The concept of recovery has gained increasing popularity with mental health professionals, family members, and consumers. As opposed to the traditional definition of recovery as an “asymptomatic end state” (i.e., “I have recovered from influenza”), the emerging definition acknowledges that it is not so much the final extent of symptomatic relief but rather, more fundamentally, recovery represents an “ongoing process of learning to live with [and]… despite the limitations of [psychiatric illness]” (1). Recovery has been described in various ways (2–8) (Table 1). Importantly, many of the principles of recovery are already thought to be part of good psychiatric practice, such that to some extent this is not “new” and should be part of the residents’ training anyway. This approach pertains primarily to chronic mental illnesses. Evidence regarding the efficacy and cost-effectiveness of recovery is still very much in its infancy.
Not withstanding these important caveats, the concept of recovery has received strong endorsement from two major policy reports, the Surgeon General’s Report on Mental Health and Illness (9) and the President’s New Freedom Commission on Mental Health (8). These powerful documents use the term “transformation,” implying that true progress will not be made unless there is a fundamental paradigm shift in mindset and in practice.
Although now a powerful influence in the public mental health system, the concept of recovery has received little support or discussion among the academic community. In our experience, mental health psychiatry and psychology trainees are still relatively uninformed about recovery. This is salient since (1) there is a national trend toward integrating best practices into residency training and (2) if mental health transformation toward recovery is a realistic goal, then trainees should receive instruction so that they will be prepared for later practice within the prevailing ideological and therapeutic framework. Moreover, gaining acceptance of recovery among mental health trainees is, in and of itself, one aspect of this “transformation.”
The recovery movement has gained prominence in Georgia, especially with the now widespread use of Certified Peer Support Specialists (CPSS) within the public mental health system. In recognition of the value of academia, the Division of Mental Health, Developmental Disabilities, and Addictive Diseases forged a new relationship with the Department of Psychiatry of the Medical College of Georgia to develop a model curriculum on recovery for training in academic centers.
In September 2005, we conducted two resident-led focus groups to obtain trainees’ perceptions of the Recovery Model as a viable entity of mental health treatment. Group 1 was composed of 11 psychiatry residents and three psychology residents. Group 2 included nine psychiatry residents and three psychology residents. Three CPSS attended each session. The following topics were covered: the Recovery Model, the CPSS training curriculum, and developing a Wellness Recovery Action Plan (WRAP) with consumers. The WRAP is a consumer driven treatment (Action) Plan with explicit steps toward meaningful outcome goals for the patient. Resident opinions regarding the recovery model were obtained through a discussion format, which was audio recorded, and through an anonymous post-group questionnaire.
Observations From Analysis of Audiotape
An initial topic of discussion during the focus groups was the residents’ perceptions of a “realistic goal for our patients.” Residents tended to give textbook answers for determinants of treatment prognosis such as diagnosis, treatment history, and pre-morbid functioning level. One resident stated that she would “Ideally like to see them back to the place they were before they got sick… but I do not think this is always going to happen.” Another resident stated with cautious optimism, “You would like to shoot for the stars… but it may not be realistic.” In contrast, the CPSS was clear to point out that recovery and peer services address “what the illness does to you, not the symptoms.”
Most residents gave a definition of recovery involving a return to pre-morbid functioning. In contrast to recovering from a traditional illness such as influenza, one resident stated, “I do not recover from diabetes because it is a lifelong illness—[if I recover, the illness] is not coming back to haunt me… if someone says recover, I think they are going to beat it, they are going to recover from it, it is going to be gone.” One resident stated his lack of preparedness to think of recovery in nontraditional terms: “This is not what I was thinking when I decided to go into psychiatry… [this] was not terminology that was used.”
Despite lack of familiarity with recovery from mental illness, several residents acknowledged being more familiar with recovery principles as applied to substance abuse disorders. The substance abuse framework was helpful to conceptualize the ideas of the recovery movement. One resident stated that in recovery from substance abuse, “there is always a possibility for relapsing” and that recovery could be “an ongoing process.” Additionally, Alcoholics Anonymous (AA) and Narcotics Anonymous (NA) were discussed as widespread and generally well-accepted equivalents of peer support within substance abuse treatment.
Following this discussion, peer support specialists attempted to further clarify the concepts of recovery by explaining recovery in the language of the consumer movement. According to one CPSS, recovery is getting back “what you have lost on the other side of the illness, not an absence of symptoms… but living a meaningful and productive life despite the limitations [of] illness.” The CPSS emphasized that recovery was more about the opportunity to learn a skill set to help one manage one’s illness, not to be free of illness.
Residents’ reactions ranged from calling these concepts “very abstract,” “holistic,” “interdisciplinary,” and “more time-consuming than the traditional model.” Residents stated they would want to talk more about this subject and admitted that this was a new framework with which to view their patients. Some residents felt recovery would have different meaning in an inpatient versus outpatient setting. In terms of outpatient care, residents stated that they felt they were afforded a more long-range perspective (as compared with inpatient care). Although outpatient visits seemed a better venue for emphasizing recovery principles with patients, residents expressed skepticism that brief “med check” appointments [for medication management] would afford them the time to introduce supplemental procedures outside of their primary responsibilities. It is possible that our outpatient practice setting is preparing clinicians for more of a medication management than counseling approach to care.
Next, the CPSS discussed the recovery-oriented practice of teaching patients a daily plan to control symptoms. Residents acknowledged that many patients “have not been able to find effective strategies on their own” and that such practices may provide needed support for patients. Additionally, it was stated that “some people just want meds to fix everything” and that education is necessary about what to realistically expect from medications and how to control their environment using personal coping skills. Some residents still expressed hesitancy about such a paradigm shift, believing that “… our primary goal continues to be managing meds because [patients] will not have the capacity to do other things without the medication.”
Following this conversation, peer support specialists gauged the extent to which residents believed their patients capable of recognizing circumstances that lead to an increase in symptoms. Some residents believed that teaching patients these skills was critical for recovery (emphasizing more dependence on the clinician), whereas others stated that patients will not learn these concepts, despite the practitioner’s efforts, until they are ready to do so. One resident suggested that these skills can be taught by the clinician “pick[ing] up on trends and introduc[ing] that back to the patient… asking [if the patient can] think of any similarities between two instances… thinking in terms of ‘every time I do ____ I have a relapse.’”
Residents were also introduced to the concept of a WRAP, which was explained as a compilation of daily activities (created by the patient) for maintaining wellness. Residents expressed favorable attitudes toward the maintenance of a WRAP in a location the patient could easily access, such as a 3-ring binder, and stated that structuring sessions around the WRAP would be a way to provide coherence for the visit. The group facilitator also pointed out advantages of the WRAP from a patient perspective such as the potential to increase investment in therapy and patient empowerment.
Finally, the CPSS educated residents about the GA CPSS program and training curriculum. Residents stated that having a CPSS in the academic outpatient clinic would provide additional resources for the patient, could provide a synergy among services already provided, and could help with feelings of loneliness and empathy experienced by patients. Resident concerns included the job being overwhelming for the CPSS, the limited training provided for CPSS, and the possibility of de-compensation and treatment during his or her employment.
Observations From Review of Questionnaires
The approach of using a questionnaire to understand resident perceptions about recovery was less successful; approximately 25% of attendees did not complete post-group questionnaires. This was probably due to timing constraints. Among those who returned questionnaires, there was interest in obtaining more information about the Recovery Model, about WRAPs and the role of the CPSS. A majority of the residents indicated that they would prefer to be educated on these issues in a workshop or lecture format. Other preferences included asking to see a plan for implementation of recovery principles in our clinic, obtaining information regarding recovery on the Medical College of Georgia website, viewing live or taped interviews with a patient receiving peer support services, and interacting personally with a CPSS.
Additionally, residents gave feedback on potential advantages and disadvantages of using WRAPs. Advantages included patient empowerment, increasing patient involvement/investment in therapy, increased compliance and structure, a method of reinforcing coping skills learned in treatment, and using the WRAP as a measure to prevent future mental health crises. Disadvantages included concerns that patients with poor insight may not be able to create a WRAP, may put treatment providers in a bind if plans are unrealistic, and may lead to patients feeling a false sense of control over their illness. The majority of residents indicated that they would like to be educated further about WRAPs through handouts or other written materials.
Following a presentation on consumerism (given by LF and IP) and the launch of our new MCG-MHDDAD partnership, this was our first effort to directly explore how recovery might best be introduced to psychiatry and psychology trainees. While we were pleased with this educational event and appreciated the feedback, our focus group was not without some drawbacks. Residents were familiar with one another, whereas traditionally, focus groups are held with individuals who do not know one another so as not to inhibit the flow of conversation. The CPSS presence may have been another potential influence upon disclosure; residents may not have felt comfortable offering criticisms of the recovery movement in the presence of these individuals.
Despite inherent limitations to this educational approach, we were encouraged that trainees showed interest in learning more about recovery. The focus groups engendered a lively discussion that mirrored many of the topics discussed in other arenas—Is recovery a process or is it an outcome? Can people with mental illness achieve recovery? What does this mean for me as a clinician? We chose the use of focus groups as our first step to introduce the concept of recovery. We considered that this approach—as opposed to formal didactics or other journal club literature review—would be more apt to stimulate discussion among trainees and, thus, give us a baseline appreciation of the awareness/interest in recovery among future mental health practitioners. Our continued work, given this initial feedback, will now focus on hiring a CPSS so that residents will have actual hands-on experience with this approach. Additionally, we are proceeding to develop a curriculum on recovery with an intent to pilot this with our incoming class of psychiatry and psychology trainees.
This report was prepared as a part of an educational partnership between the Georgia Department of Human Resources (Office of Consumer Relations, Division of Mental Health, Developmental Disabilities, and Addictive Diseases) and the Medical College of Georgia Department of Psychiatry and Health Behavior.