What Is Recovery?

The most proximal predecessor of the recovery movement is the consumer/survivor/ex-patient movement of the 1970s, a social movement that stood in opposition to the medical model of mental illness (Bassman, 2001). This antipsychiatry movement sought to give voice to former psychiatric patients who felt silenced and disenfranchised by the system intended to serve them, with the goal of liberation. Professionals, or nonpatients, were excluded, and groups such as the Insane Liberation Front formed around the goals of activism and the development of mutual-help alternatives to professional services (Chamberlin, 1990).

Recovery stemmed from these earlier movements, but diverged. Individuals in the recovery movement also sought social justice and hoped to empower individuals by rejecting the labels of mental illness that were often accompanied by poor prognoses given to them by professionals. Recovery supported the capacity of individuals to redefine their lives and find meaning regardless of the symptomatic and functional effects of mental illness. Like those in the consumer/survivor/ex-patient movements, leaders in the recovery movement used social activism and mutual-help as tools. However, instead of liberating individuals from the system, many recovery leaders sought to change the mental health system to be consistent with these values. This included those who obtained professional mental health degrees (Frese & Davis, 1997), published in academic journals to educate professionals, and collaborated with mental health professionals both for work and for their own care (Deegan, 1997; Mead & Copeland, 2000). This opened the door for well-intentioned professionals who had been previously excluded from the consumer/survivor/ex-patient reform efforts to join the cause.

Although many are still fundamentally opposed to the medical model (Braslow, 2013), today most efforts to implement recovery are either within or parallel to medical model services, rather than in replacement of them. The modern mainstream recovery movement seeks to reform the existing mental health service system to increase the focus on strengths and resilience (Anthony, 2000; Braslow, 2013; Resnick & Rosenheck, 2006). In spite of widespread acceptance of the broad goals of the recovery movement, there remains a great deal of variability about the definition of recovery itself. There is no consensus as to a singular definition of the recovery concept (Gordon, 2013; Onken, Craig, Ridgway, Ralph, & Cook, 2007).

Recovery and Positive Psychology as Mainstream Movements

The growth of the recovery movement from the radical movements of the 1970s is similar to the growth of positive psychology from humanistic psychology. Some point to the humanistic psychology movement of the 1950s and 1960s as the precursor to the positive psychology movement. The positive psychology movement and the humanistic psychology movements share a focus on helping individuals strive toward growth and the promotion of optimal functioning (Bohart & Greening, 2001). However, the humanistic psychology movement saw the medical model approach of labeling and categorizing mental illnesses as inconsistent with the larger goal of promoting an understanding of the whole person (Joseph & Linley, 2006). Humanistic psychologists also worked toward scientific inclusiveness, broadening the scientific methods that captured the range of human experience, including qualitative methods (Friedman, 2008; see also, Robbins, Chapter 3, this volume). Although the movements are similar in some ways, founders of the emerging positive psychology movement initially sought to differentiate it from these two fundamental humanistic elements. Although the extent of the overlap between positive psychology and humanistic psychology continues to be debated, the positive psychology movement as a whole continues to operate within the medical model (Joseph & Linley, 2006), to the disappointment of some who seek a fuller embracing of the humanistic philosophy. These positive psychologists fully reject the medical model, the notion of diagnosis, and the incorporation of psychology as part of the pathology-oriented health-care field, and instead support a wholesale change in ideology (Maddux, 2005; Maddux & Lopez, Chapter 25, this volume). Like those in the consumer/survivor/ex-patient movement, these psychologists seek a revolution. However, this continues to be a minority view. If the recovery movement is the modern mainstream adaptation of the consumer/survivor/ex-patient movement, the positive psychology movement is perhaps the modern mainstream adaptation of humanistic psychology.

For the purposes of this chapter, we remain agnostic on the fundamental issues of the dominance of the medical model, and whether these movements are sufficient for true reform (for two thoughtful discussions of recovery in this context, see Braslow, 2013, and Hopper, 2007). Instead, we acknowledge our mainstream perspective as well-intentioned professionals working with a medical model system, and seek to speculate on how some of the best of the positive psychology movement might inform the development of a mental health system consistent with the goals of the recovery movement, which, for lack of a better term, we refer to as a recovery-oriented mental health system.

A system is more than a group of service providers and programs. It may consist of individual programs staffed by a group of providers, but a system is more than the sum of its parts (Litaker, Tomolo, Liberatore, Stange, & Aron, 2006; Rosenblatt, 2009). From the bottom up, a system of care has at least three levels: (1) the individual client level, (2) the program, and (3) the system itself. In the first section of this chapter, we describe how recovery on the individual level, roughly equivalent to the first two pillars of positive psychology (subjective experience and positive characteristics) might benefit from positive psychology interventions. We then turn to the much less explored level of organizations and institutions, and hypothesize how the study of positive institutions and positive psychology in the workplace might foster recovery-oriented service systems. The third pillar of positive psychology, the study and development of positive institutions, may also provide useful tools for conceptualizing and developing recovery-oriented mental health systems.

Given the diversity of thought in mental health reform movements, it is no surprise that there is no singular term used to describe people who receive mental health diagnoses and/or receive services from mental health programs. In this chapter we use the simple term individual to refer to this group of people wherever possible, occasionally adding in mental health systems when necessary for clarification.

Positive Interventions in a Recovery-Oriented System

Positive psychologists have developed a range of positive interventions that aim to increase pleasure, engagement, and meaning in life. Such interventions may be useful for individuals in mental health systems, though they have typically only been applied with nonclinical populations. Many, over 100 (Seligman, Steen, Park, & Peterson, 2005), such interventions have been developed. An extensive review of these interventions is outside the scope of this chapter and can be found elsewhere (e.g., Bolier et al., 2013; Seligman et al., 2005; Sin & Lyubomirsky, 2009). This section highlights three common tenets of positive interventions and recovery, and how positive interventions might inform recovery-oriented treatment.

There are at least three principles shared between positive interventions and recovery: (1) Mental illness and well-being are not mutually exclusive; (2) interventions can and should be expanded beyond the traditional scope of psychiatric care; and (3) individual differences should be important factors in treatment. By highlighting these three overlapping values we hope to support the view that positive interventions can guide treatment planning for the creation of positive, recovery-oriented therapeutic interventions.

Evidence for Positive Interventions

Interventions targeting hope and positive self-beliefs are likely candidates for translation to a recovery paradigm. Several studies have highlighted the important role that hope and self-esteem play in contributing to recovery outcomes. Specifically, hope and self-views influence recovery from psychosis (Hodgekins & Fowler, 2010). Low self-esteem has been associated with the development of delusions and hallucinations in individuals with psychosis (Romm et al., 2011), and less hopeful illness beliefs are associated with poorer quality of life for those with early psychosis (Theodore et al., 2012). Given that recovery outcomes may be better for those with more hope and positive self-schemas, the inclusion of positive interventions to promote hope and self-esteem in recovery-oriented treatment could improve outcomes for individuals. By boosting self-esteem and hope (i.e., the factors that mediate recovery-consistent outcomes) positive interventions may augment the improvements garnered via recovery interventions. An example of this might be incorporating hope therapy groups (e.g., Cheavens, Feldman, Gum, Michael, & Snyder, 2006) into the treatment of individuals. An 8-week hope intervention has been shown to increase hope and other psychological strengths (Cheavens et al., 2006). Hope therapy may maximize the benefits gained from other recovery-oriented programming by building and nurturing hope, which can then promote recovery.

Combining Positive Interventions and Recovery-Consistent Interventions: Potential Applications

Positive interventions might be incorporated into and improve existing self-management interventions, such as Wellness Recovery Action Planning (WRAP; Copeland, 1997), Wellness Self-Management (Salerno et al., 2011), and Illness Management and Recovery (Gingerich & Mueser, 2005). Although they vary in specific content, self-management interventions are designed to help individuals learn to better manage chronic disorders, including medical disorders (Barlow, Wright, Sheasby, Turner, & Hainsworth, 2002). Mental health self-management strategies employ such strategies as psychoeducation, identifying protective factors, teaching self-care skills, and detailing crisis plans, which ensure that personal choice and autonomy exist even during periods of crisis. Positive interventions may enhance self-management interventions, with the timing guided by positive psychology research. For example, it has been shown that gratitude visits have more intense, but shorter-lived positive changes (Seligman et al., 2005). As such, a gratitude visit might be most useful during periods when the individual needs a more intense burst of positive emotions. Similarly, completing acts of kindness all in one day, as opposed to over the course of several days, is associated with increased happiness levels (Lyubomirksy, Sheldon, & Schkade, 2005). These are potentially useful to either provide a boost at the beginning of treatment to increase optimism and self-esteem, or they could be implemented during more acute phases to counter negative emotions and avoid crises.

Research on positive interventions can also educate us as to how recovery-oriented interventions should be offered. A meta-analysis of 51 positive interventions (Sin & Lyubomirsky, 2009) suggested that intervention format influences outcomes, with the greatest effect sizes for individually administered interventions, followed by group-based interventions, and, finally, self-administered formats. The aforementioned three positive interventions that have been provided to individuals in mental health systems—multimodal integrative cognitive stimulation therapy, positive living, and well-being therapy—were offered via group format. However, the evidence from Sin and Lyubomirsky calls into question this mode of delivery. It is possible that adapting these interventions to be administered individually may elicit even greater improvements and recovery outcomes.

Individual interventions are not always feasible given staff resources. As such, maximizing the number of individuals who receive services must be considered when determining the feasibility and appropriateness of various interventions. While an individualized course of well-being therapy might be most effective, it may be more important to have a large number of people get a moderate benefit from a group treatment as opposed to a few individuals have a maximum benefit via individual therapy. As such, cost-effectiveness research would be beneficial to help inform decisions as to how resources should be allocated within positive, recovery-oriented systems.

Recovery-Oriented Mental Health Systems

The third pillar of positive psychology, the study and development of positive institutions, may provide useful tools for conceptualizing and developing recovery-oriented mental health systems. Like the recovery concept itself, no consensus has been reached about the key components of a recovery-oriented service system. As Braslow (2013) writes, “Though brimming with well-meaning platitudes about hope and the urgent need for ‘system transformation,’ the recovery literature tells us much less about how to practically construct a recovery-based system of care” (p. 801). Further, the literature on systems change in mental health ranges widely in scope, alternatively referring to the entire United States publically funded mental health system (New Freedom Commission on Mental Health, 2003), a single mental health agency (Anthony, 2000), or general principles for service delivery (Sowers, 2005). Although rarely explicitly addressed, many of these writings hint at an understanding that mental health systems have multiple inputs and levels, including policy (Jacobson & Curtis, 2000); challenges of poverty and the larger social context (Hopper, 2007); the need for coordination of services across programs (Hogan, 2008); policies, procedures, and values within agencies (Anthony, 2000); how service providers are organized, trained, and supervised, and the services that these providers deliver (Sowers, 2005).

Many mental health administrators believe that transformation is a straightforward workforce development problem, and typically provide training to service providers on the history and meaning of recovery. The expectation is that they will develop recovery attitudes and beliefs, and by so doing, create a transformed culture of recovery. Additionally, they may train providers to deliver specific interventions that they believe will help to enhance recovery-consistent outcomes. However, even if training is skillful, providers are engaged, and both attitudinal and behavior change occurs, will this result in increased recovery-consistent outcomes for individuals receiving services? Is it accurate to say that a group of providers with recovery attitudes providing recovery-consistent interventions is truly a recovery-oriented system?

Training providers in recovery-consistent beliefs and attitudes is a necessary but minimally effective strategy in the development of recovery-oriented systems. It is necessary because providers must understand what the system is hoping to accomplish, but it is not sufficient for at least three reasons. First, there is a preponderance of evidence that provider trainings, even those designed to develop specific skills and competencies, do not easily result in provider behavior change, and that uptake of complex behavioral interventions requires targeted trainings with follow-up consultation or supervision (Sholomskas et al., 2005). Second, the recovery literature has yet to provide convincing evidence that our current training approaches in broad recovery attitudes have successfully increased desired outcomes. Finally, the emerging field of implementation science suggests that implementation of new practices requires change on multiple levels in an organization, not just at the level of the individual provider (Proctor et al., 2009). Thus, there is room for improvement in training providers as part of a recovery-oriented system.

If a system is more than the sum of its parts, recovery must somehow become an intrinsic part of the system itself. The study of positive organizational psychology¹ may help to further inform these efforts on these two levels: on the system level, to provide practical understanding of how entire mental health systems can become positive organizations, and on the program or provider level, to provide guidelines on how best to support providers to be part of a recovery system.

Suggestions for Future Research

The synergies between the positive psychology and recovery movements were first outlined in publication in 2006 (Resnick & Rosenheck, 2006). Since then, the research in both positive psychology and in recovery has multiplied, but the area of intersection between the positive psychology and recovery movements remains largely uninvestigated. Researchers who wish to pursue this area have a wide-open field. Based on the small sample of positive psychology research applied to the recovery movement outlined earlier, we recommend several broad areas of future research.

Clinical researchers might begin by testing the efficacy of positive interventions for the full range of individuals receiving services in mental health systems. Positive interventions, such as those described earlier, have predominantly been evaluated in nonclinical samples and in those with mild to moderate depressive and anxiety disorders. Likewise, researchers might investigate the feasibility and efficacy of augmenting positive interventions into existing recovery practices. One example of this would be to compare a group treatment of WRAP planning and a group treatment of WRAP augmented with positive interventions (e.g., using the gratitude visit in the WRAP plan for when a boost of positive affect is needed) to determine if that addition of positive interventions has any incremental benefit, and on what domains. These are the most obvious preliminary steps on the individual level. If these areas of investigation prove successful, research on whether positive interventions ultimately support individuals' ability to flourish in meaningful life roles, such as in relationships and employment, would be of great utility.

Research on positive organizations is an area for general expansion, not just in the overlap between positive psychology and recovery. Although there has been an increase in the number of peer-reviewed articles in positive organizational psychology in the last decade, the overall number is not great and the majority is theoretical rather than empirical (Donaldson & Ko, 2010). The application of positive organizational psychology in the development of recovery-oriented mental health systems is thus replete with opportunity. One specific target is to develop and test programs that support provider flourishing, such as those that support provider hope, compassion, and the use of the provider's own strengths. Although a truly recovery-oriented system might support provider flourishing as a worthy goal in its own right, future research might also investigate the link between provider flourishing and distal outcomes, such as improvement among those receiving services, for example, the demonstrated links between employee attitudes and performance described earlier. Finally, organizational researchers might work to understand the role and effect of organizational policies and structures, and how policies and structures can create positive organizations across organization types.

Conclusion

Theoretical synergies between positive psychology and recovery have been established (Farkas, 2007; Resnick & Rosenheck, 2006; Slade, 2010), yet the work of empirically demonstrating the utility of this cross-pollination of ideas has yet to occur in any meaningful way. This chapter expands the conversation from one that focuses on theoretical parallels to one that seeks concrete applications of positive psychology at all levels of a recovery-oriented system. We strongly advocate for those in positive psychology to expand their reach to include clinical populations and health-care organizations. Both positive psychology and recovery are engaged in a search to rediscover the full humanity of psychology and our health-care system. And for this, we will need all of our finest thinkers and healers to join together.

Summary Points

• Positive psychology has the potential to inform the development of a recovery-oriented system on three levels: (1) clinical interventions, (2) strategies to improve provider well-being, (3) policies and structures that support the development of a positive, recovery-oriented organization.
• Positive interventions and recovery-oriented care share a conceptualization of mental illness and well-being as existing on separate dimensions, and that treatments should be focused on bolstering the positive domains that are unique to each individual.
• Positive interventions designed for nonclinical populations developed as part of positive psychology have the potential to enhance the well-being of the full range of individuals receiving mental health services.
• Future research should examine the efficacy of positive interventions in the full range of individuals receiving mental health services as stand-alone interventions, and as additions to and augmentation of existing recovery-oriented care.
• The positive organizational psychology focus on the development of resilient employees and enhancement of positive attitudes in employees should be investigated for their potential in building a recovery-oriented workforce.
• Policies and technologies that support positive organizations should be studied for the potential to develop positive organizational systems.

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