A Practical Guide to Recovery-Oriented Practice: Tools for

Transforming Mental Health Care

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 A Practical Guide to
Recovery-Oriented Practice
Tools for Transforming
Mental Health Care

Larry Davidson
Janis Tondora
Martha Staeheli Lawless
Maria J. O’Connell
Michael Rowe

3
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Library of Congress Cataloging-in-Publication Data

A practical guide to recovery-oriented practice : tools for transforming mental health care / by Larry
Davidson ... [et al.].
p. ; cm.
Includes bibliographical references and index.
ISBN 978-0-19-530477-0
1. Community mental health services. 2. Mentally ill—Rehabilitation. 3. Mentally ill—Services for. 4.
Mental health policy. I. Davidson, Larry.
[DNLM: 1. Mental Disorders—rehabilitation. 2. Social Support. 3. Civil Rights. 4. Community Mental
Health Services. 5. Health Care Reform. 6. Mentally Ill Persons—psychology. WM 140 P8936 2008]
RA790.P66 2008
362.2′2—dc22 2008016589
____________________________________________

4
9 8 7 6 5 4 3 2 1

Printed in the United States of America on acid-free paper

5
This book is dedicated to individuals living with serious mental illness, their loved ones, and the
practitioners who devote their careers to assisting them as they enter into and pursue recovery.

6
Contents

Acknowledgments

Introduction

1. The Recovery Movement and Its Implications for Transforming Clinical and Rehabilitative Practice

2. A Model of Being in Recovery as a Foundation for Recovery-Oriented Practice

3. The Top 10 Concerns about Recovery Encountered in System Transformation

4. Practice Standards for Recovery-Oriented Care

5. The Role of the Recovery Guide: A Recovery-Oriented Alternative to Clinical Case Management

Appendix

References

Index

7
Acknowledgments

Most importantly, we would like to acknowledge and thank Thomas Kirk, Jr., Commissioner of the
Connecticut Department of Mental Health and Addiction Services (DMHAS), and his senior staff for
making the work described in this volume possible. As we describe in the Introduction, this book was based
largely on the work we have done in collaboration with Connecticut DMHAS over the previous seven years,
since Tom was first appointed Commissioner. His vision and courage in pursuing that vision, and his
willingness to cultivate a close public–academic partnership despite the challenges often involved in such
collaborations, have been crucial in providing us with the opportunity to begin to operationalize recovery in
practice. This book would not exist without his steadfast and confident support and the talents and dedication
of his senior leadership.
We also would like to thank Oxford University Press and our editors for having the foresight to agree to
publish such a book before the idea of operationalizing recovery had come into vogue. This book has been
seven years in the making, and Oxford’s willingness to support its publication has been instrumental to our
commitment to put these ideas on paper. While most of the material in this volume is new, we have had
occasion to publish earlier versions of some selected pieces in a series of journal articles which we have
published over the past few years. We cite these articles in appropriate places throughout the volume. It is our
strong belief, however, that each chapter takes on additional salience and value when brought together with
the others, producing a whole that is significantly greater than the sum of its parts.
Next, we would like to acknowledge our colleagues, both at Yale and beyond, who have been intimately
involved in different aspects of this work over time. First, the staff and faculty of the Yale Program for
Recovery and Community Health, past and present, including most prominently Kimberly Antunes, Luz
Ocasio, Luis Bedregal, Joan Bushey, Miriam Delphin, Jennifer Frey, Dietra Hawkins, Stephanie Lanteri,
Lesley Schwab, Mary Snyder, and David Stayner. We thank also the long-standing spiritual godfather, and
cheerleader, of our program, John Strauss. The qualitative research upon which some of this material is based
was conducted in collaboration with Marit Borg, Isabel Marin, Roberto Mezzina, Jaak Rakfeldt, Dave Sells,
and Alain Topor. Among naturally intuitive “recovery coaches” from whom we have learned much, we would
include Patty Benedict, Debbie Fisk, Ann Joy, Heather McDonald, Dorian Grey Parker, and Kyle Pedersen.
Finally, one of the hallmarks of Connecticut’s initial transformation efforts was the leadership provided by
the recovery community. As a testament to the tireless advocacy efforts of Karen Kangas, first outside of and
then eventually inside of DMHAS itself, this culminated in the late 1990s with Tom Kirk—then acting as
Deputy Commissioner under the leadership of the late Albert Solnit—inviting the recovery community to
present its vision for a transformed system. Key leadership was provided in this effort by Yvette Sangster, then
Director of Advocacy Unlimited, Inc., and Bob Savage, then Director of the Connecticut Community for
Addiction Recovery. In addition to Karen, Yvette, and Bob, we thank the hundreds of people in recovery who
have shown us the way, either by role modeling recovery in their lives or by being willing to share with us their
stories. We hope that what we offer in this book represents some compensation to them for all of their hard
work and generosity. They, obviously, are the true heroes in this story, as it should be.

8
9
Introduction

The first part of the twenty-first century promises to offer unprecedented opportunities for substantive
reforms of mental health policy and practice aimed at improving the lives of people with serious mental
illnesses, their loved ones, and their communities. Beginning with the adoption of “recovery” as the
overarching aim of care in the 1999 landmark Report on Mental Health of the Surgeon General (DHHS,
1999), the U.S. government has moved steadily over the intervening years to articulate an increasingly radical
vision of the nature of the changes required to make mental health services both accessible and effective.
When held up against the expectations put forth by the Surgeon General, the President’s New Freedom
Commission on Mental Health, which issued its final report in 2003, found the mental health system to be
“fragmented and in disarray,” leading to “unnecessary and costly disability, homelessness . . . and
incarceration.” In particular, the Commission emphasized that our current approach to care “simply manages
symptoms and accepts long-term disability” (DHHS, 2003, p. 1). It wasn’t until the release of the Federal
Action Agenda (DHHS, 2005), which followed on the Commission’s recommendations, that the degree of
“transformation” required was made fully apparent and explicit. In that document we read:

Mere reforms to the existing mental health system are insufficient . . . transformation is not
accomplished through change on the margins but, instead, through profound changes in kind
and in degree. Applied to the task at hand, transformation represents a bold vision to change
the very form and function of the mental health service delivery system to better meet the
needs of the individuals and families it is designed to serve. . . . Transformation . . . is nothing
short of revolutionary. It implies profound change—not at the margins of a system, but at its
very core. In transformation, new sources of power emerge and new competencies develop.
(DHHS, 2005, pp. 1, 5, 18)

Students of the history of mental health policy will not be unfamiliar with this kind of sweeping rhetoric,
of course. Both the legislation launching the wide-scale construction of state hospitals in the mid-1800s and
the legislation responsible for the depopulation of those same hospitals in the mid-1900s used similarly
dramatic language. While both of these legislative initiatives did lead to major shifts in the location and nature
of the delivery of mental health care, it is questionable whether either resulted in significant improvements in
the lives of people with serious mental illnesses and those of their loved ones. It remains the case at this
juncture in the history of mental health policy that the Los Angeles County, Cook County, and Riker’s Island
jails are the largest institutions housing people with serious mental illnesses in the United States—a situation
not unlike that faced by Dorothea Dix when she began to offer religious education to female inmates in the
1840s. While skepticism in the face of such “revolutionary” rhetoric is therefore certainly justified by history, it
would be a tragic mistake to allow the current window of opportunity to close without taking full advantage of
this rare invitation to rethink the nature and delivery of mental health care from the ground up.
In this book, we offer a beginning attempt to do just that. Our foundation for doing so is twofold. First,
we have been conducting empirical research on processes of recovery from and in serious mental illnesses (a

10
distinction we clarify in the first chapter) for the past 15 years, extending the body of research that began to
accumulate in the 1970s demonstrating that many, if not most, people diagnosed with serious mental illnesses
experience significant improvement over time (see, e.g., Bleuler, 1978; Ciompi, 1980; Harding, Brooks,
Ashikaga, Strauss, & Breier, 1987a, 1987b; Strauss & Carpenter, 1972, 1974, 1977). Within the context of
these long-term longitudinal studies, we have held up a magnifying glass to the details of the everyday lives of
people with serious mental illnesses to see what helps them, and what hinders them, in their daily efforts to
live with, manage, and overcome effects of their illness. In addition to in several journal articles, much of this
work has been published in a previous volume (Davidson, 2003) and will be assumed, and only cursorily
reviewed, as a basis for what follows. Readers who feel the need for more grounding in this literature are
referred to our earlier publications (e.g., Borg & Davidson, 2007; Davidson, 1997, 2003; Davidson, Haglund,
et al., 2001; Davidson, O’Connell, Tondora, Staeheli, & Evans, 2005; Davidson, Staeheli, Stayner, & Sells,
2004; Davidson, Stayner, & Haglund, 1998; Davidson, Stayner, Lambert, Smith, & Sledge, 1997; Davidson,
Stayner, et al., 2001; Davidson & Strauss, 1992, 1995; Mezzina et al., 2006; Rowe, 1999).
Informed by these same findings, our second foundation for the principles, practices, and tools that we
present below is provided by work we have carried out over the last seven years in collaboration with the State
of Connecticut’s public sector behavioral health authority, the Connecticut Department of Mental Health and
Addiction Services (CT DMHAS). Under the bold and visionary leadership of Thomas J. Kirk, Jr., PhD,
who has served as commissioner since 2000, and Arthur C. Evans, PhD, who was deputy commissioner from
2000 to 2004, we have had the opportunity and the privilege to contribute to taking the first few steps toward
transforming a statewide system of behavioral health care for adults to promote resilience and recovery. We
draw much of the material presented in this book from the work we have been able to conduct in
collaboration with CT DMHAS and its senior leadership. As a result, the materials we offer have been field
tested and bear marks of the trials by fire they have endured thus far. We readily acknowledge, though, that
these efforts are preliminary and constitute only a beginning to what we envision to be a decades-long process
of transformation.
Given the fact that the policy window that was opened by the Surgeon General and New Freedom
Commission reports, and which currently is being propped open by the subsequent Federal Action Agenda,
may close at any time, we felt it important to share these preliminary efforts with the field. As states across the
country, and countries around the globe, begin to embrace the process of transformation, there is an urgent
need for concrete ideas, guidance, and tools that can be used as alternatives to existing approaches to care.
This is the focus of the present volume.
Prior to launching into the particulars of recovery-oriented practice, some background will be needed. In
our first chapter, we begin with a much-abbreviated review of the current status of adults living with serious
mental illnesses in the United States. Rather than duplicating the efforts of the New Freedom Commission,
whose report provides an extensive review of this topic, we will focus only on the stark circumstances of the
everyday lives of far too many people with serious mental illnesses, which serve as the backdrop for our
transformation efforts. Next, we will discuss the various meanings of recovery currently at play in order to
reduce confusions and ambiguities surrounding use of this term. This discussion will include, but will not be
limited to, distinguishing between recovery from a serious mental illness and being in recovery with a serious

11
mental illness, a distinction we have found increasingly useful as our work has evolved (see, e.g., Davidson &
Roe, 2007). Returning to this task again in Chapter 2, our concern is that until consensus is achieved as to
what precisely we are attempting to promote, and for whom and by what means we are promoting it, little
progress will be made in doing so.
Based on this discussion of concepts of recovery, our first chapter then offers a conceptual framework for
rethinking the nature of serious mental illnesses and their care accordingly. Convinced that enduring
transformation will require dramatic changes in theory as well as in policy and practice, we make the case that
mental health care has failed to appreciate fully that human beings are always already functioning as active
agents, shaping their own lives and contexts at the same time as they are being shaped by their experiences
and environments—a perspective that we refer to under the rubric of “action theory” (e.g., Davidson,
Flanagan, Roe, & Styron, 2006; Davidson & Shahar, in press; Joas, 1999).
A slight digression on the tone of the following volume may be in order here, as several of the reviewers of
an earlier draft of this manuscript took issue with our use of terms such as failed, as in “failed to appreciate
fully that human beings are always already functioning as active agents, shaping their own lives and contexts at
the same time as they are being shaped by their experiences and environments.” Note that in the last sentence
of the preceding paragraph we describe “mental health care” as failing to appreciate the fact that people with
serious mental illness remain active agents in their own lives. We do not fault mental health practitioners,
either individually or collectively, for this perceived failure, but rather the systems of care in which we all
work. We pause to make this distinction, as we wish to be clear that the criticisms of existing services and
models of care we offer in the following chapters should not be construed as directed toward practitioners per
se. We are ourselves practitioners and appreciate that people who choose to work in this field do so out of
compassion and a genuine desire to make positive differences in the lives of individuals who are struggling.
Nothing that we write in this volume should be taken to imply otherwise.
You might wonder, why do we need to assure you of this? A major impediment to providing training in
recovery-oriented care has been the concern among system leaders and managers that direct-care staff will be
offended by the notion that what they are currently providing may not be the best care possible. If we are
offering practitioners new skills and tools, one might think, this must imply that what they have been doing
for the last couple of decades or so has been neither effective nor helpful. As one thoughtful leader in
Connecticut pointed out, however, this is not ordinarily the assumption of medical staff attending continuing
medical education seminars. They assume that medicine continues to evolve and that they should not be
practicing today the way their successors (or they themselves) did a decade or two ago. Breakthroughs are
being made in medicine every year. Why should the same not be true in mental health?
Our experience has not borne out the concerns of system leaders and managers who wish for us to tread
lightly in our critiques of current approaches to care. When and where we have been given license to offer
training in recovery-oriented care, these offerings have been oversubscribed and have generated waiting lists.
Practitioners have typically been enthusiastic and eager in their desires to acquire new skills and tools that will
enable them to be more helpful to their clients, precisely because they are in this field primarily to be helpful to
their clients (i.e., not for the pay or prestige). They all too readily appreciate the limitations of current
approaches, as they encounter them every day in their practice. In suggesting the need for revolution, we thus

12
are not telling them anything they are not already made intimately familiar with on a daily basis, even though
they may understand the source of these difficulties somewhat differently.
Most practitioners and system leaders would agree, in principle, that the individuals they attempt to serve
could be served better. They may cite various obstacles and challenges as accounting for the current status of
care, including long-standing inequities in political priorities leading to inadequate funding of mental health
care, gaps in services and lack of integration and coordination in care, lack of training and difficulties in
recruitment and retention of a competent and culturally diverse workforce, stigma and discrimination in
society, and other issues. We take no issue with this list and agree that all of these challenges limit the quality
(and quantity) of existing services and systems and are formidable difficulties. We hold no individual
practitioner or collective professional body responsible for these issues, except for our society as a whole. It is
just that to this list we add an additional set of obstacles that we also attribute to the history of, and societal
attitudes toward, mental illness. We refer to these obstacles in our first chapter under the rubric of
“mentalism.”
Describing current structures within the mental health system and society as “mentalist” refers primarily to
a cultural phenomenon; it is not to be construed as a criticism of direct-care staff or individual practitioners
any more than critiques of institutional racism should be taken to refer to, or be the fault of, individual
workers. What we are critical of in the following is the state of current mental health systems and the people
they are meant to serve. We take the talk of the need for “revolution” seriously and suggest that current
models of care and current services do not serve individuals with serious mental illnesses as well as they might
—not due to poor motivation or performance of individual practitioners, managers, agencies, or organizations
but due to a culture of mentalism that pervades systems as a whole. This is why we need a revolution and not
just a quality-improvement initiative.
It is our long-term hope that it will be in the “overthrow” of mentalism that answers to the other legitimate
and formidable obstacles and challenges described above will emerge. Perhaps it will be in the “new sources of
power” that emerge through transformation that we, as a society, will find a way—finally—to redress the
trauma, torture, and inequities that have befallen people with serious mental illnesses for centuries. Perhaps it
will require 500 individuals in recovery and their families to rally outside the mayor’s office, 5,000 individuals
in recovery and their families to rally outside the state capital, or 500,000 individuals in recovery and their
families to rally outside of the nation’s capital for adequate political will to be mustered for mental health to
ultimately be addressed “with the same urgency as physical health” (DHHS, 2003, p. 7). This is the way civil
rights have traditionally been reclaimed in our society; why should it be different in mental health?
In our second chapter (the digression ends here) we begin to sketch out a map for our eventual journey to a
post-mentalist mental health system. As we wish to base this map first and foremost on what people with
serious mental illnesses need to do in order to manage their illness and reclaim their lives, we go to some
lengths to describe what we think we know to date about the processes and components of recovery. Drawing
from both our own empirical research and a review of first-person accounts and the research literature, we
highlight concretely some of the ways in which people with serious mental illnesses play active roles in their
own recovery, underscoring the importance of hope, self-determination, and community inclusion as
cornerstones of recovery-oriented care. We integrate these findings into a model of recovery, which then

13
serves as the foundation for development of recovery-oriented approaches to care. If, as we suggest, getting
“into” and pursuing recovery is primarily the responsibility of the person living with the serious mental illness,
then the focus of recovery-oriented care should be supporting the person’s own efforts in doing so. Chapter 2
begins to lay out the various directions in which practitioners can go in their efforts to accomplish this.
In the chapters that follow, we delve in more depth and detail into the implications of what we know about
recovery for designing, implementing, and evaluating recovery-oriented practice. In the third chapter, we
examine the 10 most common concerns about recovery that we have encountered in our system-
transformation efforts, sharing some of our struggles in making and keeping clear how recovery is a
revolutionary concept for mental health care. In Chapter 4, we describe at length the practice guidelines that
we have developed for recovery-oriented care, including sample standards for each of the eight domains of
recovery-oriented practice here identified. The fifth and concluding chapter describes the key principles and
elements of a “recovery guide” model that we offer as an alternative to current forms of case management.
Finally, an appendix is included which offers two tools for assessing the recovery-oriented nature of care and
the training and education needs of students, trainees, and mental health practitioners faced with the
challenge of providing such care.
We hope that this volume will represent a first substantive step forward in successfully revolutionizing care
to elicit and build on the agency and inherent resilience of people with serious mental illnesses—people who
currently represent the most valuable, but also most untapped, resource available to our systems of care and to
our society as a whole. While much work certainly remains to be done in implementing, evaluating, and
refining the ideas presented here, we take comfort from the Taoist sentiment that a journey of a thousand
miles still begins with a single step. In that respect, we thank you for joining us as we embark.

14
A Practical Guide to
Recovery-Oriented
Practice

15
1 The Recovery Movement and Its Implications for Transforming Clinical
and Rehabilitative Practice

We begin with a snapshot of the world we hope to leave behind. While it may not be necessary to reiterate
the reasons why transformation is needed for most readers—who, as we noted in the Introduction, may be
only too familiar with the challenges presented by our current systems of care—we think it useful nonetheless
to establish a point of departure. We also strive throughout this volume to make our ideas concrete through
the use of stories derived from our own experiences, putting a human face on what might frequently appear to
be abstract or idealistic concepts. In our experience, and in our previous publications (e.g., Davidson, Stayner,
et al., 2001), there has been very little about mental health concepts of recovery that are either abstract or
idealistic. In fact, we have consistently stressed the everyday nature of recovery (Borg & Davidson, 2007),
finding it embodied and exemplified in such mundane activities as washing one’s own dishes, playing with a
child, or walking a dog.
We strive to continue this concrete focus in what follows, alternating our exposition of principles and
practices with descriptions of real-life examples from our practice. This not only is our own preference in
teaching and training but was strongly encouraged by the reviewers of an earlier draft of this book. We are
happy to oblige.

A Day in the Life of (Far Too Many) People with Serious Mental Illness
Passage of legislation such as the Rehabilitation Act of 1973 and the Americans with Disabilities Act of 1990
held great promise for individuals with disabilities, especially in relation to their opportunity to participate
fully in all aspects of community life. Unfortunately, it is now widely recognized that the implementation of
these acts for persons with serious mental illness lags far behind parallel efforts in the broader disability
community, with expectations for expanded access and opportunity largely still to be realized (Chirikos, 1999;
Fabian, 1999; Hernandez, 2000; Wylonis, 1999).
In response to this national tragedy, several recent calls have been made for radical reforms to the mental
health system. The Surgeon General’s Report on Mental Health, for example, called for mental health services
to be “consumer oriented and focused on promoting recovery” (DHHS, 1999, p. 455). The Olmstead Supreme
Court decision, also of 1999, upheld the “integration mandate” of the Americans with Disabilities Act and
demanded an expansion of opportunities for full community inclusion for people with psychiatric disabilities,
while also requiring their active participation in the development of their community integration plans. It
remains the case, though, that the full impact of the changes required to implement Olmstead has yet to be
realized. There remains in particular a significant need to educate people with mental illnesses and ensure real
choice, as well as a need to expand infrastructure and create a new set of resources, benefits, services, and
supports that will enable these individuals to participate fully in community life. The following story illustrates
these points.

In his frequent efforts to promote the transformation agenda in Connecticut, Commissioner of

Mental Health and Addiction Services Tom Kirk, PhD, tells the story of a 27-year-old man

16
 named Steve whom he met during a visit to a supported housing program. When he asked the
staff how Steve was doing in his recovery, Commissioner Kirk reports that they responded
favorably about how well Steve was doing in the program: following the rules, taking his
medication as prescribed, and having his symptoms relatively under control. When asked if this
was the kind of life they hoped this young man would live for the foreseeable future, the staff
seemed puzzled, confident that they were doing their best to serve him. His condition, after all,
was stable, and he had not been admitted to the hospital for several years.
Commissioner Kirk, however, was not satisfied. He asked the staff to go one step further
and consider whether or not this would be the kind of life that would make them content were
they in Steve’s place. Once it was phrased this way, the staff began to think that more could be
done for, and expected from, this clever college graduate who was engaging, who loved cars
and racing, and who had aspirations of becoming a mechanic. But how could they help him
with that? They had little idea as to what they could do beyond treating his schizophrenia and
encouraging him to participate in program activities as a way of luring him away from his
television set. Becoming a mechanic seemed a long way off, if it was to be possible at all.

Steve’s story, unfortunately, is living evidence of how our current mental health system, in the words of the
New Freedom Commission Report, “simply manages symptoms and accepts long-term disability” (DHHS,
2003, p. 1). On any given day, there are more than 8 million Americans who, like Steve, are consigned to the
long-term disability that historically has been associated with serious mental illnesses. Schizophrenia, bipolar
disorder, and depression currently take a profound toll on the lives of people who experience them, as well as
on their families and the community at large. This toll was powerfully documented in the Global Burden of
Disease project, in which 5 of the 10 leading causes of disability worldwide were found to be mental illnesses
(Murray & Lopez, 1996). In the United States, for example, mental illness is the number one cause of
disability, accounting for more burden than that associated with all forms of cancer (McAlpine & Warner,
2002; WHO, 2001). Yet only 6% of all health care expenditures are devoted to the prevention and treatment
of serious mental illnesses—a grossly inadequate investment in light of the overall burden these disorders
impose (Mark et al., 2005).
Disproportionately low allocation of funding to address psychiatric disability follows on the
disappointments of the deinstitutionalization era, in which state psychiatric hospitals were closed without
redirecting commensurate resources to build community support systems. In fact, adjusted for inflation and
population growth, states spent 30% less on mental health in 1997 than they did in 1955 (Bernstein, 2001;
Manderscheid & Henderson, 2001). The original intention of community support systems was to provide
persons with disabilities the opportunities they needed to experience a meaningful sense of community
membership and enjoy all of the associated rights, freedoms, and responsibilities. Without adequate support,
and despite the best intentions of deinstitutionalization, what has largely resulted has been only the physical
co-location of persons with serious mental illnesses in community settings. Like the young man described
above, people living outside of institutions far too often lack access to the supports they need in order to
participate as fully integrated members and citizens of their communities.
As a result, research on community life for people with psychiatric disabilities is replete with poignant

17
descriptions of loss; loneliness; and enduring, but unfulfilled, desires for love, friendship, and valued social
roles (Davidson & Stayner, 1997). In addition to being shut out of the normal social and interpersonal
rhythms of community life, people with serious mental illness continue to be denied equal employment
opportunities. In fact, a person discharged from a psychiatric inpatient unit has a better chance of returning to
the hospital than to work (Anthony, 1994). When compared to individuals with other types of disabilities,
people with serious mental illness continue to have the lowest success rates of vocational rehabilitation, with
fewer than 15% being competitively employed at any given time (Anthony, 1994; Kirsh, 1996; Marrone,
Gandolfo, Gold, & Hoff, 1998). Even among those individuals who have access to supported employment,
many find that their jobs do not last beyond an initial, brief period, with little if any opportunity for
advancement.
Finally, despite the fact that the staggering costs of lost productivity and direct treatment expenditures
associated with these disorders continue to rise (Connolly, Marrone, Kiernan, & Butterworth, 1996; Estroff,
Zinuner, Lachiotte, Benoit, & Patrick, 1997; Mischoulon, 1999), most individuals with serious mental illness
rarely receive care that is considered to be “evidence-based” (Drake et al., 2001; Hoagwood, Burns, Kiser,
Ringeisen, & Schoenwald, 2001; McClellan, 2002; Torrey et al., 2001), with a significant proportion
receiving no formal treatment at all (Lehman & Steinwachs, 1998; NCD, 2002). As is true in other forms of
health care, this lack of access is greatest among people of color (DHHS, 2001). Far too many Americans
with serious mental illness fall through the gaps of a poorly formed patchwork of ineffective safety nets that
serve to trap people in dependency and despair—what Deegan has come to refer to as “handicaptivity”
(Federal Task Force, 1992; Lamb & Weinberger, 1998; NCD, 2002). It is in the face of such stark realities
that the New Freedom Commission on Mental Health framed its overarching goal for mental health care as
being “a life in the community for everyone” (DHHS, 2003, p. 1).
Given this bleak portrait of the circumstances of many individuals living with serious mental illness in the
United States at the beginning of the twenty-first century, it is certainly reasonable to ask how a civilized
society would allow, and perpetuate, such neglect. When we took people out of state hospitals by the tens of
thousands in the 1960s and 1970s, we promised them life “in the community in a normal manner” (Joint
Commission on Mental Illness and Health, 1961, p. xvii). What happened? Why has deinstitutionalization
been such an apparent failure? Part of the answer to this question lies in political and economic forces that lie
outside of mental health and continue to confine individuals with serious mental illnesses to the margins of
our communities, a sociological phenomenon that unfortunately did not disappear with the asylums. But part
of this answer also lies in the history of contemporary psychiatry and its attitudes toward, and understandings
of, serious mental illnesses.

Recovery from Serious Mental Illness

The Federal Action Agenda insists that “transformation is not accomplished through change on the margins.”
The “margins” this report refers to are the same margins the concept of recovery has largely hovered by for the
past 30 years. Having emerged from two distinct sources in the mid-1970s, reforms of mental health policy
and practice have come about as far as they can since that time as long as this concept remains confined to the
margins of the field. These two sources—longitudinal clinical research stimulated by the World Health
Organization and the Consumer/Survivor Movement founded by people with histories of institutionalization

18
—came together in the mid-1970s in what has since been called the Community Support Movement (which
we referred to above; Parrish, 1989; Turner & TenHoor, 1978). Despite the best efforts of thousands of
earnest practitioners, people in recovery, and families strenuously advocating over the last 30 years the
fundamental refashioning of the mental health system based on the community support model, this
movement and its distinctive components (such as self-help and psychiatric rehabilitation) have remained
peripheral to the field as a whole, regardless of how this is measured (e.g., by penetration rates, percentage of
funding allocated, or numbers of providers).
While we describe these developments in more detail farther on, it is important for our present purposes to
underscore the Action Agenda’s insistence that further enhancing these marginal components of the field will
not be sufficient to achieve transformation. No matter how well-intentioned or useful these programs may be,
system leaders who propose to transform their systems simply by adding more peer support or psychiatric
rehabilitation programs will merely be bringing their systems into line with expectations articulated almost 30
years ago, expectations that not only are outdated but also stop well short of the “revolution” required by
transformation. As the revolution entailed in transformation is required in order to reorient services to
promote recovery, a brief historical and conceptual digression into the various meanings of this concept in
relation to serious mental illness will help to clarify how this is so.
Toward the end of the nineteenth century, Emil Kraepelin, the father of descriptive psychopathology,
identified a disease entity he labeled dementia praecox, meaning “premature dementia.” He chose this term to
describe a disease he conceptualized as having a characteristic downward and deteriorating course beginning
in adolescence, leading irreversibly to severe, persistent impairment, and ending in a premature state of
incoherence and eventual death. Although his observations were based primarily on long-term residents of
psychiatric institutions, his basic idea that dementia praecox—later referred to as schizophrenia—inevitably
leads to progressive deterioration appears to reign in some sectors of the field to this day. This is not only true
in the mental health field at large but continues to be true even in many professional training programs that
are preparing future generations of mental health practitioners. It is for this reason that many people with
serious mental illness still report being discouraged from taking steps forward in their recovery by a mental
health practitioner whom they quote as having told them that they would “never be able to _____ again” (fill
in the blank: “work,” “attend school,” “get married,” “live independently,” “have a family,” etc.).
As early as the 1950s, however, the deterioration of overcrowded and hundred-year-old state hospitals and
their budget-busting implications for state governments, along (secondarily) with the introduction of
psychotropic medication, began to move policy makers to consider the possibility that people could live, and
manage their illnesses, outside of hospital settings (Johnson, 1990). With the introduction of progressive
social programs and entitlements in the 1960s and 1970s, hundreds of thousands of individuals with serious
mental illness who in the past would have lived out the remainder of their lives in hospitals began to be
discharged to fledgling and underfunded community-based services. Despite the fact, noted above, that even
now—a half-century later—mental health services are funded at a level 30% lower than that provided for
hospital care prior to 1960 (Bernstein, 2001; Manderscheid & Henderson, 2001), people with serious mental
illness have experienced significant diversity in the courses and outcomes of these illnesses since being
discharged from institutional settings. Even when discharged literally from the hospital to the streets, perhaps

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with a prescription for Thorazine and an appointment with a psychiatrist or case manager for weeks down the
road, many people with serious mental illness did well outside of the hospital—better, in fact, than they would
have done had they remained in the hospital.
Readers who consider such reports to be merely anecdotal will perhaps be surprised to learn that what has
become accepted as the “heterogeneity” (Carpenter & Kirkpatrick, 1988) in outcome for serious mental
illnesses has been confirmed repeatedly over the past 30 years of empirical research involving large samples
and utilizing rigorous designs and standardized rating scales for assessing symptoms and functioning over
time. As we noted above, the World Health Organization undertook the first such major study in the late
1960s in 11 countries, following people diagnosed with serious mental illness for over 11 years (WHO, 1973).
This study was soon followed by others conducted all over the world, following people for as long as 32 years
after onset or first contact with mental health services. A highly consistent picture has since emerged.
To combat the lingering legacy of Kraepelin’s pessimism, we have recently published a collection of some
of the most important of these studies (Davidson, Harding, & Spaniol, 2005). Taken together, these studies
found that while some people diagnosed with serious mental illness did show a classic Kraepelinian
deterioration in functioning over time, they accounted for only about 25% of each sample. Equally prominent
were individuals who fell at the opposite end of the spectrum, showing no observable signs or symptoms and
no residual impairments from the disorder between 2 and 32 years after onset. These individuals also
accounted for approximately 25% of each sample. Given that signs, symptoms, and impairment are the classic
—and really the only established—markers of illness, this 25% of each sample can be considered to have
“recovered” in the traditional sense of the term. With publication of these studies, beginning in 1972, the
possibility of any form of “recovery” in relation to serious mental illness was established (e.g., Strauss &
Carpenter, 1972, 1974, 1977).
The reader may still wonder about the remaining 50% of the sample. If 25% of the sample resides at each
end of the spectrum ranging from severe and persistent disability to full recovery, what is the fate of the
remaining half? The term heterogeneity was selected, and has since been accepted, to refer to the fact that
people have experienced illnesses that fall anywhere and everywhere along this continuum. Depending upon
where the study was conducted, at least 45%, and up to 65%, of each sample was found to experience partial to
full recovery, meaning that person’s functioning and symptom levels improved over time. On the whole, then,
this body of research has established not only that recovery is possible but that partial to full recovery is at least
as common an outcome in serious mental illnesses, if not more common, than severe and persistent
impairment.
With this reversal in expectations (i.e., from expecting the person’s condition to deteriorate over time to
expecting it to improve) we come to our first major definition of the term recovery in relation to serious mental
illnesses: a sense we will refer to as “recovery from.” Recovery from serious mental illness involves the person’s
returning to a healthy condition following onset of the illness. It is based on explicit criteria of levels of signs,
symptoms, and deficits associated with the illness, and it identifies a point at which “remission” and/or
“recovery” may be said to have occurred (e.g., Andreasen et al., 2005; Liberman, Kopelowicz, Ventura, &
Gutkind, 2002). This definition thus has many advantages from the point of view of research, such as being
clear, reliable, and relatively easy to define, measure, and link to dysfunctions or well-being in other areas of

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life. Appearing as if they had never suffered from a serious mental illness, people who enjoy this sense of full
recovery could be considered to have recovered from psychosis in the same way that other people may recover
from an infection, a broken leg, or, in the case of recovery over a longer period, asthma.
This was not the only sense of “recovery” to emerge from the clinical research on course and outcome,
however. Heterogeneity was discovered not only in the course and outcome of illnesses experienced by
different people but also across various domains of functioning within any given individual and over time.
Again beginning in the 1970s, researchers discovered that serious mental illnesses were complex and
multidimensional disorders composed of several domains of functioning which were both conceptually and
empirically distinct. Some people were able to recover functioning in one or more of these areas while
continuing to experience impairments or symptoms in other areas. Not only did serious mental illnesses prove
not to be permanent conditions for many people, but they also were found not to pervade the entirety of the
person’s life as was formerly thought.
Some people, for example, could live independently and work in challenging jobs while continuing to hear
voices or entertain delusions. Others may no longer experience psychotic symptoms at all but still have
moderate functional impairments in social relationships and/or employment. Taking into account the fact that
these distinct domains are only “loosely linked” (Strauss & Carpenter, 1977), concepts of partial recovery, social
recovery, and symptomatic recovery began to be used to describe various outcomes.
The 1970s also witnessed the early advocacy efforts of those individuals who have since come to refer to
themselves as “ex-patients,” “ex-inmates,” “psychiatric survivors,” or “consumers” or “users” of mental health
services. As if these individuals were offering living proof both of full and of partial recovery from serious
mental illness, these advocates—having left or been released from mental hospitals—demonstrated by example
and argued that people with serious mental illness can, and should be entitled to, have a life beyond that of a
“mental patient.” As advocates intent on reforming mental health policy and practice, leaders of this
movement had little interest in the conceptual or empirical distinctions employed in psychiatric research,
drawing more from their own firsthand experiences of illness, incarceration, and reclamation of their lives.
In the life experiences of these advocates, the categories of abnormal and normal, illness and health, were not
nearly as black-and-white as research and diagnostic practice suggested. In fact, the lines between these
categories seemed fuzzy and permeable at best and arbitrary and political at worst (this was, for instance,
during the Cold War, when many Soviet dissidents were placed in mental hospitals). As a result, the
advocates’ agenda was not so much recovering from or getting over a mental illness such as schizophrenia as it
was figuring out how to live a safe, dignified, and autonomous life given whatever hand they had been dealt by
fate. For guidance in this process, they had to look beyond the mental health system to examples of other
populations who had faced adversity and overcome marginalization and discrimination. It is within the
context of this agenda and from this appeal outside of mental health that a second major concept of recovery
emerged.

Being in Recovery with a Serious Mental Illness

Our second major form of recovery in relation to serious mental illnesses, what we refer to as “being in
recovery” as opposed to “recovery from,” has its origin in the civil rights and independent living movements of

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the 1960s and 1970s. It also has been influenced by the notion of recovery that is integral to the self-help
community in addiction recovery, as exemplified by such abstinence-based 12-step groups as Alcoholics
Anonymous and its derivatives. As such, we might consider this form of recovery to be a kind of hybrid,
sharing some characteristics of each of its parents but also being somewhat different from both.
In the 12-step community, for example, people consider themselves to be “in recovery” when they have
managed to achieve some degree of abstinence from drugs or alcohol and are in the process of reclaiming or
rebuilding their lives beyond the limits of the addiction per se. They do not consider themselves to be have
recovered from addiction, as they view addiction as a lifelong disease that requires their ongoing vigilance and
care in order to protect their sobriety, and their newly won life, from an underlying, continuing vulnerability
to relapse. What mental health advocates appear to have found appealing in this sense of recovery is that
people with long-term and potentially disabling conditions could reclaim control over their own lives and
destinies while finding ways to minimize the destructive effects of the condition. Being “in recovery” in
relation to serious mental illness likewise entails a process of minimizing the illness and its deleterious effects
on the person’s life over time, as the person figures out how to live with and manage an illness that may be
with him or her for an extended period of time, if not for the remainder of his or her life. For the most part,
however, it is here that the overlap with addiction recovery ends.
The civil rights and independent living movements have been equally crucial to the mental health
consumer/survivor movement due to the fact that many of the more formidable barriers to recovery identified
by mental health advocates have been social and political rather than stemming from the mental illnesses
themselves. It is only recently that advocates for addiction recovery have begun to embrace a similar political
and social agenda, and this, in part, follows the example set by their counterparts in mental health. To mental
health advocates who often had been incarcerated in psychiatric hospitals against their will, it was evident
from early on that their struggles were as much social and political struggles against prejudice, stigma,
discrimination, and marginalization as they were personal struggles with particular psychiatric conditions.
As a result, this concept of recovery refers primarily to a person diagnosed with a serious mental illness
reclaiming his or her right to a safe, dignified, and personally meaningful and gratifying life in the community
despite his or her psychiatric condition. It emphasizes self-determination and such normal life pursuits as
education, employment, sexuality, friendship, spirituality, and voluntary membership in faith and other kinds
of communities beyond the limits both of the disorder and of the mental health system, and consistent with
the person’s own values, preferences, and goals. What is conspicuously absent in this concept of recovery is
any notion of “cure.” In fact, what has since come to be referred to as the “recovery movement” offers an
alternative concept to that offered by clinical research, one that really only makes sense in the absence of clinical
or symptomatic recovery. Whether this concept will be seen as contradictory or complementary to the clinical
concept of recovery remains to be determined, but it is essential for our purposes to note that it is a very
different concept with very different implications for practice (Davidson, Schmutte, Dinzeo, & Andres-
Hyman, 2007).
So what has been meant by “being in recovery” for someone living with a serious mental illness, and what
implications does this shift have for clinical practice and policy? Basically, we understand being “in” recovery
to refer to a process of containing and minimizing the destructive impact of the illness while identifying and

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building on a person’s strengths and interests in order for the person to have an identity and a life beyond that
of a “mental patient.” To the degree that this form of recovery involves managing symptoms, there is
sympathetic overlap between this concept and current practice, and it is in this area that many people find
existing mental health services most useful to them. However, to the degree that this form of recovery also
involves establishing, reestablishing, or reclaiming a meaningful life in the community in the presence of
enduring disability, this concept departs from much of current clinical and rehabilitative policy and practice. It
is perhaps because this concept of rebuilding a life in the presence of a disability has not traditionally been
within the purview of clinical psychiatry that these more positive elements of recovery are at times relegated to
the category of “personal growth and development”: something, in other words, that may be put off
indefinitely until the “real” work of treatment and rehabilitation is completed. For many people with serious
mental illness, however, existing treatments and rehabilitation may not be that effective for an extended period
of time, if ever. For these people, being in recovery is not a matter of growth and development but of suffering
and survival.
From our perspective, dismissing these positive elements of recovery by referring to them under the rubrics
of “growth and development” or “quality of life” is a tragic mistake with far-reaching and disastrous
consequences. More than the recovery skeptics and nay-sayers, it is this kind of fundamental
misunderstanding of the nature of this form of recovery that we fear poses the major threat to real, substantial,
and sustained change in mental health (i.e., transformation). By limiting the relevance of this form of recovery
to considerations of growth, development, or quality of life, we have overlooked the crucial importance of civil
rights, or the lack thereof, in determining the everyday lives, opportunities, and health of people with serious
mental illness. We also make it possible for systems of care to claim a recovery-orientation by adding a few
new components or programs that explicitly address such issues as education, employment, or sexuality
without making any substantive changes to existing structures. This view has led some influential policy
makers to suggest, for example, that if you reallocate 5% of your state mental health budget to peer support
services that address quality-of-life issues, you will achieve transformation. While offering the appeal of
simplicity, we suggest that such directives will instead sound the death knell of the recovery movement.
It is perhaps easier to appreciate the central, as opposed to peripheral, importance of this issue in the lives
of people with serious mental illnesses if we appeal to an analogy drawn from the broader disabilities field. As
we noted above, the independent living movement led by people with physical disabilities was one source of
inspiration for this form of recovery. Examples drawn from the broader disability field provide a clearer
glimpse into what this concept of recovery adds to current approaches beyond a focus on “quality of life.”
In the case of paraplegia, for instance, several things need to be in place for the person who has lost his or
her mobility to resume the activities he or she enjoyed prior to his or her accident or illness. The most
obvious, but also perhaps therefore the most often overlooked, requirement is that the person not wait to
regain his or her mobility before pursuing these and other activities. This is occasionally referred to as
“acceptance” of his or her trauma and disability, but for many people such a notion of acceptance connotes
resignation and despair. The same has been true in mental illness, with many people refusing or being
reluctant to “accept” the diagnosis of psychosis because of the helplessness and hopelessness—as well as the
stereotypical pessimistic prognosis—associated with it. We prefer, then, to refer to the fact that the person

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will not have to wait to regain his or her mobility in order to resume his or her life. While not preferable, it is
nonetheless possible to have a life without use of one’s legs.
Once the person acknowledges that he or she cannot simply sit around and wait to regain his or her
mobility, a next step would be to be fitted for, and learn to use, prostheses or other compensatory tools such as
a wheelchair. No matter how well a person learns to maneuver his or her wheelchair, however, certain
activities will remain extremely difficult, if not impossible, to resume unless other environmental
accommodations are made. This is why the independent living movement put such effort into lobbying for
passage of the Rehabilitation Act of 1973, which required public spaces to be accessible to people in
wheelchairs. Without curb cuts in sidewalks and handrails installed in bathrooms, the world remained fairly
restricted for people who used wheelchairs. Similarly, without Braille signs posted on doors and elevators, and
without the mandate that service dogs be allowed in public spaces, people who had lost their vision would be
very limited in their access to the opportunities and activities that make up the lives they want to lead in the
community.
For people with these and other disabilities, issues of access and accommodation are not considered to be
solely issues of growth and development or quality of life but are viewed rather as fundamental to the rights
and responsibilities of citizenship. While they do not restore the person’s mobility or vision, they can and do
restore the person’s status as a valuable and contributing member of society. It is for this reason that these
issues are framed as issues of civil rights and social justice rather than as issues of health care. The same should
be true, according to the recovery movement, for people with psychiatric “disabilities.”
This approach is what is implicit in the notion of being in recovery. Advocates make this case explicitly in
emphasizing that the recovery movement was first and foremost a civil rights movement (Davidson, 2006),
but this emphasis is quickly lost or overlooked in clinical settings, where the focus typically remains on
disorder, deficit, and disability. Practitioners have been trained primarily to focus on minimizing and/or
containing pathology. On the surface, this would seem to have nothing to do with issues of civil rights or
citizenship (except for the person’s right to appropriate care). At best, perhaps these issues become relevant as
the person’s condition improves and he or she starts to reintegrate into community life. But from the
perspective of the person with the psychiatric disability, focusing on deficit and pathology not only is overly
narrow and limited in its utility; it misses the very point of the civil rights argument. It would be pointless for
society to accord people with disabilities the rights of citizenship if those rights were made contingent on the
person’s overcoming his or her disability first. It is precisely in the presence of enduring disability that these
rights become most pressing and most relevant.
Similarly, it is when people with serious mental illness are most disabled by their illness that their civil
rights and responsibilities become most pressing and most relevant. In an analogous fashion to physical
disability, being in recovery speaks primarily to the person’s rights of social inclusion and self-determination
irrespective of the nature or severity of his or her psychiatric condition. Recovery refers to the rights to access
and join in with those elements of community life the person chooses, and to be in control of his or her own
life and destiny, even and especially while remaining disabled.

A Revolution in Mental Health?

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