A Summary of Recovery Principles with Suggestions as to
What the Implications are for Practice.
John Good
Hope:
Described by Jacobson and Greenley (2001) as, at its most basic level, the individuals belief that recovery is possible.
'- recognising and accepting that there is a problem, committing to change, focusing on strengths rather than on weakness or the possibility of failure, looking forward rather than ruminating on the past, celebrating small shifts rather than expecting seismic change, reordering priorities and cultivating optimism'.
Miller (1992) identified ways to inspire hope including; cognitive strategies, determinism, a philosophy of life and world view, spiritual strategies, relationships with care givers, family bonds, a sense of being in control and goal accomplishment.
Acceptance:
Anthony (1993) states that recovery can occur even though symptoms may remain, “It is about living a valued and valuable life with difficulties and finding ways of coping with and understanding problems, as much as getting rid of them”.
Control:
Jacobson and Greenley (2001) describe control as a healing process and state that it is about finding ways to relieve symptoms or reduce the social and psychological effects of stress.
Control also has another meaning according to Repper (2000) and this concerns who is in control. She suggests that recovery is only possible if the person has taken control and that this is a necessary precursor to empowerment. These two meanings of control are brought together in the work of Kirkpatrick et al (2001). Participants in this study stated that “taking control” meant having control over their lives and their symptoms through the use of medication, recognising early signs of illness and thereby preventing relapse. They also highlighted making a conscious effort as being important.
Repper (2000) states that people who have recovered speak of not wishing to be rushed, fitted into formulas or having to live up to others plans, they want to be in control.
Finding Meaning:
Pettie and Triolo (1999) define two kinds of meanings, those given to us by society and those we chose for our selves in order to make sense of our lives. It is, they state, these latter kinds of meanings which play a large role in recovery when they adequately explain why we are and where we are in terms of the bigger picture. The meaning arrived at by some of “illness as evolution” is highlighted as being particularly positive in terms of recovery as it allows the sufferer to view the illness as a learning opportunity and thereby turns it into something positive.
Empowerment:
Jacobson and Greenley (2001) view empowerment as a corrective for the lack of control, sense of helplessness and dependency that often come with prolonged contact with the mental health system. They state that it has three components consisting of autonomy, courage and responsibility and that full empowerment demands that people live with the consequences of their decisions.
Learning:
Deegan (1996) who writes from her own experience:
“Choice, options, information, role models, being heard, developing and exercising a voice, opportunities for bettering one's life – these are features of a human interactive environment that support the transition from not caring to caring, from surviving to becoming an active participant in one's own recovery process…. Each person must find what works for him or her. This means that we must have the opportunity to try and to fail and to try again. In order to support the recovery process, mental health professionals must not rob us of the opportunity to fail.”
Davidson and Strauss (1992) conclude that systems which offer only a passive or reactive role for patients set up further obstacles to the persons rediscovery of self and their recovery.
Similarly Repper (2000) states that anyone seeking to define service users experience, categorise their symptoms and prescribe and evaluate their treatment might be seen as detracting from the proactive role of each individual in their own recovery.
What is needed therefore is a system which offers real choices and encourages active participation from the client in order to foster recovery.
This brings up a number of tensions however such as how can patients be treated as autonomous human beings while ensuring their safety and well being? Who does know best, about what and at what time?
Relationships:
Kirkpatrick et al (2001) the important aspects of relationships were being there, providing encouragement, showing understanding and giving support.
Similarly, Repper (2000) states that a common factor in recovery is the presence of people who believe in and stand by the individual. These people are described as those who try to listen, understand and encourage recovery without forcing it or becoming frustrated when nothing seems to change.
Barker et al (2001) also point out that many relationships suffer and many friends are lost when someone becomes psychotic and it is important that this issue is addressed within the recovery process.
Jacoboson and Greenley (2001) describe recovery as a profoundly social process and go on to state that much of what is being recovered is a way of being with people or rejoining the social world. This, they state, is often achieved by providing help for others further back on the journey to recovery.
Sense of Self:
According to Davidson and Strauss (1992), the process of rediscovering and reconstructing an enduring sense of self as an active and responsible agent provides a crucial source of improvement for people struggling to recover from serious mental illness. Pettie and Triolo (1999) suggest that this process begins with certain questions which they say often plague those with psychiatric disability; who am I?, What happened? And where is the me I thought I would be? The authors go on to state that it is finding the answers to these questions that marks the beginning of the recovery journey.
But why this need to rediscover an identity or sense of self?
The term identity crisis was coined to explain the experiences of World War Two veterans who had suffered an abrupt disruption to the continuity of their lives and were subsequently confused and disorientated. Pettie and Triolo (1999) suggest that a similar process occurs immediately following the initial acute episode of a serious mental illness. This is given backing in personal accounts of the onset of schizophrenia presented by Barker et al (2001) where it is stated that clients narratives often describe a catastrophic disruption to the persons sense of self and place in the world. Indeed some clients described the experience as the ending of the world as they knew it and one said that they felt their sense of self had disappeared.
Estroff (1989) also noted that psychiatric patients often lose their “selves” inside mental illness and it is only when they have reconnected with a sense of self apart from the illness that recovery can begin. Pettie and Triolo (1999) observed that after the acute phase of the illness people may begin to perceive two different versions of themselves, the person they were before the illness and the person they have become.
The former, they suggest is always viewed as more positive compared to the latter. They also state that a third or future self that could include and transcend the illness is almost impossible to conceive initially. They suggest that, when it does become possible, the initial stages of forming this new identity consist of the person testing themselves out within the immediate environment and discovering what is relevant to them. Their new identity may be formed by reflection with the peers surrounding them, in most cases other psychiatric patients. This, it is suggested, is not necessarily a negative factor as there are likely to be people both in advance of the individual in terms of recovery and others that are behind. The ones that are behind on the recovery journey may serve as a useful reference point helping the person recognise their achievements while the ones ahead can act as an inspiration.
Yanos et al (2000) also found that interaction with recovering peers has an impact on empowerment, hopefullness and learning adaptive coping strategies all of which aid recovery.
A prerequisite for developing a sense of self is to have the freedom to do so and in order to do so they must have the freedom to learn through their own mistakes, see Deegan (1996) quoted in previous sections. Barker et al (2001) observe that this is impossible for the individual to do when families are over protective and recommend that services should work with families to reduce this behaviour which can act as a barrier to the person developing independence and a sense of self.
Social Inclusion:
Anthony (1993) suggests that the barriers and discrimination that people experience as a consequence of their difficulties can limit life far more than a persons cognitive and emotional problems.
Repper (2000) agrees with this and cites a lack of access to a decent income, housing, work and friends as holding back the process of recovery.
She further states that public attitudes are changed very little by public education and that it is personal acquaintance with people who have found ways of coping with their mental health problems that changes personal prejudices.
Implications for Practice
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