In Brief
The recovery model is a humanistic, empowering approach to mental health treatment focused on patient wholeness and integration into functional, supportive relationships. Despite its name, it is NOT limited to substance abuse or trauma, and a patient doesn't have to have hit a low point in their lives to start applying it.
The foundation of the recovery model is that most patients with psychiatric illness—including severe cases—can regain agency, empowerment, and independence within their lives and maintain a level of functioning greater than that of the acute or premorbid phases of illness. SAMHSA has outlined four “dimensions” for supporting the recovery process: health (managing symptoms and making informed choices which support well-being), home (stability and safety), purpose (independence, income, and resources to meaningfully participate in life), and community (supportive social networks and relationships which elicit love and hope). Alternately, the CHIME model of recovery highlights the importance of the client/patient’s hope, agency and self-determination, and sense of potentiality and meaning and purpose in life, and the restructuring of personal narratives in a person-centered, strengths-oriented framework, as key elements of the recovery process.
In Depth
The origins of the recovery model may be found in the psychiatric deinstitutionalization and civil rights movements of the 1960s and 1970s and their direct descendants, the “psychiatric survivor” or “consumer/survivor/ex-patient” (1980s) and psychiatric rehabilitation movements (1990s), which culminated in the codification of novel national mental health policies.
Not one, but many, "recovery models"
Historically, there have been two broad interpretations of the recovery model: the clinical-medical model, which focuses on the patient’s “return to health,” and the consumer-survivor model, which deemphasizes symptom remission and focuses instead on the patient’s agency in defining what “recovery” means to them and how they can reintegrate into their lives. There’s an element of social constructionism here: for example, societal views of psychological illness, and shifts in economic policy, affect the availability of recovery-oriented care and whether the medical or survivor model is emphasized, as well as whether patients are socially marginalized and made to feel that they are “pathological” and “ill” or empowered (“having” a diagnosis rather than “being” that diagnosis). Both of these interpretations, however, hold that patients with a history of trauma, psychiatric illness, or substance abuse and dependency -- including severe cases -- can regain control over their lives and maintain a level of functioning greater than that of the acute or premorbid phases of illness. More recently, therapeutic practice has come to emphasize the comorbidity of mental illness, substance abuse and dependence, and trauma. We've begun to recognize that neglecting trauma can result in misdiagnosis, ineffective treatment, and re-traumatization, leading to augmentation of the recovery model as trauma-informed recovery. Trauma-informed recovery accentuates the validation of traumatic experiences and minimization of interventions which re-trigger past trauma.
Both trauma-informed recovery and the recovery model view recovery and reintegration as a personal, subjective process subject to community and society influence, and underscore the client’s self-determination, sense of potentiality and personal empowerment, and independence as key factors. The restructuring of personal narrative in a person-centered, strengths-oriented framework is, therefore, a key element of the recovery process. The United States Substance Abuse and Mental Health Services Administration (SAMHSA) has identified four factors or “dimensions” which support this process: the ability of a client to manage their own symptoms and to make informed choices which support well-being (“health”); stability and safety in the client’s circumstances (“home”); the client’s independence, income, and adequate resources to meaningfully participate in life (“purpose”); and social networks and relationships which support the client and elicit love and hope (“community”). Other authors have elaborated and codified these dimensions as the acronym CHIME, an initialism for connectedness, hope, identity, meaning, and empowerment factors. Under the CHIME model, recovery depends upon the client’s needs for safety and security, relationships with themselves and others, and a personal meaning or purpose in their own lives.
The SAMHSA and CHIME models aren't mutually exclusive. For example, interpersonal relationships with the therapist, support team, friends, family, community, peer support groups, and others who believe in the client’s potential and who support them in the long term without the possibility of shaming or violence (“connectedness”), are requisite for, and a function of, the client’s sustained optimism, trust, and willingness to persevere (“hope”). Connectedness and hope are, in turn, related to the client’s “identity”: a durable sense of self, the ability to grieve for lost opportunities or time, acceptance of others, and social belonging. The client’s perceived “meaning” or purpose in life, which arises from development of a new personal narrative and new or reclaimed social, community, or work roles, is also contingent upon their sense of agency and capacity for autonomy, including self-management and coping and problem-solving skills, which contribute to their “empowerment."
Postmodernism, society, and recovery: Relational cultural theory
Postmodern models of psychotherapy view experience and language as both deeply personal and simultaneously influenced by the meanings assigned to that language by society. In other words —no pun intended — language influences our perceptions, individually and collectively. Our experience of the world, and society’s experience of us, are mutually intertwined. Likewise, our client’s trust, support, and agency, among other factors, are subject to the perceptions and expectations not only of their mental health team, but also to those of their family, peers, and community. However, trauma, “mental illness,” and the associated labeling not only reflect and affect the client’s personal experience and their experience of others, but can also be destructive to others’ experience of them and to their relational ability and capacity for trust. A recovering client's prospects — for income, for freedom from future violence, and for access to healthcare during and following the recovery process — depend on community programs. Funding for those programs is often dependent on how the community sees mental health: whether clients are stigmatized as “pathological” and “ill,” and socially marginalized, or empowered as “having” a diagnosis rather than “being” that diagnosis. Shifts in economic policy determine whether the medical or survivor model is emphasized and what types of recovery-oriented care are available to the client.
Unfortunately, stigmatized clients have less power or capacity to produce change — not only in society as a whole, but also in their families and relationships.
From the perspective of relational cultural theory, the desire for connection with others is innate, yet all mental health needs and trauma contribute to a belief that the world is dangerous, out of control, or that we are disconnected from life or that it has lost meaning. This belief permeates a client’s personal language, symbols, and experiences. Left unchecked, it becomes self-fulfilling, and the client is at risk of disconnection, self-destructive and self-blaming thoughts and behaviors, and a risk of re-victimization. The antidote is connection. Human connections aren't merely encounters, but an active process which can be mutually rewarding and, when they result in a sense of safety and well-being, can foster growth. Mutual, fostering relationships lead to a greater sense of vitality, participation, interpersonal clarity, worthiness, and a connection to oneself and to others, as well as an increased motivation to connect to others. Healthy relationships are suffused with empathy — they facilitate growth into reality, clarity, and relatedness. People in empathetic relationships shape each other through authenticity, emotional availability, and mutual respect over and above their differences.
And yet, each of us withhold aspects of ourselves from others so that we might be accepted. This is called the central relational paradox, and it holds particularly true for those individuals with a history or label of mental illness or trauma.
Recovery in family therapy
The upshot of all this is that a client's ability to heal is interconnected with their ability to redefine the way they see themselves and others, how they integrate themselves into that new context, and whether they're able to reclaim intrapersonal and interpersonal acceptance, agency, and trust. That reclamation, in turn, depends on whether they can meet their basic needs, including safety and stability; the client’s ability to make informed choices and regain their independence and control over their lives; and their ability to initiate and sustain healthy, fulfilling relationships with themselves and others. The assumptions of the recovery model imply that relationships directly inform the client’s internalized sense of worthiness as well as their motivation to continue initiating and sustaining human connections.
The mental health team, family, and peers are as much a part of the recovery process as the client. Healing begins in the therapy room by focusing on building, or rebuilding, the client’s relational self by providing psychoeducation to normalize symptoms, facilitating development of relational and coping skills, and reducing the client’s distress and fear of “going crazy.” Therapists can also help clients become aware of their history and how it influences their relational connections in the present, including the authenticity and supportiveness of their relationships with self and others. Finally, the therapist can collaborate with the rest of the client’s support and case management team to ensure that the client is educated about any medications and their adverse effects, facilitating client agency.
A survey of the literature suggests at least three “best practices” for recovery treatment:
For the most severe psychiatric disability or substance abuse issues, clients may benefit from the clinical-medical approach in the early stages of recovery and the psychiatric-survivor model in later phases.
Focusing on structural change within the client’s family is associated with more positive outcomes than treatment which is focused solely on the client themselves.
The odds of success can be increased by identifying the “root cause” of the presenting issue, where possible; facilitating transformation of the client’s personal and relational self; and coordinating and reconciling the client’s support systems.
Portions of this post were previously submitted to National University as a research paper on the recovery model.
References & Further Reading
Deegan, P. E. (1988). Recovery: The lived experience of rehabilitation. Psychosocial Rehabilitation Journal, 11(4), 11.
Elliott, D. E., Bjelajac, P., Fallot, R. D., Markoff, L. S., & Reed, B. G. (2005). Trauma‐informed or trauma‐denied: Principles and implementation of trauma‐informed services for women. Journal of Community Psychology, 33(4), 461-477.
Field, B. I., & Reed, K. (2016). The Rise and Fall of the Mental Health Recovery Model.
Francis East, J., & Roll, S. J. (2015). Women, poverty, and trauma: An empowerment practice approach. Social Work, 60(4), 279-286.
Frese, F. J., Stanley, J., Kress, K., & Vogel-Scibilia, S. (2001). Integrating evidence-based practices and the recovery model. Psychiatric Services, 52(11), 1462-1468.
Galbin, A. (2014). An introduction to social constructionism. Social Research Reports, 6(26), 82-92.
Gold, E. (2007, Aug). From narrative wreckage to islands of clarity: Stories of recovery from psychosis. Canadian Family Physician, 53(8), 1271-1275. https://www.ncbi.nlm.nih.gov/pubmed/17872833
Jacob, K. (2015, Apr-Jun). Recovery model of mental illness: A complementary approach to psychiatric care. Indian Journal of Psychological Medicine, 37(2), 117-119. https://doi.org/10.4103/0253-7176.155605
Jacobson, N., & Curtis, L. (2000). Recovery as policy in mental health services: Strategies emerging from the states. Psychiatric Rehabilitation Journal, 23(4), 333.
Kaliski, S., & De Clercq, H. (2012). When coercion meets hope: Can forensic psychiatry adopt the recovery model? African Journal of Psychiatry, 15(3).
Kaloudis, A. (2022, 15 Mar). What is relational-cultural theory? The importance of connection in eating disorder recovery. Renfrew Center. https://renfrewcenter.com/what-is-relational-cultural-theory-the-importance-of-connection-in-eating-disorder-recovery
Kress, V. E., Haiyasoso, M., Zoldan, C. A., Headley, J. A., & Trepal, H. (2018). The use of relational‐cultural theory in counseling clients who have traumatic stress disorders. Journal of Counseling & Development, 96(1), 106-114.
Leamy, M., Bird, V., Le Boutillier, C., Williams, J., & Slade, M. (2011, Dec). Conceptual framework for personal recovery in mental health: Systematic review and narrative synthesis. The British Journal of Psychiatry, 199(6), 445-452. https://doi.org/10.1192/bjp.bp.110.083733
Lenz, A. S. (2016). Relational‐cultural theory: Fostering the growth of a paradigm through empirical research. Journal of Counseling & Development, 94(4), 415-428.
Lewis, V., Allen-Byrd, L., & Rouhbakhsh, P. (2004). Understanding successful family recovery in treating alcoholism. Journal of Systemic Therapies, 23(4), 39-51.
Mobley, J. A. (2009). 'Crash’: Modernism meets postmodernism. American Counseling Association Annual Conference and Exposition.
Neimeyer, R. A. (1998). Social constructionism in the counselling context. Counselling Psychology Quarterly, 11(2), 135-149. https://doi.org/10.1080/09515079808254050
Onken, S. J., Craig, C. M., Ridgway, P., Ralph, R. O., & Cook, J. A. (2007, Summer). An analysis of the definitions and elements of recovery: a review of the literature. Psychiatric Rehabilitation Journal, 31(1), 9. https://doi.org/10.2975/31.1.2007.9.22
Owen, I. R. (1992). Applying social constructionism to psychotherapy. Counselling Psychology Quarterly, 5(4), 385-402.
Ralph, R. O., Lambert, D., & Kidder, K. A. (2002). The recovery perspective and evidence-based practice for people with serious mental illness. Behavioral Health Recovery Management Project. https://citeseerx.ist.psu.edu/viewdoc/download?doi=10.1.1.527.4463&rep=rep1&type=pdf
Ramon, S., Healy, B., & Renouf, N. (2007). Recovery from mental illness as an emergent concept and practice in Australia and the UK. International Journal of Social Psychiatry, 53(2), 108-122.
Reeves, E. (2015). A synthesis of the literature on trauma-informed care. Issues in Mental Health Nursing, 36(9), 698-709. https://doi.org/10.3109/01612840.2015.1025319
Repper, J., & Perkins, R. (2003). Social inclusion and recovery: A model for mental health practice. Elsevier Health Sciences.
Substance Abuse and Mental Health Services Administration (SAMHSA). (2020). Recovery and recovery support. Retrieved 22 Feb from https://www.samhsa.gov/find-help/recovery
United States Public Health Service, Office of the Surgeon General, United States Substance Abuse Mental Health Services Administration, Center for Mental Health Services, & Health, N. I. o. M. (1999). Mental health: A report of the surgeon general. Department of Health and Human Services, US Public Health Service.
Walker, M. T. (2006). The social construction of mental illness and its implications for the recovery model. International Journal of Psychosocial Rehabilitation, 10(1), 71-87.
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