From the Field by William A. Anthony, Ph. D.

The need for recovery-compatible evidence-based practices

Mental Health Weekly    November 5, 2001

As discussed by Ronald W. Manderscheid, Ph.D., and Marilyn J. Henderson in a

recent From the Field column (see MHW, Oct. 8), the concept of evidence-based

practice is developing rapidly.  It needs to be emphasized, however, that

mental health system planners‚€™ interest in incorporating evidence-based

practices into their system planning efforts is occurring concurrently with

the concept of recovery-oriented system planning.  Unfortunately, from a

recovery perspective, much of what is important to people‚€™s recovery has not

been uncovered by current evidence-based practices. Like the ‚€œemperor who had

no clothes‚€, are we fooling ourselves as a field into thinking we have

covered much of what is important?

Our service-delivery system over most of the last century has been built on

the mistaken assumption that people with severe mental ill-nesses do not

recover, and in contrast typically deteriorate over time. Service systems and

interventions have been designed to stave off this deterioration, and more

recently, to maintain people in the community. As a result, much of the

existing, published, evidence-based practice research was conceived without

an understanding of the recovery vision and/or implemented prior to the

emergence of the recovery vision. Thus, the system planning implications of

current, pub-lished, evidence-based practice research are deficient

in speaking to a system built on a recovery philosophy and mission.

For example, consumer outcomes reported as impacted in journal articles are

often not the outcomes that most closely define recovery. The outcome

variables often reported as positively impacted in randomized clinical trials

are variations on hospital relapse, or inpatient hospitalization, or

symptomatology, or becoming employed.  Typically these include variables such

as recidivism,

ength of hospital stay, days spent in the community, ratings of psychiatric

symptoms or days employed. In a recovery era these outcomes may be less

important than measures that are more related to people‚€™s goals or

experienced progress. Measures related to people‚€™s experience of progress

(e.g., empowerment, well being, physical health, recovery of meaningful

roles) rather than relapse have become more relevant to questions of

recovery. Simple counts of employment‚€”yes or no, or hospitalization‚€”yes or


are an enormous conceptual distance from what might be considered to be

recovery outcomes.

In addition, subjective outcomes seem to be considered as less important

outcomes in current evidence-based practice research. Yet, recovery

assumptions and data suggest that there is no one path to recovery, and that

goals and processes that are indicative of recovery for one person may be

different for another person. Evidence-based practice research published to

date has rarely

found an impact on qualitative measures of outcome that may be gathered

through interview and narrative. When evidence-based practices are

promulgated for replication without taking subjective measures into account,

possible important philosophical elements of a practice may be omitted

because they are not empirically linked to the traditional outcomes reported.

For example having people with psychiatric disabilities design and administer

programs may be important because these tasks inculcate a set of program


that include self-determination and respect. These values may alter the

nature of a person‚€™s experience in the program in ways that are critical to

recovery and therefore be an important component of a ‚€œbest practice,‚€ but

may not be picked up unless subjective measures are included.

In summary, currently published, evidence-based practice research has

infrequently demonstrated a positive impact on recovery-related process and

outcomes (e. g., having choices, feeling respected, positive changes in

meaningful work, self esteem, empowerment, etc.). The parade to implement

evidence-based practice in recovery oriented systems may wish to ‚€œrest in

place‚€ until the emperor is more completely dressed. The notion of

evidence-based practice and the vision of recovery-oriented services can work

well together. However if evidence-based practice research is to immediately

inform our development of recovery-based services, then the concept of

evidence-based practice must be broadened to include ‚€œencouraging and

promising but

not yet confirming‚€ evidence-based practices.

William A. Anthony, Ph. D., is a professor and director of the Boston

University Center for Psychiatric Rehabilitation,

940 Commonwealth Ave West, Boston, MA. 02215

Source:  Mental Health Weekly   November 5, 2001