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The United States

The development of the recovery model can be traced to various parallel activities in the USA during the 1990s. Firstly, a number of consumer/sur- vivors with SMI wrote poignant and well-read personal memoirs detailing the lived experience of recovery (and barriers and facilitators thereof) from a first-person perspective (Mead and Copeland 2000). These memoirs appeared emblematic of the wider experience of people with SMI (Ridgway 2001). Perhaps most significant among these are the various writings of Patricia Deegan, which have played a major role in furthering understanding about the concept of recovery. Deegan notes that “recovery is not the same thing as being cured” (1997, p. 20) and instead involves being “in the driver’s seat of my life, I don’t let my illness run me” (1993, p. 10). A common theme running through these first-person perspectives is a desire to live an independent and autonomous life in the community, even in the presence of ongoing symptoms. Davidson and Roe (2007) call this “recovery in mental illness”.

Secondly, research stemming from rehabilitation science suggested that new interventions and supports can effectively facilitate this desire for independence and autonomy. For example, the development and refinement of supported employment interventions suggested that people with SMI, who had previously been written off as unemployable, could find gainful employment in the community (Mueser et al. 1997; Drake et al. 1996). Likewise, new models of supported housing indicated that people with SMI need not live in heavily monitored congregate housing settings, but instead could live independently without restrictive rules or on-site supports (Carling 1993; Tsemberis 1999). Common across these new interventions was a desire to facilitate autonomy among people with SMI, moving them away from a service-dependent lifestyle towards a normative life in the community.

Thirdly, a series of epidemiological studies indicated that as many as 40% of people with SMI show complete remission of symptoms 5-10 years after first onset (Harding and Zahniser 1994; Hegarty et al. 1994; Harding et al. 1987). These studies indicated that, contrary to popular belief, SMI is not by definition a chronic and deteriorating condition. Rather, clinical recovery as traditionally defined, is a common outcome for people living with SMI, with Davidson and Roe (2007) calling this “recovery from mental illness”.

Taken together, the above led to a formulation and understanding of recovery in the USA as living an autonomous and meaningful life in the community, rather than being an object of an overbearing and paternalistic mental health system. This is perhaps best encapsulated in the now seminal definition of recovery quoted at the beginning of this chapter, developed by Dr William Anthony from the Boston University Center for Psychiatric Rehabilitation (1993).

The concept of recovery has been officially endorsed in the USA through various governmental activities. Probably the most significant initiative in this regard is the 2003 New Freedom Commission on Mental Health. At the behest of President George W. Bush, this commission of experts surveyed extant US mental health services and wrote a report making a series of recommendations. The report noted that service delivery was fragmented and disjointed, which frustrated opportunities for recovery, and also noted that people with SMI suffered numerous inequities including very low rates of employment and overrepresentation among the homeless population. The commission argued that the system must be transformed to “ensure that mental health services and supports actively facilitate recovery” (Hogan 2003, p. 1), noting that “recovery refers to the process in which people are able to live, work, learn, and participate fully in their communities” (New Freedom Commission 2003, p. 5). Specific commission recommendations include individualized care plans and increased access to evidence-based practices including supported employment and supported housing.

This set in motion the transformation of many public mental health systems to provide better recovery-oriented services, with many states (e.g., Connecticut) now providing quality recovery-oriented interventions such as supported employment and supported housing. That said, many other systems continue to fall short of “achieving the promise” of recovery, and there is an acknowledged need for further reform to make systems truly recovery oriented (Drake and Whitley 2014).

Other assertive governmental activities have gone some way towards promoting recovery. The 1990 Americans with Disabilities Act (ADA) prohibits discrimination against an individual with a physical or mental disability, ensuring equity in areas such as employment. The US Supreme Court confirmed that mental illnesses were covered by the ADA in the landmark 1999 Olmstead Decision, which upheld the right of people with SMI to live in the community, demanding an end to unnecessary segregation in institutional settings. The Department of Justice, backed by both the ADA and the Olmstead decision, is now working to ensure that states enact this right in practice. Other legislative efforts considered to foster recovery include the Patient Protection and Affordable Care Act (2010), which aims to improve quality and expand access to health care for people with mental and physical illnesses.

In recent years, the literature on recovery in the USA has diversified to encompass previously under-researched factors. Much emphasis has recently been placed on the importance of peer support for recovery (Davidson et al. 2012). A peer supporter is someone with lived experience of mental illness who draws upon his or her own experience to help others with mental illness progress in life. Peer supporters can be paid or unpaid. Research suggests that peer support is highly valued by people with SMI and can promote various aspects of recovery including treatment adherence, physical health and illness self-management (Druss et al. 2010; Chinman et al. 2014).

Other recent research has focused on the role of religion/spirituality in recovery. Some studies have found that religiosity and a personal relationship with God can assist in recovery, especially where a person with SMI simultaneously suffers from substance use disorder (Corrigan et al. 2003; Fallot 2001). This may be especially amplified in minority communities, for example, African Americans, who have traditionally been disenfranchised from formal mental health care systems (Whitley 2012) and who may experience higher levels of racial oppression and stigma (Armour et al. 2009; Leamy et al. 2011). Interestingly, the theme of psychotropic medications is absent from much of the recovery literature in the USA which takes a decidedly psychosocial, rather than biological, bent.

To summarize, notions of recovery within the USA are diverse, which is unsurprising given the size and heterogeneity of the country. That said, there are some commonalities running through the conceptualization of recovery therein. Firstly, much emphasis has been placed on living an autonomous, productive and meaningful life within the community. This correlates with culturally valued notions of “rugged individualism” and the “productive citizen” (Myers 2010). Secondly, evidence-based interventions that encourage and facilitate such independence, such as supported employment and peer support, are frequently labelled “recovery-oriented” (Whitley et al. 2012). Thirdly, societal efforts to promote recovery have been mandated by various governmental activities including the President’s New Freedom Commission and the Supreme Court’s Olmstead decision. Recovery as commonly conceptualized in the USA could thus be considered an individual journey towards autonomy, facilitated by independence-promoting psychosocial interventions and robustly enforced social justice legislation.

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