model of disability, and there may be differences in the acceptance of diagnostic "labels" and treatments. a review of research suggested that writers on recovery are rarely explicit about which of the various concepts they are employing. the reviewers classified the approaches they found in to broadly "rehabilitation" perspectives, which they defined as being focused on life and meaning within the context of enduring disability, and "clinical" perspectives which focused on observable remission of symptoms and restoration of functioning. from a psychiatric rehabilitation perspective, a number of additional qualities of the recovery process have been suggested, including that it: can occur without professional intervention, but requires people who believe in and stand by the person in recovery; does not depend on believing certain theories about the cause of conditions; can be said to occur even if symptoms later re-occur, but does change the frequency and duration of symptoms; requires recovery from the consequences of a psychiatric condition as well as the condition itself; is not linear but does tend to take place as a series of small steps; does not mean the person was never really psychiatrically disabled; focuses on wellness not illness, and on consumer choice. a consensus statement on mental health recovery from us agencies, that involved some consumer input, defined recovery as a journey of healing and transformation enabling a person with a mental health problem to live a meaningful life in a community of his or her choice while striving to achieve his or her full potential. ten fundamental components were elucidated, all assuming that the person continues to be a "consumer" or to have a "mental disability". conferences have been held on the importance of the "elusive" concept from the perspectives of consumers and psychiatrists. one approach to recovery known as the tidal model focuses on the continuous process of change inherent in all people, conveying the meaning of experiences through water metaphors. crisis is seen as involving opportunity; creativity is valued; and different domains are explored such as sense of security, personal narrative and relationships. initially developed by mental health nurses along with service users, tidal is a particular model that has been specifically researched. based on a discrete set of values (the ten commitments), it emphasizes the importance of each person's own voice, resourcefulness and wisdom. since 1999, projects based on the tidal model have been established in several countries. for many, recovery has a political as well as personal implication—where to recover is to: find meaning; challenge prejudice (including diagnostic "labels" in some cases); perhaps to be a "bad" non-compliant patient and refuse to accept the indoctrination of the system; to reclaim a chosen life and place within society; and to validate the self. recovery can thus be viewed as one manifestation of empowerment. such an empowerment model may emphasize that conditions are not necessarily permanent; that other people have recovered who can be role models and share experiences; and that "symptoms" can be understood as expressions of distress related to emotions and other people. one such model from the us national empowerment center proposes a number of principles of how people recover and seeks to identify the characteristics of people in recovery. in general, recovery may be seen as more of a philosophy or attitude than a specific model, requiring fundamentally that "we regain personal power and a valued place in our communities. sometimes we need services to support us to get there". recovery from substance dependence particular kinds of recovery models have been adopted in drug rehabilitation services. while interventions in this area have tended to focus on harm reduction, particularly through substitute prescribing (or alternatively requiring total abstinence) recovery approaches have emphasized the need to simultaneously address the whole of people's lives, and to encourage aspirations while promoting equal access and opportunities within society. some examples of harm reduction services include overdose reversal medications (such as narcan), substance testing kits, supplies for sterile injections, hiv, hbv, and hcv at-home testing equipment– and trauma-informed care in the form of group therapy, community building/events, case management, and rental assistance services. the purpose of this model is to rehabilitate those experiencing addiction in a holistic way rather than through law enforcement and criminal justice-based intervention which can fail to address victims’ circumstances on a need-by-need basis. from the perspective of services the work may include helping people with "developing the skills to prevent relapse into further illegal drug taking, rebuilding broken relationships or forging new ones, actively engaging in meaningful activities and taking steps to build a home and provide for themselves and their families. milestones could be as simple as gaining weight, re-establishing relationships with friends, or building self-esteem. what is key is that recovery is sustained.". key to the philosophy of the recovery movement is the aim for an equal relationship between "experts by profession" and "experts by experience". trauma-informed recovery trauma-informed care is a philosophy for recovery that combines the conditions and needs of people recovering from mental illness and/or substance abuse into one framework. this framework combines all of the elements of the recovery approach and adds an awareness of trauma. advocates of trauma-informed care argue the principles and strategies should be applied to individuals experiencing mental illness, substance dependence, and trauma as these three often occur simultaneously or as result of each other. the paradigms surrounding trauma-informed care began to shift in 1998 and 1999. in 1998, the center for mental health services, the center for substance abuse treatment, and the center for substance abuse prevention collaborated to fund 14 sites to develop integrated services in order to address the interrelated effects of violence, mental health, and substance abuse. in 1999, the national association of state mental health program directors passed a resolution recognizing the impact of violence and trauma and developed a toolkit of resources for the implementation of trauma services in state mental health agencies. trauma-informed care has been supported in academia as well. scholars claim that neglecting the role of trauma in a person's story can interfere with recovery in the form of misdiagnosis, inaccurate treatment, or retraumatization. some principles of trauma-informed care include validating survivor experiences and resiliency, aiming to increase a survivor's control over her/his/their recovery, creating atmospheres for recovery that embody consistency and confidentiality, minimizing the possibilities of triggering past trauma, and integrating survivors/recovering persons in service evaluation. in practice, trauma-informed care has shown to be most effective when every participant in a service providing context to be committed to following these principles. in addition, these principles can apply to all steps of the recovery process within a service providing context, including outreach and engagement, screening, advocacy, crisis intervention, and resource coordination. the overall goal in trauma-informed care is facilitating healing and empowerment using strengths-based empowerment practices and a comprehensive array of services that integrate co-occurring disorders and the multitude of needs a recovering person might have, such as drug treatment, housing, relationship building, and parenting support. these approaches are in contrast to traditional care systems. advocates of trauma-informed care critique traditional service delivery systems, such as standard hospitals, for failing to understand the role of trauma in a patients life. traditional service delivery systems are also critiqued for isolating the conditions of a recovering person and not addressing conditions such as substance abuse and mental illness simultaneously as part of one source. specific practices in traditional service delivery systems, such as unnecessary procedures, undressing for examinations, involuntary hospitalizations, crowded emergency rooms, and limited time for providers to meet with patients, have all been critiqued as insensitive to persons recovering from trauma and consequential mental illness or substance abuse. limited resources and time in the united states healthcare system can make the implementation of trauma-informed care difficult. there are other challenges to trauma-informed care besides limits in the united states healthcare system that can make trauma-informed care ineffective for treating persons recovering from mental illness or substance dependence. advocates of trauma-informed care argue implementation requires a strong commitment from leadership in an agency to train staff members to be trauma-aware, but this training can be costly and time-consuming. "trauma-informed care" and "trauma" also have contested definitions and can be hard to measure in a real world service setting. another barrier to trauma-informed care is the necessity of screening for histories of trauma. while agencies need to screen for histories of trauma in order to give the best care, there can be feelings of shame and fear of being invalidated that can prevent a recovering person from disclosing their personal experiences. concerns some concerns have been raised about a recovery approach in theory and in practice. these include suggestions that it: is an old concept; only happens to very few people; represents an irresponsible fad; happens only as a result of active treatment; implies a cure; can only be implemented with new resources; adds to the burden of already stretched providers; is neither reimbursable nor evidence based; devalues the role of professional intervention; and increases providers' exposure to risk and liability. other criticisms focused on practical implementation by service providers include that: the recovery model can be manipulated by officials to serve various political and financial interests including withdrawing services and pushing people out before they're ready; that it is becoming a new orthodoxy or bandwagon that neglects the empowerment aspects and structural problems of societies and primarily represents a middle class experience; that it hides the continued dominance of a medical model; and that it potentially increases social exclusion and marginalizes those who don't fit into a recovery narrative. there have been specific tensions between recovery models and "evidence-based practice" models in the transformation of us mental health services based on the recommendations of the new freedom commission on mental health. the commission's emphasis on recovery has been interpreted by some critics as saying that everyone can fully recover through sheer will power and therefore as giving false hope and implicitly blaming those who may be unable to recover. however, the critics have themselves been charged with undermining consumer rights and failing to recognize that the model is intended to support a person in their personal journey rather than expecting a given outcome, and that it relates to social and political support and empowerment as well as the individual. various stages of resistance to recovery approaches have been identified amongst staff in traditional services, starting with "our people are much sicker than yours. they won't be able to recover" and ending in "our doctors will never agree to this". however, ways to harness the energy of this perceived resistance and use it to move forward have been proposed. in addition, staff training materials have been developed by various organisations, for example by the national empowerment center. some positives and negatives of recovery models were highlighted in a study of a community mental health service for people diagnosed with schizophrenia. it was concluded that while the approach may be a useful corrective to the usual style of case management - at least when genuinely chosen and shaped by each unique individual on the ground - serious social, institutional and personal difficulties made it essential that there be sufficient ongoing effective support with stress management and coping in daily life. cultural biases and uncertainties were also noted in the 'north american' model of recovery in practice, reflecting views about the sorts of contributions and lifestyles that should be considered valuable or acceptable. assessment a number of standardized questionnaires and assessments have been developed to try to assess aspects of an individual's recovery journey. these include the milestones of recovery (mor) scale, recovery enhancing environment (ree) measure, recovery measurement tool (rmt), recovery oriented system indicators (rosi) measure, stages of recovery instrument (stori), and numerous related instruments. the data-collection systems and terminology used by services and funders are said to be typically incompatible with recovery frameworks, so methods of adapting them have been developed. it has also been argued that the diagnostic and statistical manual of mental disorders (and to some extent any system of categorical classification of mental disorders) uses definitions and terminology that are inconsistent with a recovery model, leading to suggestions that the next version, the dsm-v, requires: greater sensitivity to cultural issues and gender; to recognize the need for others to change as well as just those singled out