What was the Icarus Project?

Introduction

The Icarus Project was a media and activist endeavour broadly aligned to the anti-psychiatry movement and recovery approach, arguing that mental illness should be understood as an issue of social justice and that a person’s mental state can improve through greater social support and collective liberation.

It shares similarities with the academic fields of Psychopolitics and Mad Studies. The name is derived from Icarus, a hero in Greek mythology, and is metaphorically used to convey that the experiences of mental distress and other extreme mental states can lead to “potential[ly] flying dangerously close to the sun.”

Brief History

In 2002, musician Sascha Altman DuBrul wrote “Bipolar World”, an article published in the San Francisco Bay Guardian. The article described his experiences being diagnosed with bipolar disorder. Among the dozens of e-mails and other correspondence that he received after this publication was a letter from Ashley McNamara, now known as Jacks, an artist and writer who identified strongly with DuBrul’s experiences. DuBrul and McNamara corresponded for a few weeks before finally meeting in person and deciding to start The Icarus Project. Years later, musician-activist Bonfire Madigan Shive and counsellor/activist Will Hall became a key leader in The Icarus Project’s administration and development.

In the Journal of Medical Humanities, co-founder DuBrul wrote of The Icarus Project:

Though we did not fully understand it in the early days, we were walking in the footsteps of a large body of knowledge and thought from the 1960s, grouped under the category of Anti-Psychiatry.

He also noted the group and its members were inspired by a range of social trends and schools of thought including anarchism, permaculture/sustainable ecology, LGBTQ rights, harm reduction, global justice movement, the Beat Generation, counterculture, and punk rock. He writes, “Our response to the label ‘bipolar’ was not a ‘normal’ response, which is why the Icarus Project brought a new perspective to psychic diversity. To create this perspective, we drew inspiration from many social movements and subcultural communities that came before us. So even though our response was unusual, it did not arise in a vacuum. In creating the Icarus Project, we wove together the ideas and practices in these movements to imagine a powerful new counter narrative to the dominant mental health narrative that went beyond a questioning of the language around ‘bipolar’ and critiqued the system itself.”

The first step, they decided, was creating a website where people who identified with “bipolar and other ‘mental illness’ [could] find real community and contribute to it.” DuBrul states that by 2003, “The Icarus Project website was up and running, and a virtual community began to evolve around the discussion forums.” He notes that user-generated content online enabled The Icarus Project’s growth: “We were attracting interesting people, creating discussion forums with names like ‘Alternate Dimensions or Psychotic Delusions’ and ‘Experiencing Madness and Extreme States.’ There was no place else where people who used psych meds and people who did not, people who identified with diagnostic categories and people who did not, could all talk with each other and share stories. Because of the outreach in the anarchist and activist community, there was a high percentage of creative people with a radical political analysis. And with the (seeming) anonymity of the Internet, people felt comfortable being honest and sharing intimate stories about their lives. Our website served as a refuge for a diverse group of people who were learning the ways in which new narratives could be woven about their lives.”

Mission

The Icarus Project’s stated aims are to provide a “support network and education project by and for people who experience the world in ways that are often diagnosed as mental illness.” The national Icarus Collective staff is set up to support local groups instead of creating the smaller organisations themselves. The responsibilities of the local group are to gather people locally for support, education, activism, and access to alternatives to mainstream medical diagnosis and treatment. The Project advocates self-determination and caution when approaching psychiatric care. It encourages harm reduction, alternatives to the prevailing medical model that is accepted by the vast majority of mental health professionals, and self-determination in treatment and diagnosis. Key members of The Icarus Project state that they “envision a world with more options to navigate mental health issues: options that support self-determination, centre people who are most impacted by mental health-based oppression, and most critically, uplift social transformation as central to individual wellbeing.”

In 2005, Journalist Jennifer Itzenson noted that the Icarus Project accepts those with a wide range of perspectives on mental health issues, but also describes “an edge of militancy within the group,” particularly among those who reject medication. Itzenson also writes that while medical professionals applaud groups like the Icarus Project for providing a sense of support and community, and combating social stigmas related to bipolar and other mental health issues, the group’s questioning of the medical paradigm is “misguided” and that rejecting medication is a “potentially fatal choice” for those with bipolar disorder. A Newsweek article provides the following perspective on The Icarus Project’s stance towards medication: “While some critics might view Icaristas as irresponsible, their skepticism about drugs isn’t entirely unfounded. Lately, a number of antipsychotic drugs have been found to cause some troubling side effects.”

Writer Mark Lukach describes in an article for Pacific Standard his experience asking co-founder Sascha Altman DuBrul about the role of psychiatric medication as a part of his wife’s recovery from a bipolar diagnosis. Lukach articulates The Icarus Project’s approach to self-determination in psychiatric treatment. Lukach wrote:

“As for medication, DuBrul said that he believed that the answer to the question of whether or not to use pharmaceuticals needed to be far more nuanced than yes or no. The best response might be maybe, sometimes, or only certain medications. For instance, DuBrul shared that he takes lithium every night because he’s confident that, after four hospitalizations and over a decade with the label bipolar, the medication is a positive part of his care. Not the whole solution, but a piece.”

Anthropologist Erica Hua Fletcher describes Icarus Project member’s diverse ways of discussing altered mental states in the Journal of Medical Humanities. Fletcher writes:

While many Icarus contributors have found relief through the use of psycho-pharmaceutical interventions and other bio-psychiatric technologies, they also have experienced the limitations of medical paradigms and language to recognize the fullness of their lives. Because of this, they frequently adopt alternative words and phrases beyond bio-psychiatric terms to describe their mental states such as “neurodivergent processing,” “diasporas of distressing symptoms,” “sensory/cognitive/emotional trauma,” or “cognitive-emotional terror.” “Bipolar disorder” is interchangeable with highs and lows; “psychosis” can be seen as a reckoning; and nonconsensus realities can describe extreme experiences, which psychiatrists could label as symptoms of “schizophrenia” (such as hearing voices others do not hear or seeing objects others do not see). Such alternative words and phrases do not diminish the utility of bio- psychiatric terminology nor do they directly undermine medical treatment options, yet they allow for a range of descriptors and call for attention to individual needs and desires. They call us to listen to personal stories, to forces at work within communities, and to reevaluate the languages that enframe mental illness as such.” She goes on to state, “Alternative language beyond the biomedical paradigm of mental illness fosters a diversity of paradigms. Moreover, it can create a reflective space for those with mental suffering (and for their healthcare providers) to see themselves outside of a medical identity, reevaluate their self-care regimens, advocate for the care they would like to receive, and connect to others who may have similar concerns about ascribing to solely psycho-pharmaceutical interventions.”

As of early 2018, Icarus Project staff describe their expertise in social activism, herbalism, and labour organising; none is a licensed medical or mental health professional. Icarus Project advisory board members describe themselves as educators, artists, activists, writers, healers, community organisers, and other creative types and some identify as Latinx, queer, trans, people of colour or mixed race, and trauma survivors; none is a licensed medical or mental health professional. Leadership currently offers publications on self-care and community care, workshops and training for peers, training and talks for providers, peer support spaces, webinars, and other events.

Structure/Funding

The Icarus Project is currently under the fiscal sponsorship of FJC, a non-profit 501(c)3 umbrella organization arm of an investment firm, based in New York City. The Icarus Project currently gets the bulk of its money from foundation grants, including the Ittleson Foundation, but it also has many individual donors.

The Icarus Project Network

Places where local chapters met included Anchorage, Alaska; Asheville, North Carolina; Atlanta, Georgia; Boston, Massachusetts; Conway, Arkansas; Chicago, Illinois; Los Angeles, California (Wildflowers’ Movement); Minneapolis, Minnesota; Madison, Wisconsin; New York City, New York; Northampton, Massachusetts (Freedom Centre); Philadelphia, Pennsylvania; Portland, Oregon; San Francisco (Bay Area), California; Columbus, Ohio; Gainesville, Florida.

Media Mentions

The Icarus Project has been mentioned in passing in The New York Times as a resource for those who “don’t want to ‘get better'”, by Frontline 20/20, and many local media outlets.

Publications

Educational materials published by The Icarus Project have been published in Spanish, German, French, Italian, Japanese, Greek, and Bosnian/Croatian. Some of these publications are listed below:

  • In March 2004, The Icarus Project released Navigating the Space Between Brilliance and Madness; A Reader and Roadmap of Bipolar Worlds. The book is currently in its 6th printing.
  • In July 2006, The Icarus Project released the first draft of Friends Make the Best Medicine: A Guide to Creating Community Mental Health Support Networks.
  • In 2008, The Icarus Project released Through the Labyrinth; A Harm Reduction Guide to Coming Off Psychiatric Drugs, and in 2009 this publication was translated into Spanish and German and made available for free download on the Icarus Project website.
  • In 2012, The Icarus Project released Mindful Occupation: Rising Up without Burning Out.
  • In 2015, The Icarus Project released Madness and Oppression: Personal Paths to Transformation and Collective Liberation.

Filmography

Films about Icarus Project members are listed below:

  • Ken Paul Rosenthal (2010). Crooked Beauty. 30 min. Poetic documentary featuring Jacks McNamara. In Mad Dance Mental Health Film Trilogy.
  • Ken Paul Rosenthal (2018). Whisper Rapture. 36 min. A doc-opera featuring Bonfire Madigan Shive.

What is Recovery Coaching?

Introduction

Recovery coaching is a form of strengths-based support for people with addictions or in recovery from alcohol, other drugs, co-dependency, or other addictive behaviours. They work with people who have active addictions, as well as those already in recovery. Recovery coaches are helpful for making decisions about what to do with one’s life and the part addiction or recovery plays in it. They help clients find ways to stop addiction (abstinence), or reduce harm associated with addictive behaviours. These coaches can help a client find resources for harm reduction, detox, treatment, family support and education, local or online support groups; or help a client create a change plan to recover on their own.

Recovery coaches do not offer primary treatment for addiction, do not diagnose, and are not associated with any particular method or means of recovery. They support any positive change, helping persons coming home from treatment to avoid relapse, build community support for recovery, or work on life goals not related to addiction such as relationships, work, or education. Recovery coaching is action-oriented with an emphasis on improving present life and reaching future goals.

Recovery coaching is unlike most therapy because coaches do not address the past, do not work to heal trauma, and put little emphasis on feelings. Recovery coaches are unlike licensed addiction counsellors in that they are non-clinical and do not diagnose or treat addiction or any mental health issues.

Refer to Recovery Model.

Relationship to Life Coaching

Similar to life and business coaching, recovery coaching uses a partnership model wherein the client is considered to be the expert on his or her life, the one who decides what is worth doing, and the coach provides expertise in supporting successful change. Recovery coaching focuses on achieving goals important to the client, not just recovery-related goals. The coach asks questions and offers reflections to help the client reach clarity and decide what steps to take. Recovery coaching emphasizes honouring values and making principle-based decisions, creating a clear plan of action, and using current strengths to reach future goals. The coach provides accountability to help the client stay on track.

Other Similar Terms

The moniker “recovery coach” is used for a variety of specific addiction support roles. The main distinction is between the professional or highly compensated recovery coach and the volunteer or agency-employed peer recovery support specialist. Recovery support roles include the following:

Sober Escort

A sober escort, or travel escort, is a paid sober travel companion or travel escort that accompanies a client to an event, to treatment, or to court, to ensure the client maintains sobriety. Transportation can be a significant challenge to a newly abstinent person. Whether the client is interested in maintaining an ongoing recovery or just needs to stay abstinent for a period of time, getting from point A to point B can be difficult. This version of a recovery coach may be required to transport a person in recovery across town, across the state, or across the county.

Sober Companion

A sober companion or sober coach works full-time with the client: full work days, nights, weekends or extended periods where the coach is by the client’s side 24 hours a day. This long-term option can begin with treatment discharge and may develop into a coaching relationship that continues for several weeks, months or longer.

When returning home from treatment, the client trades a secure, drug-free environment for a situation where they know there are problems. The sober companion may provide the symbolic and functional safety of the treatment centre. This coach will introduce the client to 12-step meetings, guide them past former triggers for their addiction, and support them in developing a recovery plan. The sober companion helps the client make lifestyle changes in order to experience a better quality of life in the first crucial days after discharge from a treatment centre. Sometimes a recovery coach is necessary to keep a client sober in order to regain custody of a child.

Recovery Support Specialist

A recovery support specialist (RSS) or a peer recovery support specialist (PRSS) is a non-clinical person who meets with clients in a recovery community organisation or goes off-site to visit a client. They may volunteer for these coaching services, or be employed by a recovery community organisation for a low wage. The recovery support specialist ensures there is a contract for engagement, called a personal recovery plan. This is a key component of the recovery management model, which all RSSs follow. These specialists are sometimes also called “recovery coaches”. William L. White, researcher and original author of the recovery management model, uses the term “recovery support specialist”. This is referenced in the paper titled “Recovery Oriented System of Care (ROSC) Substance Use Disorder (SUD) Glossary of Terms”, compiled by the Bureau of Substance Abuse and Addiction Services (BSAAS). Another term for a peer recovery support specialist is “peer mentor“.

Family Recovery Coach

The family plays an important role for a person in recovery but is often neglected by traditional models of recovery. Specially trained family recovery coaches strive to create a calm, objective, non-judgmental environment for the family of a recovering addict. They are knowledgeable in specific models that help the family cope with the changes that they have gone through living with an active addict or living with a recovering addict. Regardless of an addict’s choices, working with a family recovery coach may help a spouse, partner, or loved ones avoid the mental obsession that plagues many families affected by addiction and learn to lead sane and productive lives.

Phone or Virtual Recovery Coach

A phone or virtual recovery coaching relationship may be established to continue beyond the face-to-face meeting of a client and a recovery coach. Today, many treatment centres are embracing virtual recovery coaching, and linking phone or virtual recovery coaches with clients prior to leaving treatment, as a way to continue the connection to the treatment centre, as well as meeting the guidelines of an aftercare programme. Online virtual coaching programmes also exist, either fee-based or for free, that will help anyone apply the methods of recovery (e.g. developing a recovery plan and building recovery capital), whether the client has completed a stay at a treatment centre or has relapsed many months after treatment.

Legal Support Specialist

Lawyers dealing with criminal drug cases or drug courts sometimes request a type of recovery coaching to ensure a client (perhaps under house arrest, enrolled in a drug court outpatient programme or pending trial) stays sober as per the law’s mandate. Recovery coaches with the required certification and legal knowledge are contracted for this purpose. Certified Peer Recovery Support Specialists, Licensed clinical social workers or certified alcohol and drug counsellors with training in assessments can perform these tasks. The court will request them to perform a client assessment and work with the client on a continuing basis and re-assess after a period of time. The coach will then draft a letter to the court and offer suggested placement in a residential alcohol/drug treatment centre, an outpatient treatment programme, or a sober living facility. A legal support specialist can also appear in court with the client and provide transportation to or from the courthouse.

In the Emergency Departments of Hospitals

The AnchorED programme, developed in 2014 with a group of Rhode Island hospitals and the Anchor Community Recovery Centre in Providence RI, was launched in an attempt to reduce the instance of accidental opioid overdose by connecting overdose patients with Certified Recovery Coaches in the emergency departments of regional hospitals. The AnchorED programme is now a benchmark in this field and is used nationwide. This programme is meant to connect people experiencing an overdose, or revived from an overdose in the ED in the hospital emergency departments with peer-to-peer recovery support. Specially trained ED Peer Recovery Specialists are on call to all Emergency Departments 24/7 and called in when individuals are transported to a hospital emergency department having survived an opiate overdose. The hours immediately after an overdose are medically risky, but they also present a unique opportunity. The AnchorED trained recovery coaches will make sure that patients and their families know that substance use disorder is a medical condition and that recovery is possible. Recovery Coaches engage with those who have survived an opiate overdose, listen and be present to answer questions patients may have about recovery supports or treatment options. These coaches also provide recovery and treatment information to family members. These same coaches offer post-discharge recovery contact and support to the revived patients for a period of weeks.

Brief History

Alida Schuyler, a coach credentialed by the International Coach Federation (ICF), who was in recovery from addiction, wrote the first recovery coach certification training programme specifically aimed at training students to coach people with addictions. She also created the first special interest group for recovery coaches, and she co-founded the non-profit Recovery Coaches International with Andrew Susskind.

William L. White used the term “recovery coach” in his 2006 paper “Sponsor, Recovery Coach, Addiction Counselor”, but later adopted the term “peer recovery support specialist” to emphasize a community-based peer model of addiction support.

White’s Recovery Management model, adapted from the Minnesota Model, includes recovery coaching (peer recovery support specialist) and was developed in 2006. Many recovery coaches use different recovery approaches adapted from the Minnesota Model. Schuyler developed a professional model of life coaching for addiction recovery by blending the Minnesota Model and Harm Reduction model with the core competencies of the ICF.

Through the research of White, David Loveland, Ernest Kurtz, and Mark Saunders, and the efforts funded through Faces and Voices of Recovery, the Fayette Companies, Great Lakes Addiction Technology Transfer Centre, the Chestnut Health Systems and many other universities, research on recovery coaching is progressing rapidly. The theory has been developed that recovery coaching reduces relapse by providing ongoing support developing healthy problem-solving skills and self efficacy (reaching worthwhile goals), as well as connecting with the local recovery community for additional support. In other words, recovery coaching helps the client develop the cognitive skills necessary for considering options and consequences, making clear choices, planning, and taking actions toward a healthier life and recovery goals.

Recovery coaching is currently offered by some notable 12-step treatment centres as well as several private “academies” and “institutes” with certifications that are usually country and/or state specific. Be sure to check local laws for compliance.

Addiction Recovery Support Groups

Recovery coaches encourage (but most do not require) participation in groups such as Alcoholics Anonymous, Narcotics Anonymous, Al-Anon, or non 12-step groups such as LifeRing Secular Recovery, SMART Recovery, Moderation Management, and Women for Sobriety. They also work with individuals who dislike groups to help them find their own path to recovery.

Niches within Recovery Coaching

Recovery coaches may work with any type of addict. There are also niches within recovery coaching such as those who work exclusively with families of recovering individuals, or a financial coach who works on rebuilding an overspender’s credit rating. Many peer recovery support specialists work with individuals who have left the prison system and are attempting to rebuild their lives. Some recovery coaches specialise in emotional and financial recovery after divorce.

A few recovery coaches specialise in merging the characteristics of recovery coaching within a life coaching framework. This concept takes into account the often overlooked reality that those in early recovery tend to have unique difficulties in applying the realities of day-to-day living within their new sober lifestyle. Such unique coaching styles are able to span far beyond the recovery component and properly introduce outside influencers, such as family relationships, employment, schooling, and relationships.

For those requiring a higher level of care, such as medical detoxification for heroin or opiate withdrawal, or 24/7 sober companion and oversight services, there exist recovery coaching firms which specialise in providing what could often be described as an alternative to inpatient or outpatient treatment. Companies like The Addictions Coach and others which have nationwide credentials are able to essentially bring the addiction treatment component to the client, no matter where he or she may be located.

What Recovery Coaches Do

Recovery coaches support the client in achieving and maintaining a solid foundation in recovery, and building upon recovery to achieve other life goals that make recovery worthwhile. David Loveland and Michael Boyle wrote a lengthy manual on recovery coaching and how to guide an individual through creating their recovery plan. William White, preeminent scholar on addictions, worked closely with the Philadelphia community-based recovery centre PRO-ACT to prepare a document outlining the “Ethical Guidelines for the Delivery of Peer-Based Recovery Support Services”. These documents provide a discussion of what a recovery coach does. Also included in these guidelines are the definition of coaching roles as they relate to others in the realm of personal conduct and conduct in service relationships with the community service provider or treatment team. White’s document presents a simple statement of core competencies.

What is the Recovery Model?

Introduction

The recovery model, recovery approach or psychological recovery is an approach to mental disorder or substance dependence that emphasizes and supports a person’s potential for recovery. Recovery is generally seen in this model as a personal journey rather than a set outcome, and one that may involve developing hope, a secure base and sense of self, supportive relationships, empowerment, social inclusion, coping skills, and meaning. Recovery sees symptoms as a continuum of the norm rather than an aberration and rejects sane-insane dichotomy.

William Anthony, then Director of the Boston Centre for Psychiatric Rehabilitation, developed a quaint cornerstone definition of mental health recovery in 1993.

“Recovery is a deeply personal, unique process of changing one’s attitudes, values, feelings, goals, skills and/or roles. It is a way of living a satisfying, hopeful, and contributing life even with limitations caused by the illness. Recovery involves the development of new meaning and purpose in one’s life as one grows beyond the catastrophic effects of mental illness.”

The use of the concept in mental health emerged as deinstitutionalisation resulted in more individuals living in the community. It gained impetus as a social movement due to a perceived failure by services or wider society to adequately support social inclusion, and to studies demonstrating that many people do recover. A recovery approach has now been explicitly adopted as the guiding principle of the mental health or substance dependency policies of a number of countries and states.

In many cases practical steps are being taken to base services on a recovery model, although a range of obstacles, concerns and criticisms have been raised both by service providers and by recipients of services. A number of standardised measures have been developed to assess aspects of recovery, although there is some variation between professionalised models and those originating in the psychiatric survivors movement.

Refer to Recovery Coaching.

Brief History

In general medicine and psychiatry, recovery has long been used to refer to the end of a particular experience or episode of illness. The broader concept of “recovery” as a general philosophy and model was first popularized in regard to recovery from substance abuse/drug addiction, for example within twelve-step programs.

Application of recovery models to psychiatric disorders is comparatively recent. The concept of recovery can be traced back as far as 1840, when John Perceval, son of one of Britain’s prime ministers, wrote of his personal recovery from the psychosis that he experienced from 1830 until 1832, a recovery that he obtained despite the “treatment” he received from the “lunatic” doctors who attended him. But by consensus the main impetus for the development came from within the consumer/survivor/ex-patient movement, a grassroots self-help and advocacy initiative, particularly within the United States during the late 1980s and early 1990s. The professional literature, starting with the psychiatric rehabilitation movement in particular, began to incorporate the concept from the early 1990s in the United States, followed by New Zealand and more recently across nearly all countries within the “First World”. Similar approaches developed around the same time, without necessarily using the term recovery, in Italy, the Netherlands and the UK.

Developments were fuelled by a number of long-term outcome studies of people with “major mental illnesses” in populations from virtually every continent, including landmark cross-national studies by the World Health Organization from the 1970s and 1990s, showing unexpectedly high rates of complete or partial recovery, with exact statistics varying by region and the criteria used. The cumulative impact of personal stories or testimony of recovery has also been a powerful force behind the development of recovery approaches and policies. A key issue became how service consumers could maintain the ownership and authenticity of recovery concepts while also supporting them in professional policy and practice.

Increasingly, recovery became both a subject of mental health services research and a term emblematic of many of the goals of the Consumer/Survivor/Ex-Patient Movement. The concept of recovery was often defined and applied differently by consumers/survivors and professionals. Specific policy and clinical strategies were developed to implement recovery principles although key questions remained.

Elements of Recovery

It has been emphasized that each individual’s journey to recovery is a deeply personal process, as well as being related to an individual’s community and society. A number of features or signs of recovery have been proposed as often core elements and comprehensively they have been categorised under the concept of CHIME.

CHIME is an abbreviation of:

  • Connectedness;
  • Hope and optimism;
  • Identity;
  • Meaning & purpose; and
  • Empowerment.

Connectedness and Supportive Relationships

A common aspect of recovery is said to be the presence of others who believe in the person’s potential to recover and who stand by them. According to Relational Cultural Theory as developed by Jean Baker Miller, recovery requires mutuality and empathy in relationships. The theory states this requires relationships that embody respect, authenticity, and emotional availability. Supportive relationships can also be made safer through predictability and avoiding shaming and violence. While mental health professionals can offer a particular limited kind of relationship and help foster hope, relationships with friends, family and the community are said to often be of wider and longer-term importance. Case managers can play the role of connecting recovering persons to services that the recovering person may have limited access to, such as food stamps and medical care. Others who have experienced similar difficulties and are on a journey of recovery can also play a role in establishing community and combating a recovering person’s feelings of isolation. In practice, this can be accomplished through one-on-one interviews with other recovering persons, engaging in communal story circles, or peer-led support groups. Those who share the same values and outlooks more generally (not just in the area of mental health) may also be particularly important. It is said that one-way relationships based on being helped can actually be devaluing and potentially retraumatising, and that reciprocal relationships and mutual support networks can be of more value to self-esteem and recovery.

Hope

Finding and nurturing hope has been described as a key to recovery. It is said to include not just optimism but a sustainable belief in oneself and a willingness to persevere through uncertainty and setbacks. Hope may start at a certain turning point, or emerge gradually as a small and fragile feeling, and may fluctuate with despair. It is said to involve trusting, and risking disappointment, failure and further hurt.

Identity

Recovery of a durable sense of self (if it had been lost or taken away) has been proposed as an important element. A research review suggested that people sometimes achieve this by “positive withdrawal” – regulating social involvement and negotiating public space in order to only move towards others in a way that feels safe yet meaningful; and nurturing personal psychological space that allows room for developing understanding and a broad sense of self, interests, spirituality, etc. It was suggested that the process is usually greatly facilitated by experiences of interpersonal acceptance, mutuality, and a sense of social belonging; and is often challenging in the face of the typical barrage of overt and covert negative messages that come from the broader social context. Being able to move on can mean having to cope with feelings of loss, which may include despair and anger. When an individual is ready for change, a process of grieving is initiated. It may require accepting past suffering and lost opportunities or lost time.

Formation of Healthy Coping Strategies and Meaningful Internal Schema

The development of personal coping strategies (including self-management or self-help) is said to be an important element. This can involve making use of medication or psychotherapy if the patient is fully informed and listened to, including about adverse effects and about which methods fit with the consumer’s life and their journey of recovery. Developing coping and problem solving skills to manage individual traits and problem issues (which may or may not be seen as symptoms of mental disorder) may require a person becoming their own expert, in order to identify key stress points and possible crisis points, and to understand and develop personal ways of responding and coping. Developing a sense of meaning and overall purpose is said to be important for sustaining the recovery process. This may involve recovering or developing a social or work role. It may also involve renewing, finding or developing a guiding philosophy, religion, politics or culture. From a postmodern perspective, this can be seen as developing a narrative.

Empowerment and Building a Secure Base

Building a positive culture of healing is essential in the recovery approach. Since recovering is a long process, a strong supportive network can be helpful. Appropriate housing, a sufficient income, freedom from violence, and adequate access to health care have also been proposed as important tools to empowering someone and increasing her/his self-sufficiency. Empowerment and self-determination are said to be important to recovery for reducing the social and psychological effects of stress and trauma. Women’s Empowerment Theory suggests that recovery from mental illness, substance abuse, and trauma requires helping survivors understand their rights so they can increase their capacity to make autonomous choices. This can mean develop the confidence for independent assertive decision making and help-seeking which translates into proper medication and active self care practices. Achieving social inclusion and overcoming challenging social stigma and prejudice about mental distress/disorder/difference is also an important part of empowerment. Advocates of Women’s Empowerment Theory argue it is important to recognise that a recovering person’s view of self is perpetuated by stereotypes and combating those narratives. Empowerment according to this logic requires reframing a survivor’s view of self and the world. In practice, empowerment and building a secure base require mutually supportive relationships between survivors and service providers, identifying a survivor’s existing strengths, and an awareness of the survivor’s trauma and cultural context.

Concepts of Recovery

Varied Definitions

What constitutes ‘recovery’, or a recovery model, is a matter of ongoing debate both in theory and in practice. In general, professionalised clinical models tend to focus on improvement in particular symptoms and functions, and on the role of treatments, while consumer/survivor models tend to put more emphasis on peer support, empowerment and real-world personal experience. “Recovery from”, the medical approach, is defined by a dwindling of symptoms, whereas “recovery in”, the peer approach, may still involve symptoms, but the person feels they are gaining more control over their life. Similarly, recovery may be viewed in terms of a social model of disability rather than a medical model of disability, and there may be differences in the acceptance of diagnostic “labels” and treatments.

A review of research suggested that writers on recovery are rarely explicit about which of the various concepts they are employing. The reviewers classified the approaches they found in to broadly “rehabilitation” perspectives, which they defined as being focused on life and meaning within the context of enduring disability, and “clinical” perspectives which focused on observable remission of symptoms and restoration of functioning. From a psychiatric rehabilitation perspective, a number of additional qualities of the recovery process have been suggested, including that it: can occur without professional intervention, but requires people who believe in and stand by the person in recovery; does not depend on believing certain theories about the cause of conditions; can be said to occur even if symptoms later re-occur, but does change the frequency and duration of symptoms; requires recovery from the consequences of a psychiatric condition as well as the condition itself; is not linear but does tend to take place as a series of small steps; does not mean the person was never really psychiatrically disabled; focuses on wellness not illness, and on consumer choice.

A consensus statement on mental health recovery from US agencies, that involved some consumer input, defined recovery as a journey of healing and transformation enabling a person with a mental health problem to live a meaningful life in a community of his or her choice while striving to achieve his or her full potential. Ten fundamental components were elucidated, all assuming that the person continues to be a “consumer” or to have a “mental disability”. Conferences have been held on the importance of the “elusive” concept from the perspectives of consumers and psychiatrists.

One approach to recovery known as the Tidal Model focuses on the continuous process of change inherent in all people, conveying the meaning of experiences through water metaphors. Crisis is seen as involving opportunity; creativity is valued; and different domains are explored such as sense of security, personal narrative and relationships. Initially developed by mental health nurses along with service users, Tidal is a particular model that has been specifically researched. Based on a discrete set of values (the Ten Commitments), it emphasizes the importance of each person’s own voice, resourcefulness and wisdom. Since 1999, projects based on the Tidal Model have been established in several countries.

For many, recovery has a political as well as personal implication – where to recover is to: find meaning; challenge prejudice (including diagnostic “labels” in some cases); perhaps to be a “bad” non-compliant patient and refuse to accept the indoctrination of the system; to reclaim a chosen life and place within society; and to validate the self. Recovery can thus be viewed as one manifestation of empowerment. Such an empowerment model may emphasize that conditions are not necessarily permanent; that other people have recovered who can be role models and share experiences; and that “symptoms” can be understood as expressions of distress related to emotions and other people. One such model from the US National Empowerment Centre proposes a number of principles of how people recover and seeks to identify the characteristics of people in recovery.

In general, recovery may be seen as more of a philosophy or attitude than a specific model, requiring fundamentally that “we regain personal power and a valued place in our communities. Sometimes we need services to support us to get there”.

Recovery from Substance Dependence

Particular kinds of recovery models have been adopted in drug rehabilitation services. While interventions in this area have tended to focus on harm reduction, particularly through substitute prescribing (or alternatively requiring total abstinence) recovery approaches have emphasised the need to simultaneously address the whole of people’s lives, and to encourage aspirations while promoting equal access and opportunities within society. From the perspective of services the work may include helping people with “developing the skills to prevent relapse into further illegal drug taking, rebuilding broken relationships or forging new ones, actively engaging in meaningful activities and taking steps to build a home and provide for themselves and their families. Milestones could be as simple as gaining weight, re-establishing relationships with friends, or building self-esteem. What is key is that recovery is sustained.”. Key to the philosophy of the recovery movement is the aim for an equal relationship between “Experts by Profession” and “Experts by Experience”.

Trauma-Informed Recovery

Trauma-Informed care is a philosophy for recovery that combines the conditions and needs of people recovering from mental illness and/or substance abuse into one framework. This framework combines all of the elements of the Recovery Approach and adds an awareness of trauma. Advocates of trauma-informed care argue the principles and strategies should be applied to individuals experiencing mental illness, substance dependence, and trauma as these three often occur simultaneously or as result of each other. The paradigms surrounding trauma-informed care began to shift in 1998 and 1999. In 1998, the Centre for Mental Health Services, the Centre for Substance Abuse Treatment, and the Centre for Substance Abuse Prevention collaborated to fund 14 sites to develop integrated services in order to address the interrelated effects of violence, mental health, and substance abuse. In 1999, the National Association of State Mental Health Programme Directors passed a resolution recognising the impact of violence and trauma and developed a toolkit of resources for the implementation of trauma services in state mental health agencies. Trauma-informed care has been supported in academia as well. Scholars claim that neglecting the role of trauma in a person’s story can interfere with recovery in the form of misdiagnosis, inaccurate treatment, or re-traumatisation. Some principles of trauma-informed care include validating survivor experiences and resiliency, aiming to increase a survivor’s control over her/his/their recovery, creating atmospheres for recovery that embody consistency and confidentiality, minimising the possibilities of triggering past trauma, and integrating survivors/recovering persons in service evaluation. In practice, trauma-informed care has shown to be most effective when every participant in a service providing context to be committed to following these principles. In addition, these principles can apply to all steps of the recovery process within a service providing context, including outreach and engagement, screening, advocacy, crisis intervention, and resource coordination. The overall goal in trauma-informed care is facilitating healing and empowerment using strengths-based empowerment practices and a comprehensive array of services that integrate co-occurring disorders and the multitude of needs a recovering person might have, such as drug treatment, housing, relationship building, and parenting support.

These approaches are in contrast to traditional care systems. Advocates of trauma-informed care critique traditional service delivery systems, such as standard hospitals, for failing to understand the role of trauma in a patients life. Traditional service delivery systems are also critiqued for isolating the conditions of a recovering person and not addressing conditions such as substance abuse and mental illness simultaneously as part of one source. Specific practices in traditional service delivery systems, such as unnecessary procedures, undressing for examinations, involuntary hospitalisations, crowded emergency rooms, and limited time for providers to meet with patients, have all been critiqued as insensitive to persons recovering from trauma and consequential mental illness or substance abuse. Limited resources and time in the United States healthcare system can make the implementation of trauma-informed care difficult.

There are other challenges to trauma-informed care besides limits in the United States healthcare system that can make trauma-informed care ineffective for treating persons recovering from mental illness or substance dependence. Advocates of trauma-informed care argue implementation requires a strong commitment from leadership in an agency to train staff members to be trauma-aware, but this training can be costly and time-consuming. “Trauma-informed care” and “trauma” also have contested definitions and can be hard to measure in a real world service setting. Another barrier to trauma-informed care is the necessity of screening for histories of trauma. While agencies need to screen for histories of trauma in order to give the best care, there can be feelings of shame and fear of being invalidated that can prevent a recovering person from disclosing their personal experiences.

Concerns

Some concerns have been raised about a recovery approach in theory and in practice. These include suggestions that it: is an old concept; only happens to very few people; represents an irresponsible fad; happens only as a result of active treatment; implies a cure; can only be implemented with new resources; adds to the burden of already stretched providers; is neither reimbursable nor evidence based; devalues the role of professional intervention; and increases providers’ exposure to risk and liability.

Other criticisms focused on practical implementation by service providers include that: the recovery model can be manipulated by officials to serve various political and financial interests including withdrawing services and pushing people out before they’re ready; that it is becoming a new orthodoxy or bandwagon that neglects the empowerment aspects and structural problems of societies and primarily represents a middle class experience; that it hides the continued dominance of a medical model; and that it potentially increases social exclusion and marginalises those who do not fit into a recovery narrative.

There have been specific tensions between recovery models and “evidence-based practice” models in the transformation of US mental health services based on the recommendations of the New Freedom Commission on Mental Health. The Commission’s emphasis on recovery has been interpreted by some critics as saying that everyone can fully recover through sheer will power and therefore as giving false hope and implicitly blaming those who may be unable to recover. However, the critics have themselves been charged with undermining consumer rights and failing to recognise that the model is intended to support a person in their personal journey rather than expecting a given outcome, and that it relates to social and political support and empowerment as well as the individual.

Various stages of resistance to recovery approaches have been identified amongst staff in traditional services, starting with “Our people are much sicker than yours. They will not be able to recover” and ending in “Our doctors will never agree to this”. However, ways to harness the energy of this perceived resistance and use it to move forward have been proposed. In addition, staff training materials have been developed by various organisations, for example by the National Empowerment Centre.

Some positives and negatives of recovery models were highlighted in a study of a community mental health service for people diagnosed with schizophrenia. It was concluded that while the approach may be a useful corrective to the usual style of case management – at least when genuinely chosen and shaped by each unique individual on the ground – serious social, institutional and personal difficulties made it essential that there be sufficient ongoing effective support with stress management and coping in daily life. Cultural biases and uncertainties were also noted in the ‘North American’ model of recovery in practice, reflecting views about the sorts of contributions and lifestyles that should be considered valuable or acceptable.

Assessment

A number of standardised questionnaires and assessments have been developed to try to assess aspects of an individual’s recovery journey. These include the:

  • Milestones of Recovery (MOR) Scale;
  • Recovery Enhancing Environment (REE) measure;
  • Recovery Measurement Tool (RMT);
  • Recovery Oriented System Indicators (ROSI) Measure;
  • Stages of Recovery Instrument (STORI); and
  • Numerous related instruments.

The data-collection systems and terminology used by services and funders are said to be typically incompatible with recovery frameworks, so methods of adapting them have been developed. It has also been argued that the Diagnostic and Statistical Manual of Mental Disorders – in reference to the then DSM-IV – (and to some extent any system of categorical classification of mental disorders) uses definitions and terminology that are inconsistent with a recovery model, leading to suggestions that the next version, the DSM-V, requires: greater sensitivity to cultural issues and gender; to recognise the need for others to change as well as just those singled out for a diagnosis of disorder; and to adopt a dimensional approach to assessment that better captures individuality and does not erroneously imply excess psychopathology or chronicity.

National Policies and Implementation

United States and Canada

The New Freedom Commission on Mental Health has proposed to transform the mental health system in the US by shifting the paradigm of care from traditional medical psychiatric treatment toward the concept of recovery, and the American Psychiatric Association has endorsed a recovery model from a psychiatric services perspective.

The US Department of Health and Human Services reports developing national and state initiatives to empower consumers and support recovery, with specific committees planning to launch nationwide pro-recovery, anti-stigma education campaigns; develop and synthesize recovery policies; train consumers in carrying out evaluations of mental health systems; and help further the development of peer-run services. Mental Health service directors and planners are providing guidance to help state services implement recovery approaches.

Some US states, such as California (see the California Mental Health Services Act), Wisconsin and Ohio, already report redesigning their mental health systems to stress recovery model values like hope, healing, empowerment, social connectedness, human rights, and recovery-oriented services.

At least some parts of the Canadian Mental Health Association, such as the Ontario region, have adopted recovery as a guiding principle for reforming and developing the mental health system.

New Zealand and Australia

Since 1998, all mental health services in New Zealand have been required by government policy to use a recovery approach and mental health professionals are expected to demonstrate competence in the recovery model. Australia’s National Mental Health Plan 2003-2008 stated that services should adopt a recovery orientation although there is variation between Australian states and territories in the level of knowledge, commitment and implementation.

UK and Ireland

In 2005, the National Institute for Mental Health in England (NIMHE) endorsed a recovery model as a possible guiding principle of mental health service provision and public education. The National Health Service (NHS) is implementing a recovery approach in at least some regions, and has developed a new professional role of Support Time and Recovery Worker. Centre for Mental Health issued a 2008 policy paper proposing that the recovery approach is an idea “whose time has come” and, in partnership with the NHS Confederation Mental Health Network, and support and funding from the Department of Health, manages the Implementing Recovery through Organisational Change (ImROC) nationwide project that aims to put recovery at the heart of mental health services in the UK. The Scottish Executive has included the promotion and support of recovery as one of its four key mental health aims and funded a Scottish Recovery Network (SRN) to facilitate this. A 2006 review of nursing in Scotland recommended a recovery approach as the model for mental health nursing care and intervention. The Mental Health Commission of Ireland reports that its guiding documents place the service user at the core and emphasize an individual’s personal journey towards recovery.