Why the Need for Measures of Recovery?
Why would one wish to measure outcomes in mental health, and in particular, why would one wish to measure recovery? Trauer (2010, p. 99) pointed out that outcome measurement can be useful for several key stakeholders: good outcome measures can provide useful information that can assist managers to evaluate their services; likewise, clinicians, and importantly, consumers and their carers can benefit from good outcome measurement – outcome measures can be used to monitor consumer progress, while consumers and their carers can engage more fully in that process.
Finally, good outcome measurement can inform policy makers (Trauer, 2010). In Chapter 1 we posited that consumers are increasingly advocating for recoveryoriented mental health services (Acuff, 2000; Crowley, 1997; Curtis, 2001). Internationally, this notion has been incorporated into mental health policy, for example, in the United States (New Freedom Commission on Mental Health, 2003a, 2003b), Australia (Australian Health Ministers, 2003), New Zealand (Minister of Health, 2005), Ireland (Mental Health Commission, 2005), Canada (Mental Health Commission of Canada, 2009), United Kingdom (Cross-Government Strategy: Mental Health Division, 2009) and Israel (Ramon et al., 2009). In our own recovery research, we have fielded enquiries from Eastern and Western Europe, Scandinavia, Central Asia, South-East Asia and the Middle East. Although a number of countries have incorporated a recovery-orientation into policy, there is no definitive description of what this entails. Various policies highlight the need for a consumer orientation, fostering hope, meaning, fulfilment, an active sense of self, personal responsibility and resilience, and for promoting choice, social inclusion and rights (see Slade, 2009). An approach to recovery-focused practice, based on the processes of the stage model of psychological recovery, was provided by Slade (2009). The framework identifies and elucidates four tasks of mental health practitioners: to support hope by fostering relationships and social inclusion; to offer intervention options which foster self-management and personal responsibility; using the assessment process to support the person in finding meaning in their experience; and supporting identity and encouraging personal growth by promoting personal goal-planning and engendering hope (Slade, 2009).
In parallel with the movement towards recovery-oriented services, there is increasing pressure to use only evidence-based practices – those that have demonstrated positive effects on outcomes (Australian Health Ministers, 1992; New Freedom Commission on Mental Health, 2003a, 2003b; Mental Health Commission, 2005; Minister of Health, 2005; Cross-Government Strategy: Mental Health Division, 2009; Mental Health Commission of Canada, 2009). Some hold that the notion of evidence-based practice, as an outgrowth of evidence-based medicine, is incompatible with the recovery vision (Tanenbaum, 2005; Bonney and Stickley, 2008; Fisher and Happell, 2009). Often, treatment effectiveness studies have been conducted in relation to medications, and effectiveness has therefore been determined by measures of symptoms, hospitalizations and functioning. These types of outcomes may not fully represent the individual consumer’s definition of recovery, and do not reflect recovery-oriented approaches to treatment. For example, a self-admission to hospital may be the result of a person’s taking responsibility for his or her treatment, rather than a failure of treatment (Anthony, 2000). Tanenbaum (2005) questioned whether the elimination of symptoms without relieving suffering could be considered effective treatment, and found that consumers are likely to regard treatments – even those found to be effective in research – as merely tools to facilitate person-led recovery (Tanenbaum, 2008).
However, Torrey et al. (2005) and Silverstein and Bellack (2008) have countered that there are many evidence-based practices in use that are in keeping with the principles of recovery-oriented services, and that the two notions are complementary.
The key, according to those authors, is to use recovery-oriented principles in service provision; for example, giving information about treatments to promote informed choice. While this is certainly in keeping with the aims of the recovery movement, much evidence-based practice research has not been conducted within a recovery framework, and has not demonstrated substantial effects on consumeroriented outcomes (Anthony, Rogers and Farkas, 2003). The issue is with how ‘effectiveness’ is defined and what outcomes are measured (Tanenbaum, 2005).
There are two overarching arenas of outcome measurement: research, including investigations of the outcomes of schizophrenia and treatment effectiveness; and clinical assessment, which, in assessing individual outcomes, also informs the evaluation of services. Below we provide a brief overview of approaches to outcome measurement in these domains and how they are changing with the focus on recovery-oriented services.
Why would one wish to measure outcomes in mental health, and in particular, why would one wish to measure recovery? Trauer (2010, p. 99) pointed out that outcome measurement can be useful for several key stakeholders: good outcome measures can provide useful information that can assist managers to evaluate their services; likewise, clinicians, and importantly, consumers and their carers can benefit from good outcome measurement – outcome measures can be used to monitor consumer progress, while consumers and their carers can engage more fully in that process.
Finally, good outcome measurement can inform policy makers (Trauer, 2010). In Chapter 1 we posited that consumers are increasingly advocating for recoveryoriented mental health services (Acuff, 2000; Crowley, 1997; Curtis, 2001). Internationally, this notion has been incorporated into mental health policy, for example, in the United States (New Freedom Commission on Mental Health, 2003a, 2003b), Australia (Australian Health Ministers, 2003), New Zealand (Minister of Health, 2005), Ireland (Mental Health Commission, 2005), Canada (Mental Health Commission of Canada, 2009), United Kingdom (Cross-Government Strategy: Mental Health Division, 2009) and Israel (Ramon et al., 2009). In our own recovery research, we have fielded enquiries from Eastern and Western Europe, Scandinavia, Central Asia, South-East Asia and the Middle East. Although a number of countries have incorporated a recovery-orientation into policy, there is no definitive description of what this entails. Various policies highlight the need for a consumer orientation, fostering hope, meaning, fulfilment, an active sense of self, personal responsibility and resilience, and for promoting choice, social inclusion and rights (see Slade, 2009). An approach to recovery-focused practice, based on the processes of the stage model of psychological recovery, was provided by Slade (2009). The framework identifies and elucidates four tasks of mental health practitioners: to support hope by fostering relationships and social inclusion; to offer intervention options which foster self-management and personal responsibility; using the assessment process to support the person in finding meaning in their experience; and supporting identity and encouraging personal growth by promoting personal goal-planning and engendering hope (Slade, 2009).
In parallel with the movement towards recovery-oriented services, there is increasing pressure to use only evidence-based practices – those that have demonstrated positive effects on outcomes (Australian Health Ministers, 1992; New Freedom Commission on Mental Health, 2003a, 2003b; Mental Health Commission, 2005; Minister of Health, 2005; Cross-Government Strategy: Mental Health Division, 2009; Mental Health Commission of Canada, 2009). Some hold that the notion of evidence-based practice, as an outgrowth of evidence-based medicine, is incompatible with the recovery vision (Tanenbaum, 2005; Bonney and Stickley, 2008; Fisher and Happell, 2009). Often, treatment effectiveness studies have been conducted in relation to medications, and effectiveness has therefore been determined by measures of symptoms, hospitalizations and functioning. These types of outcomes may not fully represent the individual consumer’s definition of recovery, and do not reflect recovery-oriented approaches to treatment. For example, a self-admission to hospital may be the result of a person’s taking responsibility for his or her treatment, rather than a failure of treatment (Anthony, 2000). Tanenbaum (2005) questioned whether the elimination of symptoms without relieving suffering could be considered effective treatment, and found that consumers are likely to regard treatments – even those found to be effective in research – as merely tools to facilitate person-led recovery (Tanenbaum, 2008).
However, Torrey et al. (2005) and Silverstein and Bellack (2008) have countered that there are many evidence-based practices in use that are in keeping with the principles of recovery-oriented services, and that the two notions are complementary.
The key, according to those authors, is to use recovery-oriented principles in service provision; for example, giving information about treatments to promote informed choice. While this is certainly in keeping with the aims of the recovery movement, much evidence-based practice research has not been conducted within a recovery framework, and has not demonstrated substantial effects on consumeroriented outcomes (Anthony, Rogers and Farkas, 2003). The issue is with how ‘effectiveness’ is defined and what outcomes are measured (Tanenbaum, 2005).
There are two overarching arenas of outcome measurement: research, including investigations of the outcomes of schizophrenia and treatment effectiveness; and clinical assessment, which, in assessing individual outcomes, also informs the evaluation of services. Below we provide a brief overview of approaches to outcome measurement in these domains and how they are changing with the focus on recovery-oriented services.
