Recovery-Oriented Principles Provide a Dynamic Reframing of Patient Care in Schizophrenia

Since the mid-20th century, the treatment of schizophrenia has shifted from the institutional setting to the community care setting.¹ Older treatment models focused on a chief complaint based on positive or negative psychotic symptoms, with limited consideration for the patient’s goals outside symptom treatment. Patients who suffer from the negative symptoms of schizophrenia have deficiencies in motivation and struggle to create or develop their own goals.² In acute care settings, when a patient is too ill to engage in meaningful goal planning, a chief complaint, and targeted symptom management makes sense, but this approach has downsides. Beck’s theory of modes describes those subject to this model of care as being in “patient” mode, where the individual assumes they lack agency, reinforcing ideas that they are weak, incapable, or passive characters in their own lives.^3,4 The institutional setting and symptom management approach likely exacerbates the amotivation that patients with schizophrenia experience. Oftentimes, the physician determines the goals of treatment, limiting patients’ opportunities to develop their own motivations and choose goals that are relevant to their day-to-day life.

In the intervening decades since the transition to the community care setting, the recovery movement emerged with a patient-centered approach.⁵ Where the older institutional models assume the patient must be managed by a source external to the individual, the recovery model entails establishing a partnership with the patient, empowering them to make goals in collaboration with providers. This shared approach can be framed as shared risk-taking.⁶ The physician and patient develop a “chief goal” and tailor treatment to address symptoms that impede achieving this goal. This approach can guide the patient into an “adaptive mode,” in which the patient is their best self.³ This is often achieved when the patient connects with at least one other person and participates in a mutually beneficial activity, shifting focus toward the recovery of the individual’s interests, values, and aspirations.^3,7 Below, we outline a key case in which we transitioned from a symptomatic, chief complaint-driven treatment, to a goal-based treatment to facilitate an adaptive mode.

Mr EN is a 35-year-old African American male veteran with schizophrenia who was referred to our clinic in his mid-20s for recovery-oriented treatment. He was unemployed, not in school, and spent most of his time at home alone. His social interactions consisted of going to the corner store 3–4 times a week. Mr EN’s positive symptoms were relatively well controlled on olanzapine 20 mg. He spent his evenings watching television and drinking alcohol, sometimes to excess. He intermittently participated in group therapy sessions and came to medication management appointments consistently. During one of his visits, we shifted our focus from symptom and side-effect assessments to goals assessment. He completed a goal worksheet for his next appointment and listed 1–2 goals he wished to accomplish. We learned he was interested in returning to school to complete his Associate’s degree. We then identified short- and medium-term steps required to accomplish this goal. Through these discussions, we discovered EN was using a lot more alcohol than he had disclosed and was struggling to stop. We therefore prescribed naltrexone 50 mg to reduce alcohol-associated cravings. EN went to a local community college with our program’s peer specialist and enrolled in classes. With the return to school, EN became concerned about olanzapine-induced weight gain and daytime sedation that was making it difficult to stay awake during class. After considering switching antipsychotic medication versus reducing the dose of olanzapine, EN decided to attempt a lower dose since his symptoms were manageable. He went on to obtain his AA degree and then completed both a BA and an MA in the next 5 years. Despite episodic symptom exacerbation, EN is employed full-time, engages in a sport that he enjoys, is financially independent, and has a full and meaningful life. He has stopped using alcohol and manages his breakthrough psychotic symptoms using cognitive behavior therapy skills and as-needed olanzapine. With our support, he continues to achieve and redefine his goals.

Shifting the focal point of care from the traditional “chief complaint” to a recovery-centered “chief goal” affected many aspects of EN’s care. His goals to return to school, advance his career, and address his alcohol use allowed us to appreciate his symptoms as they related to his everyday functioning and base medication decisions on how they would affect his quality of life. EN’s original dosing of olanzapine 20 mg likely served to meet the physician’s objective of stabilizing after a psychotic break, but it did not align with the patient’s goals and needs in the community setting. By focusing on the patient’s self-defined goals, his physician was better able to engage with him and foster a higher-quality rapport. Crucially, as EN felt empowered to share his aspirations, he also felt more comfortable sharing the human details of his day-to-day struggles.

As the time we spend with our patients shrinks, the integration of recovery principles into service delivery dynamically reframes patient care by fostering an egalitarian doctor-patient relationship. Focusing on recovery enhances the quality of clinical interactions by empowering the individual and providing valuable information to guide treatment decisions. A “chief goal” approach mitigates burnout on the provider’s end and prevents the arrest of recovery on the patient’s side. Inpatient psychiatric units that adopt recovery-oriented cognitive therapy approaches have shown reductions in the use of seclusion and restraint, as well as, improvement in staff attitudes.⁸ Success with this approach has prompted the Veterans Health Administration to make transitioning to a Veteran-driven, recovery-oriented system of care a key objective of our mental health services.⁹ Our hospital is exploring ways of incorporating recovery-oriented principles in other clinics, to test the impact of such an approach on clinical outcomes and staff burnout. Ultimately, we hope that the use of recovery-oriented treatment will make a positive impact on the lives of those who are served while inspiring caregivers to provide the best possible care for their patients.