Many individuals with serious mental illness recover completely or function well, yet little is known about factors that foster or impede this process. Good relationships with clinicians and continuity of care have been posited to facilitate better outcomes, but continuity of care findings have been inconsistent. These issues are explored in an analysis of data from an NIMH funded study of 178 persons with serious mental illness which combines extensive quantitative and qualitative data to create a portrait of recovery trajectories and to identify key factors important in the recovery process.

HMO Members (93 women, 85 men) with serious mental illness completed in-depth interviews detailing personal/mental health histories and completed questionnaires that included quality of life and recovery assessments. Data were linked to health plan service use and clinical provider records. Qualitative data show that strong, positive, trusting relationships with clinicians, developed over time, can aid recovery. In an environment where clinicians can focus on care and there is low turnover with an emphasis on departmental support of collaboration between clinicians and members and a focus on long term continuity of care there is a greater opportunity for a good fit between members and clinicians. When “fit” with providers is good, long-term continuity of care allows development of close, collaborative relationships, fostering better self-care, and decisions controlled or strongly influenced by consumers. Clinicians are most valued if they are competent, flexible and persistent, caring, kind, interested, trustworthy, and trusting, allow a comfortable emotional distance, treat encounters as “normal” rather than clinical, and develop relationships “like friendships.” Such relationships increase willingness to seek help when needed, persistence in care when treatments are not effective, and support “normal” rather than “mentally ill” identities, maintaining community integration.

Based on qualitative analyses, we conceptualized relationships between mental health care and recovery, testing this conceptualization using covariance structure modeling. We found direct positive relationships between recovery-oriented patient-driven care and a) satisfaction with clinicians, b) satisfaction with medications, and c) recovery. Continuity of care indirectly affected quality of life via satisfaction with clinicians; satisfaction with medications was associated with fewer symptoms; fewer symptoms were associated with recovery and quality of life. Model fit was good, explaining 66% of the variance in quality of life and 56% in recovery. Continuity of care provides opportunities for developing supportive relationships with clinicians. Recovery-oriented, caring, and collaborative care foster recovery and “normal” identities.

This research was conducted with members of Kaiser Permanente Northwest and illustrates how a group model HMO with low physician turnover can provide integrated services to a population usually treated in the public mental health system. Many of the recent experiences in transferring responsibility for mental health services to private HMOs or managed care companies have been less than satisfactory (e.g. Tenncare). The Kaiser system represents another model of managing care without sacrificing quality and therefore has broad implications for current public policy.