Yes, recovery is possible

Peter Ashenden was determined not to let his severe depression keep him from finishing his college degree and getting a job. The clinical staff at the day facility where he was receiving treatment in the 1980s had a different idea: a sheltered workshop for people with disabilities. “The workshop was putting caps on lipstick tubes for six hours a day,” remembers Ashenden, who now directs consumer and family affairs at the insurance company OptumHealth.

To Ashenden, that’s a perfect example of what happens when a mental health system hasn’t embraced the idea that people can recover from mental illnesses. Now, as part of a team at APA devoted to an initiative called Recovery to Practice, he’s working to ensure that psychologists get the training they need to help people with mental health conditions live meaningful lives in the community and achieve their full potential.

Funded by the Substance Abuse and Mental Health Services Administration (SAMHSA), the five-year initiative has a dual mission: to create an online repository of resources on recovery principles (see sidebar) and practices and to develop recovery-focused training for mental health professionals.

APA is one of five national mental health organizations to partner with SAMHSA; the other grantees include the American Psychiatric Association, American Psychiatric Nurses Association, Council on Social Work Education and National Association of Peer Specialists. Like the other organizations, APA will share resources and develop a recovery-oriented curriculum that will be used to train its constituency.

“SAMHSA has made Recovery to Practice a priority, and I am pleased that APA is one of the organizations involved in moving this initiative forward,” says Gwendolyn P. Keita, PhD, executive director of APA’s Public Interest Directorate. “Recovery is a growing movement, and it is important that psychologists are involved.”

Research changes minds

“Until fairly recently, it was assumed that people with serious mental illness would never recover,” says Mary A. Jansen, PhD, who chairs APA’s Task Force on Serious Mental Illness and Severe Emotional Disturbance and is a member of the Recovery Advisory Committee that guides APA’s Recovery to Practice initiative. “Individuals were often warehoused in state mental institutions.”

When new medications allowed many of those people to return to their communities, most psychologists and other mental health practitioners still believed they would never regain full functioning, says Jansen, director of Bayview Behavioral Consulting in Vancouver. Then research by psychologists and others in the 1970s began to show that people could recover, and individuals with serious mental illnesses began to advocate for services that would help them achieve recovery.

By 2003, mental health recovery had become the overarching goal of President George W. Bush’s New Freedom Commission on Mental Health. The commission’s 2003 report, Achieving the Promise: Transforming Mental Health Care in America, argued that the nation’s mental health system was broken and identified the major flaw as the lack of a vision of recovery. The commission also laid out a challenge: “We envision a future when everyone with a mental illness will recover, a future when mental illnesses can be prevented or cured, a future when mental illnesses are detected early and a future when everyone with a mental illness at any stage of life has access to effective treatment and supports — essentials for living, working, learning and participating fully in the community.”

Now the Recovery to Practice initiative is working to make that vision a reality.

“It’s really no different than if you have a heart attack or another chronic illness,” says Jansen. “Once you recover from the acute stage, you generally begin a recovery process, with a team of professionals and interventions all working toward helping you get back to the highest level of functioning you can achieve.” Now the push is on to get that same focus on rehabilitation into the mental health field and into the mainstream of psychology, says Jansen.

“In the late 1970s into the 1990s, interventions were specifically designed for people with serious mental illnesses, many of whom had lost considerable functioning in part because they had languished in environments where no one believed they could do anything,” she says.

In the same way that cardiologists might encourage heart attack patients to stop smoking, start exercising and work on lowering their cholesterol, she says, psychologists and others committed to a recovery-oriented approach now use psychosocial rehabilitation interventions to assist people with mental health conditions. These services, says Jansen, are designed to involve individuals in a partnership with professionals as they try to gain — or regain — a meaningful life, however they define it.

That recovery-oriented approach shouldn’t just be used with people who have severe depression, schizophrenia, bipolar disorder and other serious mental illnesses, adds Jansen. It’s also useful for any mental health condition that keeps someone from functioning as well as he or she could.

In 2009, APA’s Council of Representatives passed a resolution endorsing the concept of recovery for people with serious mental illness. “This resulted from a commitment by APA’s Committee for the Advancement of Professional Practice (CAPP) to place increased emphasis on recovery within psychology practice,” says Katherine C. Nordal, PhD, executive director for APA’s Practice Directorate.

But the recovery movement hasn’t become well integrated into psychology yet, says Andrew T. Austin Daily, the APA staffer who directs the association’s Recovery to Practice project.

An analysis by APA staff, the Recovery Advisory Committee and APA’s Committee for Assessment and Training in Recovery revealed multiple economic, political, social and technological barriers to integrating recovery into psychology. One obstacle is inadequate reimbursement for providing recovery-related services. Some psychologists are reluctant to change their practice orientation; others may fear people with serious mental illnesses. There’s a shortage of affordable housing options, supported employment programs and other services that psychologists can point patients to as they begin re-integrating into their communities. And because few training standards and best practices exist, psychologists simply may not know how to use this orientation to facilitate their clients’ recovery.

“The big challenge is addressing psychologists’ perceptions of recovery and how it impacts their work,” says APA 2011 President Melba J.T. Vasquez, PhD. “But another challenge that APA really cares about is getting recovery into education and training: It’s important for both our students in graduate doctoral programs but also for our current providers to learn these recovery concepts and principles and put them into practice.”

Working with a recovery mindset is very different from what psychologists traditionally do, adds Vasquez. For example, in therapy sessions with the mother of a son with serious mental illness, Vasquez didn’t just focus on helping to ease her distress. She also reached out to a social worker and others in the community to help the woman find housing and a job for her son. “Working collaboratively with others in the community is important,” says Vasquez, “and we’re not usually trained to work that way.”

Training materials

To help psychologists get that training, APA’s Recovery to Practice team is developing a curriculum for doctoral psychology training programs that emphasizes recovery outcomes and explains recovery-related principles and practices.

“This process should be greatly facilitated by the tremendous work of CAPP’s Task Force on Serious Mental Illness and Severe Emotional Disturbance, which spent years developing and revising the Catalog of Clinical Training Opportunities: Best Practices for Recovery and Improved Outcomes for People with Serious Mental Illness,” says Nordal.

Still in draft form, the curriculum features more than a dozen modules on such topics as the recovery movement’s history, the scientific foundations of recovery, health disparities, ethics and how to incorporate recovery principles into such tasks as clinical assessment, treatment planning and interventions.

The APA team will spend the next year developing the curriculum and plans to have it ready for pilot testing by the end of next summer. The hope is to have three or four graduate training directors incorporate the curriculum into their programs and provide feedback. The Recovery to Practice team will then modify the curriculum as needed and either do another round of pilot testing or move ahead with working with the psychology training councils on dissemination and marketing.

APA also plans to go beyond the SAMHSA-funded project in its efforts to spread the word on recovery. In addition to the curriculum for graduate students, APA will develop versions for use in internship programs as well as continuing-education programs for psychologists already in practice.

For Jansen, the focus on recovery is especially timely given the roll-out of health-care reform.

“Health-care reform is all about promoting wellness: getting people to be as healthy and productive members of society as they can be,” she says, adding that this will ultimately reduce costs. “If psychology as a profession doesn’t embrace the notion of recovery and the need to train psychologists in the rehabilitative interventions needed to assist people to recover, psychology will likely be left behind.”

Rebecca A. Clay is a writer in Washington, D.C.