Mental Health Recovery Model
In discussing the implications of a recovery model on service users/survivors and mental health services, it is essential to define recovery. In illustrating the controversial nature of this concept it is pragmatic to discuss service users and workers in mental health because implications of the recovery model affect both, but in different ways. It is important to realize there is a division in the focus of each group; service users generally want independence from services while health care providers focus on methods and models (Bonney & Stickley, 2008).
In working together both groups can improve the provision of recovery services. Traditionally, rehabilitation is provided within hospitals and is medically based and determined by professionals (Unit 21, pg 67). Alternatively, ‘recovery‘ defined in service user literature is the powerful idea that people can return to a full life following experiences of mental distress (Unit 21, pg 59; Mental Health Foundation, 2009). Anthony (1993, cited in Unit 21, pg 62) notes that recovery enables people to understand their problems and allows them to cope with setbacks. This implies hope and being believed in by others so is a social model.
Jan Wallcraft notes most mental health literature neglects the idea of recovery (Audio 4). Additionally, John Hopton (Audio 4) believes it is important recovery is defined by the person experiencing distress rather than professionals. The role of professionals within recovery based services is an issue necessitating redefinition of roles (Unit 21, pg 67). Although the recovery model outlined is positive, the concept is not without detractors. Recovery implies getting over ‘illness’, but it doesn’t necessarily imply illness; rather it entails a process in line with recuperating from physical exercise.
Nonetheless, according to the illness viewpoint, mental distress is seemingly restricted to a medical model and an implied medical ‘cure’ – medication. This predominant model accounts for the inadequate help for those wanting to reduce or stop taking medication. Additionally, much mental health policy and practice encourages people to continue taking drugs (Unit 21, pg 70). Furthermore, some believe the medical model doesn’t anticipate recovery. Coleman (cited in Unit 21, pg 61) believes this is because of a lack of recognition that individuals can return to the life they had prior to illness.
Accordingly, the focus is on compliance, risk avoidance and dependency with a resulting negative impact on service users. Lindow (Reading 32) believes the ‘illness’ framework promotes pessimism and that its paternalism loses sight of service users as self-determining adults. In this context, incorporation of recovery implies a change in approach. For example, to foster independence, staff could reduce interventions, doing only what is essential (Bonney ; Stickley, 2008). This would be challenging as workers need to protect an individual’s right to independence while recognizing that the public also needs protection sometimes.
One implication of the recovery model is that it could lead to the neglection of those believed less likely to recover and feelings of failure in people who don’t recover (Unit 21, pg 76). John Hopton (Audio 4) notes this may increase mental distress. These are potential risks; additionally Frese et al. (2001, cited in Unit 21, pg. 67) argue that those with severe mental distress are unlikely to benefit from recovery as they don’t have capacity to understand they are ‘ill’. Frese et al. say those who can understand recovery may benefit from responsibility. Those not so well want better treatments and some control.
Although service users should have input, Frese et al. note enthusiasm for recovery should not consequently deny treatment to those who need it. Their implication is that not all can benefit from recovery. However, Paul Beresford (Audio 4) notes it should be a question of what an individual can contribute regardless of the severity of their mental distress, someone who has been in hospital many times over a long period can still contribute something. This more inclusive definition is in keeping with the holistic framework while recognizing the complexity of recovery for those experiencing mental distress.
Bonney and Stickley (2008) note the theme of power is often raised by service users. If, as predicted by the DOH in 2003, services are to become increasingly individual focused, the system needs to place power with service users. There is increasing amounts of service user literature that places an emphasis on individuals defining their own journey of recovery (Unit 21, pg 66) rather than having it imposed on them by workers. Peter Beresford (Audio 4) notes that currently there are inequalities in mental health services with limited service user power but considerable professional power.
Bonney and Stickley mention Martyn (2002, cited in Bonney and Stickley 2008) who proposes professionals should be present by service user invitation only. A less radical aim is that of a gradual transfer of responsibility in power from services to individuals during recovery. It is important such involvement confers genuine power to individuals, rather than being tokenistic (Jacobson 2004, cited in Bonney and Stickley 2008). It should be noted service users do not necessarily associate recovery with being symptom free. Rather, it involves coping with distress and living well.
Rachel Perkins (Unit 21, pg 65), a clinical psychologist with a manic depression diagnosis, notes the recovery model shifts focus away from services on to the individual recovery journey. One area embracing this is self-help. An example is the Wellness Recovery Action Plan (WRAP; Unit 21, pg 65) developed by service user Mary Ellen Copeland. It encourages awareness, self-care improvement and strategies for dealing with mental distress to promote wellness. Another way service users can promote recovery is by utilizing support from others who have experienced similar distress e. g. via organizations like the Hearing Voices Network.
This forms part of the way in which Grierson (2003, cited in Unit 21, pg 65) sees recovery progressing. Firstly, an individual needs to identify their experience, which can be assisted by peer support. The next stage includes understanding experiences, also aided by peer support. The final stage of acceptance and living involves reclamation of a service user’s life. This indicates that recovery doesn’t need to have an end point, it is an ongoing process. It can be seen as the development of insight and is a holistic approach (Unit 21, pg 66) where many different areas can affect an individual’s mental health.
The implication is that individuals need to be central in defining their own recovery. For workers, a focus on peer support implies services need to be user led, based on service users’ experiences and driven by these. Accordingly, best practice would be that workers enable peer support (Unit 21, pg 69). However, another method is that service users set up services themselves. Anam Cara is a voluntary sector, user-run crisis house in Birmingham (Unit 21, pg 73) which embodies this approach. The aim is to give an alternative to hospital admission with a focus on recovery. People can refer themselves or be referred via local services.
Service users report that this has had a large impact on their recovery due to the acceptance provided. This approach implies that professionals are not as central as in traditional services. However, an alternative is to equip workers with skills necessary to extend the availability of recovery based services within mainstream mental health care. Mary O’Hagan in a resource for training in New Zealand (Unit 21, pg 73–74) noted that to do this workers need to provide relevant information i. e. on community services, and to provide information while accommodating diverse views on distress, treatment and recovery.
This is very much in line with a holistic approach. It has been argued that the social stigma faced by those who have, or have had, mental health problems is often more problematic than mental distress itself (May cited in Unit 21, pg 64; Bonney ; Stickley, 2008). For example, the World Psychiatric Association found misconceptions about schizophrenia included those with diagnoses don’t recover and are dangerous (Unit 21, pg 61). However, Warner (cited in Unit 21, pg 61) illustrated that actually 20–25% recover completely and another 20% can recover productive lives even if not symptom free.
Also relevant is a report which says the overrepresentation of individuals with schizophrenia in violent crime is usually attributable to substance abuse rather than mental health problems (Medical News Today, 2009). Warner showed that those in the developing world were twice as likely to recover. This could be due to greater social acceptance and support from society. One implication is that mental health services need to take into account social support where possible. The potential loss of benefits and support from services once an individual is deemed ‘recovered’ (Unit 21, pg 71) may prevent recovery.
Resulting financial worries and lack of resources can impact on every part of an individuals’ life. Many service users are on benefits, however the system isn’t flexible enough to incorporate those with variable capacity for work to move in and out of employment (Unit 21, pg 71). Also, Disability Living Allowance focuses on long-term physical impairment rather than periods of mental distress. Housing is also an issue as it is central in providing hope for the future. Browne et al. (2008) note most service users want to live in their own accommodation. Others may require access to supported living.
Thus different options need to be available. Browne et al. note that in Australia the current discussion on graded levels of housing support could be a good way of gradually moving towards independence. Implied within the areas of finance, employment and housing is the recognition that recovery is not always a straightforward path. Williams (2004) notes that a major disincentive to recovery is that once out of crisis, services are often withdrawn. This feels like abandonment when help is still needed. Due to this, many may find it easier to retain a service user identity rather than negotiating an inflexible system.
To address this requires systematic change, provision of employment and benefit advisors and continued support where needed. Workers also need to recognize the juncture in recovery after crisis, but before a full return to independence. Although it seems recovery is not widely incorporated into current mental health services, initial steps have been taken. The Department of Health (DOH) published The Journey to Recovery in 2001 (cited in Unit 21, pg 62) and mentioned an increasing focus on recovery. However, standards such as the National Service Framework have not yet been revised to include recovery or ways of measuring success.
Attempts in the USA have been made to develop service user orientated outcome measures. One system used in Ohio (Unit 21, pg 75) involves questionnaire responses recorded and tracked by computer. This approach has not been accepted so far in the UK. In conclusion, it has been illustrated that recovery is complex and has many implications for service users and mental health workers. The recovery model implies a necessary shift from traditional medical rehabilitation towards flexible services providing individualistic, holistic care that acknowledges the gradual nature of recovery.
For service users recovery implies taking responsibility and reclaiming power. However, recovery can be problematic in the area of access to benefits and the logistics of changing traditional models of care. Services are moving towards a recovery model, but there is substantive work to be done to result in a changed paradigm.
- Bonney, S. and Stickley, T. (2008). Recovery and mental health: a review of the British Literature. Journal of Psychiatric and Mental Health Nursing, 15, 140–153.
- Browne, G. , Hemsley, M. and St. John, W. (2008). Consumer perspectives on recovery: a focus on housing following discharge from hospital. International Journal of Mental Health Nursing, 17, 402–209.
- Lindow, V. (2000). ‘What we want from community psychiatric nurses’ in Speaking Our Minds (Read, J. and Reynolds, J. Eds). Milton Keynes: The Open University.
- Medical News Today (2009). Schizophrenia does not increase risk of violent crime. http://www. medicalnewstoday. com/articles/151269. php Accessed 1st June 2009.
- Mental Health Foundation (2009). Recovery. http://www. mentalhealth. org. uk/information/mental-health-a-z/recovery/ Accessed 29th May 2009.
- Open University (2004a). K272 Challenging Ideas in Mental Health, Unit 2 ‘A Holistic Approach: Hilary’s Story’. Milton Keynes: The Open University.
- Open University (2004b). K272 Challenging Ideas in Mental Health, Unit 21 ‘Recovery in Mental Health’. Milton Keynes: The Open University.
- Open University (2004c). K272 Challenging Ideas in Mental Health, Audio 4, Track 2: Reflecting on recovery. Milton Keynes: The Open University.
- Williams, A. (2004). ‘The strain of feeling better ‘ in K272 Challenging Ideas in Mental Health, Module 4, Reading 32. Milton Keynes: The Open University, pp. 45–48.