Managing risk and recovery: redefining miscibility of oil and water.

Recovery is becoming a dominant emphasis in mental as well as in physical health care. It calls for deliberate collaboration by clinicians with patients as empowered service consumers. As a model for mental health care, recovery emphasizes a holistic rather than a purely therapeutic approach and focuses on the broader concern of the patient’s quality of life rather than the narrow tableau of symptom reduction. It strives to prioritize the wishes of the patient and that individual’s autonomy. A large international survey of patients, professionals, caregivers, and advocates involved in institutional mental health care identified 11 elements as being essential to care. Their rankings of these components showed a strong consensus supporting the recovery model, beginning with quality of treatment and supportiveness of staff members and including human rights, self-management and autonomy, and institutional environment. These striking results challenge oncedominant paternalistic values held by clinicians. The change is most obvious on the inpatient psychiatric unit, where patients are expected to conform to the rules and dictates imposed on them. In the past, their consent to treatment, let alone their collaboration with clinicians, seemed irrelevant, since they were hospitalized for treatment of illnesses that were seen as compromising or even precluding their capacity to give such consent. Upon admission they relinquished considerable autonomy automatically, including their property rights and freedom of movement, association, and even of scheduling their time and choosing their food. No more. Psychiatric inpatients are expected to take an active role in determining many key aspects of their treatment and their environment. From the day of admission they are called on to articulate their goals and expectations, prioritize their listing of problems, and collaborate in working toward their expeditious discharge. They are expected to weigh in on the selection and evaluation of treatment modalities, particularly medications. Caregivers no longer ask so much whether the patient is following articulated medication regimens. Rather, the question is whether the medications are delivering what the patient wants from them. Reflecting this, the patient is beginning to disappear from the literature authored by some professional groups, replaced by the consumer. Such developments as these are now the wellrecognized, widely accepted, and generally approved results of the so-called recovery movement in psychiatry. Although this recovery model is fitted to and considered efficacious in the civil inpatient setting, it remains out of place in the forensic inpatient unit. Of necessity, the restrictions and limitations imposed on the patient’s autonomy far outstrip almost anything found in the civil inpatient unit before the recovery movement’s influence. The impositions of the fundamental concern for everyone’s safety principally include scaled back property rights, limitations on moving about, clothing restrictions including shoelaces and belts, limitations on freedom of communication, and diminished privacy. Some newly admitted forensic patients experience a particularly rude awakening, especially if they happen to have had recent experience in the civil inpaAll three authors are with the Department of Psychiatry, Yale University School of Medicine, New Haven, CT, where Dr. Hillbrand is Assistant Clinical Professor of Psychiatry, Dr. Young is Clinical Professor of Psychiatry, and Dr. Griffith is Professor of Psychiatry and of African-American Studies. Dr. Hillbrand is also Director of Psychology, Connecticut Valley Hospital, Middletown, CT. Address correspondence to: Marc Hillbrand, PhD, Connecticut Valley Hospital, PO Box 351, Middletown CT 06457. E-mail: marc.hillbrand@ po.state.ct.us.