What is Recovery?

Recovery in the context of mental health is one of my biggest passions.  I noted in a previous post (link below) how pleased I was that the NHS Trust I work for is increasingly implementing recovery-focussed approaches into practice.  Whilst this is a step in the right direction, it is my contention, particularly in light of recent reading, that it is not enough.  The crux of what leads me to believe this lies with a simple question: what is recovery?  The extent to which services, interventions, etc. are deemed to be conducive to recovery will inevitably vary depending on how you answer this question, and I posit that the generally accepted definition of recovery is somewhat different to the one I subscribe to.  As a result, in some cases, ‘recovery’ interventions may be damaging in certain ways, if helpful in others.  I’ll explain why…

I have been fortunate in recent months to come into contact with a lovely lady by the name Marion Aslan, founder and director of charity Elemental Wellbeing, who has become a great source of influence and inspiration for me.  In The Art of Thriving: Beyond Recovery, Marion addresses the issues of defining and implementing recovery in great depth.  Here, I will synthesise some important points made in the book with my own judgements and observations, in order to illustrate my concerns over the credibility and efficacy of recovery approaches within mental health services.

Many readers are likely to disagree with and even be offended by some of the things I say here, and many will probably see some of my views as quite cynical.  I will start on a positive note, which is that I believe everyone has the propensity to recover from what society calls mental illness.  I use that phrase because I personally prefer the term distress and have recently learnt a lot about what my friend Marion terms “the politics of madness and the psychiatric deception”.  I have touched on this in previous posts and will do more of the same later, but in a nutshell - and I know this is a very bold statement - knowing the facts leads me to view mental illness essentially as something that is defined, constructed, created and perpetuated by psychiatry.  With this in mind, here is a quote from Marion’s book:

“[Psychiatry] contains madness by seeing symptoms of illness rather than consequences of distress and ‘treating’ these so-called symptoms in a superficial way.  Instead of working with distress and allowing the individual to flourish, they are often maintained.  If this were not true why do so many people remain in the system for years, the same problems that brought them to psychiatry continuing to hinder their growth and independence?  Workers…talk about ‘revolving door clients’ as if it were the fault of the individual…rather than any inherent failing within the system.”

In other words, rather than helping people to become better, services are often perpetuating problems by taking a closed-minded, reductionist medical approach.  As such, the introduction of recovery approaches – in my experience, largely in the form of peer support workers and recovery education – is refreshing and encouraging.  The question is, are these approaches really facilitating recovery?  To continue addressing this question, let me go back to the topic of defining recovery.

The NHS confederation notes three key principles in recovery, as highlighted by mental health service users.  These are:

• the continuing presence of hope that it is possible to pursue one’s personal goals and ambitions
• the need to maintain a sense of control over one’s life and one’s symptoms
• the importance of having the opportunity to build a life beyond illness

This all sounds good to me, but unfortunately, in practice, it’s not really happening like that.  Somewhat paradoxically, the very same web page the above was taken from also defines recovery as “ the process through which people find ways of living meaningful lives with or without ongoing symptoms of their condition”.  The problem, to me, lies in the concept of living with symptoms of an ongoing condition, although I am encouraged by the addition of the term ‘or without’.   


It seems to me, from experience, that the assumption by most is that recovery is about managing a condition, maintaining a certain level of functioning, avoiding crisis, but continuing to suffer symptoms of some chronic condition.  Since such ‘symptoms’ are simply elements of human experience (that cause varying degrees of distress) that have been medicalised and categorised into illnesses by psychiatry, this is quite frustrating. 



Onto a positive note: people can and do recover from mental ‘illness’.  By this I do not just mean people function in society without crisis and manage their symptoms effectively; I

mean they become completely free from the illness, the diagnosis, the mental health system.  They thrive.  How do they do this?  According to Marion, recovery comes when “support challenges the long-term ways of working found in traditional services.  Warmth of welcome, sharing of knowledge and common ground…offers a fertile place for people to put their distress into context, find acceptance of their coping strategies and behaviours which some in psychiatry deem maladaptive…organisations [that provide this type of support, give] the individual a sense of purpose, responsibility and self-worth.  This is the thriving which my colleagues and I firmly believe in.”



As I write this, I am reminded of a talk given by Rachel Perkins at a recovery conference I attended last year.  Rachel notes the importance of recognising the difference between clinical and non-clinical recovery.  Clinical recovery is about reduction in symptoms, maintenance of a decent level of functioning, usually by taking medication long-term.  Non-clinical recovery is about building a meaningful life and reaching a state of wellbeing and functioning that is quite possibly beyond where the person was before becoming distressed or ‘unwell’.  



This way of working challenges the status quo and the lucrative medical model embraced by psychiatry and mental health services; therefore, it can be incredibly difficult to secure funding and support for such endeavours.  Meanwhile, available resources are generally allocated to those ‘recovery’ approaches that may be serving to perpetuate the illness-medication model, thus contributing to the problem of ‘revolving door patients’ referred to previously.  This is actually the opposite of recovery, so it is somewhat a paradox!  “If the medication works as well as it is purported to, why are people still in the system – often with their original problems unresolved?”.  More on this in a later post.  



As much as each person is different, so is each person’s experience of mental distress and their recovery journey.  Medicalisation detracts from this, not only causing harm in many cases but culturally reducing our ability to deal with distress autonomously.  I was inspired by the aforementioned talk by Rachel Perkins, who spoke of the notion that each one of us should be experts in our own recovery and wellbeing and that of those around us.  As such the very notion of a recovery ‘model’ is almost futile.   


Unfortunately the notion of individualisation is not really present in many mental health services at the moment; it seems that the notion of recovery has been watered down and moulded to fit the already existing modes of treatment: as Marion notes, the implementation of recovery principles such as service user involvement are “manipulated to fit into the organisational box...[they embrace] what suits and fits into the still predominantly biochemical system”.  I have witnessed this myself in peer support workshops I have co-facilitated in my workplace, where alongside endeavouring to teach people valuable skills to manage their distress, there is still seemingly relentless reference to the notion that one has a severe and enduring illness and must learn to live with this, helped by medication.  And so I find myself greeting these sessions with an odd mixture of admiration and disdain.  

Medication puts a sticking plaster on distress without addressing the issues behind it

As I write I am struck by thoughts of research into depression, which I have been investigating elements of for an upcoming university assignment.  Such research sometimes talks of recovery from depression, often measured by a reduction in symptoms based on a generic measurement tool.  Whilst I can see why such tools are useful, I strongly feel we need to move away from this limited view and to give people enough respect and credit to believe that they can truly recover and thrive, and to embed this into the way we work with people in distress.  Medication may help reduce symptoms, but it does nothing to deal with whatever issues and traumas caused the distress in the first place. 



This reminds me of my previous post about interpretations of suffering.  If we take suffering not as a sign of illness but as a part of human experience, we can then see it as something that can be worked through and learnt from.  To quote Marion again, “we have to take responsibility for our own recovery and not rely on others to do it for us!  Recovery is hard work!”  This is likely another key contributing factor to a lack of real recovery in services: quick fix approaches are (arguably), at the point of delivery, quicker and more efficient; there is enormous pressure on beds in mental health services and medication is seen as the quickest way to get someone out of hospital.  I maintain that in the long run this is less effective and far more likely to end up with further crises and hospital admissions, where true recovery approaches would not have led to this.  


What’s to blame for services not living up to promises to recovery recovery-focussed care?  Pressure on staff time and unnecessary bureaucracy are factors, but the unrelenting medical approach and the culture is creates is probably most to blame.  The Art of Thriving talks of service users becoming disillusioned with services because staff see the patient in terms of illness and not wellness or sanity, interpret coping strategies as ‘symptoms’, focus on medication and fail to recognise the relationship between life events and mental distress.



And so arises the need to go beyond recovery and embrace The Art of Thriving.  This will be different for each individual, but crucially, facilitating recovery and thriving in a meaningful way cannot happen without there being a shift in the culture of mental health services.  Related to this is the question as to whether hospital is even the right environment for the majority of people experiencing mental distress.  I honestly don’t believe it is.  If things are to improve and true recovery is to be achieved by more than just the odd few individuals who break free from the psychiatric system, I feel what is needed is a wholesale review of the way we support people in distress.  I won’t say anything further on this other than that I take a great interest in Loren Mosher’s Soteria House project, which you can learn about in this video:
 

 

In the context of our current cultural perspective of mental illness, my views are controversial, and as I stated earlier I know my view will be challenged by a lot of people.  I realise I have made some bold statements and not all of these are completely backed up in this piece; there is only a certain amount I can say in just one post and will return to some of the key issues later.  But please know my sole aim is to help people overcome distress and live meaningful lives.  It is unfortunate that these values are so heavily contradicted by the current psychiatric system and that I must so radically criticise the work currently being done in the field.  However, I hope you can find some agreement with my approach based on what I’ve said here. 



So, to return to our original question; what is recovery?  I have demonstrated here how my view of it contrasts with psychiatry's, and would be interested to know others' take on this.  It is your choice whether to believe in recovery, whether to believe in thriving, whether to believe in the biomedical approach to mental health, whether to believe in individuals’ ability to master their own wellbeing.  I hope that whatever you choose to believe is based on sound knowledge of the truths behind it.  I believe there are a hell of a lot of people out there who simply want to do the best for others, as I do, and hope that more and more of us will start challenging the current system and channelling our efforts towards true recovery.


NOTE: for copies of The Art of Thriving (£6 + P&P) and other books by Marion Aslan, please contact marionaslan@aol.com



Links:




Previous post mentioned in introduction: http://laurenscloud.blogspot.co.uk/2013/10/all-we-do-is-aim-for-better-things.html


NHS Confederation – Recovery: http://www.nhsconfed.org/Publications/briefings/Pages/Supportingrecoveryinmentalhealth.aspx



Elemental Wellbeing: http://elementalwellbeing.org/
  

Freedom

elementalwellbeing.org

I have recently been fortunate enough to come into contact with a lovely lady by the name Marion Aslan, who runs the charity Elemental Wellbeing.  Elemental Wellbeing provides non-medical approaches to mental wellbeing, with a particular focus on the THRIVE approach and emancipation from diagnoses of mental illness.  Marion recently asked me to write a few lines on emancipation; I got a bit carried away and the result is this piece!

To me, the importance of emancipation from a diagnosis of a mental health conditions is obvious.  I say this not just because I feel strongly that this is the case, but also because research evidence firmly supports the statement.  Worryingly, said evidence is not even a new phenomenon; huge problems with mental health diagnoses were unearthed back in the 1970s, when Rosenhan and colleagues conducted a brave and fascinating experiment to see how easy it would be to get themselves admitted to psychiatric hospitals. 

Having reported no other symptoms than hearing a voice saying the word ‘thud’, all eight participants in the aforementioned experiment were admitted to their respective hospitals for anywhere between several weeks and several months, despite acting perfectly normally and feeling quite well.  What got them out was not convincing staff that they were not unwell, but agreeing that they were and feigning getting better. 

It doesn’t end there!  When Rosenhan came into contact with one of the hospitals after the episode outlined above, he was challenged to send more people there to try and get admitted.  This challenge was accompanied by a promise that they would be spotted this time.  The hospital later contacted him to boast that they had uncovered 41 ‘fakes’.  How many people had Mr Rosenhan actually sent, I hear you ask? None.

For me, the Rosenhan experiment is one of the most poignant I’ve ever read about, and the perfect illustration of the dangerously ambiguous nature of mental health diagnosis.  But there are other factors that support my argument too: Results from similar studies supports the above findings, plus there is other research to show that in a great many cases, one psychiatrist will give a different diagnosis to the same patient as another psychiatrist.  We should also give consideration to the fact that our diagnostic criteria for ‘mental illnesses’ are based on nothing more scientific than a bunch of guys at the APA (American Psychiatric Association) sitting in a conference room and pondering what name to give to each collection of symptoms that psychiatry deems as constituting a mental illness.

Collectively, the above points serve to illustrate the very arbitrary nature of the diagnosis of mental health conditions.  To me, this is slightly sickening and made worse by the fact that once a person has been labelled with a mental health diagnosis, psychiatry holds them to have a lifelong illness, and it is near impossible to shake off that label.  The reason I find this so disgusting is that psychiatry will then proceed to deem every single thing that person does as a feature of their illness, which is incredibly unhelpful in the process of enabling that person to recover and achieve a high level of functioning beyond their diagnosis.

To illustrate my point in more detail, I’m fairly confident that elements of my own experience and behaviour could, on occasions, be interpreted as signs of ‘mental illness’; something like bipolar disorder.  If I challenged you to spend a month or two interpreting my behaviour as though I were a psychiatric patient with this diagnosis, I reckon I would probably appear as ‘mad’ as anyone else with that label!  What’s happening is that a medical label is being placed on normal human experience, which I maintain is a dangerous practice.

To me it is incredibly unfair that people should be subjected to this kind of preconception just because they have had periods of difficulty and distress, and it would be far more productive to recognise such periods as transient experiences that can be fully recovered and moved on from completely. 

Many of my colleagues who work in the field of mental health will argue that there are some patients who will never recover, will always need medication and will always be susceptible to further episodes of difficulty, or ‘illness’.  My own stance is that each person is different, and to be honest I am currently unsure whether I believe this is ever the case or not.  However, to me, even if there are some people who will suffer multiple periods of distress throughout their lives, surely it is far more helpful to those people to allow them space to be free from diagnosis and to live accomplished and meaningful lives?  I feel that the concept of mental illness is an unhelpful and quite inhumane one, and much prefer to treat people as people rather than illnesses, move away from the assumption that they will be forever subject to their psychiatric label, and ultimately empower people (or rather allow them to empower themselves) to recover and thrive. 

http://elementalwellbeing.org/elemental-wellbeing-thrive-approach/thrive-approach-mental-wellbeing/