by Hunter L. McQuistion, MD

The mental health recovery paradigm has taken root and it is beginning to flourish. Federal, state, and local mental health authorities are increasingly adopting recovery as a substrate on which to design services. Indeed, recovery"s tenets are at the base of the President"s New Freedom Commission on Mental Health.

As code for partnership in the process of moving through life with an illness, recovery is increasingly accepted as a means with which to build a salutary alliance between clinicians and people with psychiatric disorders. Concerning psychiatry, the person-centered approach it advocates is harmonious with training professionals to address patients with dignity and empathy.

Recovery's investment in the sanctity of personal goals is likewise consistent with the profession's focus on adaptation and development over the life cycle. It has even penetrated into the psychiatric mainstream. In 2005, the American Psychiatric Association issued this Position Statement:

The American Psychiatric Association endorses and strongly affirms the application of the concept of recovery to the comprehensive care of chronically and persistently mentally ill adults, including the concept of resilience in seriously emotionally disturbed children. The concept of recovery emphasizes a person's capacity to have hope and lead a meaningful life, and suggests that treatment can be guided by attention to life goals and ambitions. It recognizes that patients often feel powerless or disenfranchised, that these feelings can interfere with initiation and maintenance of mental health and medical care, and that the best results come when patients feel that treatment decisions are made in ways that suit their cultural, spiritual, and personal ideals. It focuses on wellness and resilience and encourages patients to participate actively in their care, particularly by enabling them to help define the goals of psychopharmacologic and psychosocial treatments. The concept of recovery has a long history in medicine and its principles are important in the management of all chronic disorders. The concept of recovery enriches and supports medical and rehabilitation models . . .(italics original)

The statement goes on to highlight the intrinsic value of hope and notes the partnership between psychiatrists, patients, and other professionals in the process of recovery. It is unusual when organized psychiatry-and its ordinarily conservative stance--is ahead of practice, particularly in areas not strictly identified as scientific, such as psychopharmacology, but it's happened with recovery.

Case in point: I have been lately involved in interviewing potential training directors at my institution. It is a major teaching hospital and department of psychiatry where community service is valued and the academic pursuit of leading edge care for people with serious disorders is pursued with vigor. The committed, articulate teachers who wish to lead our department's efforts in educating medical students and psychiatric residents have gotten a favorite question from me: what have you heard about the recovery paradigm? Answers vary from vague acknowledgment to curious ignorance.

Many have noted that "we all have something to recover from" in our lives, thus binding us together, enabling us to be more sensitive clinicians. Psychiatry's own "recovery" will be about really understanding this, and integrating it into the basic "core competencies" that are required acquisition in residency. Ironically, it relates to what are viewed as old-fashioned psychoanalytically based tenets that the therapist him or herself is "the tool" in healing: one who engages, uses his or her own responses to inform treatment, and to understand the totality of a person.s background.

Since 2005, the Royal College of Psychiatrists has required that British trainees receive training directly from, or directly influenced by, mental health consumers and caregivers, through commentary on relevant educational modules, selection of relevant teachers, and by directly sharing experiences, advancing dialogue and understanding.

This is an example for us in the United States and similar mandates here could motivate and then help residency training directors to teach recovery, and its technical component, rehabilitation. A recent survey on psychiatric residency education by Michael Yedidia and his colleagues at New York University had mixed outcome on this score. Although 83% of residency training directors indicated that psychiatric rehabilitation was important in education, some key ingredients of rehabilitation were endorsed with less enthusiasm, questioning how deeply residency directors understand rehabilitation principles. For example, only half of those surveyed prioritized knowing how to assess people for vocational rehabilitation potential or how to interact with housing program staff. Similarly, just over a third believed that teaching residents to work in alternative settings, such as shelters, and helping homeless patients work on the goal of housing was important.

Mark Ragins, a psychiatrist who has thought a lot about this issue, describes the challenge as less one of skills, but more of making two difficult adjustments that permits the skills to fall into place. The first is transitioning to a collegial or coaching role with the patient and the second is appreciating that a psychiatrist is "just one member of the community," a person among many who must actively maintain contact with other team members in developing and maintaining a plan with a patient.

By extension, I'd underscore that managing mental illness is just one, albeit important, aspect of a person's life. The psychiatrist's role must therefore acquire a new perspective, losing unrealistic expectations of control over functional outcome, while paradoxically gaining a freedom to tune into a person's needs so as to actually improve functioning.

What we are witnessing is a generational phenomenon. Along with the gradual destigmatization of mental illness, the development of the recovery paradigm is a post-deinstitutionalization outgrowth of the former mental health "survivor" and current consumer movements. As in all fields of medicine today, we are experiencing more patients asserting themselves, even if not always perfectly (do any of us?). So, psychiatry's own recovery-oriented goal needs to assure that the next generation of psychiatrists will hear their patient's words and not become irrelevant to their goals. To make that happen, we teachers have some catching up to do.

Hunter L. McQuistion, M.D., is Director of Integrated Psychiatric Services at St. Luke’s-Roosevelt Hospital in New York City. Previously he was Chief Medical Officer for Mental Hygiene Services at the New York City Department of Health and Mental Hygiene. A national expert on underserved populations, he is the author of dozens of publications and his most recent book, Clinical Guide to the Treatment of the Mentally Ill Homeless Person, explores the intersection of mental illness, homeless families, and services that make a difference to their lives. He is the recipient of NAMI’s Exemplary Psychiatrist Award.