What appears to be missing from the proposed definition is a statement that "recovery" (as opposed to the process of recovery) means living like people without a mental illness live, the core elements of which are having your own place to live, a job, and a partner and/or family. The proposed definition should be revised to make clear that people will be able to achieve "recovery" in this sense, which is readily feasible with current technologies promoted by SAMHSA, including scattered site supported housing, supported employment, assertive community treatment (ACT) and peer support. In addition, the proposed definition must include the explicit expectation that service systems will be re-oriented to enable individuals to live in their own place, have a job, and have a partner and/or family.

These elements are critical to make recovery a meaningful concept rooted in concrete expectations about what is needed to afford individuals with mental illnesses the opportunity to live full lives as members of their communities, consistent with the ADA's integration mandate and the Olmstead decision. Without these elements, the proposed definition of recovery would enable service systems to continue treating individuals with mental illnesses living much as they have in the past, without providing the chance to live the same way that the rest of us do. The definition of recovery cannot be one that permits these individuals to remain dependent while "working on" a recovery that public service systems can and should put in their reach. Recovery must encompass more than a set of slogans about hope, respect, relationships and purpose. It must include the specific expectations above that are necessary to make these concepts meaningful.

Robert Bernstein, PhD
President and CEO
Bazelon Center for Mental Health Law
www.bazelon.org

SAMHSA’s proposed recovery definition is a good framework for adults; however, it is too narrow if applied to children, youth and emerging adults. Half of adults with mental illness experienced onset of that illness prior to age 14 . People in recovery are just as likely to be parents as the general population.

Increasing resiliency skills and promoting protective factors are integral to children and youth becoming adults not debilitated by their experiences with emotional, behavioral (in-cluding substance use) or mental health symptoms or disorders.

Two additional guiding principles are needed to include the support of people who parent children and youth.
• The principle of family driven/youth-guide needs to be added to consumer-driven and
• Family supports for parenting of children.

Parents of children also need to have:
• Peer parent support services;
• Practical parenting techniques to address the needs of the family and the child;
• Health promotion skills;
• Information about the physical, emotional and environmental causes and remedies for trauma, behavioral or mental health or substance use disorders;
• Safe neighborhoods and natural support for themselves and for their children; and
• Community-based services for their child or youth or emerging adult experiencing emotional, behavioral (including substance use) or mental health disorders.

Resiliency skill building and the promotion of protective factors by parents, while called prevention and wellness, are the framework for ensuring sound mental health in adults. Effective parenting skills, resiliency skill building, trauma-informed care and positive loving role-models prevent some mental health disorders or keep them from getting worse.

Maslow’s model, included in SAMHSA’s proposed definition, does not adequately represent that people need benefits from all five stages concurrently. In addition to basic health and safety needs, children and youth still require daily doses of belonging, esteem and love needs. Parents fulfill those levels of needs for children and youth. The skill building and support provided by parents must be a part of the health care rubric for children’s mental health. Parenting learning effective parenting skills, resiliency skill building, and how to increase protective factors is parallel to parents learning nutrition, exercise and physical crisis intervention for a child that has childhood diabetes.

Specific changes to the adult definition of recovery:
• Change “mental and substance use disorders” to “behavioral health disorders”.
• Define the health domain as: “Promote wellness and increase resilience for individuals to decrease or eliminate symptoms of behavioral disorders.”
• Define the home domain as: “Ensure that permanent housing and supportive services and a living wage is available for individuals with or in recovery from behavioral health disorders. Parents of children and youth who experience behavioral health disorders need to be able to earn a livable wage and have respite services.”
• Define the purpose domain as: “Increase gainful employment and educational opportunities for individuals with or in recovery from behavioral health disorders. Promote hope and success of children, youth and adults who have experienced behavioral disorders.”
• Define the community domain as: “Promote peer support and social inclusion for adults, parents with children and youth and the inclusion in the community of individuals with or in recovery from behavioral health. Promote the effective community based services for children, youth and emerging adults.”

Specific changes to the adult definition of recovery:
• Change “mental and substance use disorders” to “behavioral health disorders”.
• Define the health domain as: “Promote wellness and increase resilience for individuals to decrease or eliminate symptoms of behavioral disorders.”
• Define the home domain as: “Ensure that permanent housing and supportive services and a living wage is available for individuals with or in recovery from behavioral health disorders. Parents of children and youth who experience behavioral health disorders need to be able to earn a livable wage and have respite services.”
• Define the purpose domain as: “Increase gainful employment and educational opportunities for individuals with or in recovery from behavioral health disorders. Promote hope and success of children, youth and adults who have experienced behavioral disorders.”
• Define the community domain as: “Promote peer support and social inclusion for adults, parents with children and youth and the inclusion in the community of individuals with or in recovery from behavioral health. Promote the effective community based services for children, youth and emerging adults.”

What appears to be missing from the proposed definition is a statement that "recovery" (as opposed to the process of recovery) means living like people without psychiatric diagnoses live, the core elements of which are having your own place to live, a job, and a partner and/or family. The proposed definition should be revised to make clear that people will be able to achieve "recovery" in this sense, which is readily feasible with current technologies promoted by SAMHSA, including scattered site supported housing, supported employment, and peer support. In addition, the proposed definition must include the explicit expectation that service systems will be re-oriented to enable individuals to live in their own place, have a job, and have a partner and/or family.

These elements are critical to make recovery a meaningful concept rooted in concrete expectations about what is needed to afford individuals with psychiatric diagnoses the opportunity to live full lives as members of their communities, consistent with the ADA's integration mandate and the Olmstead decision. Without these elements, the proposed definition of recovery would enable service systems to continue treating individuals with psychiatric diagnoses much as they have in the past, without providing the chance to live the same way that the rest of us do. The definition of recovery cannot be one that permits these individuals to remain dependent while "working on" a recovery that public service systems can and should put in their reach. Recovery must encompass more than a set of slogans about hope, respect, relationships and purpose. It must include the specific expectations above that are necessary to make these concepts meaningful.

Much like the term "survivor" in the cancer field, the concept of recovery in the area of adult mental health has been important for instilling hope and optimism, particularly among consumers and families, and for changing the way many people think about the possibility of improved mental health outcomes over time. However, we feel that the current effort to define "recovery" universally for substance abuse and all mental disorders (from serious, biologically-based illness to more transitory, environmentally-based disorders) is fraught with problems. We feel a better approach moving forward would be to identify a new mental health term (or terms) that can inspire the same spirit without the drawbacks that are inherent to the term recovery.

Our concerns with "recovery" are the following:
1. The term "recovery" is so closely tied to the substance abuse arena that it is likely impossible at this point to advance a definition in the public consciousness that does not include the concept of sobriety (see The Betty Ford Institute Consensus Panel (2007). What is recovery? A working definition from the Betty Ford Institute. Journal of Substance Abuse Treatment, 33, 221–228).

2. The 1999 report Mental Health: A Report of the Surgeon General, noted that "The definitions [of recovery] do not... imply full recovery, in which full functioning is restored and no medications are needed. Instead they suggest a journey or process, not a destination or cure." Nevertheless, the common usage of the terms "recover" or "recovered" do imply fully getting over an illness (thesauruses list cured, recovered, and healed as synonyms). This contradiction creates ongoing tension and confusion about what is meant by "recovery", particularly among the lay public.

3. Should recovery mean the same thing for the process of optimizing functioning in the presence of such diverse contexts as addiction, biologically based brain disorders that may begin before birth, other chronic mental illnesses with biological and environmental contributing factors, and more transitory disorders that describe maladaptive functioning in the face of life experiences? The attempt to apply the term across these contexts is part of what leads to the confusion about whether recovery is a perpetual state or one that can be completed. One alternative would be to use different terms in different contexts. Another alternative would be to refer to the process as "optimizing health," recognizing that optimal health will differ not only from context to context, but from individual to individual.

Finally, we have been intrigued by the term "reClaiming" used by the Federation of Families for Children's Mental Health in the title of their newsletter (Reclaiming Children), or "Re/Claiming" as described in the SAMHSA-funded report "A Public Health Approach to Children's Mental Health: A Conceptual Framework (published by Georgetown University). In the report, Re/Claiming is used to define interventions that work toward optimizing health for children while taking into account identified mental health problems or diagnoses. The term is written that way so it can either refer to "reclaiming" health in the case of children who trying to restore a prior higher level of health, or "claiming" health in the case of children who may have had impaired functioning since birth and are striving for a level of optimal health they have yet to experience. We also like Re/Claiming because the word itself is inherently active, while the word Recovery can apply to passive or active processes (e.g., lying in bed while recovering from an injury). While Re/Claiming is currently used to describe a category of interventions, particularly in child mental health, perhaps it could serve as a better match for the definition of recovery being proposed by SAMHSA as part of the current effort.