Science Meets the Human Experience: Integrating the Medical and Recovery Models

By Ken Duckworth, M.D. | Apr. 10, 2015
Mapping Out the Brain

The best way to maximize progress on a challenging journey is to use every resource at your disposal. On a journey, it is often best to maximize scientific (e.g., compass, maps, equipment) resources, as well as learn from prior experience by using hope and intuition. Similarly, in the world of living with mental illness, two models—the medical model and the recovery model—are each great tools to promote progress.

I have come to see that these models can make a big difference for people, particularly when they are integrated. I use a “both/and,” not an “either/or,” approach with the young adults I serve as a psychiatrist at the Prevention and Recovery from Early Psychosis Clinic (PREP) at Harvard University. Together, we use all the tools available for the journey of recovery: science, diagnosis, shared medical decision-making, hope, strengths, education, work and family.

The recovery model is relatively new in the field of mental health and clearly speaks to the needs of many people living with mental illness. It emphasizes many things, but hope, empowerment, peer support and self-management stand out to me as key principles of the model. The medical model has a long tradition and is rooted in evidence and science. At its best, the medical model can be implemented with humanity and compassion. I hope to make a case for both of these models and ultimately show why they are complementary.

The Recovery Model

Recovery means different things to different people, but some similar principles are found across most models, and its concept has its roots in the substance-abuse community. The Substance Abuse and Mental Health Services Administration (SAMSHA) engaged in a process with many stakeholders to come up with the following definition for recovery from mental illness and substance use disorders: A process of change through which individuals improve their health and wellness, live a self-directed life and strive to reach their full potential.

Through the Recovery Support Strategic Initiative, SAMHSA has outlined four major dimensions that support a life in recovery:

  • Health. Overcoming or managing one’s disease(s) or symptoms—for example, abstaining from the use of alcohol, illicit drugs and unprescribed medications if one has trouble with addiction—and for everyone in recovery, making informed, healthy choices that support physical and emotional wellbeing.
  • Home. A stable and safe place to live.
  • Purpose. Meaningful daily activities, such as a job, school, volunteerism, family caretaking or creative endeavors, and the independence, income and resources to participate in society.
  • Community. Relationships and social networks that provide support, friendship, love and hope.

Strengths

The recovery model speaks to people’s goals and addresses the ways in which they want to live. It focuses on the goal of having a good life that is not deficit- and symptom-focused. The recovery model involves many aspects of life that are common to all people, thereby promoting shared concerns. It focuses on the individual’s experience as a source of expertise. It also creates positive expectations for people engaged in a recovery process, and supports a strong peer culture. Finally, the recovery model instills hope in a field that has long lacked this kind of vision.

Weaknesses

A vulnerability of the model is that the subjective experience of recovery is inherently hard to measure. In a world with shrinking resources, things that aren’t measured are often not adequately attended to or funded. There are a few measures of recovery that are in process, but there is no consensus on using them in the field or a strong way to validate the quality of these measures. Another criticism of the model is that some people with psychosis do not see themselves as ill (the neurological condition known as anosognosia), have not responded to treatment and have overwhelming symptoms. These individuals and their families may feel that the higher expectations fostered by the recovery model leave them behind.

The Medical Model

The medical model relies on science—such as a correct biological diagnosis and research. Diagnosis is rooted in pathology—i.e., what is wrong—in order to develop ways to help either cure or reduce symptoms. The medical model relies on scientific proof of a pathological process or treatment interventions that can be replicated in other studies.

Strengths

The medical model involves the pursuit of scientific truth and has objective facts as its ideal. The model has been robustly successful in acute conditions such as infectious disease and has made great strides in helping people, such as guiding the medical community toward which chemotherapy best treats which cancer or which antibiotic works best for which bacteria. Through this model, some conditions, such as HIV infection, have been turned from being lethal conditions to being chronic-but-manageable illnesses. Medical model care, at its best, marries science with compassion for the individual in treatment. Excellent doctors employ science while also using Dr. Francis Peabody‘s philosophy: “... for the secret of the care of the patient is in caring for the patient.”

Weaknesses

In psychiatry, conditions don’t generally lend themselves to acute intervention models. In regards to illnesses that are more chronic, the medical model has been criticized for being too deficit-oriented and physician-defined. The medical model can also ignore a person’s strengths and thereby turn people off by being too pathology-based. Psychiatry faces the additional challenge of dealing with the incredibly complex brain, so the underlying biology that leads to clear treatments based on neurobiology is elusive—at least for now.

Integrating the Two Models

Can the first-person vision for hopefulness and reliance on experience be integrated with scientific knowledge to inform better care and outcomes? Yes. I believe that integrating these models is the best way to promote better care and outcomes for both individuals and systems. As a field, we are moving toward this kind of integration, but it—like many things in life—is a process. Here are some examples of how the two models can work together.

The Wellness Recovery Action Plan (WRAP), developed by Mary Ellen Copeland, helps people self-manage their experiences and promotes illness-management strategies. This model was created by Copeland to attend to her own challenges and has intuitive appeal. Research studies now validate its effectiveness. This means that the program isn’t only a subjective positive for the individuals who use it; it is worthy of replication, dissemination and funding.

Similar findings have concluded that an intervention known as Illness Management and Recovery (IMR), which was developed at Dartmouth College, also has scientific validity. The idea that recovery-oriented strategies pass research muster adds another important dimension to their success.

Similarly, NAMI’s Family-to-Family program, developed by Dr. Joyce Burland, is the classic, home-grown NAMI signature program that many NAMI readers and members have taken or taught. It was declared an evidenced-based practice in 2013. The medical model of scientific inquiry led Dr. Lisa Dixon, a service researcher, to demonstrate that NAMI Family-to-Family worked better than a placebo (people on the waiting list did not show the same results). The medical model took a creative homegrown idea and validated it with scientific inquiry.

Cognitive Enhancement Therapy (CET) is a model of “brain training” that is based on the idea that “neurons that fire together wire together.” It is a way to encourage recovery by promoting an active approach to cognition and upholding the construct that the brain is plastic and not fixed. CET is a good example of a recovery approach that grew out of the medical model, as it has its roots in stroke rehabilitation. It has now been studied in individuals in the early stage of psychosis and has been found to make a positive difference in cognition for those individuals. Studies are now underway to examine how it can be used for people living with major mental illnesses who have had cognitive problems for longer periods of time.

Diagnosis is one of the cornerstones of the medical model. Yet diagnosis can also be a key to organizing a recovery plan. For example, if a person lives with bipolar disorder, then taking antidepressants is unlikely to be of much help in the depressive phase (see the Systematic Treatment Enhancement Program for Bipolar Disorder (STEP-BD) study), and they may actually make things worse by activating mania. A diagnosis of bipolar disorder also increases the need for self-care: getting regular sleep, managing stress, exercising and creating supportive relationships. These are key recovery self-care principles that research has demonstrated to be effective for the management of bipolar disorder.

Even when there isn’t such a clear course charted from an accurate diagnosis, I have been impressed by the fact that the diagnosis itself can still provide relief and hope. I was recently thanked for telling a person that I thought her major issue was in the self-regulation of emotions that is commonly found in borderline personality disorder. She responded with relief, exclaiming, “Now I can do something about it!” When I was first training as a psychiatric resident, the term “borderline” was often used derisively. Today, led by the work of Dr. Marsha Linehan (whose own recovery with this condition was featured in the New York Times), borderline personality disorder is viewed as a challenge that has scientifically validated strategies.

The recovery strategies of several interventions— dialectical behavioral therapy (DBT) and mentalization have been well-studied—focus on developing skills for how to handle difficulties in managing emotions. The work of DBT is recovery-based and has been shown in research to reduce the risk of suicide. This is another great example of integration: A recovery intervention developed by a person who thrived while living with the condition has the scientific validity to promote the prevention of suicide.

Symptoms sometimes confuse people when we talk about recovery. Can a person be in recovery when they are still hearing voices? Some traditional medical practitioners might say no—that symptom control is what defines recovery. I think a more modern view says that recovery with an illness as opposed to only from an illness is possible. We don’t have cures in our field, so living with auditory hallucinations is likely to be part of life for those affected by them. I encourage people to maximize their biological return to minimize their symptoms, and to also find goals that they want to focus on, like love and work. Engaging in life fully is a way to embrace recovery, with or without symptoms.

Shared decision-making is another great example of how these models can be well integrated. For example, at my clinic, considering a change in medicine that is helping but is generating medical risk is a common dilemma. By looking at the science (and the limits of what we know) and incorporating what the person knows about their stresses, supports and capacity for risk, only then can a sensible collaborative course be charted. Recovery meets medical model again in the office. The key is to learn from all decisions scientifically and experientially.

Learning is one essential aspect of both the recovery and medical models. The recovery model emphasizes experiential learning and how that learning can be used to help self-manage and to offer support for a person on his or her journey. The medical model looks at levels of knowledge to see what can be reliably identified, validated and ultimately treated. Consequently, learning is a core thread that runs through both models. As long as we are all learning and using all the tools at our disposal, we are moving forward in our journeys.

Comments
LLF
I have been working in this field for a year now, and I honestly do not believe that this "recovery" model is even possible for most of my clients! How do you recover from a mental illness?? It is not like a broken leg or the flu you DO NOT recover from a mental illness!! You can train them to do the things they need to be more independent but without the 24hour supervision most with chronic and severe mental illness will never reach this level. BE realistic!!!
9/5/2016 3:13:19 PM

Troy
I don't know effective Mary Ellen Copeland's Wellness Recovery Action Plan (WRAP), but I really wonder why NAMI decided to list Ms. Copeland's plan as a recovery model, when upon perusing her website, you come across articles like this:

Reviving the Myth of Mental Illness
by Steven Morgan
http://mentalhealthrecovery.com/info-center/reviving-the-myth-of-mental-illness/

She is influential and I don't know why she would allow articles like this to be on her website unless she was in agreement that mental illness is a myth. Don't Scientology and their front group, Citizens Commission on Human Rights (CCHR) and other antipsychiatry groups say the same thing about mental illness being a myth?
2/12/2016 2:42:48 PM

Susan Inman
Dr Grant, your story is heartbreaking. We have had early psychosis intervention programs in Canada for many years and I have seen what a difference they make to the stability of people with the most severe mental illnesses. Here's a link to the toolkit used in the British Columbia (BC) programs:

http://www.earlypsychosis.ca/pages/resources/downloads

But, of course, often people have only been able to benefit from these programs because BC's mental health act, while not perfectly implemented, does enable many people to receive the help that they don't initially understand that they need.

I have been concerned about NAMI's interest in Open Dialogue; this is not the evidence based model used in Canada for early psychosis intervention. When I spend time exploring OD's literature, it appears to adhere to the kind of family blaming literature popularized by one of its heroes, Gregory Bateson. Anthropologist Bateson was sure that mixed messages from parents was a causal factor for schizophrenia.

http://www.taosinstitute.net/open-dialogue-approach-wksp

Canadian programs emphasize science based education for its clients and their families.

I write about mental illness policies from the perspective of family caregivers for people living with psychotic disorders. Here is a link to an archive of these articles:

www.huffingtonpost.ca/susan-inman/
5/6/2015 5:21:36 PM

Susan Inman
Dr Grant, your story is heartbreaking. We have had early psychosis intervention programs in Canada for many years and I have seen what a difference they make to the stability of people with the most severe mental illnesses. Here's a link to the toolkit used in the British Columbia (BC) programs:

http://www.earlypsychosis.ca/pages/resources/downloads

But, of course, often people have only been able to benefit from these programs because BC's mental health act, while not perfectly implemented, does enable many people to receive the help that they don't initially understand that they need.

I have been concerned about NAMI's interest in Open Dialogue; this is not the evidence based model used in Canada for early psychosis intervention. When I spend time exploring OD's literature, it appears to adhere to the kind of family blaming literature popularized by one of its heroes, Gregory Bateson. Anthropologist Bateson was sure that mixed messages from parents was a causal factor for schizophrenia.

http://www.taosinstitute.net/open-dialogue-approach-wksp

Canadian programs emphasize science based education for its clients and their families.

I write about mental illness policies from the perspective of family caregivers for people living with psychotic disorders. Here is a link to an archive of these articles:

www.huffingtonpost.ca/susan-inman/
5/6/2015 5:20:47 PM

Dr. R. Grant
Nice review by Dr. Duckworth, but I already knew most of that.

What helps me the most here is to read the validating thoughts of others that are virtually identical to ones I've been having and voicing for the past few years. Many members of my state NAMI don't seem to understand what I'm talking about anymore. Several of the family members who initially understood my situation have left the organization. I refer to the opinions voiced about how the Recovery Model is not very applicable to the most severely mentally ill, such as my now twenty-something child with (untreated again) childhood-onset sz and total anosognosia, and the problem of non-scientific\medical thinking on the part of some "mental health care providers" and NAMI leaders.

This by Susan Inman is a virtual paraphrase of a point I've made several times in the past couple of years: "NAMI was created by families to help the people with the most severe illnesses and it has strayed from this noble goal."

I've started to feel like an outlier in my state NAMI, the organization that provided the F2F course and support that helped save me, at least for a few years. (In return I have volunteered hundreds of hours teaching various NAMI courses and much more.) F2F materials still teach the bio-psycho-social model, but it's seeming to me like the bio part is progressively being abandoned due to some sort of wishful magical thinking that I as a general internist as well as a "family member" am having a tough time understanding and tolerating. I've come close to giving up on my state NAMI several times lately, despite an inspiring NAMI National annual conference in DC last fall and intend to start donating more to the TAC than NAMI.

I agree that it's very important to help those with the brain diseases known as serious mental illnesses who are not nearly as ill as my "mentally ill loved one," but I hope this will not result in abandoning the smaller number of the sickest of the sick.

One reason I'm still hanging in is because NAMI seems to embrace early intervention efforts during the prodrome\early phases. I started taking my "family member" to child psychiatrists in elementary school, but they dismissed my concerns. Long story, but he might not be as disabled and wretched had he received the early intervention for which I pleaded. I'll never know.
5/1/2015 12:14:21 PM

Donna Pitts
It is bewildering to me that so many people in the mental health field either do not know the horrors of unmedicated psychosis or they simply avoid talking about programs for the 4% because they just don't get it and don't care to. That's unfortunate. The lack of attention to the needs of the most severely symptomatic is responsible for headline after headline after headline of people with severe brain disease simply being shot dead. This is a problem. There is no diagram for this! No 2 cases of psychosis are alike. These programs are good for those who struggle day to day, just to cope. I'm sure they learn a lot and find comfort in the programs, even when they are at their most low emotional state because hope is so much a part of this recovery process. All the hope in the world didn't keep my son from having to get so psychotic and paranoid that he broke a law and was put in jail--the same as the remainder of the 11 million people who are routinely denied medical treatment. These models can not save my son from himself when he becomes psychotic. I'm sure he would spit at the very thought of sitting through a class with a bunch of people and he can't tell real conversation from the auditory hallucinations. No. It wouldn't work. It wouldn't have worked to save Senator Deeds' son, Gus. But you've done a good job of explaining how this could work for the seriously mentally ill. Can you provide a similar model for people whose psychosis is severe? I'll bet you could, and I would really like to see it because we who care for someone in the 4% are eager to bring comfort to our children, as we see them dying every day all across the nation, and sometimes when they are at home, we are witness to them dying just a little bit each day for lack of hope. You provide hope for your percentage of people with serious mental illness on issues specific to them. Thank you for doing this. Now, how about a little hope for the ones who are trying to stay sane and alive?
4/23/2015 7:49:40 PM

Julia Brower
some people with psychosis do not see themselves as ill (the neurological condition known as anosognosia), have not responded to treatment and have overwhelming symptoms. These individuals and their families may feel that the higher expectations fostered by the recovery model leave them behind. - See more at: https://www.nami.org/Blogs/NAMI-Blog/April-2015/Science-Meets-the-Human-Experience-Integrating-th.aspx#sthash.Vuq0kmR5.dpuf
The recovery model DOES leave the most severely ill behind. And by focusing almost exclusively on this model, organizations like NAMI And SAMHSA are leaving these individuals and their families feeling abandoned by the very people who are supposed to be helping them.
4/19/2015 9:01:33 AM

John Wilford
Great article overall. It explains the difference between the recovery and medical models very well and that both have their place in treatment for the mentally ill. While the medical model addresses the immediate needs, long term recovery models promote and provide the continuum of care necessary to prevent the recitivision of sufferers back through institutionalized organizations. Long term recovery models, such as the one provided by Clubhouse International are cost effective, evidenced based practices which are endorsed by Substance Abuse and Mental Health Services Administration of the United States Government. It is these types of strength based models that help make mental illness manageable and turn people with a mental illness into productive and contributing members of the communities that they live in.
4/18/2015 11:06:10 PM

John Harmon
Great article! Thanks so much for the clarifications on Recovery Model and Medical Model
4/17/2015 8:15:58 PM

Laura Pogliano
Unfortunately, those most severely affected, like my son was before he passed away, are not able to participate in recovery, but are pushed through a recovery model, with all kinds of non-medical ideas and non-proven "therapies" and his real need, for a medical treatment for a drastic brain illness, are secondary.
4/16/2015 11:29:59 AM

Susan Inman
It's very important that articles like this are written to help us all try to figure out what these two competing paradigms actually believe and how they impact services.

However, as the parent of a daughter who lives with a schizoaffective disorder and significant disabilities, I think the recovery model and its impact on the delivery of mental health services isn't receiving the careful scrutiny that is needed. This movement has been negatively impacting people with the most severe psychotic disorders and the families who are trying to help them. The recovery movements does not support:

> appropriate public education about science based ways of understanding psychotic brain disorders - This delays people's ability to access and maintain necessary medically based treatment.

> appropriate education about the medical model for peer support workers - Peers' over-reliance on their own lived experiences and frequent immersion in alternative thinking leaves them inadequately prepared to respond appropriately to people with the most severe psychotic disorders. I have seen and frequently hear about peer workers (who don't have actual brain disorders) undermine people's medical treatments and their relationships with supportive families. (I support the work of appropriately trained peer support workers.)

> the need for Assisted Outpatient Treatment for people who are too ill to understand that they need treatment

However, I want to focus attention here on NAMI's failure in recent years to promote one of the programs that can be the most useful in helping people with severe illnesses recover: supported volunteer work.

I was very hopeful when I opened NAMI's large project last year on "The Road to Recovery, Employment and Mental Illness." The document acknowledges on p.4 that "Studies show that most adults with mental illness want to work and approximately six out of 10 can succeed with appropriate supports." Okay. What about the 40% who can't succeed and whose needs aren't addressed in the recovery model's almost exclusive focus on paid employment? The recovery movement's advocacy for paid employment means that longstanding successful programs supporting volunteer work are losing funds; this has happened to the program in Vancouver, BC that has been offering my daughter crucial help. The recovery advocates have no problems with this since its leaders don't need these services themselves.

I am retaking NAMI's extraordinary Family to Family course which changed my life for the better 12 years ago. However, I was shocked last night to see some of the new material in Class 10 on "The Vision and Potential of Recovery." In avoiding any balanced analysis in its celebration of the leadership and direction of the recovery movement, this class is failing to alert family caregivers to the ways the recovery movement can make recovery much less likely for people with the most severe mental illnesses. NAMI was created by families to help the people with the most severe illnesses and it has strayed from this noble goal. A major low point for me was NAMI's recent Board President Keris Myrick visit to Canada in which she spoke about psychosis in ways that are
incompatible with a medically based understanding of mental illnesses. Her vision of psychosis, and its ability to leave people "weller than well" ignores the real needs of the people that NAMI is forgetting about.

http://www.huffingtonpost.ca/susan-inman/mentall-illness_b_5354545.html
4/15/2015 1:11:29 PM

Hakon Heimer
Bravo Ken! Thanks for taking on this ambitious task of reconciling two models that should not be thought of as mutually exclusive, but as complementary. Your column deserves a wide audience (we should all share it on our social media), and I hope it will generate much discussion. I only have one minor suggestion -- let's add the word "yet", to the statement, "We don’t have cures in our field." I truly believe that if we can get sufficient research resources, we can find treatments that do eliminate distressing voices, crippling anxiety, or crushing depression.
4/15/2015 10:10:54 AM

KAJ
Hopeful.
4/11/2015 4:26:39 PM

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