CLINICAL HANDBOOK OF SCHIZOPHRENIA

572 VIII. SPECIAL TOPICSassumes from the start that Celeste is a competent adult doing her best to manage a disablingcondition that she neither asked for nor deserved as punishment for some earliermisdeeds. It assumes that Celeste can and will figure out how best to live with her disability,and that she has many areas of health and competence alongside her disability. It assumes,most importantly, that Celeste knows what is best for Celeste, and that the role ofthe clinician is to offer knowledge, expertise, and resources for Celeste’s considerationand benefit.From a theoretical point of view, then, this approach assumes that schizophrenia isan illness like other illnesses, for which a range of effective interventions are available forpeople. It also recognizes that adults with schizophrenia are autonomous, and that ultimatelythe choice—in concert with their loved ones, if they so choose—of which interventionsthey agree to try, under what conditions, in what circumstances, and with what intendedoutcomes, is theirs. In addition to serving people with schizophrenia, who havedemanded this kind of care over the last decade, this model of collaborative decisionmaking is taking over other domains of medicine as well. What is revolutionary about itin mental health is that it requires us to treat psychiatry more broadly, primarily as aform of medicine or health care. This is the nature of the revolution that people with psychiatricdisabilities have brought about and one from which they vow not to turn back;that is, the consumer/survivor movement has established that people with serious mentalillnesses such as schizophrenia remain citizens of their communities, with all of the rightsand responsibilities associated with citizenship, unless, until, and only for as long as clearand compelling evidence of extenuating circumstances (e.g., serious and imminent risk)obligates society to interfere with their personal sovereignty. In all other circumstances,the illness is theirs to manage, as are their lives.IMPLICATIONS FOR ASSESSMENT AND TREATMENT:WHAT MAKES CARE “RECOVERY ORIENTED”?So what must be done differently in the delivery of mental health services to make themlegitimately recovery-oriented? Is it enough that services be offered respectfully, andmaintain the client’s dignity and worth? Although this certainly would be a welcome improvementfrom much of current practice, it falls well short of the aim of promoting recovery.What is missing? In defining transformation, as noted earlier, the Federal government’sAction Agenda spoke of “new sources of power” that needed to emerge, and “newcompetencies” that need to be developed. Let’s begin here.What are the new sources of power that emerge in recovery-oriented care? It isprimarily the power of the person with the psychiatric disability that is tapped andbrought into the process—a process that currently affords the person an almost entirelypassive and subordinate role. In a recovery-oriented system of care, recovery is notsomething that he or she might “help” along by being compliant. Recovery is the responsibilityof the person with the serious mental illness. Recovery must be pursued; itdoes not occur simply in response to medication or other treatments. Recovery, in thissense, refers primarily to what the person with the psychiatric disability does to managehis or her illness and to reclaim his or her life in the presence of enduring disability.Thus, the major source of power driving this process is the person’s own efforts,energies, and interests.This brings us to the second question, which pertains to the emergence of “new competencies”in transformation that belong primarily to mental health providers. Similar toprogressive educators, midwives, and orchestra conductors, the recovery-oriented clini-