By “recovery,” we mean far more than simple symptomatic remission or a significant reduction in scores on validated rating scales (e.g., PANSS, MADRS). Recovery in mental health is a broad, multidimensional concept that can be defined in various ways, including as a return to functioning. However, we favor here a more specific and descriptive definition: the individual’s attainment of the five existential dimensions of recovery, grouped under the acronym AiLES: Autodétermination/autonomie (Empowerment), Identité (Identity), Lien social (Connectedness), Espoir (Hope) et Sens (Meaning),, Social connection, Hope, and Meaning.

This conceptualization corresponds to the French-language adaptation of the CHIME model—a framework widely used in mental health (Connectedness, Hope, Identity, Meaning, Empowerment)—developed from the lived experience of people with mental health conditions and describing the core dimensions of personal recovery.* 

Rational and Optimal Pharmacotherapy: Four Key Elements

You address all of the following elements to ensure pharmacotherapy that is both rational and recovery-oriented:

1. 1. Regular review of treatment (medications and/or brain stimulation)

      1. • Ensuring that treatments correspond to revised diagnoses

         • Following current algorithms and clinical practice guidelines

         • Adjusting according to response and tolerability, while avoiding polypharmacy

   2. Choosing treatments that promote not only stability but also recovery

   3. Actively considering adherence-related issues

   4. Exploring approved options for treatment-resistant cases
      
      

1. Regular Review of Treatment

You regularly reassess pharmacological and/or brain stimulation treatments to ensure they remain adapted to clinical evolution, updated diagnoses, and the patient’s individual characteristics, including comorbidities.

The objective goes beyond merely maintaining stability; it aims to support progression toward recovery, in accordance with the CHIME/AiLES model (Connectedness, Hope, Identity, Meaning, Empowerment).

Regular review helps prevent therapeutic inertia—the continuation of treatments that have become less relevant, often out of fear of destabilization—which can hinder recovery through medication accumulation, side effects, or tolerance.

You adjust treatments using combination, augmentation, or substitution strategies, based on current clinical guidelines. Polypharmacy is generally to be avoided, as its long-term risks often outweigh its benefits. An integrated biopsychosocial approach is preferred: a balance between pharmacological and non-pharmacological treatments, reducing exclusive reliance on medication (criteria to follow).

2. Medications That Promote Recovery

You favor medications that offer not only a good tolerability profile, but also effects likely to support recovery, notably through activating, pro-cognitive, and minimally sedating properties, thereby limiting psychomotor slowing. Medication selection is based on a regular, shared assessment of the benefit–risk ratio, in collaboration with the patient.

Thus, a medication that improves concentration or energy level may be preferred, even if it is less effective on certain symptoms, when this choice optimizes overall functioning and the pursuit of life goals, always with the patient’s agreement.

Well-adapted medication facilitates the patient’s engagement in other therapeutic modalities, particularly non-pharmacological ones, and promotes synergy between pharmacological and non-pharmacological approaches.

3. Consideration of Adherence-Related Issues

Poor adherence can sometimes be mistaken for treatment resistance. When identified as a clinical issue, you explore additional strategies beyond usual clinical follow-up, strengthening of the therapeutic alliance, and patient education.

These strategies may include:

• choosing another molecule when nonadherence may be related to insufficient efficacy or inadequate tolerability;

• using long-acting injectable formulations;

• selecting medications with longer half-lives;

• verifying medication intake through plasma level monitoring, when clinically relevant. In cases of confirmed and voluntary nonadherence, this can then be addressed through an open and collaborative discussion aimed at identifying solutions to reduce nonadherence or, if necessary, to adjust therapeutic goals (e.g., a patient accepting a higher risk of relapse in exchange for a lower dose). The measures proposed are solutions, not punishments.

4. Approved Options for Treatment-Resistant Cases

If the preceding strategies do not ensure stability or support recovery, you then consider—when available and according to diagnosis—the use of treatments specifically indicated for treatment-resistant forms:

• • • • • clozapine in the context of treatment-resistant schizophrenia;

        • electroconvulsive therapy (ECT) in cases of treatment-resistant major depression or catatonia.

Although more complex to initiate, these options may prove necessary. Chronic suffering related to incomplete stabilization and/or recovery can undermine dignity as much as an acute crisis. It may therefore be preferable to resort to these treatments earlier, especially in light of recent advances that have made them more accessible and safer.

Current clinical guidelines:

Schizophrenia:

Addington, D., Addington, J., Abidi, S., et al. (2017). Canadian Guidelines for the Pharmacological Treatment of Schizophrenia Spectrum and Other Psychotic Disorders in Adults. Canadian Journal of Psychiatry, 62(9), 604–616.​

Health Quality Ontario. (2023). Schizophrenia Care in the Community for Adults: Quality Standard.

 Bipolar affectifve disoder:

Keramatian, K., Chithra, N. K., & Yatham, L. N. (2023). The CANMAT and ISBD Guidelines for the Treatment of Bipolar Disorder: Summary and a 2023 Update of Evidence. Focus, 21(4), 344–353.

 Major depressive disorder:

Lam RW, Kennedy SH, Adams C, et al. Canadian Network for Mood and Anxiety Treatments (CANMAT) 2023 Update on Clinical Guidelines for Management of Major Depressive Disorder in Adults. Can J Psychiatry. 2024;69(5):297–312.

 Anxiety disorders:

Katzman, M. A., Bleau, P., Blier, P., Chokka, P., Kjernisted, K., Van Ameringen, M., & Walker, J. R. (2014). Canadian clinical practice guidelines for the management of anxiety, posttraumatic stress and obsessive-compulsive disorders. BMC Psychiatry, 14(Suppl 1), S1

 Insomnia disorder:

Morin CM, Khullar A, Robillard R, Desautels A, Mak MSB, Dang-Vu TT, Chow W, Habert J, Lessard S, Alima L, Ayas NT, MacFarlane J, Kendzerska T, Lee EK, Carney CE. Delphi consensus recommendations for the management of chronic insomnia in Canada. Sleep Med. 2024 Dec;124:598-605.

Write to us to suggest other relevant clinical tools and guidelines based on your area of expertise:

 tngominh@cpac-apcc.org 

Dynamic search for the optimal dose

Whereas the previous criterion focused on the choice of the most appropriate molecule or combination, this one is concerned with adjusting the optimal dose over time, based on clinical evolution. You therefore pursue, in a dynamic manner, the minimum effective dose —in other words, the optimal dose— which constitutes the second fundamental principle of rational, recovery-oriented pharmacotherapy. This search is described as “dynamic” because a dose that is effective today may no longer be effective in three months.

Until the 1980s, during the era of psychiatric institutionalization, the approach was diametrically opposed, often favoring the maximum tolerated dose for the most severely ill patients, with little consideration for side effects or the goal of recovery. These practices frequently induced marked psychomotor slowing and hindered recovery.

However, overprescription and polypharmacy remain very common in psychiatry and constitute, more often than is believed, a reason for current or future nonadherence. Indeed, they can increase the risk of adverse effects and give patients the impression that their prescriber has little confidence in non-pharmacological means to help them cope.

While eliminating superfluous medication is often desirable once the person is stabilized and out of the acute phase, the dynamic search for the minimum effective dose should not be confused with systematic deprescribing.

The concept of the “minimum effective dose” is another way of expressing the attainment of the best benefit–risk ratio, that is, the dose that provides relatively satisfactory clinical efficacy while maintaining a relatively low level of adverse effects—efficacy being defined here as support for recovery rather than simple symptom control. In more familiar terms, it refers to a treatment that is “good and low-cost” in terms of side effects. This objective does not necessarily imply a dose reduction; on the contrary, the minimum effective dose/optimal dose may sometimes require an increase in order to obtain a significant clinical benefit. In the context of severe and persistent disorders, a marked reduction in medication is often unrealistic in the absence of an integrated biopsychosocial approach, since pharmacological reduction would then need to be compensated by an intensification of non-pharmacological interventions.

Thus, treatment adjustment must remain dynamic and guided by clinical evolution, with the following objectives:

• satisfactory symptom control;

• promotion of capacities that support recovery (preservation of motivation, energy, and cognitive functions, etc.);

• prevention of relapse;

• while limiting adverse effects and the risk of developing medication tolerance (e.g., benzodiazepines, antipsychotics).
  
  

While it is common—and expected—to see an escalation of pharmacological input when a patient is unstable, the opposite is much rarer: a reduction when the patient is stable. Pharmacological inertia is therefore frequently favored, such that, in practice, medication is either increased or maintained as is. In this context, it can be difficult to envision the objectives of reducing pharmacological input in a patient who is nevertheless stabilized. Yet, a cautious reduction of polypharmacy or adjustment toward lower doses can fully align with an integrated treatment strategy aimed at other significant objectives, such as:

• Promoting engagement in non-pharmacological interventions

A cautious reduction of polypharmacy or adjustment toward lower doses can promote engagement in non-pharmacological interventions, whose effects are generally more durable. Moderately reducing the “pharmacological safety net” may expose the person to greater short-term discomfort, but it also encourages the adoption of protective behaviors, fostering responsibility, autonomy, and more sustainable recovery. This may translate into reduced substance use, a break from isolation, or greater acceptance of external help.

This perspective is often experienced positively by patients, who then show greater motivation and increased engagement in non-pharmacological strategies, for example:  “By gradually exposing myself to social situations, I learn to better manage my social anxiety and may eventually need fewer anxiolytics or antipsychotics.”

By analogy, as in orthopedic rehabilitation, the gradual removal of a crutch may increase initial discomfort but encourages rehabilitation efforts and accelerates functional recovery.

• Empirically testing the usefulness of treatment

A cautious reduction in medication also makes it possible to empirically test its usefulness by clarifying certain clinical ambiguities:

• • • • • a re-emergence of symptoms suggests that the treatment remains useful in preventing relapse;

        • maintenance or even improvement of the clinical state with less medication indicates that real progress has been made and that the treatment may no longer be necessary to the same extent as before.

    • Strengthening the therapeutic alliance and trust

Prescribers often surprise patients by proposing a possible reduction in medication as part of a minimum effective dose strategy, an approach that contrasts with more common practices often centered on treatment intensification and polypharmacy. Such a proposal is generally perceived by the person as a sign of trust. The patient then feels freer to express themselves, both regarding their wishes for dose reduction and other concerns they may not have dared to raise previously, without fear of being judged or of their comments being immediately met with fear, reluctance, or condemnation.

This clinical stance strengthens the therapeutic alliance, reduces implicit tensions, and decreases the risk of concealed nonadherence—a frequent reality. It is all the more beneficial as it conveys hope and fosters empowerment, as illustrated by this perception frequently expressed by patients:  “My doctor or clinician thinks I could do better even if I relied less on medication, as long as I stay active and maintain healthy habits.”

Whatever the reason for the reduction, the patient perceives that the prescriber is acting in their best interest rather than out of dogmatism, which consolidates the therapeutic relationship and supports the recovery process.

Caution and vigilance in the search for and maintenance of the minimum effective dose

The search for and maintenance of the minimum effective dose require constant patience and vigilance. As the saying goes, “not enough is as bad as too much”: two opposite pitfalls must be avoided—maintaining excessive doses or prolonged polypharmacy, and, conversely, reducing medication too much or too quickly.

• Excessive pharmacotherapy

The dose required to stabilize a patient in the acute phase is not necessarily the dose that should be maintained long term, as confirmed by longitudinal patient follow-up, and not merely by observations during acute care episodes. Regular reassessment is therefore essential, particularly after hospitalization, in order to adjust treatment according to the evolution—or resolution—of biological stressors (e.g., relapse related to nonadherence or substance use) and psychosocial stressors. Pharmacological adjustments aimed primarily at controlling situational symptoms should, by definition, remain temporary. Yet, in practice, prescriptions initially intended to be short term—such as anticholinergics, benzodiazepines, hypnotics, or PRN quetiapine—frequently become chronic in the absence of systematic reassessment. This phenomenon is also common during transitions of care to primary care.

• Insufficient pharmacotherapy

Conversely, a reappearance of symptoms may occur several months after a strategic reduction, due to so-called delayed risks, particularly when the person does not adopt sufficient lifestyle hygiene or fails to develop effective stress-management strategies. Clinical experience also shows that some patients simply cannot benefit from dose reduction, even when they optimally implement non-pharmacological recommendations. A failed attempt at pharmacological tapering can allow the patient to more clearly recognize the usefulness of their treatment and thereby promote better long-term medication adherence.

It is therefore essential to adequately prepare the patient and support them through this pharmacological transition. A lighter pharmacological safety net requires increased vigilance and greater accountability, both from the patient and the care team—a sine qua non for taking such a risk—notably by:

• • monitoring and recognizing early signs of decompensation;

  • maintaining close follow-up;

  • mobilizing the patient’s support network, which can contact the treating team if signs of relapse appear;

  • reducing medication very gradually and allowing sufficient observation time before considering further reductions (the use of long half-life medications, such as long-acting antipsychotics, can facilitate this very gradual taper);

  • maintaining a structured routine;

  • avoiding aggravating factors (e.g., substance use);

  • promoting engagement in other aspects of treatment (see subsequent criteria);

  • etc.

The foundation of recovery: basic lifestyle hygiene

Optimal and well-balanced pharmacotherapy is essential, but on its own it is not sufficient in the current context of caring for patients living with severe and persistent disorders. It must be part of a truly integrated treatment plan that combines pharmacological and non-pharmacological interventions in order to promote recovery. We refer to basic life hygiene as the first component of non-pharmacological treatment. It is indispensable and should be addressed even before other, more active non-pharmacological interventions, such as behavioral activation, psychotherapy, or spirituality (see subsequent criteria).

At this stage, your support consists of teaching and reinforcing these fundamental habits:

• getting up in the morning, even in the absence of planned activities;

• establishing and maintaining a daily routine;

• eating a healthy diet, without aiming for perfection;

• staying actively engaged, even through small rewarding activities;

• reducing or stopping substance use;

• maintaining adequate sleep hygiene (educational sheet on sleep hygiene).
  
  

When accumulated and sustained over time, these simple yet structuring habits help counter inertia and paralyzing rumination (“When your mind is whirly, keep busy”). They form the foundation upon which other essential non-pharmacological interventions for recovery can be built. Moreover, basic life hygiene—although it may appear rudimentary—represents a powerful therapeutic tool: by contributing significantly to a reduction in overall destabilization (↓ stress, ↓ substance use, ↓ fluctuations), it can, when clinically appropriate, support a gradual reduction in the need for other stabilizing interventions, including close follow-up or medication. 

Supporting activation: moving from preoccupation to action

Once the foundations of basic life hygiene are minimally achieved or consolidated, it becomes essential to actively support patient activation. People living with severe and persistent psychiatric disorders are often overwhelmed by worries, ruminations, or paralyzing thoughts. In this context, you apply a simple yet powerful principle: “When your mind is whirly, keep busy.”

You therefore encourage the patient to integrate three complementary forms of activation into daily life:

• • • Physical activation: moving, mobilizing the body;

    • Social activation: going out, breaking isolation, meeting and interacting with others;

    • Mental and creative (cognitive) activation: engaging the mind through work, learning, discovery, play, or creation.

These forms of activation are not merely momentary distractions. When repeated and sustained over time, they help restore a sense of agency, control, and personal competence—fundamental elements of recovery, directly linked to Empowerment (the “E” in CHIME).

Addressing all of these therapeutic dimensions simultaneously may seem daunting, both for the clinician and for the patient. However, simple and accessible tools make it possible to introduce the concept of activation quickly and effectively, without overburdening the consultation:

• • • Illustrated activation prescription to remind patients of activation and lifestyle hygiene tasks – Tool: Life hygiene prescription

    • "Just of it" dice: a playful tool offering both activation activities and mindfulness techniques –  https://dice.deprescription.org 

These clinical tools present activation as a concrete, progressive, and customizable approach, thereby strengthening patient engagement in the recovery process. 

References :

• Richards, David A et al. Cost and Outcome of Behavioural Activation versus Cognitive Behavioural Therapy for Depression (COBRA): a randomised, controlled, non-inferiority trial The Lancet, Volume 388, Issue 10047, 871 - 880
• Dauwan, M., et al. (2016). “Exercise Improves Clinical Symptoms, Quality of Life, Global Functioning, and Depression in Schizophrenia: A Systematic Review and Meta-analysis.” Schizophr Bull 42(3): 588-599.
• Cooper M, Avery L, Scott J, Ashley K, Jordan C, Errington L, Flynn D. Effectiveness and active ingredients of social prescribing interventions targeting mental health: a systematic review. BMJ Open. 2022 Jul 25;12(7):e060214.
• Stickley T, Wright N, Slade M. The art of recovery: outcomes from participatory arts activities for people using mental health services. J Ment Health. 2018 Aug;27(4):367-373.

Fostering collaboration and voluntary engagement: Collaboration ≠ Obligation

Having a biopsychosocial plan—that is, having a reasonably clear understanding of what needs to be done to improve (criteria 1–2–3–4)—is essential, just as it is essential to apply this plan (the current criterion and those that follow). To increase the likelihood of success in implementing the plan, collaboration and active engagement with the patient are indispensable.

Many strategies exist to foster collaboration and mutual engagement, as opposed to forced engagement (e.g., treatment orders or other more or less explicit forms of coercion). The following are key characteristics sought in such collaboration:

1. Collaboration that respects the freedoms and responsibilities of each party

You adopt a non-coercive stance by recognizing that both the clinician and the patient remain free in their choices, insofar as the person is capable of consenting and making decisions. When this freedom is recognized and assumed on both sides, resistance naturally decreases and authentic collaboration becomes possible. Mature collaboration emerges from the convergence of two inseparable factors: freedom and responsibility. Fully assuming the freedom of each party nurtures the therapeutic alliance and promotes engagement and responsibility-taking, both of which are essential to recovery.

Concretely, this collaboration may translate into decisions that are sometimes difficult but coherent. For example, you may refuse to prescribe a benzodiazepine (exercise of the prescriber’s freedom) if the patient does not agree to engage in parallel (patient’s responsibility) in a process of reducing substance use or gradual exposure to stressors, with the goal of desensitization and longer-term well-being.

Conversely, the patient may refuse (exercise of their freedom) an intervention they consider too aggressive or premature. This choice must be respected. Your role then consists of encouraging engagement through other means, notably by improving lifestyle hygiene, psychosocial activation, and other relevant non-pharmacological interventions—responsibilities that remain the patient’s and that may sometimes prove just as effective, or even more so, than the initially proposed intervention, particularly because the person then feels more in control of their trajectory.

Collaboration is fundamentally bidirectional. The patient may refuse certain recommendations and assume the associated risks, provided they are capable of consenting and deciding. For their part, the clinician may refuse to perform certain therapeutic actions when repeated refusals compromise the fulfillment of their caregiving mandate. Your responsibility then is to provide adequate information, respect the expressed choice, and remain present, patient, and compassionate, recognizing that change is a difficult process.

Thus, demonstrating conscious patience means not prematurely terminating care or the therapeutic relationship out of frustration or annoyance (e.g., “If you don’t follow my recommendations, go elsewhere”). However, this patience does not preclude setting limits. On the contrary, it involves maintaining the relationship while establishing a clear and safe framework when the person repeatedly or excessively puts themselves at risk. In cases of incapacity to consent to care and refusal of a treatment likely to significantly improve quality of life, the physician should consider appropriate legal steps, including treatment orders, which may exceptionally temporarily override the person’s right to decide about their treatment.

A flexible and humane collaborative approach therefore implies neither complacency nor conflict avoidance. On the contrary, you have a responsibility to provide structure, set boundaries, and, when necessary, confront respectfully. Failing this, a status quo may develop and contribute to perpetuating the person’s difficulties. Genuine collaboration thus rests on mutual respect for autonomy, with a sincere intent to help, aimed at recovery, and grounded in a shared spirit of flexibility, responsibility, and openness.

2. Useful collaboration, oriented toward clear recovery goals

Collaboration is not a blank check and cannot be taken for granted indefinitely. It is valuable and must be used judiciously—that is, in the service of a clear and concrete treatment plan. This collaboration aims at implementing a biopsychosocial plan focused on responsibility-taking, as outlined in criteria 1 to 4.

Collaboration creates a context conducive to accepting offered help and making the efforts required for change, allowing the person to gradually reclaim the dimensions of their recovery (CHIME/AiLES). It must therefore be accompanied by concrete commitments (“therapeutic homework”), in the form of resolutions to adopt, actions to take, and attitudes to develop, within a personalized, targeted, and evolving treatment plan. In other words, effective collaboration involves reciprocal responsibilities and unfolds within an active rather than passive dynamic.

Medical follow-up serves precisely to monitor these mutual commitments, whether they concern, for example: appropriate medication adherence (patient’s responsibility); ongoing evaluation of the relevance of the molecule and dosage to optimize the benefit–risk ratio (prescriber’s responsibility); or the implementation of agreed-upon non-pharmacological goals, such as limiting screen time (an sleep hygiene advice) or completing a daily walk as proposed.

3. Longitudinal collaboration

Recovery unfolds over time and generally requires more patience than simple stabilization, particularly for people living with severe and persistent mental disorders. In this context, collaboration cannot be episodic; it is necessarily longitudinal. Time allows the therapeutic relationship to mature and to establish a genuine climate of mutual trust, an essential condition for developing a form of therapeutic intimacy that enables more nuanced identification of the person’s strengths, vulnerabilities, and goals, and thus the delivery of more relevant and targeted interventions.

The more durable the collaboration—especially when it has weathered ups and downs that were acknowledged and repaired—the greater the impact of interventions. With trust established, there is less fear, and expectations on both sides can be addressed with greater openness and less discomfort. This matured collaboration then becomes a form of useful therapeutic complicity, placed at the service of achieving the person’s goals.

A meaningful therapeutic relationship that unfolds over time inevitably brings expectations: expectations that follow-up, treatment, and invested efforts have meaning and yield results. When the relationship is sufficiently mature, these expectations do not generate guilt—which would be counterproductive—but instead become mobilizing. Conversely, the absence of expectations or follow-up may be experienced by the person as a form of indifference or abandonment, undermining hope and the capacity for self-determination.

Because collaboration and trust are built over time, change has more opportunity to occur. Various change-support strategies can then be implemented and given time to bear fruit, including approaches based on positive or negative reinforcement, framed in a spirit of respect and reciprocity (“therapeutic deals”). For example: “I genuinely want to help you, but you also need to want to help yourself. If you make efforts to reduce your substance use and become more active, I commit to supporting your request for…”

Reference:

• Kelly PJ, Deane FP. Therapeutic homework to support recovery from severe mental illness. Psychiatr Serv. 2009 Oct;60(10):1391

Mobilizing family members and other mental health professionals

For a person living with a severe and persistent psychiatric disorder, episodic care centered on a single provider is rarely sufficient. Promoting recovery generally involves coordinated actions on multiple levels—medical, psychological, social, functional, and existential—and therefore goes beyond pharmacological adjustment alone or the patient–physician relationship. This may include, for example, ensuring a minimum income, stable housing, access to services (financial, legal assistance), or adapted opportunities (employment, volunteering, training). To provide truly recovery-oriented biopsychosocial care, mobilizing family members and a multidisciplinary team is often essential.

The principles described in the previous section on collaboration with the person (Criterion 5) fully apply here, but at a systems level: the more actors involved, the more important it becomes to clarify freedoms, responsibilities, and shared objectives.

1) Collaboration that respects the freedoms and responsibilities of each party

You adopt a non-paternalistic stance grounded in respect for freedoms—particularly freedom of opinion, according to each person’s expertise and role. This logic applies here to multiple actors (family members and professionals), making it essential to clarify roles, limits, and responsibilities. A shared minimal agreement is necessary; otherwise, engagement becomes fragile and the risk of splitting increases (patient vs. family, family vs. team, professionals among themselves).

You strive to maintain a climate of mutual respect, acknowledge legitimate disagreements, and bring discussions back to a realistic common ground: safety, stability, and recovery goals.

• Example 1 – disagreement between family and treating team:
  A family that does not condemn the substance use of a relative living at home, believing it has no major impact on their condition (family’s freedom of opinion), can hardly demand that the team compensate for this position by intensifying interventions, notably through pharmacological escalation (clinical freedom and responsibility of the team). In this context, family meetings may be organized to share perspectives and seek a realistic common ground centered on the patient’s goals and recovery.

• Example 2 – interprofessional disagreement:
  A social worker may feel that tutorship is necessary, while the physician considers the measure premature (freedom of professional opinion). The clinician may propose this option again as the clinical situation evolves, while respecting the current decision and maintaining healthy collaboration. This mutually respectful stance fosters openness, a constructive work climate, and genuine collaboration free of paternalism.

2) Useful collaboration, oriented toward clear recovery goals

Collaboration with family members and professionals is not an end in itself; it must serve a concrete care plan aligned with the person’s goals and the various dimensions of recovery (CHIME/AiLES). It allows interventions to be tailored to needs, values, limits, and life projects, while ensuring a coherent distribution of roles according to each person’s expertise.

This coordination makes concrete levers possible that facilitate patient engagement: access to housing or stable income, establishment of structuring routines, support for activation, involvement of family members, or targeted pharmacological adjustments used strategically.

Example: Following a team discussion, it is recognized that a patient has made significant efforts to break isolation and shows increased trust toward care providers. The patient is now more willing to expose themselves to stressors they previously avoided, while fearing being paralyzed by panic if an activity goes poorly. To support this gradual risk-taking, the physician agrees to prescribe a PRN benzodiazepine, to be used as needed during outings, only if other anxiety-management strategies prove insufficient.

This example illustrates how coordinated work, made possible through collaboration among different care providers, allows for the mobilization of a broader range of change strategies—particularly behavioral ones, such as positive or negative reinforcement—and makes the care plan more realistic, coherent, and applicable, thereby increasing the likelihood of progress toward recovery.

3) Longitudinal collaboration

Recovery unfolds over time and generally requires more patience than simple stabilization. Collaboration with family members and professionals therefore cannot be episodic; it must be longitudinal, capable of weathering periods of stagnation, relapse, and disagreement.

Sustained collaboration - supported, among other things, by staff stability, which is not always guaranteed  - helps establish lasting trust, better understand the person’s history, strengths, and vulnerabilities, and offer more targeted interventions. It also fosters team cohesion, strengthens consistency of the clinical message, avoids contradictory messaging, and helps maintain realistic expectations, with a lower risk of splitting. Finally, it is crucial during transitions (hospital–community, specialized care–primary care), which are high-risk periods for loss of follow-up and splitting.

Example illustrating intervention synergy (longitudinal and recovery-oriented)

A patient who is partially stabilized following a recent medication adjustment (psychiatrist) gradually becomes more aware of their situation and expresses a desire to improve quality of life. The team—particularly the peer support worker—helps the patient explore aspirations across the CHIME/AiLES dimensions. The patient wishes to live independently near family members; the social worker evaluates the project, assists with budget revision, and encourages redirecting part of substance-related expenses toward this goal. An employment counselor proposes an accessible step: flexible volunteering in a community center. With the patient’s consent, the family is mobilized to rebuild connections and provide concrete support for activation (e.g., gym membership conditional on participation).

Over time, the patient regains motivation, energy, and hope; becomes more active and better supported; feels less overwhelmed by symptoms; and the team can consider a gradual reduction in medication in a safer and better-supported context.

This example illustrates how coordinated intervention by all involved often generates a synergistic impact greater than that of isolated or siloed actions: by gradually investing in life projects with coordinated support from the team and loved ones, the person regains motivation, hope, and autonomy, which may ultimately allow—within a safer context—therapeutic adjustments that support recovery.

Potential partners in recovery 

Promoting hope and spirituality in a practical and accessible way

In the current era, where limited resources are primarily devoted to emergency situations, medical practice often focuses on stabilization and interventions deemed indispensable, such as crisis management and the reduction of imminent risks. Interventions aimed at restoring dignity and helping people rediscover meaning in their lives too often become secondary, or even perceived as optional. This tool is specifically intended to help rebalance care, by reminding us that clinical intervention should not be limited to emergencies alone. On the contrary, in the medium and long term, helping a person find meaning and reasons to live is a powerful lever for risk reduction and crisis prevention.

Survival is not enough: you support the person in living fully, going beyond the interventions already presented—dynamic medication adjustment (criteria 1 and 2), encouragement of life hygiene and activation (criteria 3 and 4), and mobilization of the person’s and their entourage’s engagement and collaboration (criteria 5 and 6). You also intervene at the existential and spiritual level, supporting the person in their process of giving meaning to their life (what do they want to accomplish this week, this year, in 10 years?), rather than limiting yourself to the sole role of guardian of their stability.

Meaning is indeed one of the central dimensions of recovery (the “M” in CHIME). It is neither an imposed meaning nor a projection of the clinician’s values, but the person’s own meaning, often linked to the pursuit of greater freedom: freeing oneself from symptoms, living more peacefully, reducing stress, escaping the judgment of others or society, staying occupied, providing for oneself, meeting others, starting a family, discovering, enjoying oneself, traveling, learning, creating, etc.

To move forward, it is often necessary to begin by making peace with the past and the present. The person is then led to recognize and accept certain sometimes difficult realities, such as mourning the loss of permanent mental stability or of certain life projects initially envisioned. Your role also consists of accompanying the person so that they can persevere and maintain hope, despite the persistence of mental vulnerability or discouraging circumstances.

Below are different ways to nurture hope and help the person give meaning to their experience.

• A clinical stance that fosters hope and engagement

Your stance in itself constitutes a powerful therapeutic lever. By remaining calm, grounded, and confident, you implicitly convey a message of hope and safety.

• • • You provide genuine emotional support by taking the time to acknowledge, feel, and validate the patient’s suffering, while maintaining a professional posture.

    • You demonstrate confidence without fostering false hope. Through your sensitivity, patience, and compassion, you implicitly communicate that pain can be endured and transformed (implicit hope).

    • While validating distress, you propose your interventions calmly and confidently, showing that solutions always exist—even if they are sometimes less appealing than what was initially hoped for (“it is never the end of the world”)—and that you will accompany the person through difficult moments (explicit hope).

• Existential and spiritual support

When the situation calls for it, you invite the person to acknowledge difficult circumstances and to engage in existential reflection (the meaning of their suffering, of their life, etc.), a reflection often triggered by despair. As this topic can be intimidating, a model of practical, simple, and accessible spirituality is proposed, based on three complementary ingredients:

References :

• Le 4e P de l'approche intégrée visant le rétablissement: la Philosophie se joint à la Pharmacothérapie, Psychothérapie et le soutien Pratique Dr Tin Ngo-Minh, Congrès annuel de l’AMPQ 2021
• La dyspnée existentielle. Dr Tin Ngo-Minh - Webinare de la FMSQ janvier 2022