Consumer models of recovery: can they survive operationalism?
Authors: JANET WALLCFRAT
Journal: World Psychiatry (2012)

Bellack and Drapalski have clearly set out the case for the importance of the recovery model, and how it is currently influencing US state mental health systems to move away from paternalistic services which generate "feelings of hopelessness and helplessness". They cite the work of consumer-professionals in demonstrating the subjective nature of mental illness and recovery, while at the same time undermining the impact of this work by questioning whether these spokespeople may be "a distinct good outcome subgroup" (a problem which could be overcome if all psychiatric patients were encouraged to give their histories in their own words, rather than these being recorded only via case-notes and diagnostic categories!). The authors' main concern is to develop an operational definition of recovery based on the US Substance Abuse, Mental Health Services Administration (SAMHSA) definition, and to introduce their recovery measure (Maryland Assessment of Recovery in People with Serious Mental Illness, MARS). They begin by quoting the most influential definition of recovery, that of Anthony 1. However, along with most of those who quote Anthony, they omit his second paragraph, which is of high importance to consumers and users of mental health services: "Recovery from mental illness involves much more than recovery from the illness itself. People with mental illness may have to recover from the stigma they have incorporated into their very being; from the iatrogenic effects of treatment settings; from lack of recent opportunities for self-determination; from the negative side effects of unemployment; and from crushed dreams. Recovery is often a complex, time-consuming process. Recovery is what people with disabilities do. Treatment, case-management and rehabilitation are what helpers do to facilitate recovery" 1. Anthony's definition is inconveniently long, and controversially uses the word "iatrogenic", but it helps to do two things: to place the ownership of the process of "recovery" firmly with the person recovering, and to emphasize the complexity of the process. Bellack and Drapalski's operational definition, and presumably the MARS instrument, is strongly linked to their own theoretical perspective that "personal agency" and "self-efficacy" are the key principles underpinning recovery. "Self-efficacy" is defined as a set of beliefs about one's capacity to manage internal and external experiences. Since this is their starting point, it is not surprising that the MARS tool in operation confirms that these psychological aspects are the main determinant of recovery. While following the logic of their argument so far, I found myself out of tune with their conclusions, and began to question their process of operationalizing recovery. They begin the process by dismissing consumer models of recovery as insufficiently psychological. This in itself could be a point of disagreement with consumer researchers, but maybe it is also reasonable to examine the value of operationalization itself. P. Bridgman developed the concept of operationalization in the early 20th century, to enable researchers to carry out empirical work in areas where the variables do not have an essence observable to the senses. Green 2 says that Bridgman set out to provide a simple solution to a complex problem. However, "like all too many simple solutions to complex problems, it turned out to not really solve the problem at all". If the measure defines the concept, which has no essential existence of its own, there can be no convergence in psychological discovery, since there is nothing to be discovered. In the case of recovery, operationalization risks rendering meaningless or irrelevant the ontological aspects of recovery, and most of the narrative material which clearly matters to individuals who view their recovery as the result of their personal journey through life, and their process of making sense of their own experiences. Slade 3, a UK psychologist, found a similar problem in writing about recovery. He made a distinction between "clinical recovery" which has been tightly defined, to make it suitable for use in empirical research, and "personal recovery", which has "high ecological validity — it emerges from the narratives of people with mental illness who describe themselves as recovered or in recovery", but which is more difficult to operationalize. Slade argues however that it is not impossible to use empirical quantitative research to investigate what helps recovery, and points to principal components emerging from narrative studies, including "empowerment, hope and optimism, knowledge and life-satisfaction". The MARS instrument is at an early stage of testing and may prove to be a valuable addition to the existing panoply of recovery measures, but it would be unwise to dismiss, as the authors do, measures based on consensus conferences and work done directly with consumers. Some of these measures have already been tried and tested, including the Recovery Assessment Scale 4. This was tested on 1,824 persons with serious mental illness, and produced five factors: personal confidence and hope, willingness to ask for help, goal and success orientation, reliance on others, and no domination by symptoms. An Australian study 5 found that it had convergent validity with other recovery measures, and was consistent with consumer literature on recovery. Social relationships are found to be another key factor in recovery. A Swedish study 6 based on 58 patient narratives found that "recovery from mental illness is a social process in which the helping factors have to do with the quality of social relationships, irrespective of whether those are formed in inpatient care, in medicinal circumstances, in psychotherapy, with families or friends, or in the company of other persons in the same situation". Similarly, research led by service users in the UK found relationships to be the most important common factor in helping people with mental health problems to build coping strategies 7. Given Bellack and Drapalski's findings that recovery oriented treatment was not significantly influencing recovery outcomes, there is a need to remain aware of all the aspects of what recovery means to consumers. Perhaps, instead of adjusting the model of recovery to fit established research methods and concepts, it would be better to adjust the research methods to fit the complex concept of recovery.