The Struggle to Define “Recovery” In Community Mental Health Policy and Practice

BACKGROUND AND PURPOSE: In 2003, the President's New Freedom Commission on Mental Health placed “recovery” at the forefront of community mental health reform. Critics responded that the report failed to resolve a deep conflict in the definition of “recovery” between consumer emphases on autonomy, hope, and process, and the medical definition of measurable reductions of a disability (Crowley & O'Malley, 2007). Debate over what recovery means has entered the national policy arena in the struggle to clarify (and limit) federal payments for rehabilitation services (1905(a)(13) of the Social Security Act). In 2007, rule changes were proposed to restrict Medicaid coverage only to services that produce measurable reductions in a diagnosed mental disability and that restore functional abilities (Federal Register, 2007). These changes raise crucial questions for community mental health about how to define and fund services for chronically disabled people, especially for services that support social integration and connectedness (Ware et al. 2007; 2008). This study examines the practices of mental health workers in an organization dedicated to promoting connectedness among consumers. It asks how the tensions between consumer- and medically-driven definitions of recovery enter the practice setting and shape the care consumers receive.

METHODS: This ethnographic study uses participant observation, interviewing, and archival research to examine the interface of policy and practice. Over a twelve-month period, the author spent 1100 hours observing the day-to-day routines of street-level workers in a community mental health organization, using field notes to track emerging patterns of practice. Semi-structured interviews were conducted with 53 case managers and agency administrators to understand the challenges workers faced. Interviews were also conducted with 11 state policymakers and stakeholders to provide high-level accounts of how recovery policy changed in the state between 2008 and 2011. Field notes, transcriptions, and archival documents were analyzed thematically and continuously using qualitative software.

RESULTS: This study finds that recovery is an essential category for defining practice, but that strong differences exist between administrators and line workers over what recovery means. Administrators indicate Medicaid audits as a source of threat to the agency and stipulate that clinical services must demonstrate measurable progress toward targeted goals. Workers mobilize a grassroots definition of recovery to contest administrative requirements, contending that even when medical progress is not evident necessary services are being provided. Workers take recovery to mean a restored sense of dignity and value, which may not translate into measurable outcomes. These differences produce sharp conflicts in the work setting, placing line workers and administrators in opposition and generating continual disagreements about how to provide socially supportive programming.

IMPLICATIONS: This study shows that the unsettled tensions of recovery policy delegate to the street-level, where they become a source of disagreement and conflict. Under the administrative pressure to define recovery in terms of measurable outcomes, hassles over clinical records become a terrain for redefining and contesting program mission. This organizational struggle impacts mental health consumers, limiting services that support social integration.