Delivering medical care for patients with serious mental illness or promoting a collaborative model of recovery?

There is a tension between models of ‘recovery’,which are increasingly important in mental health policy andpractice, and systematic models of care delivery based on thenotion of ‘chronic illness’. A collaborative approachiscentral to the development of high-quality recovery-orientedmental healthcare.

IS SERIOUS MENTAL ILLNESS A CHRONIC CONDITION?

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IS SERIOUS MENTAL ILLNESS...

A hundred years ago Emil Kraepelin suggested that once patientshad been diagnosed as suffering from dementia praecox, theyfaced an inevitable decline towards a poor outcome (Kraepelin, 1919).In his classic 1961 text, Asylums: Essays on the Social Situationof Mental Patients and Other Inmates, Goffman described howthe process of institutionalisation socialised people intothe role of a good patient, someone ‘dull, harmless andinconspicuous’, which in turn reinforced notions of chronicityin severe mental illness (Goffman, 1968). This idea of inevitableinexorable decline has, however, become increasingly challengedby an emerging evidence base from long-term follow-up studiessuggesting that approximately half the people diagnosed witha psychotic illness have a favourable outcome (Harrison et al, 2001)and that early intervention during the initial ‘criticalperiod’ of a first episode of psychosis improves the chanceof recovery in the short and longer term (Birchwood, 1998).There is also increasing evidence that sociocultural factorsare important in the genesis of psychosis and that focusingon social recovery can improve patient outcomes (Warner, 2003).

DECONSTRUCTING RECOVERY

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DECONSTRUCTING RECOVERY

There is, however, no single agreed definition of ‘recovery’ and indeed the largely consumerled literature from the USAsuggests that it can mean different things to different peopleat different points in their illness pathway. William Anthonyhas developed a widely used definition of ‘recovery’as

‘a way of living a satisfying, hopeful and contributinglife even with the limitations caused by illness. Recoveryinvolves the development of a new meaning and purpose in one’slife as one grows beyond the catastrophic effects of mentalillness’ (Antony, 1993: p. 21).

There are also few conceptual models underpinning the notionof recovery. Strauss et al (1985) developed the theory of‘wood shedding’ where, following an initial improvement,the individual’s condition may ‘plateau’for long periods and then suddenly improve in a discontinuousmanner. More recently, Jacobson & Greenley (2001) developeda model that encompasses both the need for internal conditionsof hope, healing and empowerment experienced by the personin recovery and external conditions that facilitate recovery,such as the implementation of the principle of human rightsand the development of recovery-oriented services. An overarching message from this literature is that hope and restoration ofa meaningful life are possible despite a diagnosis of seriousmental illness.

DIFFERENT MODELS OF CARE

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DIFFERENT MODELS OF CARE

With the exception of many of those working in rehabilitationservices, the recovery model – despite its growing evidencebase and patient support – has yet to make a significantimpact on the working practices of the majority of mental healthprofessionals in primary or secondary healthcare. Chronic careis the dominant framework.

Models of care based on ‘chronic disease management’,a more active approach to maximising quality of care in chronicillness, have recently found favour in policy circles (Department of Health, 2004a)and are now being widely adopted in primary and specialistcare for common chronic conditions such as diabetes, depressionand heart failure (more information can be obtained from theImproving Chronic Illness Care website http://www.improvingchroniccare.org). There is now evidence that models of care based on chronicdisease management can improve outcomes for people with seriousmental health problems (Simon et al, 2005). However, collectiveidentification with the chronic illness ‘label’fits less well with mental illness than many other chronic conditionsand, in contrast to many health professionals, patients arefar less likely to identify themselves as someone with a chronicillness (Lester et al, 2005). Instead, they prefer a socialmodel of illness that emphasises recovery, at least in termsof quality of life issues such as returning to work and regainingfamily ties, and acknowledge the importance of patients being involved in supporting others in their recovery (Lester et al, 2005).

There are also policy tensions between frameworks such as theNational Service Framework for Mental Health (Department of Health, 1999) and the more recent National Health Service Improvement Plan (Department of Health, 2004b), which emphasise chronicity,and others that highlight the importance of recovery. The Journeyto Recovery (Department of Health, 2001) stated that the mentalhealth system should support people in settings of their ownchoosing and enable access to community resources includinghousing and work or whatever they felt was critical to theirown recovery. The fifth of ten essential shared capabilitiesfor the whole mental health workforce formulated by the NationalInstitute for Mental Health in England and the Sainsbury Centrefor Mental Health in 2004 is ‘promoting recovery’ (Department of Health, 2004c). The National Service Frameworkfor ‘long-term conditions’, although not overtlydirected at mental health service users, has relevance forpatients with serious mental illness and includes over 300references to rehabilitation.

Such different policy imperatives, theoretical frameworks andaspirations for care can lead to problems in creating environments,structures and processes that encourage recovery in a way thatmakes sense to both patients and health professionals. Arewe intending to deliver (mostly if not entirely) medical carefor a chronic condition, or promoting collaborative models of care to improve recovery? If the latter, this raises a seriesof issues, including the need to develop practical methodsto enable the health service and health professionals to promoterecovery in practice.

HOW CAN WE DEVELOP ‘RECOVERY’ IN PRACTICE?

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HOW CAN WE DEVELOP...

Policy contradictions are not the prerogative of mental healthservice planners, although they are a frequent occurrence (Glasby et al, 2003). However, there does need to be a more consistent policy directionto support and inform commissioners and providers in developingnew services. At a structural level, employing people who usemental health services as a result of rather than in spiteof such experience emphasises national commitment to the philosophyand practice of recovery and also contributes to social recoveryat an individual level. The introduction of Support Time andRecovery workers has led to the employment of existing andformer service users with a specific remit to facilitate pathwaysto recovery through, for example, providing companionship andfriendship and helping people to live ‘ordinary lives’.Within a primary care setting, the job description of graduateprimary-care mental health workers now includes lived experienceas a desirable quality.

The important ingredient for the individual is the underpinningphilosophy of recovery that encompasses hope and therapeuticoptimism within a continuing professional–patient relationship.At the level of the consultation, more attention needs to bepaid to finding a shared, acceptable language that reflectsnew ways of framing the doctor–patient relationship. Perhapswe should actively avoid the term ‘chronic disease management’and instead talk of collaborative models of care, drawing onWagner’s chronic care model (Wagner et al, 1996; Von Korff et al, 1997;also see http://www.improvingchroniccare.org). In a collaborativemodel, informed, activated patients, involved in their own care,are the key to developing recovery-oriented services. Health professionals need to be prepared and proactive, with resourcesand expertise. In a collaborative doctor–patient relationship,the patient is an active participant able to make choices (forexample, about medication) in partnership with a health professional.To work, this requires a professional with knowledge of theevidence base and appropriate expertise, and organisationalsystems and support in place to deliver care; crucially, however,the professional is able to accept that patients with seriousmental illness can both reflect on their mental distress andprovide a valuable understanding of their illness and treatmentpreferences, even if these lie outside currently recognisedguidelines and protocols. Recovery-oriented services also needhealth professionals to believe that they can make a differenceand, for some, this may mean changing the way they conceptualise the course of serious mental illness (Roberts & Wolfson, 2004). In essence, therefore, if we want to develop recovery-orientedservices for people with serious mental illness, we need tooffer systematically organised and personally tailored collaborativehelp, treatment and care in an atmosphere of hope and optimism.

REFERENCES

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