The recovery model and complex health needs: What health psychology can learn from mental health and substance misuse service provision

Introduction

The term ‘recovery’ seems to be the new buzz word in UK health service policies for substance misuse. Having been introduced to community mental health policies, the Drug Strategy (HM Government, 2010) now uses the term ‘recovery’ when ‘treatment’ would have sufficed a few years ago. Recovery approaches appear to be acknowledged in the intervention discourse in this field, with service users being supported to ‘choose recovery’ (May, 2010) while the necessary resources for recovery are claimed to be social, physical, human and cultural capital (Best and Laudet, 2010).

Recovery principles are based on individualised patient-centred values – what the individual sees ‘recovery’ to be – meaning ‘different things to different people’ (HM Government, 2010: 18). This implies that evidence for practice needs to be governed by outcomes determined by service users. Substance misuse represents a challenge to recovery principles because outcomes such as reduction in offending are currently based on the values of powerful stakeholders at government level and determined by evidence of what works for the minority who reach treatment (Bennett and Holloway, 2010; Tucker and Roth, 2006). The problem is that evidence-based practice (EBP) currently governs health service delivery favouring bio-medical positivist research while the recovery approach uses the values of end users and requires qualitative evidence. In their current form, the two appear to be incompatible. Recovery approach evidence is likely to come not just from academic forms of research but also through social action and advocacy. It is suggested here that the principles of EBP need to change in order to accommodate recovery principles and that health psychology has an important role to play in encouraging the development of evidence to support service transition to recovery.

The recovery model

The concept of recovery is significantly different from ‘cure’ or ‘remission’. The aim of recovery is defined by Browne as ‘helping people be who they are – not making them into what we believe they should be’ (Browne, 2006: 153).

Recovery model (RM) origins lie in the psychiatric survivor movement in the USA (Resnick and Rosenheck, 2006), which sees a diagnosis of schizophrenia as stigmatizing, dis-empowering and delivering a negative prognosis. The RM focuses on helping people lead more fulfilling lives even in the presence of symptoms, focusing on strengths instead of deficits. In clinical practice this is seen in humanistic and social terms with emphasis particularly on social inclusion, empowerment, hope and self-development (Jacobson and Greenley, 2001; Ramon, 1989). Recovery model processes are individualized – what is useful for the individual – and client-centred, based on a collaborative relationship between client and practitioner (Anthony, 2003a; Conner and Delaney, 2007).

A principal factor in support of the RM approach is the emergence of longitudinal evidence that schizophrenia in not as debilitating as once thought. Several long-term studies highlighted remarkable recovery rates among community patient cohorts (Harding et al., 1987; Harrison et al., 2001) whose health improvements were no longer being masked by in-patient institutionalization. World Health Organization studies across countries and cultures confirmed similar recovery rates and demonstrated that long term recovery is not due to improved medical treatment. Developing world patients with limited access to medications showed better recovery rates than patients in industrialized countries who received specialist psychiatric care and were socially disabled by being in contact with mental health services (Harrison et al., 2001; Jablensky et al., 1992).

The introduction of recovery as a model in mental health services in the USA and the UK had a shaky start as the principles of patient-centred values were poorly understood and debate ensued as to whether professional health providers should get involved (Chamberlin, 1990). A barrier to adoption of recovery principles is the incompatibility with the epistemology of EBP which is still based on a positivist value system while the recovery movement is clearly about action and self-determination. The original principles of the RM could address some of the service access problems of those with chronic substance dependence but EBP currently does not accommodate recovery approach evidence.

The problem of evidence-based practice

Evidence-based practice is promoted as needing to favour positivist and reductionist methodologies over expansive and inductionist evidence (Sackett et al., 1996). It therefore assumes sophistication in pre-existing knowledge around health research; which factors will be examined as influences and outcomes. Reductionist methodology simplifies complex aetiological factors of sociologically derived health problems by collapsing variables, making assumptions of representativeness and using proxy variables to represent target factors. For example, a street-living 19-year-old heroin user from a rural middle-class family is likely to be reduced statistically to an under 25, low socio-economic status, inner-city population group, while having very different characteristics and service needs to someone more represented by those demographics. The EBP hierarchy also systematizes the process of information management from primary research to the practice area. Reliance on the systematic review compounds the errors in reduction of data through a process of eliminating the context of the primary studies from the findings (MacLure, 2004; Pearson and Coomber, 2010).

By both these processes, the EBP hierarchy ensures that only known factors are addressed and results are majorative; they only apply to the majority of homogenous patient populations that are included in the evaluation. This excludes those with poor access to the evaluation process, those with contributory factors that are unexplored and those who are either relative minorities among patient groups or grouped into heterogeneous patient groups due to social and research convention (i.e. by gender, race, age). This process also reduces the richness of the data including the context of the health problem and its resolution. By eliminating contextual information from the systematic review, the evidence loses something important to patients who live with the context of their health problem. In a review for the UK Health Development Agency, Marks (2002a) suggests the narrowness of the evidence base and the lack of more inclusive methods are among several key reasons why EBP will struggle to provide genuine health care improvements. Marks notes that the slowness of EBP adoption in practice suggests that EBP as it stands does not meet practice needs.

However, change may be on the way. Health challenges are being seen increasingly from a wider sociological health perspective as problems become more complex than can be accounted for in a simple agent-environment disease model, and health psychology can contribute to widening the health agenda. Marks (2002b) and Murray and Poland (2006) suggest critical health psychology addresses a wider base of factors such as power, politics and social exclusion and suggest that health psychologists need to become more socially active. Prilleltensky (cited in Fox, 2008) calls for critical psychology to bridge the gap between theoretical critique and activist psychology to empower the population towards improved health and well-being, to generate effective tools to counter oppression and move beyond critique towards action. Kelly et al. (2010) push bio-medical EBP further into the public health realm by explaining why the UK’s health advisory agency, the National Institute for Health and Clinical Excellence (NICE), will include social and psychological evidence and widen the evidence base for policy guidelines. They touch on the bigger picture for health psychology by recognizing the ‘length of the causal chain in public health’ (Kelly et al., 2010: 1060) and use the prevention of hepatitis C among injecting drug users as an example of the need to address social, behavioural, environmental and political contexts of vulnerability.

Substance misuse and evidence-based practice

People with problem substance use are not easily categorized, nor is their ‘disease type’ homogeneous. The biological element of effect and dependence is qualified by the person’s psychological strength, motivation, social support and developmental needs. The contextual factors for the ‘disease’ of substance misuse are unique to each individual (Tucker and Roth, 2006). According to Gitlow (2007) treatment effectiveness studies using quantitative medical approaches often record high treatment failure and only provide misleading evidence that addicted patients are difficult to treat. Tucker and Roth (2006) attribute the research problems in substance misuse to three factors: that substance misuse is a long-term problem with causal and maintaining factors spanning a wide contextual spectrum, that research focuses too much on behavioural change and that policy-makers and practitioners focus on treatment delivery instead of treatment engagement.

Substance misusers in treatment are a small minority of the potential treatment population, so evidence based on treatment cohorts not only measures just the tip of the iceberg, but represents the wider user population disproportionately. Certain user populations either do not enter treatment or are over-represented in patient populations. Rassool (2006) reports that South Asian, Indian, Black and Caribbean communities and women are increasingly represented in substance misuse prevalence rates but are not similarly recognized in treatment. Luger and Sookhoo (2005) report the particular barriers to drug treatment for black and ethnic minority users are commonly family and community stigma, drug service links to the Home Office, language barriers and the disproportionate diversion of African and Afro-Caribbean drug users to mental health services. They also found that substance misuse services were perceived as ‘run for white people by white people’ (Luger and Sookhoo, 2005: 168). Women also have their own reasons for poor treatment engagement and retention such as fear of a male controlling partner or losing contact with children, involvement in the sex industry and treatment provision based on evidence from a male majority (Greenfield, 2002; Olszewski et al., 2009). There is also concern for substance misusers with co-morbid mental illness who often fall between the two stools of mental health and substance misuse service provision. These clients state a need for integrated care but service providers still present a ‘ping-pong’ effect for the clients with separate care pathways to treatment (Lawrence-Jones, 2010).

There is limited evidence explaining barriers to treatment engagement or what provision would improve engagement and treatment adherence. Evidence of what works is very limited for ‘hard-to-reach’ populations who tend to be minority groups, either in number or power such as black and minority ethnic (BME) groups, women or young males. Substance misuse service evidence is in the early stages of identifying its missing user populations, and, with high rates of treatment drop out and non-engagement, evidence based on treatment populations is unlikely to be representative of the majority of individuals with a substance misuse need. Therefore, evidence-based practice currently does not address the general substance-misusing population because the ‘missing’ data, the people not in treatment, are likely to make up a substantial core of this population (Tucker and Roth, 2006). Unfortunately, the methodologies needed to access this population tend to be de-valued by the bio-medical hierarchy of evidence. Substance misuse provision planners need bottom–up, inductive evidence providing knowledge of what prevents people considering treatment, changing behaviour or dropping out of treatment. Inductive evidence from personal testimony is more likely to provide this baseline evidence from which more reductionist methods can work without excluding key elements influential in the engagement and treatment process. Marks (2002a) argues for critical realist, constructionist and pragmatic approaches, suggesting that a clinician needs knowledge about the patient’s condition, current evidence for treatment and empathy for the patient’s values. For Dworkin (2005), Lambert (2006) and Prins (2006), anthropological and ethnographic methods would provide this type of evidence. Murray and Poland (2006) and Tucker and Roth (2006) suggest that social action and practice experience will also contribute valuable insights. As Marks notes, choice of research approach should be based on the purpose of the research not the epistemological assumptions of the research.

Qualitative evidence is a priority for substance misuse health care

Policy-makers and their agents may be getting the message that the more useful evidence comes from service users and potential service users. In 2007 the UK’s National Treatment Agency (NTA) sponsored service users to attend the International Conference on Reduction on Drug Related Harm with a view to identifying evidence-based good practice initiatives from around the world and using responder validation to test top–down ideas. The conference report, ‘Nothing about Us without Us’ (NTA, 2007) highlighted the gap between providers and service users. In one example, the service user team identified the need for peer-led outreach initiatives for treatment-excluded vulnerable groups: ‘Most [drug treatment] programmes are for heterosexual male drug users which can be intimidating … We need to develop programmes and policies that address the issues that exclude women, men who have sex with men and transgender clients’ (NTA, 2007: 16).

Ideas have been mooted that EBP needs to encompass context and inductive evidence in order to improve applicability to individuals. Tucker and Roth (2006) suggest evidentiary pluralism should be the different gold standard for EBP. The adoption of a form of qualitative systematic review in realist synthesis is proposed by Pawson and Bellamy (2006) as a means to incorporate qualitative evidence into an integrated framework of evidence. The European Monitoring Centre for Drugs and Drug Addiction (EMCDDA) includes qualitative research in its drug misuse epidemiology programme, recognizing the need for the development of rational policies based on useful knowledge (EMCDDA, 2000). The clandestine nature of drug use begs for ethnographic methodologies to bring to light the meaning of drug use in context-based cultures (Rhodes, 2000). The EMCDDA recognizes that qualitative evidence is missing from drug control and treatment policies and that qualitative methods offer flexibility in research otherwise governed by statistical, clinical or biomedical methods. Qualitative approaches such as small-scale ethnographic studies have demonstrated practice effectiveness, for example, providing harm reduction services in keeping with new drug injecting trends in Holland (Cramer, 2000), and localized action research targeting Asian drug users which significantly increased the number of Asians entering a treatment service in London (Patel, 2000). The qualitative contributions from those examples indicate that contextual and timely knowledge can impact on practice by obtaining the relevant situational evidence rather than generalizable and majorative evidence.

The recovery model and substance misuse

Tucker and Roth (2006) recommend that evidence for substance misuse service provision needs to focus on the processes of service engagement for individuals rather than disease and care-based outcomes. These ideas are suggested by recovery model proponents like Anthony (2003b), who points out that randomized controlled trial (RCT) studies focus on the outcomes of controlled interventions but do not control the processes. For example, variables between clinicians, environments or client needs, are randomized out of RCT results when they could be the factors that enlist engagement and effectiveness. He proposes that, to incorporate the RM into EBP, the processes rather than the outcomes should be studied so that client- and context-based factors become part of the evidence that informs practice. This is supported by O’Conner and Delaney (2007) who point out that the RM itself is about the process of recovery, not a model with outcome goals.

Barriers to change

The World Health Organization’s Ottawa Charter (WHO, 1986) indicates that health and well-being is not just about absence of disease but the presence of factors that enable someone to live healthily. This notion resonates with the recovery model focus on strengths rather than deficits. For socially disenfranchised people, these positive elements to their health status need also to be recognized and addressed. In mental health practice there has been a change in emphasis of care for severe and enduring conditions such as schizophrenia from medical model symptom management to psychosocial care and a focus on quality of life (Jacobson and Greenley, 2001; NIMHE, 2005). A developing focus on community-based psychology (Burton et al., 2007), has facilitated a change in care philosophy emphasis from behavioural to humanistic, from disease to social and psychosocial health, from provider-based values to user-based values and from a deficit view of disability to a recovery approach. There are also green shoots of recovery principles appearing in the substance misuse field, while the same arguments for RM principles can be seen to apply to other enduring and socially complex health problems such as asthma, diabetes, rheumatoid arthritis and cardiac disease (Shepherd et al., 2008).

There is a danger however that EBP will water down the principles of RM so that it becomes another ‘medical model’ tool in all but name. Evidence-based practice is a strong organizing force that currently supports a bio-medical approach to health care. For Griffiths (2005) EBP can be critiqued on the basis of its assumptions and contexts of power rather than the hierarchy of evidence and its consequences. This view identifies the problem that others have with EBP in its inflexibility and exploitation; EBP is not a force in itself but is a convenient and effective tool in power relations.

For some, EBP confers administrative power to managers through economic/fiscal control of health care. In countries with state supported health care, EBP aids governments in restricting medical authority (Rappolt, 1997; Mykhalovskiy and Weir, 2004). In the UK, the NHS has seen a sea-change in health administration, with control switching from clinical to administrative managers, supported by health directives, targets and NICE guidelines (Lambert, 2006; Niessen et al., 2000; Williams and Garner, 2002). In the USA, fiscal control is seen to be in the interests of private providers (Rodwin, 2001). Arguably, EBP in a privatized health system benefits health insurance companies through control of treatment options, and pharmaceutical companies which can produce RCT evidence for their products, and have a commercial interest in promoting this evidence to practitioners and patients (Moncrieff, 2007; Read, 2005).

Potential service users may have an ally in the policy-makers who have aims more in keeping with service users than current evidence providers. Davies (2006) argues that policy-makers not only need answers to broad questions about what works but how to make it work in different environments and contexts. Policy-makers need evidence of implementation across and within localities that mirrors the devolution of policy making. This may be especially so in substance misuse services in the UK which have a devolved policy and planning structure to meet local needs in substance misuse (HM Government, 2010; Home Office, 1998), often characterized specifically in different geographical areas. For example, ‘recreational’ use poses greater health service and anti-social problems in holiday and weekend party environments, whereas areas with high unemployment present problems with drug-related acquisitive crime and high heroin overdose rates (Ghodse et al., 2001).

Many of the critics of EBP have identified the de-powering of the individual clinician and the threats to patient choice and involvement. Interestingly, some commentators see control being taken away from the individual clinician but being invested instead in the medical corporate institution, believing that an entity so involved in health care will maintain control by adopting and embracing EBP; that the ‘real’ battle for control is between medicine and the State (Freshwater and Rolfe, 2004; Mykhalovskiy and Weir, 2004). In such a conflict, it could be that the patient becomes just so much collateral damage. Health psychology is currently on both sides of this divide; providing evidence-based behaviour change models that fit into the agent–disease model, and critiquing the socio-political environment of health and well-being (Leventhal et al., 2007; Marks, 2002b).

A critical health psychology perspective

Complex social health problems such as substance misuse, diabetes and coronary heart disease are influenced by the much neglected third aspect of the bio-psychosocial model of health and illness. They are determined by social, cultural and politico-economic influences that govern behaviour, negate choice and determine lifestyle (Marks, 2002b). Substance misuse health threats can be argued to be largely socio-cultural and politico-economic, as the development of drug misuse is shown to have strong links to environmental exposure and social and familial vulnerability (Fergusson and Horwood, 1997; Pudney, 2002). Substance misuse exposes people to major mortality and morbidity risks, is socially and economically disabling and is difficult to provide for because of proscription, stigma, social exclusion and poor access to health resources. As a lifestyle category of health, it can be seen that, for some, strategies to change those aspects of health can be effective; that those with access to rehabilitation and treatment reduce their mortality and morbidity risks. However, this accessible group of substance misusers is in the minority and the unseen majority provides the evidence that the social and environmental contexts are key influences of health for this population (Gitlow, 2007).

There is a danger that those with complex health problems could also be defined by their falling outside the moral imperative of the good citizen whereby the behaviour judged as unhealthy continues, and yet the person or patient group is perceived to be able to change. Those people outside the moral norms of health behaviour, that is, the alcohol dependent, injecting drug users (IDUs), heroin-addicted sex workers, become doubly damned. Marks (2002a) suggests that a bio-medical approach makes naive assumptions of behaviour change, based on lay knowledge and that health promotion reinforces the notion that it is simply a matter of improving education and motivation. While health promotion focus remains on behaviour change, those who cannot respond to health promotion strategies at this level are at risk of being stigmatized and experiencing yet another access barrier to health. This is because wider social, cultural and political contexts are not taken into account in society’s model of health, and the lives of non-engaged substance misusers are poorly understood. Behaviour change is currently a major health policy in the UK and possibly fuelled by the promise of evidence that the tools exist to make it effective. Health psychology focuses a great deal on behaviour change models and promotes research that shows effectiveness in psychological strategies to change individual lifestyle choices. But policy-makers and outreach practitioners need to know also about ineffectiveness; when brief intervention, motivational interviewing and cognitive behavioural therapy do not work.

This current EBP era of health provision, while established on the agent–disease model of understanding, cannot address the health needs of the complex health challenges because it asks the wrong questions. Additionally, the focus on behaviour change effectiveness reduces the vision of practitioners because all-singing, all-dancing interventions such as motivational interviewing and brief intervention exist and work for some, but those for whom treatment access is impossible or those who fail treatment remain disempowered (Dalton et al., 2008). Indeed, cognitive and behaviour change approaches have put on the clothes of medical model EBP by adhering to the hierarchy of evidence criteria of what works, not how it works and why it does not work.

A role for health psychology

The development of RM in certain mental health services is seen as a qualified success in the UK (Shepherd et al., 2008) but still faces certain challenges. A key challenge is aiding the transformation of health services from a medical to a user-led culture. This is a radical change that may meet resistance or organizational absorption. The juggernaut that is EBP medicine is the threat to genuine RM service development. Shepherd et al. (2008) suggest that effective transformation needs staff training, user-led recruitment practices and a self-reflective audit system led by RM principles. This may be where a key problem lies as determining standards for audit may be the very medical-model procedures that RM services need to avoid. It may depend on who identifies the standards, how they are measured and by whom. Doubts exist among practitioners about the political agenda of implementing EBP around cost and efficiency and effort to impose transformation through staff training does not of itself overcome current opinion-based practice (Marks, 2002a; Williams and Garner, 2002). Examples of transforming mental health services exist in the USA (Ashcraft and Anthony, 2005), and the UK (Perkins et al., 2010), supported by the psychiatric, occupational therapy and clinical psychology professions, in partnership with service users (i.e. Recovery Devon, 2011). There is a clear role for health psychology to take up the baton from mental health RM innovation to engage in social action, advocacy and the production of user-oriented research evidence and tools to promote change in service provision in long term and lifestyle illness management.

Conclusion

It is argued here that a sea-change in chronic health challenges in mental health fields towards RM principles provides a model for service transition in substance misuse and many other socially complex chronic health problems. Health psychologists are well placed to promote this change across these areas of health. However, this role must also address the barriers to the transition of services towards recovery principles which are argued here to be particularly the ethos of EBP; the wider problems of power and health service provision and the role EBP has currently in empowering a medical approach to health.

Freshwater and Rolfe (2004), Lambert (2006), Neissen et al. (2000) and Prilleltensky (2003) all caution against doing nothing because of the danger that the default position of medical dominance will soon revert because of the power inherent in health institutions and their allies (governments, private health providers and third party payers). However Mykhalovskiy and Weir (2004) see EBP providing a new arena for social sciences within medicine; not dominated or sidelined by medicine and medical/biological methodologies. Social science including health psychology can and should provide the perspectives on the ‘discursive preconditions’ of EBP (Mykhalovskiy and Weir, 2004: 1060), include the context of the patient and provide methodologies and philosophies with which to critique bio-medical evidence and provide multiple perspectives (Marks, 2002a). The Ottawa Charter promises to expand health responsibility to multiple agencies working in an intersectoral approach. Evidence-based practice could be seen as opening doors for a wider research remit and is, perhaps, only governed by medicine because of its origins. Substance misuse and mental health agencies are developing an expansion of perspectives driven by a need to tackle social problems that will not go away. The field is open for health psychology to consider the wider factors such as context and environment, driven by changes in the concept of health and its widening parameters. Health psychologists can contribute to this expansion by widening their remit and helping to make recovery principles and evidence-based practice more compatible. The advent of recovery principles provides an opportunity to develop research methods for social action, user-based evidence and advocacy. These approaches to recovery are process focused and do not lend themselves easily to outcome-based medical methodologies. They do however provide social scientists and advocates the opportunity to use qualitative approaches to explore contexts and processes of complex health management.