Recovery in mental disorder

In this post I want to discuss the concept of personal recovery and its implications for mental health, research and psychiatric practice.

Since the 1990s the emphasis in mental health care has been described as changing to focus on the support of an individual’s recovery. This change represents a distinction between recovery from and recovery in mental disorder (Davidson 2007). Davidson suggests that recovery from mental disorder represents a traditional way of viewing disorder – that recovery is defined by absence of symptoms for example. Recovery in mental disorder is presented as distinct, and represents a much more interesting concept to discuss.

The nature of personal recovery?

One of the most commonly quoted descriptions of recovery is given by Anthony, writing in 1993 (Anthony 1993).

“Recovery is described 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 illness. Recovery involves the development of new meaning and purpose in one’s life as one grows beyond the catastrophic effects of mental illness.” [Emphasis added]

I want to discuss this description in individual sections, as I think that it provides some interesting questions regarding the nature of personal recovery and mental disorder in general.

“…a deeply personal, unique process…”

This opening statement raises two immediate considerations:

  1. Recovery as personal in nature
    • This highlights the role of scientific investigation in the support of mental disorder. Modern medical science works through a system of evidence based healthcare – where treatments are trailed in comparison to each other, or placebo, and statistical calculations are used to demonstrate their efficacy. This model, by necessity, works at a population level however – the application of findings at an individual client level is more complex. I do not seek to challenge the role of evidence based practice as it has provided many advantages to clinical practice – but I do want to raise the question of how individuals can be recognised within the system?
  2. Recovery as a process
    • Much of medical practice focuses on discrete end points to treatment – classically the treatment of infection for example, although the shift of disease burden towards chronic disorder, e.g diabetes, has changed this somewhat. This representation of recovery as process raises questions though – if the goal of recovery is not a discrete end point but a journey in its own right how should this alter the emphasis of clinical support?

I want to raise one further point before continuing. Psychiatrists and other doctors are trained in the assessment and diagnosis of illness or disorder. They have traditionally had the power to identify a person as ill, a patient, and therefore morally justified in adopting a sick role. If recovery is a personal experience however how does this affect this traditional sharing of power between doctors and patients?

“…changing one’s attitudes, values, feelings…”

These components described speak to the individual’s personal identity as being a target for the recovery process. Attitudes and values represent core features of our sense of self – in what manner is this to change? Anthony’s argument seems to imply that the change represents adaptation to limitations caused by illness, but this argument is not universally accepted – with other sources distinguishing between recovery from mental disorder and physical illness more explicitly.

“…the development of new meaning and purpose in one’s life as one grows beyond the catastrophic effects of mental illness.”

This statement echoes the previous excerpt in highlighting that the process of recovery involves a changing sense of self, or interpretation of experience. Mental illness is again presented as a deficit state where loss of function, however this time there is an implication of circumventing disorder – that growth will continue despite adverse experience.

Recovery and personal narrative?

The commonly cited discussion by Anthony highlights recovery as being:

  1. Personal
  2. Process not outcome
  3. Developing a growing sense of self

Human beings during social interaction use narrative in order to make sense of their personal experiences. Narratives consist of actors who adopt roles and play parts with plots or stories. The use of language to make sense of experience and begin to resolve difficulty is well recognised. Narratives in relation to illness or disorder are generally characterised by their possessing an explanation of cause and how adversity was coped with, or overcome.

Modern mental health practice has been dominated by a biomedical interpretation of mental disorder – the presentation of, for example, Schizophrenia as a neurodevelopmental condition. Other interpretations exist however – psychodynamic, cognitive and social models for example. Narrative interpretations of psychiatry represent a model that highlights the importance of working with individuals to support varying interpretations of their personal experience. This does not undermine the importance of the biomedical interpretation, merely emphasises its place as one possible interpretation of personal experience.

Narrative interpretations, working with the individual to develop personal accounts of their experience, provide a means through which many of the difficulties raised by the recovery process can be supported.

Implications for research and clinical practice

In the above discussion of the recovery process I have sought to highlight a number of questions that emerge in relation to emphasising the importance of recovery within clinical care:

  1. How can we best support personal recovery with existing population level evidence?
  2. How does the distinction between recovery as process versus outcome affect the role of mental health care services?
  3. How does the personal nature of recovery alter the power dynamics in classical clinical relationships?

If, at some level, recovery involves changing senses of personal meaning and identity then what is the role, if any, for mental health services in this process?

I have proposed that joint narrative constructions of mental disorder experiences between health professionals and clients may provide one means of beginning to address some of these questions.

The importance of the personal recovery process highlights the need for further research that can improve understanding of the nature of the process and the role of mental health services in the support of personal recovery.

References

Anthony, W. A. (1993). Recovery from mental illness: The guiding vision of the mental health service system in the 1990s. Psychosocial Rehabilitation Journal, 16, 11–11.

Davidson, L., & Roe, D. (2007). Recovery from versus recovery in serious mental illness: One strategy for lessening confusion plaguing recovery. Journal of Mental Health, 16(4), 459–470.

Lewis, B. (2014). The art of medicine Taking a narrative turn in psychiatry. The Lancet, 383, 22–23.

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