Australian Health Ministers' Advisory Council launched the National Framework for Recovery-oriented Mental Health Services (2013).

People with mental illness have the right to fulfilling, valued lives in the community, with access to accommodation, transport, and opportunities to participate and contribute, including education and employment (Our lives in 2014, 2004). This applies equally to others affected including families, whanau, and other carers (NSW Mental Health Commission, 2014). Personal connections are recognised as a social determinant of good mental health and wellbeing, and promote resilience in the individual and community. They are particularly important for people who experience mental illness, their families and other carers, therefore, and are an important resource in the recovery process.

The RANZCP, and many other mental health organisations, have clearly endorsed the importance of recovery to people with mental illness and to professional practice (NSW Mental Health Commission, 2014).

Recommendations

Psychiatrists have a key role to play in applying the principles of recovery. In particular, all psychiatrists need to:

• be aware of key elements of concept of recovery
• ensure they are knowledgeable in relevant competencies in New Zealand and Australian competency and standards documents
• review their approach to clinical practice and ensure their practice (no matter what the setting, or the nature or severity of a mental illness) is recovery-oriented.

The RANZCP:

• encourages reflection on recovery-oriented practice and its impact on individuals and families, communities, and psychiatrist practitioners and organisations
• values psychiatrists who have been affected by mental illness, able to provide hope and optimism by using their personal experience to encourage others to work through their own recovery process
• will work with the Mental Health Commissions to identify opportunities to improve the understanding of recovery and recovery-oriented practice by clinical professions, and to support the fulfilment of relevant goals within Mental Health Strategic Plans
• will develop and deliver professional resources and programs on recovery-oriented care, drawing on the expertise of people living with mental illness, and encourage integration of models of recovery and recovery-oriented practice into the Fellowship syllabus
• will develop and deliver resources on recovery-oriented care for private psychiatrists, drawing on the expertise of people living with mental illness (RANZCP, 2015)
• will work to improve education and training of the mental health and associated workforce on recovery-oriented care (National Mental Health Commission, 2014).

Acknowledgements

The RANZCP acknowledges the valuable input, presentations and materials developed by all members of the Community Collaboration Committee, past and present, on this subject.

Responsible committee: Community Collaboration Committee 

References

Australian Health Ministers Advisory Council (2013). A national framework for recovery-oriented mental health services: Guide for practitioners and providers. Canberra: Commonwealth of Australia.

Barber M E (2012). Recovery as the new medical model for psychiatry. Psychiatric Services, 63 (3): 277-279.

Deegan P (1996). Recovery and the conspiracy of hope. Available at: www.patdeegan.com/pat-deegan/lectures/conspiracy-of-hope (accessed 18 January 2016).

Department of Health (2003). Australia's National Mental Health Plan 2003-2008. Canberra: Commonwealth of Australia.

Jha A and Jha M (2012). The seven habits of recovery-oriented psychiatrists: a non-clinical guide for personal growth and development. The Psychiatrist, 36 (9): 345-348.

Mental Health Commission (2001). Recovery competencies for New Zealand mental health workers. Wellington, New Zealand: Mental Health Commission.

Mental Health Commission (2012). Blueprint II: Improving mental health and wellbeing for all New Zealanders. Wellington, New Zealand: Mental Health Commission.

Ministry of Health (2008). Te puawaiwhero: The second Maori mental health and addiction national strategic framework 2008–2015. Wellington: Ministry of Health.

National Mental Health Commission (2012). A contributing life: The 2012 national report card on mental health and suicide prevention. Sydney: National Mental Health Commission.

National Mental Health Commission (2013). A contributing life: The 2013 national report card on mental health and suicide prevention. Sydney: National Mental Health Commission.

National Mental Health Commission (2014). National review of mental health programmes and services. Sydney: National Mental Health Commission: Recommendation 22.

NSW Mental Health Commission (2014) Living well: A strategic plan for mental health in NSW. Sydney, NSW Mental Health Commission.

Our lives in 2014: A recovery vision from people with experience of mental illness for the second mental health plan and the development of the health and social sectors (2004). Wellington, New Zealand: NZ Mental Health Commission; NZ Ministry of Health, Mental Health Directorate.

RANZCP (2012). Mental Health for the Community: Principles to underpin effective mental health service delivery to the community. Melbourne: RANZCP: 3.

RANZCP (2015). RANZCP Operational Plan 2015. Melbourne: RANZCP.

Rickwood D (2006). Pathways of recovery: 4As framework for preventing further episodes of mental illness. Canberra: Commonwealth of Australia.

Roberts G and Boardman J (2014). Becoming a recovery-oriented practitioner. Advances in psychiatric treatment, 20 (1): 37-47.

South London and Maudsley NHS Foundation Trust and South West London and St George’s Mental Health NHS Trust (2010). Recovery is for all: Hope, agency and opportunity in psychiatry: A position statement by consultant psychiatrists. London: SLAM and SWLSTG.

Disclaimer: This information is intended to provide general guidance to practitioners, and should not be relied on as a substitute for proper assessment with respect to the merits of each case and the needs of the patient. The RANZCP endeavours to ensure that information is accurate and current at the time of preparation, but takes no responsibility for matters arising from changed circumstances, information or material that may have become subsequently available.