One common criticism of the concept of recovery is that, while it has offered a hopeful—even inspiring—vision for persons with mental illnesses and their loved ones, it has not provided concrete guidance for how mental health care needs to change in order to be more effective in promoting it. The 2003 Presidential “New Freedom” Commission on Mental Health had argued that a systemic transformation of mental health practice was needed to re-orient care to promoting recovery, and most states have since undertaken efforts to do so. Such efforts have been limited, though, by a lack both of resources and of a coherent conceptual framework concrete enough to operationalize recovery in practice. In this article, I will suggest that health care reform can provide the robust vehicle that has thus far been missing for informing and implementing the fundamental changes required to make the lofty vision of recovery an everyday reality.
In making this suggestion, I am arguing that health care reform will not replace recovery as the guiding vision for mental health services, as some have worried. Rather, my impression is that the kind of mental health care envisioned by health care reform is remarkably recovery-oriented in its nature and in its implications for practice. Here, I will limit my discussion to three areas in which this convergence of recovery and reform seem most substantive, but points of agreement are not limited to these.
- “An illness like any other.” One basic premise of the recovery paradigm is that mental health conditions are, in fact, health conditions. This means that so-called “normal” people develop mental health conditions just like they develop other, traditionally-defined “physical” health conditions, and that they can learn to live with, and often recover from, these conditions given timely and effective care. People are not responsible for having a mental health condition, any more than they would be for having asthma or cardiac disease (i.e., mental illness is a “no fault” disease), but they are responsible for learning about the condition they have, for accessing and appropriately utilizing available services and supports, and for exercising self-care.
Based on the provisions of the Affordable Care Act, in combination with the federal parity legislation passed in 2008, we can now expect mental health care to begin to resemble primary care in these and other ways. As encouraged by Frank and Glied in their 2006 book Better but Not Well: Mental Health Policy in the United States since 1950, health care reform will effectively end the “exceptionalism” that has undermined mental health practice since de-institutionalization. The separate but presumably equal system of mental health care that has since grown up on a parallel track to medical care has never been funded adequately and has confined many persons with serious mental illnesses to a shadow existence physically in but not socially or emotionally of their communities. It also has contributed to their dying, on average, 25 years younger than persons who do not have serious mental illnesses. At the same time, a majority of persons with mental illnesses receive care for their mental health conditions from primary care providers who have little training in the provision of mental health care, with only about one out of three receiving specialty mental health services.
Health care reform addresses these issues in a recovery-oriented way by conceptualizing mental health conditions as health conditions and insisting that care for mental health conditions be funded on a par with care for other conditions. In recognizing that a majority of care for persons with mental illnesses is delivered in primary care settings, health care reform also calls on primary care settings to expand their traditional focus and scope to incorporate mental health professionals and expertise so that the mental health care provided in these settings will be of high quality. There still will be a need for specialty mental health care for persons with the most serious and disabling disorders, but this will be funded on a par with other rehabilitative services and supports and provided in less stigmatizing settings. Persons with private health insurance who develop serious mental illnesses will no longer have to forfeit their insurance and become destitute, and parents of children who develop such conditions will no longer have to give up their legal guardianship, in order to qualify for the only long-term psychiatric services and rehabilitative supports available in most communities, which have been those funded by public dollars. Ending exceptionalism in mental health care, and integrating mental health and primary care, will do away with these largely discriminatory practices and promise to make quality, non-stigmatizing, care more accessible to more people.
- Person-centered health homes. The other major change being introduced into primary care, which is the use of health homes, is equally resonant with recovery-oriented practice and provides the needed impetus for mental health practitioners, along with all other health care providers, to offer person-centered care in a collaborative fashion.
One of the few substantive advances made thus far in transforming mental health care to a recovery orientation has been the shift from practitioner-driven treatment planning to collaborative recovery planning. Treatment plans have traditionally been deficit and problem-focused, concerned solely with what mental health practitioners need to do to treat an illness or remediate its associated deficits, driven by practitioners’ needs to document their care for reimbursement and accreditation purposes, and stipulated what pre-existing programs or services a person is to participate in or receive.
Individualized recovery plans are very different, and in a way that is highly consistent with the person-centered care plans that will be required by health homes. They are focused on the person’s own life goals and what he or she needs to pursue those goals and are thus driven by the person rather than by the practitioner. While they include a focus on illness and impairments, they reframe these issues as barriers to goal attainment and pay equal, if not more, attention to the strengths and resources (both internal and external) that the person has to draw on in overcoming or compensating for the barriers he or she faces in pursuit of the life of his or her own choosing. Finally, while recovery plans include the interventions and services to be provided by mental health, and other, practitioners in support of the person’s recovery, they also stipulate what action steps the person is committing to on his or her own behalf and the supports that will be provided to the person by others who may not be service providers (e.g., family members, friends, tutors, employers, etc.).
In moving from fragmented, uncoordinated, and practitioner-driven treatment planning to collaborative person-centered care planning within the context of the health home model mandated by health care reform, primary care providers may very well end up learning from, and adapting, the person-centered recovery planning approach of their recovery-oriented mental health practitioner colleagues.
- Patient navigators. Another prominent component of the health home model of direct relevance to this discussion is the inclusion of “patient navigators.” Based on experiences with community health workers, the role of patient navigator has been developed as an essential component of the health home model to assist individuals in connecting to needed care, help them overcome barriers to receiving care, and assist them in various other ways to maximize their effective and efficient use of appropriate services and supports. Tasks may include scheduling appointments, reminding people of appointments, providing or arranging for transportation to and/or accompanying people to appointments, and offering information, education, and support. When also trained in behavioral activation, navigators can help people prepare for health care visits and to ask questions, identify and set health-related goals, and plan specific action steps to achieve goals, as well as encourage exercise and good nutrition and assist in other daily management tasks. Especially for persons who have become demoralized by repeated failures and who feel controlled by their illnesses—such as many adults with serious mental illnesses—navigators also can be instrumental in activating self-care by instilling hope and helping people regain a sense of efficacy in relation to their health.
As a valuable addition to health homes, the patient navigation role represents an exciting opportunity, and stable source of funding, for the tens of thousands of peer staff who have been trained and hired within mental health systems over the last two decades as a core component of mental health transformation. Bringing the invaluable dimension of first-hand experiences of recovery to their work, mental health peer supporters can provide a ready role model for patient navigators within primary care, at the same time expanding the scope of their own work to include the kind of holistic health focus needed to effectively decrease the morbidity and premature mortality experienced by persons with serious mental illnesses.
The three examples provided above suggest that there can be synergy between mental health and primary care as they become integrated through the vehicle of health care reform. Mental health practitioners will be encouraged to view mental illnesses as health conditions that can be managed effectively, when not entirely overcome, while primary care providers will be encouraged to adopt a collaborative, person-centered approach to care planning that allows a prominent role for persons with first-hand experiences of self-care and recovery in activating and supporting people in learning about, living with, and recovering from whatever health conditions may happen to befall them.
Larry Davidson, PhD, is a Professor of Psychiatry and Director of the Program for Recovery and Community Health at the School of Medicine and Institution for Social and Policy Studies of Yale University. He also directs the Recovery to Practice Initiative for the federal Substance Abuse and Mental Health Services Administration. His work has focused on processes of recovery from and in serious mental illnesses and addictions, evaluation of innovative recovery-oriented practices, including peer-delivered services, and designing and evaluating policies to promote the transformation of systems to the provision of recovery-oriented care. In addition to being a recipient of psychiatric care, Dr. Davidson has produced over 275 publications, including a 2009 book entitled “A Practical Guide to Recovery-Oriented Practice: Tools for Transforming Mental Health Care” and a 2010 volume entitled “The Roots of the Recovery Movement in Psychiatry: Lessons Learned.” His work has been influential both national and internationally in shaping the recovery agenda and in translating its implications for transforming behavioral health practice.