Psychological Recovery

Beyond Mental Illness

Retta Andresen, Lindsay G. Oades, Peter Caputi

• Publisher: Wiley-Blackwell
• Year: 2011
• Print ISBN:
  9780470711422
  9780470711439
• Edition: 1
• eBook ISBN:
  9781119975168
• Topic: Psychology
• Subtopic: Clinical Psychology
• Index: Psychology

This book offers a succinct model of recovery from serious mental illness, synthesizing stories of lived experience to provide a framework for clinical work and research in the field of recovery.
• Places the process of recovery within the context of normal human growth and development
• Compares and contrasts concepts of recovery from mental illness with the literature on grief, loss and trauma
• Situates recovery within the growing field of positive psychology – focusing on the active, hopeful process
• Describes a consumer-oriented, stage-based model of psychological recovery which is unique in its focus on intrapersonal processes

Part I

Recovery in Historical Context

Chapter 1

Introduction: Recovery from Schizophrenia

Overview

In this chapter, schizophrenia serves as an exemplar of a most serious form of mental illness, which historically has been difficult to understand, classify or treat. As such, it has been widely researched over many years, generating a large body of empirical research into recovery. Much of the consumer-oriented qualitative research into recovery, however, includes other mental illnesses Therefore, we have utilized the empirical research into schizophrenia to provide ‘hard evidence’ for recovery from mental illness before expanding our work to incorporate the consumer-oriented literature.

Here we put into historical perspective how the idea that there was no hope of recovery from schizophrenia became entrenched within the mental health profession. First we present an historical overview of concepts of schizophrenia, and how these influenced diagnostic systems and prognosis. Next, we present findings from longitudinal and cross-cultural research that show that recovery, in the medical sense – that is, freedom from signs and symptoms of mental illness – occurs more frequently than once believed, and discuss why the rate of recovery went unrecognized for most of the twentieth century.

We then look at how the consumer recovery movement grew from diverse ideological standpoints, and how the consumer movement describes a form of recovery in addition to the traditional medical meaning of the term. Finally we conclude that there is a need for consensus on the consumer definition of recovery, which can be operationalized, in order to meet demands for evidence-based practice with a recovery orientation.

Early Conceptualizations of Schizophrenia

A diagnosis of schizophrenia has traditionally been considered tantamount to a ‘prognosis of doom’ (Deegan, 1997, p.16), which denied all hope of recovery or even of a reasonably satisfying life. Mental health professionals, in particular medical professionals, have a pessimistic outlook regarding the prognosis for schizophrenia (Hugo, 2001; Jorm et al., 1999). The idea that schizophrenia had an inevitable deteriorating course culminating in a life which revolved around stabilization, medication management and survival, has its roots in early descriptions, in which chronicity was considered a criterion for schizophrenia. The earliest description of schizophrenia was that of Emil Kraepelin, who, over many years of clinical observation, asserted that the diseases then known as hebephrenia, catatonia, and paranoia were all characterized by commencement in adolescence followed by a progressively deteriorating course culminating in dementia (1913, cited in Weiner, 1966/1997; Turner, 1999). Kraepelin believed that these diseases all had a common aetiology, course and outcome, and should be identified as forms of a single disorder, dementia praecox, the fundamental criterion for which was its outcome, dementia (Turner, 1999; Pull, 2002). Kraepelin considered the illness to be an irreversible disease of the brain, probably caused by autointoxication – toxicity due to metabolic or other bodily processes (Turner, 1999) – and was not open to the idea that any symptoms of the illness could have psychological underpinnings (Weiner, 1966/1997). Although 12% of Kraepelin's patients made a complete, or almost-complete, recovery (Warner, 2004), he felt that those who recovered had been incorrectly diagnosed, as an outcome of dementia was fundamental to the disease (Weiner, 1966/1997; Read, Mosher and Bentall, 2004).

Eugen Bleuler, on the other hand, did not think that dementia was an essential aspect of the disease, and he noted that the illness did not always commence in adolescence (E. Bleuler, 1911/1950). He asserted that the fundamental symptom of schizophrenia was a ‘splitting’ of the various psychic functions – a loosening of associations between ideas and incongruous emotional responses. Bleuler coined the term schizophrenia, which comes from the Greek for ‘to split’ (schizin) and ‘mind’ (phren), and advocated the use of this term to replace dementia praecox (E. Bleuler, 1911/1950). Bleuler elaborated on Kraepelin's formulation of dementia praecox with a number of new concepts. First, he argued that symptoms could range over a continuum from the almost unnoticeable to the most florid; second, he claimed that the label schizophrenia could apply to people who are making reasonable life adjustments in the community, with no psychotic symptoms; and third, he asserted that, although a person may be socially reinstated after an acute episode, residual symptoms were always present (Weiner, 1966/1997). Bleuler also argued that schizophrenia was not one single illness, but rather a group of several diseases with different aetiologies, courses and outcomes (Pull, 2002). He added two new subgroups: simple schizophrenia, which broadened the concept of schizophrenia considerably (to apparently include those who hold menial jobs and bad housewives who are nagging shrews); and latent schizophrenia, which parallels later concepts of schizoid and schizotypal personality (Wing, 1999). Bleuler's conceptualization of schizophrenia was much more psychodynamic than was Kraepelin's, and he believed that there was a link between symptoms of schizophrenia and psychological processes (Weiner, 1966/1997). Bleuler posited that the symptoms of schizophrenia may be the result of psychological factors, but was unsure as to the underlying cause of the disease. He concluded that schizophrenia was a group of disorders, some endogenous (and therefore organic), and some reactive (and therefore psychological) (E. Bleuler, 1911/1950; Clare, 1980). The organic form carried a worse prognosis than the reactive form.

In contrast to those of Kraepelin, 60% of Bleuler's patients recovered well enough to work and support themselves outside hospital. There are a number of possible explanations for this difference in outcome. First, Bleuler broadened the definition of schizophrenia to include those with a better prognosis; and second, Kraepelin would have defined recovery as freedom from symptoms, rather than social functioning (Warner, 2004). However, we cannot overlook the effects of Bleuler's more psychodynamic perspective, and his belief that there were psychogenic causes for much of the observed symptomatology (Warner, 2004). This point of view resulted in a more therapeutic approach to treatment, in which great importance was placed on minimizing hospital-based care, on the quality of the person's environment, and on providing opportunities for work (Warner, 2004). Although Bleuler did not agree that schizophrenia necessarily resulted in dementia, neither did he believe that people ever fully recovered: ‘Personally I have never treated a patient who has proved on close examination to be entirely free from signs of the illness’ (E. Bleuler, 1911/1950, p. 256).

These early formulations of Kraepelin and Bleuler have had long-reaching effects. With no firm evidence of its aetiology, schizophrenia has continued to be conceptualized and classified in terms of its clinical manifestations. Theorists have classified the symptoms of schizophrenia on a number of dimensions, in attempts to improve diagnosis and prognosis. In terms of diagnosing schizophrenia, the formulations of Bleuler (1911/1950) and Schneider (cited in Pull, 2002) have been widely influential. Bleuler differentiated fundamental symptoms from accessory symptoms. The fundamental symptoms – disturbances in association and affect, ambivalence and autism – were always present in schizophrenia, while the accessory symptoms – including hallucinations and delusions – may or may not be present, and may also be present in other illnesses. The fundamental symptoms were direct manifestations of the disorder, and therefore necessary for a diagnosis of schizophrenia, whereas the accessory symptoms were psychological reactions to the illness, and were not required for a diagnosis (E. Bleuler, 1911/1950; Pull, 2002). In contrast to Bleuler, Schneider (1950, cited in Pull, 2002) held that such symptoms as hallucinations and delusions were pathognomonic of schizophrenia. That is, these symptoms alone were sufficient to give a diagnosis of schizophrenia. Schneider differentiated between abnormal experiences and abnormal expressions (1950, cited in Pull, 2002). He identified 11 first-rank symptoms, which can be grouped into three categories: passivity experiences, in which thoughts, emotions and actions are felt to be externally controlled; auditory hallucinations in the third person; and primary delusions, which arise suddenly and without explanation from a normal perception (Clare, 1980). These abnormal experiences he called ‘first-rank’ symptoms, and the presence of any one of these was sufficient for a diagnosis of schizophrenia. ‘Second-rank’ symptoms included disturbances in language, writing and movement, affective symptoms and emotional blunting, all of which could occur in other illnesses (Clare, 1980). A diagnosis of schizophrenia could also be given when only second-rank symptoms were present (Schneider, 1950, cited in Pull, 2002).

Whereas Kraepelin's definition of schizophrenia was based on onset, course and prognosis, Bleuler focused on the dissociative symptoms and Schneider emphasized the importance of the psychotic symptoms such as hallucinations and delusions. All three formulations have been influential to varying degrees in different diagnostic systems until the present day, including the Diagnostic and Statistical Manual of Mental Disorders (4th Edition) (DSM-IV; American Psychiatric Association, 1994), the tenth revision of the International Classification of Diseases and Related Health Problems (ICD-10; World Health Organization, 1992) and Present State Examination (PSE; Wing, Cooper and Sartorius, 1974).

Diagnostic Systems and Prognostic Pessimism

For the first half of the twentieth century, there was no universal or even widespread definition of schizophrenia. In the United States, the strong psychoanalytic tradition led to a leaning towards Bleuler's broader definition, while in the United Kingdom, Schneider's first-rank symptoms were dominant, and in Europe diagnosis was largely based on Kraepelin's prognostic approach (Clare, 1980). Different countries, even different schools within a country, had widely differing conceptualizations of schizophrenia (Leff, 1988). The first classification systems for mental disorders were published in the mid-twentieth century. The World Health Organization (WHO) included mental disorders in the sixth edition of the International Classification of Diseases, Injuries and Causes of Death (ICD-6; WHO, 1948) and the American Psychiatric Association (APA) published the first edition of the Diagnostic and Statistical Manual in 1952 (DSM I; APA, 1952). However, diagnosis of schizophrenia was much more frequent in the United States than it was in the United Kingdom or Europe. Two major research programmes highlighted this problem. The United States–United Kingdom Diagnostic Project (Cooper et al., 1972) found that there were almost twice as many people admitted to hospital with a diagnosis of schizophrenia in the USA than in the UK. In addition, when UK psychiatrists diagnosed the USA schizophrenia patients, only approximately 50% were given the same diagnosis (Cooper et al., 1972). The WHO then conducted the International Pilot Study of Schizophrenia (IPSS), a transcultural research project that compared diagnostic practices across nine countries (WHO, 1973). Again it was found that many patients diagnosed with schizophrenia in the United States would have been given a diagnosis of neurosis in other centres.

Following from these studies, the DSM-III (APA, 1980) represented a major change in official diagnostic procedures, advocating the use of operationally defined phenomenological criteria based on Schneider's (1957, cited in Leff, 1988) first-rank symptoms, and specifying a minimum duration of illness of six months (Leff, 1988). As a consequence, the DSM-III diagnostic criteria were much narrower than those of its predecessors, or even the ICD criteria (Leff, 1988), which still retains simple schizophrenia, a diagnosis not requiring any psychotic symptoms (Bertelsen, 2002). The DSM-III took an atheoretical approach to classification which avoided descriptions based on an assumed aetiology, although a chronic course was still emphasized (Carpenter and Buchanan, 1994). It was not until work began on the tenth edition of the ICD (ICD-10; WHO, 1992) that international efforts were made to coordinate diagnostic criteria, mainly for the purposes of research. As a result, diagnostic criteria for schizophrenia in the fourth edition of the DSM (DSM-IV; APA, 1994) and the ICD-10 are much more closely aligned than previous systems. The ICD-10 continues to give diagnostic importance to Schneider's first-rank symptoms, and, although the DSM-IV states that no single symptom is pathognomonic for schizophrenia, the presence of ‘bizarre’ delusions, or auditory hallucinations consisting of a voice giving a running commentary on the person's behaviour, or two voices conversing, are sufficient to meet the psychosis criterion for schizophrenia.

Kraepelin's belief that all mental illnesses arise from biological causes has tended to dominate psychiatric classification systems. It was not until the DSM-IV that any remaining distinction between organic and psychological disorders was eliminated (Barlow and Durand, 1995). In practice, Bleuler's broad definitions of ‘simple’ and ‘latent’ schizophrenia became coupled to Kraepelin's organic formulation, giving a wide range of disagreeable behaviour the weight of a medical diagnosis (Wing, 1999). Thus the pessimistic prognosis inherent in Kraepelin's early formulation became incorporated into the expectations of those professionals who were ...

Table of contents

• Cover
• Title Page
• Copyright
• Dedication
• About the authors
• Foreword by Jon Strang
• Preface
• Acknowledgements
• Part I: Recovery in Historical Context
• Part II: Elaboration of the Model: From Hopelessness to Flourishing
• Part III: Measuring Recovery
• Part IV: Towards a Positive Future
• Afterword
• References
• Index