CanJPsychiatry 2014;59(5):233–235
The Canadian Journal of Psychiatry Volume 59, Number 5
May 2014
Guest Editorial
Introducing Recovery Rob Whitley, PhD1 1
Assistant Professor, Douglas Mental Health University Institute, McGill University, Montreal, Quebec. Correspondence: Douglas Mental Health University Institute, McGill University, 6875 LaSalle Boulevard, Montreal, QC H4H 1R3; [email protected].
Key Words: recovery, severe mental illness, schizophrenia, mental health services, inequity, recovery-oriented care, mental health reform Received and accepted February 2014.
T
he Mental Health Commission of Canada (MHCC) was created by the federal government in 2007; at that time, Canada was the only G8 country without a national mental health strategy.1 As such, one of the MHCC’s mandates was to recommend national mental health policy and strategy. After much consultation and discussion, the MHCC recently released its landmark document Changing Directions, Changing Lives: The National Mental Health Strategy for Canada.2 This recommends that mental health services and clinicians in Canada focus on the redefined concept of recovery. Provincial governments, including Quebec and Ontario, have also embraced recovery as a goal of mental health services.3,4 There is now a broad consensus across Canada that recovery must be a defining value and guiding principle for mental health services. This reflects an international paradigm shift across the English-speaking world; the United States, the United Kingdom, New Zealand, and Australia have also mandated that mental health services must focus their attention on the renewed concept of recovery.5–9 This paradigm shift raises various questions for psychiatrists and other mental health clinicians, the most basic of which is, what is recovery? Dr Robert E Drake and I explore this question in much more detail in the accompanying paper,10 thus only a brief summary is given here. In traditional epidemiologic and clinical terminology, recovery is generally operationalized as an outcome, defined as return to premorbid levels of health and functioning. Using such definitions, the pioneering research of Courtenay Harding and colleagues (see Harding and Zahniser,11 Hegarty et al,12 and Harding et al13) suggests that a substantial number of people with severe mental illness (SMI) achieve such recovery in the years following a first episode. Such evidence refutes the Kraepelinian perspective that mental illnesses such as schizophrenia are irreversibly chronic and progressively incapacitating.
Davison and Roe14 call this “recovery from mental illness”p 459 as it represents the traditional clinical definition of recovery. However, the concept of recovery has been stretched and enriched in recent decades to emphasize recovery as a process, or what Davidson and Roe14 call “recovery in mental illness.”p 459 This redefinition has been championed by consumer advocates such as Deegan,15 who notes that “recovery is not the same thing as being cured,”p 20 and instead involves being “in the driver’s seat of my life, I don’t let my illness run me.”16, p 10 This redefinition emphasizes recovery as a process, involving regaining a meaningful life in the community, with full participation in valued activities and social roles.17,18 As Dr Drake and I explore in the accompanying In Review paper,10 this redefinition emphasizes the importance of everyday factors, such as gainful employment, community www.TheCJP.ca
The Canadian Journal of Psychiatry, Vol 59, No 5, May 2014 W 233
Guest Editorial
integration, social support, and independent living, as essential components of recovery.19–21 All this is reflected in the MHCC’s broad definition of recovery, which states that: recovery involves a process of growth and transformation as the person moves beyond the acute distress often associated with a mental health problem or illness and develops new found strengths and ways of being.22, p 28 A second question raised by the shift toward recovery is, what is a recovery-oriented mental health service? The term recovery-oriented is frequently (over)employed to describe various interventions and approaches—the term investing such approaches with an appearance of advanced innovation and irrefutable value. However, just as naming a nation-state the Democratic Republic of Ruritania does not Ruritania a democracy make, simply labelling an approach recovery-oriented does not necessarily mean the approach promotes recovery. In making any claims about recovery orientation, scientific evidence must trump rhetoric. This scientific evidence is explored by both the papers10,23 in this in review section. The article by Dr Sean A Kidd, Dr Kwame J McKenzie, and Ms Gursharan Virdee23 examines the evidence regarding hospital and inpatient services, whereas my article with Dr Drake10 focuses on community-based services. For a community-based service to deserve the label recovery-oriented, Dr Drake and I10 argue that a discrete intervention must be proven to foster progress on the social and functional domains of life consistently identified by people with SMI as essential to recovery. For example, much qualitative research suggests that competitive employment and independent housing are desired outcomes for people with SMI. Thus interventions, such as supported employment and supported housing, can be considered recovery-oriented, inasmuch as there is substantial evidence that they are successful in helping people with mental illness reach these stated life goals.24,25 Broad approaches or guiding principles can also be assessed for their recovery orientation. For example, much research indicates that people with mental illness consider choice and autonomy within a mental health system as a vital feature of a recovery orientation. The principle of shared decision making within the clinical context is thus widely considered to be a recovery-oriented approach.26 Likewise, approaches that emphasize the strengths and capabilities of people with an SMI (rather than their deficits and weaknesses) are by definition taking a recoveryorientation.27 Such clinical approaches are unified by principles of patient choice, autonomy, empowerment, and growth. Much scholarship implies that systems that ignore these factors, and instead focus on containment, coercion, compliance, and segregation, cannot, by definition, be recovery-oriented. This is further explored in the In Review paper, with reference to in-patient settings, by Dr Kidd and colleagues.23 234 W La Revue canadienne de psychiatrie, vol 59, no 5, mai 2014
A third question raised by the paradigm shift is, what is the role for the psychiatrist in recovery? This is an under-researched and -explored question, with a widespread assumption that recovery is the domain of social workers, case managers, occupational therapists, vocational rehabilitation, clinical psychologists—in other words, anyone but the psychiatrist. This is a misleading perspective, as the psychiatrist can play a vital role in recovery, which is explored in both In Review papers in this issue.10,23 Common to all clinicians, the psychiatrist can take a recovery orientation simply by their basic stance toward the patient within the clinical encounter. Much scholarship indicates that recovery is promoted when clinicians adopt a respectful and hopeful attitude that supports patient choice, autonomy, empowerment, and growth.21 Such an attitude can perhaps be most beneficial in the medication management field, when patients are given choice and autonomy through a process of shared decision making. Shared decision making is an approach describing a collaborative endeavour between 2 experts (the patient and the psychiatrist) who share pertinent information and jointly determine the type, dosage, and extent of medication prescribed.26,28 It requires a conscious attempt to elicit patient preferences, as well as efforts at patient education vis-à-vis medication effects. Such an approach may not only improve adherence and service engagement through a strong therapeutic alliance. It can also ensure that medication is finely tuned to maximize symptom control and minimize side effects, allowing the patient the opportunity to live the kind of valued life they associate with recovery.29 Some literature suggests that systemic factors, such as time constraints in clinical encounters, high patient loads, limited availability of ancillary professionals, management resistance to change, and lack of training in recovery, can act as impediments toward a recovery orientation in psychiatry.30,31 As such, truly integrating a recovery orientation into psychiatry involves much more than attitudinal shifts among individual psychiatrists. Achieving a recovery orientation must involve systemic change as well as changes in medical education. In this sense, recovery is similar to other groundbreaking concepts, such as evidencebased medicine, where multi-level change is necessary for successful implementation. The 2 papers in this In Review section address many of the above issues in much more detail. Dr Drake and I10 review grounded notions of recovery derived from autobiographical accounts and qualitative research. We then assess the evidence to discern the extent to which such grounded notions of recovery are commonly achieved, while examining various interventions and approaches that purport to support recovery. Dr Kidd and colleagues23 examine the evidence regarding recovery-oriented practices and principles in inpatient wards and psychiatric hospitals. This is especially pertinent as it accounts for about 50% of mental health spending. Also, this is an underdeveloped literature, despite such settings often being the first point of system contact for new patients. www.LaRCP.ca
Introducing Recovery
Currently funded until 2017, the MHCC is continuing its various efforts to promote recovery, including a targeted anti-stigma campaign32 as well as an evaluation of the Housing First model for people with SMI (At Home/Chez soi).33 Likewise, numerous people across the country, including researchers, clinicians, health service managers, and consumer advocates, are working together to integrate the recovery paradigm into daily practice. These are exciting times for people working to promote recovery. It is my hope that the 2 papers in this In Review section will inform, educate, and stimulate critical thinking about recovery, ultimately leading to more recovery-oriented practice on the ground.
Acknowledgements
I thank Dr Eric Latimer for commenting on an earlier draft of this paper. The Canadian Psychiatric Association proudly supports the In Review series by providing an honorarium to the authors.
References
1. Kirby M. Mental health in Canada: out of the shadows forever. CMAJ. 2008;178(10):1320–1322. 2. Mental Health Commission of Canada (MHCC). Changing directions, changing lives: the mental health strategy for Canada. Ottawa (ON); MHCC; 2012. 3. Ministère de la Santé et des Services sociaux. Plan d’action en santé mentale 2005–10. Quebec (QC): Ministère de la Santé et des Services sociaux; 2004. 4. Open Minds, Healthy Minds: Ontario’s comprehensive mental health and addictions strategy. Ottawa (ON): Government of Ontario; 2011. 5. O’Hagan M. Recovery in New Zealand; lessons for Australia. Australian e-Journal for the Advancement of Mental Health: AeJAMH. 2004;3(1):1–3. 6. Hogan MF. The President’s New Freedom Commission: recommendations to transform mental health care in America. Psychiatr Serv. 2003;54(11):1467–1474. 7. UK Department of Health (DH). No health without mental health: delivering better mental health outcomes for people of all ages. London (GB): DH; 2011. 8. Department of Health and Aging. Fourth national mental health plan: an agenda for collaborative government action in mental health. Canberra (AU): Department of Health and Aging; 2009. 9. New Freedom Commission on Mental Health. Achieving the promise: transforming mental health care in America. Final report. DHHS publication no SMA-03–3832. Rockville (MD): Department of Health and Human Services; 2003. 10. Drake RE, Whitley R. Recovery and severe mental illness: description and analysis. Can J Psychiatry. 2014;59(5):236–242. 11. Harding CM, Zahniser JJ. Empirical correction of seven myths about schizophrenia with implications for treatment. Acta Psychiatr Scand. 1994;90(Suppl 384):140–146. 12. Hegarty JD, Baldessarini RJ, Tohen M, et al. One hundred years of schizophrenia: a meta analysis of the outcome literature. Am J Psychiatry. 1994;151:1409–1416.
www.TheCJP.ca
13. Harding CM, Brooks GW, Ashikagu T, et al. The Vermont longitudinal study of persons with severe mental illness, II: long-term outcome of subjects who retrospectively met DSM-III criteria for schizophrenia. Am J Psychiatry. 1987;144:727–735. 14. Davidson L, Roe D. Recovery from versus recovery in serious mental illness: one strategy for lessening confusion plaguing recovery. J Ment Health. 2007;16(4):459–470. 15. Deegan PE. Recovery and empowerment for people with psychiatric disabilities. Soc Work Health Care. 1997;25(3):11–24. 16. Deegan PE. Recovering our sense of value after being labeled mentally ill. J Psychosoc Nurs Ment Health Serv. 1993;31(4):7–11. 17. Anthony WA. Recovery from mental illness: the guiding vision of the mental health service system in the 1990s. Psychosoc Rehabil J. 1993;16(4):11–23. 18. Whitley R, Drake RE. Recovery: a dimensional approach. Psychiatr Serv. 2010;61(12):1248–1250. 19. Becker D, Drake R. A working life for people with severe mental illness. New York (NY): Oxford University Press; 2003. 20. Whitley R, Harris M, Drake RE. Safety and security in small-scale recovery housing for people with severe mental illness: an inner-city case study. Psychiatr Serv. 2008;59:165–169. 21. Davidson L. Living outside mental illness: qualitative studies of recovery in schizophrenia. New York (NY): NYU Press; 2003. 22. Mental Health Commission of Canada (MHCC). Toward recovery and well-being. Ottawa (ON): MHCC; 2009. 23. Kidd SA, McKenzie KJ, Virdee G. Mental health reform at a systems level: widening the lens on recovery-oriented care. Can J Psychiatry. 2014;59(5):243–249. 24. Bond GR, Drake RE, Becker DR. An update on randomized controlled trials of evidence-based supported employment. Psychiatr Rehabil J. 2008;31(4):280–290. 25. Nelson G, Laurier W. Housing for people with serious mental illness: approaches, evidence, and transformative change. J Sociol Soc Welf. 2010;37:123. 26. Deegan P, Drake R. Shared decision making and medication management in the recovery process. Psychiatr Serv. 2006;57(11):1636–1639. 27. Rapp CA. The strengths model: case management for people suffering from severe and persistent mental illness. New York (NY): Oxford University Press; 1998. 28. Adams JR, Drake RE. Shared decision-making and evidence-based practice. Community Ment Health J. 2006;42(1):87–105. 29. Deegan PE. The lived experience of using psychiatric medication in the recovery process and a shared decision-making program to support it. Psychiatr Rehabil J. 2007;31(1):62–69. 30. McHugo G, Drake R, Whitley R, et al. Fidelity outcomes in the national implementing evidence-based practices project. Psychiatr Serv. 2007;58(10):1279–1284. 31. Buckley P, Bahmiller D, Kenna C, et al. Resident education and perceptions of recovery in serious mental illness: observations and commentary. Acad Psychiatry. 2007;31(6):435–438. 32. Mental Health Commission of Canada (MHCC). Opening Minds: interim report. Ottawa (ON): MHCC; 2013. 33. Goering PN, Streiner DL, Adair C, et al. The At Home/Chez soi trial protocol: a pragmatic, multi-site, randomised controlled trial of a Housing First intervention for homeless individuals with mental illness in five Canadian cities. BMJ Open. 2011;1(2):e000323. doi: 10.1136/bmjopen-2011-000323. Print 2011.
The Canadian Journal of Psychiatry, Vol 59, No 5, May 2014 W 235
The Canadian Journal of Psychiatry Volume 59, Number 5
May 2014
Guest Editorial
Introducing Recovery Rob Whitley, PhD1 1
Assistant Professor, Douglas Mental Health University Institute, McGill University, Montreal, Quebec. Correspondence: Douglas Mental Health University Institute, McGill University, 6875 LaSalle Boulevard, Montreal, QC H4H 1R3; [email protected].
Key Words: recovery, severe mental illness, schizophrenia, mental health services, inequity, recovery-oriented care, mental health reform Received and accepted February 2014.
T
he Mental Health Commission of Canada (MHCC) was created by the federal government in 2007; at that time, Canada was the only G8 country without a national mental health strategy.1 As such, one of the MHCC’s mandates was to recommend national mental health policy and strategy. After much consultation and discussion, the MHCC recently released its landmark document Changing Directions, Changing Lives: The National Mental Health Strategy for Canada.2 This recommends that mental health services and clinicians in Canada focus on the redefined concept of recovery. Provincial governments, including Quebec and Ontario, have also embraced recovery as a goal of mental health services.3,4 There is now a broad consensus across Canada that recovery must be a defining value and guiding principle for mental health services. This reflects an international paradigm shift across the English-speaking world; the United States, the United Kingdom, New Zealand, and Australia have also mandated that mental health services must focus their attention on the renewed concept of recovery.5–9 This paradigm shift raises various questions for psychiatrists and other mental health clinicians, the most basic of which is, what is recovery? Dr Robert E Drake and I explore this question in much more detail in the accompanying paper,10 thus only a brief summary is given here. In traditional epidemiologic and clinical terminology, recovery is generally operationalized as an outcome, defined as return to premorbid levels of health and functioning. Using such definitions, the pioneering research of Courtenay Harding and colleagues (see Harding and Zahniser,11 Hegarty et al,12 and Harding et al13) suggests that a substantial number of people with severe mental illness (SMI) achieve such recovery in the years following a first episode. Such evidence refutes the Kraepelinian perspective that mental illnesses such as schizophrenia are irreversibly chronic and progressively incapacitating.
Davison and Roe14 call this “recovery from mental illness”p 459 as it represents the traditional clinical definition of recovery. However, the concept of recovery has been stretched and enriched in recent decades to emphasize recovery as a process, or what Davidson and Roe14 call “recovery in mental illness.”p 459 This redefinition has been championed by consumer advocates such as Deegan,15 who notes that “recovery is not the same thing as being cured,”p 20 and instead involves being “in the driver’s seat of my life, I don’t let my illness run me.”16, p 10 This redefinition emphasizes recovery as a process, involving regaining a meaningful life in the community, with full participation in valued activities and social roles.17,18 As Dr Drake and I explore in the accompanying In Review paper,10 this redefinition emphasizes the importance of everyday factors, such as gainful employment, community www.TheCJP.ca
The Canadian Journal of Psychiatry, Vol 59, No 5, May 2014 W 233
Guest Editorial
integration, social support, and independent living, as essential components of recovery.19–21 All this is reflected in the MHCC’s broad definition of recovery, which states that: recovery involves a process of growth and transformation as the person moves beyond the acute distress often associated with a mental health problem or illness and develops new found strengths and ways of being.22, p 28 A second question raised by the shift toward recovery is, what is a recovery-oriented mental health service? The term recovery-oriented is frequently (over)employed to describe various interventions and approaches—the term investing such approaches with an appearance of advanced innovation and irrefutable value. However, just as naming a nation-state the Democratic Republic of Ruritania does not Ruritania a democracy make, simply labelling an approach recovery-oriented does not necessarily mean the approach promotes recovery. In making any claims about recovery orientation, scientific evidence must trump rhetoric. This scientific evidence is explored by both the papers10,23 in this in review section. The article by Dr Sean A Kidd, Dr Kwame J McKenzie, and Ms Gursharan Virdee23 examines the evidence regarding hospital and inpatient services, whereas my article with Dr Drake10 focuses on community-based services. For a community-based service to deserve the label recovery-oriented, Dr Drake and I10 argue that a discrete intervention must be proven to foster progress on the social and functional domains of life consistently identified by people with SMI as essential to recovery. For example, much qualitative research suggests that competitive employment and independent housing are desired outcomes for people with SMI. Thus interventions, such as supported employment and supported housing, can be considered recovery-oriented, inasmuch as there is substantial evidence that they are successful in helping people with mental illness reach these stated life goals.24,25 Broad approaches or guiding principles can also be assessed for their recovery orientation. For example, much research indicates that people with mental illness consider choice and autonomy within a mental health system as a vital feature of a recovery orientation. The principle of shared decision making within the clinical context is thus widely considered to be a recovery-oriented approach.26 Likewise, approaches that emphasize the strengths and capabilities of people with an SMI (rather than their deficits and weaknesses) are by definition taking a recoveryorientation.27 Such clinical approaches are unified by principles of patient choice, autonomy, empowerment, and growth. Much scholarship implies that systems that ignore these factors, and instead focus on containment, coercion, compliance, and segregation, cannot, by definition, be recovery-oriented. This is further explored in the In Review paper, with reference to in-patient settings, by Dr Kidd and colleagues.23 234 W La Revue canadienne de psychiatrie, vol 59, no 5, mai 2014
A third question raised by the paradigm shift is, what is the role for the psychiatrist in recovery? This is an under-researched and -explored question, with a widespread assumption that recovery is the domain of social workers, case managers, occupational therapists, vocational rehabilitation, clinical psychologists—in other words, anyone but the psychiatrist. This is a misleading perspective, as the psychiatrist can play a vital role in recovery, which is explored in both In Review papers in this issue.10,23 Common to all clinicians, the psychiatrist can take a recovery orientation simply by their basic stance toward the patient within the clinical encounter. Much scholarship indicates that recovery is promoted when clinicians adopt a respectful and hopeful attitude that supports patient choice, autonomy, empowerment, and growth.21 Such an attitude can perhaps be most beneficial in the medication management field, when patients are given choice and autonomy through a process of shared decision making. Shared decision making is an approach describing a collaborative endeavour between 2 experts (the patient and the psychiatrist) who share pertinent information and jointly determine the type, dosage, and extent of medication prescribed.26,28 It requires a conscious attempt to elicit patient preferences, as well as efforts at patient education vis-à-vis medication effects. Such an approach may not only improve adherence and service engagement through a strong therapeutic alliance. It can also ensure that medication is finely tuned to maximize symptom control and minimize side effects, allowing the patient the opportunity to live the kind of valued life they associate with recovery.29 Some literature suggests that systemic factors, such as time constraints in clinical encounters, high patient loads, limited availability of ancillary professionals, management resistance to change, and lack of training in recovery, can act as impediments toward a recovery orientation in psychiatry.30,31 As such, truly integrating a recovery orientation into psychiatry involves much more than attitudinal shifts among individual psychiatrists. Achieving a recovery orientation must involve systemic change as well as changes in medical education. In this sense, recovery is similar to other groundbreaking concepts, such as evidencebased medicine, where multi-level change is necessary for successful implementation. The 2 papers in this In Review section address many of the above issues in much more detail. Dr Drake and I10 review grounded notions of recovery derived from autobiographical accounts and qualitative research. We then assess the evidence to discern the extent to which such grounded notions of recovery are commonly achieved, while examining various interventions and approaches that purport to support recovery. Dr Kidd and colleagues23 examine the evidence regarding recovery-oriented practices and principles in inpatient wards and psychiatric hospitals. This is especially pertinent as it accounts for about 50% of mental health spending. Also, this is an underdeveloped literature, despite such settings often being the first point of system contact for new patients. www.LaRCP.ca
Introducing Recovery
Currently funded until 2017, the MHCC is continuing its various efforts to promote recovery, including a targeted anti-stigma campaign32 as well as an evaluation of the Housing First model for people with SMI (At Home/Chez soi).33 Likewise, numerous people across the country, including researchers, clinicians, health service managers, and consumer advocates, are working together to integrate the recovery paradigm into daily practice. These are exciting times for people working to promote recovery. It is my hope that the 2 papers in this In Review section will inform, educate, and stimulate critical thinking about recovery, ultimately leading to more recovery-oriented practice on the ground.
Acknowledgements
I thank Dr Eric Latimer for commenting on an earlier draft of this paper. The Canadian Psychiatric Association proudly supports the In Review series by providing an honorarium to the authors.
References
1. Kirby M. Mental health in Canada: out of the shadows forever. CMAJ. 2008;178(10):1320–1322. 2. Mental Health Commission of Canada (MHCC). Changing directions, changing lives: the mental health strategy for Canada. Ottawa (ON); MHCC; 2012. 3. Ministère de la Santé et des Services sociaux. Plan d’action en santé mentale 2005–10. Quebec (QC): Ministère de la Santé et des Services sociaux; 2004. 4. Open Minds, Healthy Minds: Ontario’s comprehensive mental health and addictions strategy. Ottawa (ON): Government of Ontario; 2011. 5. O’Hagan M. Recovery in New Zealand; lessons for Australia. Australian e-Journal for the Advancement of Mental Health: AeJAMH. 2004;3(1):1–3. 6. Hogan MF. The President’s New Freedom Commission: recommendations to transform mental health care in America. Psychiatr Serv. 2003;54(11):1467–1474. 7. UK Department of Health (DH). No health without mental health: delivering better mental health outcomes for people of all ages. London (GB): DH; 2011. 8. Department of Health and Aging. Fourth national mental health plan: an agenda for collaborative government action in mental health. Canberra (AU): Department of Health and Aging; 2009. 9. New Freedom Commission on Mental Health. Achieving the promise: transforming mental health care in America. Final report. DHHS publication no SMA-03–3832. Rockville (MD): Department of Health and Human Services; 2003. 10. Drake RE, Whitley R. Recovery and severe mental illness: description and analysis. Can J Psychiatry. 2014;59(5):236–242. 11. Harding CM, Zahniser JJ. Empirical correction of seven myths about schizophrenia with implications for treatment. Acta Psychiatr Scand. 1994;90(Suppl 384):140–146. 12. Hegarty JD, Baldessarini RJ, Tohen M, et al. One hundred years of schizophrenia: a meta analysis of the outcome literature. Am J Psychiatry. 1994;151:1409–1416.
www.TheCJP.ca
13. Harding CM, Brooks GW, Ashikagu T, et al. The Vermont longitudinal study of persons with severe mental illness, II: long-term outcome of subjects who retrospectively met DSM-III criteria for schizophrenia. Am J Psychiatry. 1987;144:727–735. 14. Davidson L, Roe D. Recovery from versus recovery in serious mental illness: one strategy for lessening confusion plaguing recovery. J Ment Health. 2007;16(4):459–470. 15. Deegan PE. Recovery and empowerment for people with psychiatric disabilities. Soc Work Health Care. 1997;25(3):11–24. 16. Deegan PE. Recovering our sense of value after being labeled mentally ill. J Psychosoc Nurs Ment Health Serv. 1993;31(4):7–11. 17. Anthony WA. Recovery from mental illness: the guiding vision of the mental health service system in the 1990s. Psychosoc Rehabil J. 1993;16(4):11–23. 18. Whitley R, Drake RE. Recovery: a dimensional approach. Psychiatr Serv. 2010;61(12):1248–1250. 19. Becker D, Drake R. A working life for people with severe mental illness. New York (NY): Oxford University Press; 2003. 20. Whitley R, Harris M, Drake RE. Safety and security in small-scale recovery housing for people with severe mental illness: an inner-city case study. Psychiatr Serv. 2008;59:165–169. 21. Davidson L. Living outside mental illness: qualitative studies of recovery in schizophrenia. New York (NY): NYU Press; 2003. 22. Mental Health Commission of Canada (MHCC). Toward recovery and well-being. Ottawa (ON): MHCC; 2009. 23. Kidd SA, McKenzie KJ, Virdee G. Mental health reform at a systems level: widening the lens on recovery-oriented care. Can J Psychiatry. 2014;59(5):243–249. 24. Bond GR, Drake RE, Becker DR. An update on randomized controlled trials of evidence-based supported employment. Psychiatr Rehabil J. 2008;31(4):280–290. 25. Nelson G, Laurier W. Housing for people with serious mental illness: approaches, evidence, and transformative change. J Sociol Soc Welf. 2010;37:123. 26. Deegan P, Drake R. Shared decision making and medication management in the recovery process. Psychiatr Serv. 2006;57(11):1636–1639. 27. Rapp CA. The strengths model: case management for people suffering from severe and persistent mental illness. New York (NY): Oxford University Press; 1998. 28. Adams JR, Drake RE. Shared decision-making and evidence-based practice. Community Ment Health J. 2006;42(1):87–105. 29. Deegan PE. The lived experience of using psychiatric medication in the recovery process and a shared decision-making program to support it. Psychiatr Rehabil J. 2007;31(1):62–69. 30. McHugo G, Drake R, Whitley R, et al. Fidelity outcomes in the national implementing evidence-based practices project. Psychiatr Serv. 2007;58(10):1279–1284. 31. Buckley P, Bahmiller D, Kenna C, et al. Resident education and perceptions of recovery in serious mental illness: observations and commentary. Acad Psychiatry. 2007;31(6):435–438. 32. Mental Health Commission of Canada (MHCC). Opening Minds: interim report. Ottawa (ON): MHCC; 2013. 33. Goering PN, Streiner DL, Adair C, et al. The At Home/Chez soi trial protocol: a pragmatic, multi-site, randomised controlled trial of a Housing First intervention for homeless individuals with mental illness in five Canadian cities. BMJ Open. 2011;1(2):e000323. doi: 10.1136/bmjopen-2011-000323. Print 2011.
The Canadian Journal of Psychiatry, Vol 59, No 5, May 2014 W 235
