Chapter Aims
After reading this chapter you should be able to:
- identify the key features of the ‘recovery’ approach and how it compares and contrasts to the biomedical model;
- describe how the recovery approach can contribute to quality of life for people with mental health problems;
- consider the implications of the approach for the delivery of mental health nursing care.
Introduction
This chapter gives an overview of the recovery approach, comparing and contrasting it to the biomedical model of mental ill-health, currently the most dominant paradigm of mental health care in England. We will also explore how mental health nurses can facilitate recovery and in particular how they can support people with mental health problems to build a life which is personally meaningful to them and to take control of their own health and wellbeing.
Recovery: The Historical Context
It is important to be able to place the recovery approach in a historical context in order to examine motivation for change, and to decide where to place it in a civil and human rights context. From the opening of the asylums to their closure in the 1960s and 1970s, followed by the move to community care in the 1990s, most people working within mental health services come to work to help people to get better, with genuine and passionate intent. This is the case whether their role is to design, manage or deliver these services. However, the containment and restrictive nature of these asylums limited the ability to form collective action and effectively prevented the growth of service user representation. In the 1970s, one organisation formed that can justifiably be called the originator of organised service user action, namely the Mental Patients’ Union, with branches in various parts of the country (Campbell, 2005). In the mid-1980s, the service user movement began to gather pace with the rise of collective and individual advocacy across the country.
The recovery approach has developed from the growth of the service user movement which has carried an imperative for all mental health services to be humane, meet the needs and demands of the person and honour their human rights. Many individuals, such as Pat Deegan, have been inspirational in the development of this approach and take their place in service user history, particularly relating to the demand for change since the asylums. Judi Chamberlin's ground breaking book, On Our Own, first published in 1977, describes how people with mental health challenges can – individually and collectively, within and alongside wider communities – find solutions to the problems they face. The foundations of this work lay in the real-life narratives of people who had lived with and moved beyond the mental health challenges they faced, and have been developed and elaborated within this context (see O'Hagan, 2014).
Changes to service delivery have also, indirectly, catalysed the development of the recovery approach. For example, the 1980s strategy of providing care in the community and the closure of mental institutions was a catalyst for progressive collective communication and action. It was instrumental in the hugely significant service user organisation Survivors Speak Out that emerged throughout the 1980s, which was a key influence for further rights-based, user-led political and human rights organisations. The mental health charity Mind organised conferences which provided a fertile meeting ground for these ideas to flourish. The first of these, the 1985 Mind/World Federation of Mental Health Congress in Brighton, brought together national and international thinking (Campbell, 2005).
Recovery takes its place as an oppressed minority (i.e. mental health service users) seeks equality alongside other civil and human rights campaigns and follows the pathways of women's rights; rights of black and ethnic minorities; lesbian, gay, bisexual and transgender, and many more. It is important that we see recovery in its political and historical context lest we believe it is the benevolent gift of governments, mental health services or professionals. The right to recovery is a right demanded by the service user movement, and one to which everyone who needs it should have access.
Defining Recovery
There are many definitions of recovery so it is useful to start with William Anthony's who, as Director of the Boston Center for Psychiatric Rehabilitation, developed a definition which is widely regarded today as important and valuable.
[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 the illness. Recovery involves the development of new meaning and purpose in one's life as one grows beyond the catastrophic effects of mental illness.
(Anthony, 1993)
This definition, along with many others, questions beliefs that began to be challenged in the 1980s and 1990s, namely, that mental illness was chronic and could only be contained and maintained. Many of these attitudes were still rooted in kindness and care, but held low expectations and a fundamental belief in illness and chronicity. The recovery approach rejects that notion and sees recovery as an expected outcome. It is personally defined and therefore will look very different for everyone, like all human growth. It can contain setbacks and is not defined by the use of services, the presence of diagnosis or the continued use of treatment. These can be absent or present in recovery.
Definitions of recovery recognise the impact of diagnosis and the subsequent journey of finding meaning in what has happened to the individual and discovering new sources of meaning and value. In this sense, recovery is
the lived or real life experience of people as they accept and overcome the challenge of disability. They experience themselves as recovering a new sense of self, and of purpose beyond the limits of disability.
(Deegan, 1988)
The Recovery Approach
The recovery approach stresses the holistic and biopsychosocial approaches while emphasising individual and personal pathways of recovery. It does not seek to denigrate the medical approach, but it places emphasis on the entire experience of the individual rather than a narrow frame of reference defined by a perceived illness. The recovery approach takes a different starting point to the medical model in that initial consideration is given to how the individual may be assisted to achieve a life which is personally fulfilling to them, recognising their strengths, assets and abilities, rather than focusing on disabilities, deficits and symptoms.
The recovery approach draws a distinction between complete recovery (in which an individual returns to their level of functioning before they experienced mental ill health often implying that the person has been ‘cured’ or recovered) and social recovery (which focuses on helping the person towards recovery, and involves an emphasis on social support, realistic planning, significant working relationships, encouragement, appropriate treatment, choice and self-management) (Warner, 1985; Matthews, 2008). In the latter case, much emphasis is placed on the ongoing process of recover-ing from mental health problems. Here, an emphasis is placed on supporting the person holistically with an aim to improve their overall quality of life despite the presence of ‘psychiatric symptoms’. Hence, recovery in this sense
is not about regaining a problem-free life – whose life is? It is about living life more resourcefully, living a satisfying and contributing life, in spite of limitations caused by a continuing vulnerability to disabling distress.
(Watkins, 2001, p45)
Service user Comment: What is Recovery?
Recovery is a constant state for a service user. To begin with, recovery is something that you will work towards and once in that phase of your treatment it is ongoing. Reaching different levels, this can be judged by what you achieve while remaining settled in your core. Namely being symptom free. The only way I can describe this is, for example, a person who has used illegal drugs and attends an NA [Narcotics Anonymous] meeting. The core symptom of abusing the drug is gone; this is the start of recovery, however this person cannot be seen as cured. It's the steps. Support. Recognition. Acceptance. And ongoing supportive services received. These are the beginning stages of recovery. And just to...
