2.2: The Process of Recovery

David Featherston

Definition of ‘recovery’

It was once thought that stability would be the best result achievable for one who had a chronic condition such as severe mental illness, until Courtney Harding (1987) and others challenged this belief. Their findings identified multiple outcomes associated with severe mental illness.⁽¹⁾

William Anthony, Director of the Boston Center for Psychiatric Rehabilitation, was acknowledged with developing the cornerstone definition of mental health recovery. He identifies recovery as a deeply personal, unique process of changing one’s attitudes, values, feelings, goals, skills and/or roles. It is a way of living a satisfying, hopeful, and contributing life even with limitations caused by the illness. Recovery involves the development of new meaning and purpose in one’s life as one grows beyond the catastrophic effects of mental illness.⁽²⁾

A similar definition is stated in the 4th National Mental Health Plan, which refers to the 2008 National MH Policy. Recovery is a personal process of changing ones attitudes, values, feelings, goals, skills and/or roles. It involves the development of new meaning and purpose and a satisfying, hopeful and contributing life as the person grows beyond the effects of psychiatric disability. The process of recovery must be supported by individually-identified essential services and resources.

There is general recognition that it is difficult to define recovery as it is a personal journey that is unique to each individual. The importance of the ‘journey’ is acknowledged and a definition is determined by the individual who gives meaning to the journey.⁽³⁾ However, there are key components associated with the process of recovery, accomplished through support networks of carers and health professionals.^(1,4)

Individualised and person-centred
Holistic
Strength-based
Self-directed (Self-help)
Responsibility
Hope
Medication/treatment
Empowerment
Support, including peer support
Education/knowledge
Spirituality
Employment/meaningful activity

The following New Zealand definition was drawn from various New Zealand government resources.

Recovery is central to the provision of mental health services in New Zealand, and is enshrined in government policy. Recovery is defined in the Blueprint as the ability to live well in the presence or absence of mental illness (or whatever a person chooses to name their experience). Each person with mental illness needs to define for themselves what living well means to them. The definition is purposefully a broad one, because the experience of recovery is different for everyone and a range of service models could potentially support recovery. Recovery is not just a final destination, but a journey. For some the journey may be short; for others it may be a lifetime.⁽⁵⁾

The recovery approach requires mental health services to develop and draw on their own resources, but it also requires that they develop and draw on the resources of people with mental illness and their communities.

Recovery happens when:

people with mental illness take an active role in improving their lives
communities are inclusive of people with mental illness
mental health services enable people with mental illness, their communities and families to interact with each other.

The recovery approach is more compatible with community-based models of service provision than institutionally-based ones, but it is not a model of service delivery. It is an approach which can be applied to any model that draws on the resources of service users, their communities and mental health services.

Additional definitions of recovery can be seen in the glossary of terms.

A journey of self-discovery⁽⁴⁾

From the DVD Mental Illness Recovery – A Workshop

Dim lights Download

In this short video extract, Ingrid talks about her journey of self-discovery on her road to recovery, and recognises the significant impact of her doctor.

As I was getting ready I stopped at the mirror and looked at myself and I thought, you’ve come a long way girl. Look at what you are up to these days. The challenges that one has faced to get to there, to get to this point in recovery has certainly not been easy and I can actually say for me as I have grappled with this whole notion of what recovery means, for me it has been a journey and one that I suspect will never end. And one that I have had to learn many lessons, both painful and certainly positive.

So yes in amongst having it all, being one of the lucky ones, there have been times when a dark cloud has descended and I have wanted to die, I have tried to die. The very essence of my being has been tortured and I feel like I have lost my soul. But as you can see I am one of the lucky ones, I stand here today well and in a good space and that is because my journey of self-discovery on my road of recovery has been that I have come across a fantastic relationship with my doctor, who is my coach, my mentor, my reality check and what I call my dose of perspective and yes sometimes I don’t like taking the medicine she offers, but she offers it none-the-less. But it is the way she offers that medicine. She will say ‘Ingrid, now that you are an informed, educated, participant of care I can’t try all these other things of telling you what to do, what do you think we should do, what will work, what won’t work. We try different approaches and we come back and through that trust, through that honesty, through that collaboration, we both together work out the way forward in my journey of recovery.

Now I must say that through this journey my soul has been healing. The pain has been healing and yet the pain has also been an awakening, it’s provided me insights. And part of that awakening has come through knowledge, support and education. This is a health condition; I need to take responsibility for it but I also need to learn how, how do I let go of this or how do I get myself to a space where I can become well. Yet this journey is often one that is done alone but you can’t do it in isolation, you need an environment that is nurturing, safe, that is encouraging. My family have provided that love and support for me, so that I have been able to use my vulnerability today as an inner strength so that I can better understand and think about what it is that I am trying to achieve in my life and my wellness. I am of no use to anybody else unwell. So now I have had to take the responsibility to say, what am I going to do to help myself stay well and I have to say it’s hard bloody work.

Patients’ and carers’ interpretations of recovery

The following audio recording was in response to the question ‘what does the term recovery mean to you?’ It highlights the wide range of definitions and how individual the term recovery is considered.
Download

I have a huge struggle with the concept of recovery. I think it gives false hope to people. My own experience, and I can only talk from that, is that I have a condition that needs. I have nightmares most nights, I have a sense of despair always constantly with me balanced with a sense of joy but in terms of recovering from that I think that it is a matter of dealing with it, coping with it and being able to work. I have worked a long time to be very therapeutic. My psychiatrist has said to me you cannot erase your memories and therefore you will have good times and you will not have good times. You have to learn to deal with it and understand it. I think the word recovery for a lot of people who have conditions that may improve, that may be dealt with by medications or self-talk or whatever, doesn’t take away the condition, have you got a recovery, have you sort better ways of dealing with it.

Recovery is interesting. I said before that my wife had recovered from her depressive illness and also myself as I also had one. But you don’t have a full recovery. I consider that we have recovered but at the same time we are still living with all the loss and grief we’ve lost during that time and whilst we have both recovered, it’s still lingering there, it will always be there. But I do consider that we have recovered although we do struggle from day to day.

I think the term recovery can lead to false expectations. Different people have very different interpretations. For me the objective is to have good mental health which does not mean the absence of the mental disorder. I can have a strong sense of mental wellness which can balance and manage the disorder that I have. So recovery in that sense for me is having positive mental health and managing working with and understanding any disorder that I have and to live a flourishing life still with that disorder.

I would really like to endorse Michael’s comments, very close to how I see it. I think recovery is an imperfect term, for all the sorts of reasons that people have flagged, however I do find it the best of the terms available, having never identified a perfect one. For me recovery and the term define something that is a process rather than an end point that you are looking to get to. Again I guess it is consistent with my view of mental health as a spectrum; you don’t get to a particular point and stay there for ever and more. But I do think that it is possible to improve your mental well-being over time and that is a very important concept for people to be aware of because that’s what these people relate to and hope which is incredibly important.

I’m always at loggerheads with this concept of recovery. I wonder what I was like before I had my illness, was I a recovered individual then. I have the debate with my psychiatrist as to how well I am and where I am on this path to recovery. I accept that part of my recovery is due to cognitive therapy and chemically induced recovery. But I would like to believe that a lot of this is due to faith and hope and that is not something that one can quantify and I believe so feverently that part of my recovery is due to those factors and I am quite convinced that one day I will go beyond recovery.

I am not keen on the terminology of recovery as previously mentioned, I think it gives a false hope to people. I don’t believe that people with a mental disorder are ever going to be one hundred percent recovered. They always have to be cautious about what they do and I would prefer to have, if you could use the terminology, words such as management or stability in everyday activities rather than just recovery.

It just occurred to me that in a sense I think that it is desperately important that carers who are actually first experiencing this psychotic episode to actually have some sort of belief that recovery is possible. Along that path you actually begin to learn that that is not so and you perhaps begin to adjust to the fact that that is not so but I think at the beginning stages you can only think of it in terms of physical illness, that a recovery and treatment that all these wonderful people who are in the medical profession and in effect you have to have that belief and I think that that’s possibly where the notion comes from.

If a carer embraces the concept of recovery and the recovery doesn’t happen then you are going to have a dysfunctional family, where you might have a sense of resentment towards the person with the illness or the disorder because they are not recovering as you have this understanding that people will recover – that’s a worry.

Additional resources

The book, Flying with Paper Wings by Sandy Jeffs,⁽⁶⁾ offers a privileged insight into the experience of managing a severe mental illness. This is a highly recommended resource, with reference to self-management and recovery.

A Rethink publication titled 100 ways to support recovery. A guide for mental health professional is part of the Rethink recovery series is an excellent source of information on the topic of recovery.⁽⁷⁾

Psychiatrists’ interpretations of recovery

The following quotes are a selection from the Chronic Condition Self-management Fellows Survey. The range of definitions highlights the different interpretations of the term within the psychiatry profession.

‘We are dealing with chronic conditions so this is irrelevant’

‘Getting over the symptoms to pre-illness stage’

‘Recovery is the absence of symptoms – complete remission for a particular point in time difference from one diagnosis to other e.g. depression is 12 months of no symptoms, plus or minus functional and social functioning’

‘Symptom free, fully functioning in terms of work and relationships’

‘The patient’s journey from initial episode of illness through to capacity to take control of the illness and minimise impact on quality of life’

‘Actualisation of potential on an emotional, physical and social plane’

‘Decrease in symptoms that allows the consumer to function at a higher level than they are currently able if acutely unwell’

‘Empowerment of the individual to drive their health care and manage their condition’

Recovery and self-management

The process of recovery is maximising all of the elements of self-management as shown in Figure RETHINK. There are many frameworks for self-management support, such as the Flinders Model and collaborative therapy.

References

Hamilton County Community Mental Health Board. >
Anthony WA. Recovery from mental illness: The guiding vision of the mental health service system in the 1990s. Psychosocial Rehabilitation Journal. 1993; 16(4): 11–23.
Long C. 2005. <http://www.naidex.co.uk/page.cfm/link=131>
Mental Illness Recovery – A Workshop (DVD). Royal Australian and New Zealand College of Psychiatrists.
Online Orientation Programme for Overseas Trained Doctors on New Zealand’s Mental Health System. <www.mho.org.nz>
Jeffs S. Flying with Paper Wings. 2009; Vulgar Press, Melbourne.
Slade M. 100 ways to support recovery. A guide for mental health professionals. Rethink recovery series, Vol 1, 2009. (100 ways to support recovery.pdf)

Continue to Module 2 Page 3: The Chronic Care Model

7. Slade M. 100 ways to support recovery. A guide for mental health professionals. Rethink recovery series, Vol 1, 2009. (add PDF document)