Recovery is a word imbued with the hope and promise of successful treatment across the field of medicine and the gift that every provider wishes to bestow. Harnessing the power of this concept is at the heart of the recovery movement—an effort to reinvent the treatment of mental illness in the United States.
Though well-intentioned and meant as a radical break with the past, the recovery movement is actually a reflection of the many issues that have been shaping mental health policy for 50 years, according to Joel T. Braslow, MD, PhD, a psychiatrist, medical historian and recipient of a Robert Wood Johnson Foundation (RWJF) Investigator Award in Health Policy Research (2009). “The term recovery is a slippery concept. It is an amalgam of cultural beliefs, treatment practices, and ideas about mental illness that appear to be new, but are actually a continuation of the changes that began with the deinstitutionalization trend of the late 1960s and 1970s.”
In his extensive history of the recovery movement, “The Manufacture of Recovery,” published in the March 2013 Annual Review of Clinical Psychology, Braslow, a professor in the departments of history, psychiatry and biobehavioral sciences at the University of California, Los Angeles, also looks at the possible impact of this new way of viewing patients. “The movement is both a treatment philosophy and a guide to policy,” Braslow said. He examines its roots in the psychiatric practices of the 1960s and 1970s; the health consumer rights movement of the 1980s; the psychiatric survivor movement of the 1990s; the development of the field of psychopharmacology; and the advance of neoliberalism.
From Patient to Consumer
Braslow cites the publication of the report Achieving the Promise: Transforming Mental Health Care in America (New Freedom Comm. Ment. Health 2003) as the moment the recovery movement came of age. He analyzes the system that has developed since the report through the changes that occurred after the implementation of the California Mental Health Services Act of 2004 (MHSA).
“The notion that individuals can recover from severe mental illness has existed ever since the 18th century,” Braslow said. “The concept has contributed to various major mental health system changes, ranging from the asylum movement of the 19th century to the community mental health care movement of the 20th century.”
Yet, the modern concept of recovery is far more complicated, Braslow added, “because it includes a set of ideologically-rooted beliefs about illness, dependency and citizenship that influence policy.” Recovery advocates believe that a recovery-based mental health system will liberate individuals from their illnesses, as well as their dependency on the state and public mental health care.
“A critical aspect of the recovery concept is to eschew the label ‘patient’ for the politically correct label of ‘consumer,’” Braslow explained. “Recovery advocates believe that the term ‘patient’ reinforces the power that psychiatrists presumably have wielded over their hapless charges. Unlike dependent, needy ‘patients,’ ‘consumers’ are thought to be tied to their clinicians only by the free exchange of goods and services and not by the messy bonds of obligation, need, and dependency.”
The word recovery hides other interests that are often financial.” - Joel Braslow, MD
Braslow sees this transformation of patients into consumers as the result of changes in the political economy and the social circumstances of those with severe mental illness. “It is not necessarily a more humane and effective way to treat severe mental illness. Turning patients into consumers depended upon a number of factors such as the dismantling of the state mental hospital system and the spectacular growth of the psychopharmaceutical market.”
Braslow charts a five-decade movement that shifted “care for mental illness from a collective social responsibility [as exemplified by state hospital care] to a private, individual responsibility.” The process accelerated in the 1980s with the policies of the Reagan administration. “Recovery as a guiding principle nests neatly within this broader context of neoliberalism and the state policies of the past 25 years,” Braslow wrote. “Scholars now use the term neoliberalism to describe not just economics, but also policies aimed at creating free markets, contracting government social services…and reformulating citizenship as a project individuals pursue through responsible and relentless risk management and self-improvement.”
These principles are also the foundation of the MHSA. “The Mental Health Services Act was the largest increase of a state mental health services budget ever mandated. It set a precedent because all of the funds had to be recovery-oriented. The purpose was to establish the newly-defined concept of recovery as the new care paradigm in the state,” Braslow said.
Hidden Interests Misunderstood Patients
While Braslow does not attempt to determine whether the recovery movement is a success or failure, he does offer constructive criticism of some of the practices that have emerged in the wake of the MHSA.
“There are positive aspects of the recovery movement, especially the hopeful and optimistic emphasis on the idea that patients can recover,” Braslow noted. But he expressed concern about the growing tendency to equate recovery with total independence on the part of the patient. “The word recovery hides other interests—often financial—that do not have the patient’s needs at heart.”
“I believe that we might be better off without the word ‘recovery’ since it seems to hide as much as it reveals,” Braslow said. “While the recovery ideology contains many important values that most of us share, it shifts the focus away from the larger problems that those with severe mental illness face and, instead, emphasizes an almost impossible-to-define outcome.” Braslow concluded that a more patient-centered approach would focus not on recovery, but “on providing the necessary social and psychological supports to help individuals create the most meaningful lives possible.”