Recovery model of mental illness: a complementary approach to psychiatric care.

Medicine, in keeping with its status in society, always had a paternalistic culture. Doctors listened to patients’ concerns, examined them, ordered laboratory investigations, diagnosed disease, prescribed medication and prognosticated about course and outcome. While they did explain the issues to their patients, medical perspectives and opinions guided their decisions. Patients were expected to follow their advice. The prevalent paternalistic culture within the medical profession often dismissed patient perspectives and did not take kindly to objections or different points of view.

Psychiatry with its focus on symptoms and functioning developed elaborate assessments, standardized interviews and rating scales to document and monitor psychopathology. These appraisals measured positive and negative psychotic symptoms, depression and anxiety, cognitive deficits, as well as functioning. The early success of psychotropic medication in reducing symptoms of psychosis and ameliorating anxiety and depression led to optimism among mental health professionals that people with these conditions will recover from their mental illness and lead normal lives. Five decades later, mental health professionals accept that a significant proportion of people with mental disorders continue to have persistent and disabling symptoms and are unable to get back to their previous occupations and social roles. However, the quest for newer psychotropic medication also meant a continued focus on residual symptoms and deficits.

Psychiatry conceptualised phases of illness into acute, maintenance and continuation domains. It suggested concepts like relapse, recurrence, remission and recovery based on symptoms profiles over time.[1] Psychiatric models tended to view recovery from mental illness similar to that seen in physical diseases. Despite the power, influence and dominance of psychiatric concepts, once taken as standard, they have gradually began to face opposition.[2]

The late 20th century saw substantial changes in medicine and society. Contradictions between social consensus and individual values and between the larger and pervasive institutional contexts and social policies led to a re-examination of issues.[3] The general discomfort with and opposition to governmental and institutional authority led to a review of perspectives related to mental illness. The empowered and vibrant user movement in the west argued for different perspectives and approaches. The recovery model views mental illness from a perspective radically different from traditional psychiatric approaches.

A DIFFERENT PERSPECTIVE ON RECOVERY

For many people with mental illness, the concept of recovery is about staying in control of their life rather than the elusive state of return to premorbid level of functioning. Such an approach, which does not focus on full symptom resolution but emphasises resilience and control over problems and life, has been called the recovery model.[456] The approach argues against just treating or managing symptoms but focusing on building resilience of people with mental illness and supporting those in emotional distress.

While there is no single definition of the concept of recovery for people with mental health problems, there are guiding principles, which emphasise hope and a strong belief that it is possible for people with mental illness can regain a meaningful life, despite persistent symptoms. Recovery is often referred to as a process, an outlook, a vision, a conceptual framework or a guiding principle.

There is evidence to suggest that self-management strategies based on the recovery model may have more value than models based on physical health.[4] An analysis of the main themes in recovery based research suggest that the dominant themes from the stakeholder perspectives were identity, the service provision agenda, the social domain, power and control, hope and optimism, risk and responsibility. There was clear consensus around the belief that good quality care should be made available to service users to promote recovery both as inpatient and in the community.[5] The language of recovery is being increasingly employed in service delivery, mental health policy and psychiatric research.[6]

THE RECOVERY PROCESS

The recovery process provides a holistic view of people with mental illness that focuses on the person, not just their symptoms.[456] The process argues that such recovery is possible and that it is a journey rather than a destination. It does not necessarily imply a return to premorbid level of functioning and asymptomatic phase of the person's life. Nor does it suggest a linear progression to recovery but one, which may happen in “fits and starts” and, like life, have many ups and downs.

The process calls for optimism and commitment from people with mental illness, their families, mental health professionals, public health teams, social services and the community. The recovery process is profoundly influenced by people's expectations and attitudes and requires a well-organized system of support from family, friends or professionals. It also requires the mental health system, primary care, public health and social services to embrace new and innovative ways of working.

The recovery model aims to help people with mental illnesses and distress to look beyond mere survival and existence.[456] It encourages them to move forward and set new goals. It supports the view that they should get on with their lives, do things and develop relationships that give their lives meaning.

The model emphasises that, while people may not have full control over their symptoms, they can have control over their lives.[456] Recovery is not about ‘getting rid’ of problems but seeing beyond a person's mental health problems, recognizing and fostering their abilities, interests and dreams. It argues against the traditional concepts of mental illness and social attitudes, which often impose limits on people experiencing mental ill health. Health professionals often have reduced expectations, while families and friends can be overly protective or pessimistic about what someone with a mental health problem will be able to do and achieve. Recovery is about looking beyond those limits to help people achieve their own goals, aspirations and dreams. Recovery can be a voyage of self-discovery and personal growth; experiences of mental illness can provide opportunities for change, reflection and discovery of new values, skills and interests.

FACTORS WHICH SUPPORTS RECOVERY

Many factors are associated with the road to recovery and include good relationships, financial security and satisfying work.[456] The environment, which provides for personal growth, developing resilience to stress and adversity and allows people to develop cultural and spiritual perspectives, is also crucial. Being believed in, listened to and understood by families, friends and health and social service personnel are very helpful to people on the road to recovery. Getting explanations for problems or experiences and developing skills and receive support to achieve their goals are crucial to success. Support during periods of crisis is also critical.

FAILED PROMISES

The promise of psychotropic medication, of curing mental illness, failed to materialise. Despite new second generation antipsychotics and antidepressants with fewer distressing adverse effects, their efficacy is only comparable to older medication.[7] With the exception of clozapine, the other drugs are equal in antipsychotic efficacy.[8] Similarly, antidepressants, the older tricyclics and the newer serotonin and norepinephrine reuptake inhibitors, are equally efficacious in severe depression.[8] People with severe mental illness continue to have residual positive symptoms, significant negative symptoms, and marked cognitive deficits. A significant proportion of people with severe mental illness do not reach their premorbid level of function, are unable to hold down jobs and function way below their earlier potential. Many people with significant residual deficit seem to live in our communities but are not in the main stream of life. Many are unable to “get their life back on track”.

RECOVERY AND COMMUNITY

Many people with severe mental illness now live in the community. The closure of asylums and long stay psychiatric facilities has increased their numbers. And yet, far too many people live isolated lives. Many psychiatric, community and public health services fail to empower their users to engage local neighbourhoods and live in partnership with communities. Such active engagement and symbiotic relationship within community requires a mutual appreciation of the potential of people with and without mental health problems. The process of engagement and consequent recovery is strongly linked to social inclusion. A key role for mental health and social services is to support people to regain their place in the communities, take part in mainstream activities and utilize opportunities for growth along with everyone else. There is growing evidence that supports the contention that taking part in social, educational, training, volunteering and employment opportunities can support the process of individual recovery.

People with severe mental illness need to be supported to create their own recovery plans, set their own goals, map their processes, identify their strengths and weaknesses, recognize the road blocks and facilitate good practice, which keeps them well.

TOOLS TO AID TO RECOVERY

There are many websites (E.g. Mental Health Foundation. http://www.mentalhealth.org.uk/help-information/mental-health-a-z/r/recovery/) and programs, both for people with mental illness and for professionals involved in their care, which aim at recovery and wellness. They attempt to increase the person's control over their life and their mental health problems, empower them to maintain wellness, improve their quality of life and assist people achieve their dreams and goals. They focus on diverse areas covering the main aspects of people's lives, including living skills, relationships, work and identity and self-esteem.

These approaches include:

WRAP (Wellness Recovery Action Planning) (See Mental Health Recovery and WRAP website- http://www.mentalhealthrecovery.com). It is a program to facilitate recovery,

DREEM (Developing Recovery Enhancing Environments Measure). It is an outcome measure and research tool to see how ‘recovery-oriented’ a service is and also gathers information about mental health recovery from people who use mental health services. (See Recovery Devon website- http://www.recoverydevon.co.uk),

Recovery Star. This tool allows people with mental health problems and using services to enable them to measure their own recovery progress. (See Mental Health Providers Forum website- http://www.mhpf.org.uk).

Checklist of Good Practice. It represents the views of service users from both dominant and marginalized communities, (See Checklist of Good Practice - http://www.mentalhealth.org.uk/content/assets/PDF/publications/checklist-good-practice-approaches-recovery.pdf).

CONCLUSION

The current approaches to mental health and illness with their exclusive focus on symptoms, the partial response to treatment of many people with severe mental illness and their inability to get back to their pervious level of function and realize their full potential mandates complementary approaches to the care and management of people with mental health difficulties. The recovery model adds a new dimension to care and allows for people with severe mental illness to take control of their lives and give it meaning. This is a worthy goal that all mental health professionals should subscribe to and help achieve.