Recovery in Canada: Toward social equality

Abstract

This article reviews evolution of the recovery paradigm in Canadian mental health. We first trace the origins and development of the recovery concept through the literature, followed by an examination of how the recovery concept has been implemented in national and provincial mental health policy since publication of the 2006 Kirby Commission Report. Based on consultations with Canadian policymakers, and an examination of available policy documents, we explore how the dual theme of ‘recovery’ and ‘well-being’, adopted by the Mental Health Commission of Canada in its 2009 strategy: Toward Recovery and Well-being - A Framework For a Mental Health Strategy has subsequently played out in mental health policymaking at the provincial level. Findings reveal mixed support for recovery as a guiding principle for mental health reform in Canada. While policies in some provinces reflect widespread support for recovery, and strong identification with the aspirations of the consumer movement; other provinces have shifted to population-based, wellness paradigms that privilege evidence-based services and professional expertise. The recognition of social equality for people who experience mental illness emerges as an important value in Canadian mental health policy, cutting across the conceptual divide between recovery and well-being.

Introduction

This article aims to provide an understanding of how the mental health recovery paradigm is being implemented within the rapidly evolving context of Canadian mental health policy. The first ever national government report on the state of Canada's mental health system, Out of the Shadows at Last: Transforming Mental Health, Mental Illness and Addiction Services in Canada (Kirby & Keon, 2006), identified recovery as the central, guiding principle for mental health reform. The Kirby Report provoked public debate, and major mental health reform including establishment of the Mental Health Commission of Canada and the articulation of a national mental health framework for Canada in 2009, followed by a comprehensive action plan. Eight of the ten Canadian provinces have introduced, or are currently working on, new mental health strategies that address the relevance of the recovery concept for transforming their respective mental health systems.

This paper first traces the evolution of the mental health recovery concept in Canada through the literature, followed by a review of the recovery concept in Canadian national and provincial mental health policy since 2006. The uptake of recovery in Canadian policy, contrasts with experience in Australia where the linking of recovery and elements of positive psychology enabled the development of national recovery policy, as well as service implementation and evaluation guidelines (Oades & Anderson, this issue, pp. 5–10). As in New Zealand, recovery in Canadian mental health policy also evolved to include the concept of well-being, yet without the strong cultural underpinnings inherent in ‘wahanau ora’ that support a recovery orientation as distinct from medical and deficit approaches to mental illness (O’Hagan et al., this issue, pp. 56–63).

The Mental Health Commission recommended policy experts across Canada who might be willing to share their experiences. Representatives of the ten provincial health ministries, and that of the Yukon, responded to our request for informal telephone consultations. We asked them: 1) how recovery fits into their current, or forthcoming, mental health plans, and 2) what they would consider the most pressing issue in mental health recovery for their respective jurisdictions. Finally, we reviewed all provincial mental health plans published since 2006, which were available for six provinces. New plans are forthcoming for the provinces of Nova Scotia, Québec, and Newfoundland and Labrador. A draft of this article was sent to all individuals with whom we consulted for their comments. The list of current mental health plans for the Canadian provinces, and territories, is presented in the Appendix.

Origins of recovery in Canada

Mental health recovery in Canada is essentially a consumer-driven paradigm with origins in the North American ex-patient liberation movement of the 1960s and 1970s. Long before recovery became a policy issue, ex-patients were promoting recovery as self-determination, and empowerment, while advancing alternative, community-based services that opposed the traditional medical model and lifelong dependency on mental health providers (e.g. Chamberlin, 1997; Tomes, 2006). Over the past 25 years, Canadians with lived experience have advanced mental health recovery through a strong self-help tradition (Nelson et al., 2008), Nelson et al., a nationwide network of peer support activities (O'Hagan et al., 2009, 2010), and successful community economic development initiatives (e.g. Church, 1997; Hartl, 1992; Lysaght & Krupa, 2011). Mental health consumer-survivors also focused increasingly on advocacy and political change within public arenas such as legislative hearings, government committees and boards (Church, 1996; Everett, 2000; Grant, 2007; Newberry, 2004).

Consumer-survivor self-help and advocacy groups have influenced both the shift of mental health services from large institutions to the community (Davis, 2006), and the evolution of mental health policy to a recovery perspective (Amering et al., this issue, pp. 11–18). Nelson et al. (2001) describe the emergence of an empowerment-community integration paradigm in Canadian community mental health. Their study sharply criticizes the power imbalance between professionals and service users in traditional mental health systems, and segregation of people from their communities. An early recovery-orientated policy statement, the Canadian Mental Health Association's Framework for Support (Trainor et al., 1999), argued that mental health consumers need more control of their affairs. This Framework challenged government's almost exclusive recognition, and financial support, of formal services, to the detriment of consumer-run alternatives, as only one of several possible paradigms in mental healthcare (see also Trainor et al., 1997).

Conceptualizations of recovery in Canadian mental health literature

Canadian researchers have written on the emerging recovery vision over the past two decades from three related perspectives. First, personal recovery emerges from the consumer narrative literature; second, recovery as personal empowerment reflects the philosophy of the ex-patient movement and community mental health tradition in Canada. Finally, recovery is increasingly described by Canadian analysts as an issue of social equality.

Personal recovery

Canadian scholarship includes the personal narratives of mental health consumer-survivors (Capponi, 1992; Nunes & Simmie, 2002; Supeene, 1990), which describe recovery overall in terms of hope, choice, personal responsibility and reconstruction of a valued self. One study based on a review of the consumer narrative literature identified four dimensions of recovery: 1) redefinition and expansion of self; 2) empowerment; 3) time/space relationships (hope, spirituality); and 4) interpersonal relationships (Provencher, 2002). These elements informed further research on the role of work in recovery (Provencher et al., 2002). Noiseux and Ricard (2008) proposed a conceptual model of the recovery process based on hope, insight, sense of self, the instinct to ‘fight back’, and perseverance. Corin (2002) described recovery as taking control of the present, and maintaining awareness of one's inner life while re-establishing relationships with others.

In other Canadian research with mental health consumers, people defined personal recovery as ‘getting better’ from mental illness, but also as living a full life despite the persistence of illness (Piat et al., 2009a). Medication use was a complicating factor in these participants’ self-perceptions of recovery. While some equated recovery with finding an effective medication, others viewed recovery as incompatible with medication use. From another standpoint, recovery demanded compliance with medication, or some combination of medication and other supports (Piat et al., 2009b).

Recovery as personal empowerment

Recovery as personal empowerment offers a broader perspective than personal recovery, which plays out mainly within the mental health system. Personal empowerment is a concept shared by a number of marginalized social groups such as racial minorities, women, and people with physical disabilities. Viewing individuals in a social context, with particular focus on power relationships, the empowerment perspective links the concerns of people with mental illness to those of other disadvantaged groups on issues such as unemployment, social welfare, and the problem of systematic discrimination (Piat & Polvere, 2012 forthcoming). Canadian researchers Ochocka et al. (2005) underlined the negotiation that takes place in recovery between the self, as agent, and a range of external circumstances, including social support, mental health services, housing, work, and income support. Elsewhere these authors describe empowerment as an ecological process involving individual, organizational, and policy factors (Nelson et al., 2001).

Recovery and social equality

In Canada, people with physical or mental disabilities enjoy constitutionally guaranteed equality rights (Prince, 2001). Equality before the law would include access to mental health or rehabilitation services without drafting specific legislation, as occurred in the case of Israel for example (see Roe, this issue, pp. 48–). The recognition of people with mental illness as full citizens with rights to employment, housing, and other social determinants of health is increasingly reflected in Canadian writings. For example, Krupa identifies ‘social citizenship’ as part of recovery in the employment domain (Krupa, 2004; Krupa & Clark, 2009). Clément et al. (2009) include citizenship, or ‘the capacity of people to take control of their lives and participate actively in society’, in their study on recovery and housing. Other research calls for a more critical understanding of recovery in relation to culture, race and diversity (Lal, 2010).

Researchers at the British Columbia Centre for the Study of Gender, Social Inequities and Mental Health recently sought to conceptualize recovery from a social equality perspective based on principles of citizen engagement that recognize the critical impact of social and structural inequities for individuals recovering from mental illness. Their review of the recovery literature found that most studies focus on recovery as an individual journey, with less attention given to structural changes needed to ensure adequate income, housing and social environments free of discrimination (Weisser et al., 2011). Their insights suggest a major shift in thinking about recovery: from an exclusively individual responsibility, to a shared societal responsibility.

Recovery in Canadian mental health policy

Recovery in Canadian mental health policy reflects various perspectives on mental health among 10 provinces and three territories. The uptake of recovery depends upon historical, socio-cultural, and economic variations among the provinces, as well as differences among their healthcare systems, populations, and service priorities. The national government plays a limited role in mental health, as most healthcare in Canada is under provincial jurisdiction. Despite the complexities of implementing recovery in a decentralized, federal system, Canada is one of the countries where recovery has emerged as an important perspective in mental health (Adams et al., 2006, 2009).

National mental health policy

Canada's Kirby Report stated that ‘it believes recovery to be the primary goal around which the mental health delivery system should be organized’ (Kirby & Keon, 2006, Kirby & Keon, p. 42). Two recovery ‘models’ were identified: the first, an empowerment model emanating from the consumer advocacy movement; the other a psychosocial rehabilitation model representing the perspective of mental health professionals. The Kirby Report defines recovery from both a psychosocial and medical perspective:

For many individuals it is a way of living a satisfying, hopeful, and productive life even with limitations caused by the illness; for others, recovery means the reduction or complete remission of symptoms related to mental illness. (Kirby & Keon, 2006, Kirby & Keon, p. 42)

The report further identified three pillars for a recovery-orientated mental health system in Canada: choice, community, and integration of services. The report included the specific recommendation that a percentage of government funding be allocated towards consumer-run services and initiatives. The major outcome of the Kirby Report was the establishment of the Mental Health Commission of Canada in 2007, with a mandate to promote a national mental health strategy and facilitate major reform of provincial mental health policies and services (Kirby & Keon, 2006, Kirby & Keon, p. 438).

The new Commission soon presented a first draft of the national mental health framework, then held a national consultation on the document. Mulvale and Bartram (2009) reported on concerns expressed by stakeholders about adopting recovery as the overarching principle for mental health reform in Canada. Even though the majority endorsed a recovery orientation, tensions emerged from the outset over the proposed definition of recovery as:

a process in which people living with mental health problems and illnesses are empowered and supported to be actively engaged in their own journey of well-being. (Mental Health Commission of Canada, 2009, Mental Health Commission of Canada, p. 122)

Some raised further objections about the relevance of the recovery concept for specific populations such as children, youths, and seniors, and that the concept did not account for prevention and mental health promotion in the general population. Others felt that the language of recovery was inappropriate to degenerative conditions such as dementia. The Commission responded by broadening the final version of the Framework to include both recovery, as a ‘journey of healing’ for people affected by clinically defined mental health problems and illnesses, and well-being, a concept that derives from the World Health Organization's definition of optimal mental health for every individual (Mental Health Commission of Canada, 2009, Mental Health Commission of Canada, p. 5).

A mental health strategy for Canada will be released in 2012. This implementation strategy builds on the seven goals advanced in the 2009 Framework, adding specific measures, tied to adequate funding, that aim to strengthen the capacity of individuals and public sectors such as mental health and primary healthcare systems; schools, workplaces and communities, to promote recovery and well-being. Emphasis is given to actively involving service users and their families in decision-making throughout the mental health system. The strategy demonstrates that recovery is more than a medical issue in focusing on the reduction of social inequities for people with mental illness, promoting access to valued resources and supports, and cultivating leadership opportunities among people with lived experience.

Provincial mental health policy

Uptake of recovery in provincial and territorial mental health policy since 2006 has been mixed. In terms of overall orientation, provincial policies tend to privilege either recovery or population-based wellness as their dominant perspective. However, an analysis of the available provincial mental health plans reveals important conceptual distinctions between the two perspectives.

Recovery is the central guiding principle in the policies of five provinces: New Brunswick, Manitoba, Newfoundland and Labrador, Prince Edward Island and Québec, whereas a population-based health and wellness perspective guides policy in Ontario, British Columbia, Nova Scotia and Alberta. Saskatchewan has no known policy specific to mental health. Mental health planning in the territorial governments reflects an overriding concern for access to, and the sustainability of, their mental health systems. Yet our informant from the Yukon reported examples of mental health practice ‘on the ground’ that reflect a recovery orientation. It is important to note that some overlap exists between the recovery, and population wellness, perspectives. For example, the strategies for Newfoundland and Labrador, and Manitoba, all with a strong recovery orientation, also include measures to promote population health. Prince Edward Island attempts to balance an individualized recovery paradigm within a mental health system increasingly structured around population and wellness. The following section compares and contrasts how recovery fits into Canadian provincial mental health policies.

Recovery-orientated provincial strategies

Provincial mental health strategies with a strong recovery orientation including; New Brunswick, Manitoba, Newfoundland and Labrador, Prince Edward Island and Québec, share four common elements: 1) widespread consensus about recovery as a catalyst for system transformation; 2) the presence of recovery champions among high-level mental health leadership; 3) strong commitment to, and funding for, peer support and other consumer-led activities; and 4) links between recovery and social equality for people with lived experience. We review these elements based on our discussions with provincial policymakers and published provincial strategies.

Recovery as a catalyst for system transformation

In provinces with a strong recovery orientation, consensus emerged around the recovery concept as the key to system transformation. Public consultations in these provinces underlined that recovery is everybody's responsibility. Recovery is described as the ‘cornerstone’ in the new 7-year plan for New Brunswick (Province of New Brunswick, 2011), as a ‘key pillar’ in the Manitoba plan (Government of Manitoba, 2011), and the mental health system's ‘fundamental aim’ in the Prince Edward Island (PEI) strategy (Government of PEI, 2009). In Québec, where recovery is already embedded in policy as a guiding principle (MSSS, 2005), the Mental Health Department spokesperson indicated that the 2012–2017 Mental Health Action Plan will give equal or greater emphasis to recovery, further developing a recovery culture in primary care services, reinforcing the role of family doctors in providing mental health services, and improving mental health among youth. Our informant for Newfoundland and Labrador described a recent ‘explosion’ of interest around recovery in that province, in line with province-wide anti-stigma and awareness campaigns, as well as community engagement, aimed at preparing the province for future transformation at the policy level. During the planning phase for their new strategy, Prince Edward Island organized two stakeholder forums composed of mental health consumers, families, service providers, planners and funders, whereas New Brunswick took an ‘all government’ approach seeking input on their 2011 mental health plan from other government ministries.

Recovery champions among high-level leadership

Provincial representatives emphasized the importance of committed leadership in promoting recovery. The Health Minister for Newfoundland and Labrador has prioritized mental health reform, with the main focus on recovery through grassroots involvement and community-based services. In PEI, a steering committee of senior leaders in the mental health system spearheaded recovery-orientated reform in consultation with the Toronto Centre for Addictions and Mental Health (CAMH). New Brunswick's recently elected government promised to carry forward recommendations of an earlier task force in making a strong commitment to recovery-orientated mental health reform. Mental health leaders in Manitoba consulted with experts from the state of California, and organized exchange activities, in the process of translating the recovery concept into policy.

Commitment to peer support and user-led activities

A strong connection between policymakers and user/family stakeholders is another common element among provinces with recovery-orientated strategies. In Quebec, representatives of peer organizations participate in the Department of Mental Health planning sessions. The Department of Mental Health funds peer support services and training programmes through the Association des Personnes Utilisatrices de Services de Santé Mentale (APUR) and the Association Québécoise pour la Réadaptation Psychosociale (AQRP). Building community capacity in Newfoundland and Labrador includes regular and ongoing engagement of individuals and families with lived experience along with community groups; as well as funding for community self-help, peer support and other consumer initiatives. New Brunswick has instituted several collaborative, recovery-orientated measures, including plans to involve peer support workers in healthcare delivery. Mental health community advisory committees have been established across New Brunswick. Mental health consumers will be directly involved in system evaluation through client satisfaction surveys and committee involvement. In Manitoba, a network of provincially funded self-help organizations, participate in provincial planning on a regular basis.

Links between recovery and social equality

Provincial mental health policies with a recovery orientation echo the aforementioned trend in Canadian research towards viewing recovery as a social justice issue where social determinants of health play a major role. For example, both Manitoba and New Brunswick have adopted the World Health Organization definition of health as ‘a state of complete physical, mental and social well-being and not merely the absence of disease or infirmity’ (cited in Government of Manitoba, 2011, Government of Manitoba, p. 5). In this context, the Manitoba strategy defines the responsibility of mental health services in a recovery-orientated system as ‘allowing people with mental health problems and illnesses to function as full citizens in society’ (Government of Manitoba, 2011, Government of Manitoba, p. 9). The new plan builds on the previous report, Full Citizenship. A Manitoba Strategy on Disability (Government of Manitoba, 2003), which supported the need to address social inequities in addition to reforming mental health services and supports (Weisser et al., 2011). The Government of New Brunswick amended the Mental Health Act in 1994 to comply with the Canadian Charter of Rights and Freedoms (Government of New Brunswick, 1994). Québec policy also promotes a link between recovery and citizenship in defining recovery as ‘the capacity of persons to take control of their lives and to participate actively in society’ (MSSS, 2005, MSSS, p. 12).

Population health and wellness strategies

Mental health plans in Ontario, British Columbia, Nova Scotia, and Alberta, reflect an orientation that departs from a recovery perspective in several respects. The 2010 British Columbia plan, as well as the 2011 plans for Ontario and Alberta, has de-emphasized the recovery orientation of their policies in adopting a population-based wellness approach. These policies do not provide formal definitions of wellness; although the British Columbia (BC) plan does equate wellness with good mental health, aided by early intervention and quality services, as well as improved social conditions in key areas such as housing and employment. While less is known about the forthcoming Nova Scotia plan, our informants stated that future policy is expected to highlight community-based service development as well as consumer and family participation.

The identification of priorities within the mental health system in relation to different population groups marks a critical distinction between the recovery and wellness approaches, as underlined in the British Columbia document: ‘A population health approach addresses the health needs of groups of people, rather than individuals’ (BC Ministry of Health Services, 2010, BC Ministry of Health Services, p. 12). Populations in the BC plan are categorized in terms of presence or absence of mental health problems, that is, from a clinical, or treatment, perspective. There are four populations: 1) all people in British Columbia (no mental health problems), 2) people vulnerable to mental health/addictions problems, 3) people with mild to moderate mental health/addictions problems, and 4) people with severe and complex mental disorders and/or substance use problems. Similarly, the Ontario plan, a three-year strategy, aims to transform the mental health system in order to improve mental health and well-being for all Ontarians, but focuses on children and youth as a specific population group under the overarching theme of resilience. Alberta's newly released strategy understands addiction and mental health problems in terms of genetic, biological personality and environmental factors affecting the basic architecture of the human brain (Alberta Health Services, 2011, Alberta Health Services, p. 3). The plan proposes an integrated, five-tier addiction and mental health service model, organized in terms of increasing treatment complexity and intensity. The population groups represented are: children, youth and families, seniors, First Nations, Métis and Inuit people, as well as at-risk populations.

The central role of evidence-based mental health services in achieving wellness

Another assumption underlying policy in population-based strategies is that health and wellness can best be achieved through evidence-based services. The Ontario plan asserts that recovery, and mental illness prevention, depend upon ‘the right mix of integrated, evidence-informed services and supports’ (Ontario Ministry of Health and Long Term Care, 2011, Ontario Ministry of Health and Long Term Care, p. 5). Formal services are expected to ensure diversity, equity and social justice for people with lived experience, and to address stigma. The BC plan is even stronger in promoting evidence-based practice and evaluation. BC mental health services will be realigned based on research evidence, which will be used by the Ministry to develop practice standards and evaluation frameworks. Specific goals centre on improving both population mental health, and that of people with specific mental health needs, through quality and cost efficient services. Priorities, and recommendations, for people with severe and complex mental disorders centre on the implementation of evidence-based services at the community level, while ensuring access to hospital, ‘bed-based’ treatment. System accountability in Alberta focuses on service quality and client/patient safety, which will be monitored through various performance frameworks, at the service, professional, policy and legislative levels as well as through financial reporting systems. While less is known about Nova Scotia's forthcoming strategy, spokespeople stated that major emphasis will be given to an evidence-based orientation for improving community-based services.

The recovery perspective is considerably diminished in mental health strategies with a population orientation in other ways as well. Population orientated strategies do not acknowledge a specific role for service users to direct their individual recovery, to advance consumer-operated initiatives, or monitor and evaluate formal mental health services. The spokespeople for BC and Alberta both suggested that inclusion of the recovery concept in policy is unnecessary, as recovery is the ‘implicit’, or self-evident aim of all mental health service delivery. In British Columbia, consumer-operated services would be required to demonstrate evidence-based results, as a condition for funding, just as other services. Similarly, we were told that the new Ontario plan represents a strong convergence of interests among stakeholders, including those with a medical/treatment focus, but will not focus primarily on people with serious mental illness, nor does recovery have a strong implementation focus. Recovery is taken up under the heading of ‘person directed services’, meaning that service users should have an opportunity to make informed decisions about their personal care and support within the formal system. Service users are referred to as ‘essential partners’, without elaborating on the meaning of partnership, or how partnership will be exercised. Ontario's long tradition of consumer-survivor self-help, peer support initiatives and community economic development remains unacknowledged in the current report. Similarly, the Alberta plan denotes individuals and families with lived experience as ‘enablers’, and envisions that their involvement in care teams would be limited to participation on family councils.

Issues and challenges for Canadian mental health policy

Most provinces, regardless of the orientation of their mental health plans, describe the advancement, well-being and life prospects of people with mental illness, both within and beyond mental health systems, as a major challenge. Most cited the importance of social determinants of health for mental health service users. The spokesperson for Québec perhaps best articulated the concerns of mental health policymakers in terms of ‘micro’ and ‘macro’ challenges. The ‘micro’ challenge involves combating professional attitudes, and the persistence of the medical or ‘treatment paradigm’ in mental health services. He asserted that providers need to abandon the idea that, ‘if symptoms abate, I've done my job’, which means embracing the recovery concept as a wider process than simply a ‘cure’. The ‘macro’ challenge is how to make social structures more inclusive, and how to foster social integration for individuals with mental illness.

Several other provinces identified the need to change the culture of services as a key issue in system transformation to recovery. Spokespeople for Manitoba, Nova Scotia, Prince Edward Island and New Brunswick spoke about difficulties in changing provider attitudes, and stigmatizing behaviours. New Brunswick officials were working to encourage better collaboration between physicians and allied health professionals. They acknowledged there would be challenges, with some providers around changing attitudes and practices with regard to peer mentorship. More active involvement by mental health consumers and their families in services emerged as a major issue for planners in Nova Scotia and Ontario (see also Tse & Kan, this issue, pp. 40–47). How to increase support among service providers for recovery, including the need to translate knowledge, and develop curricula and competency standards, were major issues for spokespeople in New Brunswick, Manitoba and Prince Edward Island. Another major concern expressed by policymakers in Manitoba, Ontario, Nova Scotia, and Quebec, was the ‘macro’ level issue of how to reduce stigmatizing attitudes towards mental illness in the larger society.

Discussion and conclusions

The first noteworthy finding in our review of current mental health policy in Canada is that Canadian policymakers have maintained a surprisingly critical perspective towards the recovery concept as a guiding principle for mental health reform in this country. Provincial stakeholders perceived the initial individual-level definition of recovery proposed by the Mental Health Commission of Canada as inadequate not only for specific mental health populations, but also for mental health promotion and prevention in the general population. The Commission responded by proposing dual guiding principles for Canada's national mental health framework Toward Recovery and Well-Being (Mental Health Commission of Canada, 2009): ‘recovery’, as a journey of healing for individuals affected by diagnosed mental illnesses, and ‘wellness’, as optimal mental health for all individuals. As revealed in our examination of provincial mental health strategies, inclusion of the wellness concept, and its implementation in population-based policies, has tended to obscure rather than support the case for a recovery perspective in mental health.

Mental health strategies, following on Canada's national framework, are currently available or forthcoming for nine of the ten Canadian provinces – five based on a strong recovery orientation, and four with a population-based, wellness orientation. Overall, recovery-orientated strategies tend to privilege the needs and aspirations of people with mental illness over other population groups, to acknowledge the expertise of individual lived experience, and to support the various collective efforts of mental health consumer-survivors to promote their own recovery services and supports. By contrast, population-based strategies depart from a recovery orientation in several respects, most crucially in defining population groups from a medical perspective. Population policies are generally profession-centric, viewing formal mental health services as a panacea for addressing the entire range of health and social issues both inside the mental health system and in the community.

A further argument for the incompatibility between recovery-orientated and population-based mental health strategies lies in the overriding concern of the latter group for evidence-based practice. Evidence-based practice and recovery have potentially conflicting orientations and values: whereas evidence-based practice as described in these mental health plans would privilege quantifiable findings around the medical or scientific condition of service users, recovery-orientated practice is concerned with issues such as individual self-determination, choice, empowerment, and civil rights (Anthony et al., 2003; Davidson et al., 2009; Tanenbaum, 2006). Recovery privileges subjective outcomes in both research and practice.

The meaning of ‘well-being’ in Canadian mental health policy and how it is applied in the context of population-based approaches is unclear. These strategies give no definition of the concept beyond reference to well-being in relation to the WHO definition of mental health. Unlike in New Zealand, where well-being is seen as an enhancement to recovery, well-being in Canadian policies is advanced in support of population-based policies with a medical model, evidence-based orientation. The shift to a population-based, wellness perspective in the policies of influential provinces such as Ontario, British Columbia, Alberta, and the maritime province of Nova Scotia, cast a long shadow on the uptake of recovery in Canada, particularly in the extent to which these strategies fail to acknowledge and provide financial support to long-standing mental health consumer-run initiatives that were the foundation of the recovery movement in Canada.

How the recovery paradigm will take hold, and whether it will persist in Canadian mental health policy depends on directions taken by provincial mental health ministries, themselves subject to the uncertainties of electoral politics. Unlike in Australia, where national consensus has been achieved around a collaborative recovery model, Canada's national framework and implementation strategy have no binding force on the provinces, and have failed to mediate competing interests, or generate consensus in provincial policy.

Our provincial informants did not reveal any single overriding ‘national issue’ for mental healthcare in Canada; although they did identify a number of important issues for mental health policy such as peer support, housing, social determinants of health, and the need for a culture shift in mental health services. The diversity of local needs and service systems, as well as uneven degrees of exposure to the recovery perspective among the provinces may account, in part, for this finding.

There is, however, one issue that cuts across the recovery/well-being divide, and perhaps defines a uniquely Canadian perspective in mental health. This is the issue of social equality for individuals with mental illness. The concern for equality rights, and social determinants of health, as reflected in all Canadian provincial mental health strategies, has its roots in section 15.1 of the Canadian Charter of Rights and Freedoms, which establishes equal rights before the law for all Canadian citizens, and specifically includes those with either physical or psychiatric disability (DSS Canada, 1987; see also Province of New Brunswick, 2011, Province of New Brunswick, p. 3). Guaranteeing fundamental rights to citizens with disability has greater potential for recovery and social integration than legislating contingent rights in specific domains; for example, the right to rehabilitation services as described for the case of Israel in this volume (pp. 00–00); or in employment legislation as advanced, for example, in the Americans with Disability Act (Petrila & Brink, 2001).

One implication of Canada's entrenchment of equality rights and full citizenship for people with mental illness at the constitutional level is the recognition that some disabling aspects of mental illness are socially imposed; and further, that mental health recovery must extend beyond the boundaries of mental health systems to challenge society at large. As noted earlier, current research on recovery in Canada has shifted to a concern for social and structural inequities affecting individuals with mental illness, suggesting an evolution toward a ‘social model of recovery’ in Canada akin to an important perspective in the disability field that originated in the UK (Oliver, 1990, 1998; Thomas, 2002).

The struggle for a recovery perspective, as opposed to a population-based well-being perspective in Canadian mental health is ultimately a question of the extent to which policymakers are willing to acknowledge their co-existence with a well-entrenched, consumer-driven recovery movement in this country. The transformation to recovery-orientated services depends upon how policymakers and providers respect the expertise of lived experience and the role of consumer leadership in shaping mental health policy, particularly as they allocate resources. The recognition of equality rights for individuals with physical or mental disabilities under Canadian law gives our mental health population unique claims to inclusion in the transformation process.

Appendix: Current provincial and territorial mental health plans in Canada

Provinces

Government of Alberta (2011)

Creating Connections: Alberta's Addiction and Mental Health Strategy

Government of British Columbia (2010)

Healthy Minds, Healthy People. A 10-Year Plan to Address Mental Health and Substance Use in British Columbia

Government of Manitoba (2011)

Rising to the Challenge. A Strategic Plan for the Mental Health and Well-Being of Manitobans

Government of New Brunswick (2011)

The Action Plan for Mental Health in New Brunswick 2011–2018

Government of Newfoundland and Labrador (2005)

Working Together for Mental Health. A Provincial Policy Framework for Mental Health & Addictions Services in Newfoundland and Labrador and Labrador

Government of Nova Scotia (2004)

Our Peace of Mind. Mental Health Promotion, Prevention and Advocacy Strategy and Framework for Nova Scotia

Government of Ontario (2011)

Open Minds, Healthy Minds. Ontario's Comprehensive Mental Health and Addictions Strategy

Government of Prince Edward Island (2009)

The Path Forward: Prince Edward Island Mental Health Services Strategy

Gouvernement du Québec (2005)

Plan d'action en santé mentale 2005–2010. La force des liens

Government of Saskatchewan (2006)

A Report on the 10-Year Plan to Strengthen Health Care and Medical and Diagnostic Equipment Funding

Territories

Government of Northwest Territories (2005)

Mental Health and Addictions Services Framework for Action Status Report. March 2003– April 2005

Government of Yukon Territory (2008)

The Yukon Health Care Review. Final Report.

Declaration of interest: The authors report no conflicts of interest. The authors alone are responsible for the content and writing of the paper.