Uses and Abuses of “Recovery” – A Review

Ron Unger, LCSW
41
143

The World Psychiatric Journal has published an interesting article, Uses and Abuses of Recovery: Implementing Recovery-Oriented Practices in Mental Health Systems, that outlines “7 Abuses of the Concept of ‘Recovery.'”  This effort to identify problems in the use of the term “recovery” is important,  and it is good to see the many issues they raise being discussed in a major journal.  I encourage people to read the article, as I won’t be able to touch on many of its points here.  Instead, what I want to do is to add some to their list of abuses of “recovery” and to critique  some of their reasoning about what alternatives should be supported.

The authors define as part of the problem the idea that “Recovery is about making people independent and normal.”  They state:

. . . Recovery is not about “getting better” or ceasing to need support – it is about “recovering a life,” the right to participate in all facets of civic and economic life as an equal citizen. This requires a framework predicated on a human rights and a social model of exclusion: “It is society that disables people. It is attitudes, actions, assumptions – social, cultural and physical structures which disable by erecting barriers and imposing restrictions and options.”

It is true that all humans need support, and that the exact kinds of support vary by individual, and sometimes people’s problem can be simply that the society fails to provide the specific kind of support they need, or that they haven’t yet been able to find it even though such support exists.

The understanding that people have different abilities, and that a healthy society should include more people by removing barriers, comes out of the physical disability movement, where people often have physical differences which will last a lifetime and cannot change.  So, for example, a person requiring a wheelchair to get around may recover an active life when the society removes barriers to access, and provides supports like ramps and elevators.  An example in the mental health world may be where a sensitive person fails to thrive or breaks down in an ultra-competitive culture, but then is able to recover when helped to connect with the supports they need.

But it’s also true that, for many, mental health recovery is very much about “getting better” and ceasing to need various forms of special support. Mental health crisis, even of the most serious variety, is often temporary, and with the right kind of assistance at the time, people can often get back to being as independent as anyone else (though not “normal,” as we all know by now that this only exists as a setting on a washing machine).

We would do best to see that recovery comes in varieties, or flavors. Sometimes it is about learning to live better with a particular disability, and sometimes it may be about learning how to no longer have that disability.  For example, counseling approaches which offer strategies aimed at helping people overcome and not just learn to live with specific mental health disabilities should remain a part of any recovery-oriented system, even though these approaches should never be offered as the only possible route forward.

One problem in the article’s perspective on this begins with the definition of recovery that they use: “a deeply personal, unique process of changing one’s attitudes, values, feelings, goals, skills, and/or roles,” and “a way of living a satisfying, hopeful, and contributing life even within the limitations caused by illness.”

When I meet up with people who have fully recovered, it seems they may still have “differences” that used to be called “symptoms” – differences like hearing voices and experiencing altered states – but these differences are no longer seen as a problem, and often are seen as being more helpful than not.

Unfortunately, the article never questions the legitimacy of the “illness” model, and even endorses the highly flawed “Illness Management and Recovery (IMR)” protocol as a way to support recovery.  “Illness management and Recovery” teaches people that their problems result from brain problems, and stresses “medication adherence” as one of the keys to recovery.  The article states:

The centrality of medication adherence and psychoeducation about mental illness in IMR can present a barrier to its use by people seeking to support recovery. Supporting recovery is not incompatible with diagnosis and medication, but a barrier arises when diagnosis and medication are assumed to come first in steps towards recovery.

The article would have been better to acknowledge the ways that diagnosis and medication can be a very real barrier to recovery.  Oryx Cohen describes how when he was given a major “mental illness” diagnosis, he felt he had just lost his membership in the human race. This effect of being diagnosed and the “psychoeducated” about biological models is not uncommon, and is hardly consistent with the focus on “fostering hope and a belief in people” that the article identifies as critical to recovery.

We know, of course, from the studies Robert Whitaker has cited, that there is evidence that medications make recovery less likely for many who take them.

I’m curious to hear your thoughts about both what I’ve shared in this post, and about issues raised in the World Psychiatric article which I haven’t even touched on here (such as the way forced treatment can impair chances for recovery, or the way the concept of recovery can sometimes be used as an excuse to close down services that are still needed.)  I look forward to reading your comments and perspectives.

41 COMMENTS

  1. As I commented on the ISPS-US website Ron I agree with you about this article, in terms of its limits regarding the list of abuses in the hijacked recovery movement and what has come to be the two tier model of recovery. In Scotland anyway. Which is “common mental health problems” and “severe and enduring mental illness”. Schizophrenia is still seen as a stigmatising label, the people who have it are “treatment resistant” and recovery is a far away place for people who have been given this lifelong label, indelibly written in psychiatric notes.

    I am also concerned about the list of “approved” treatments in this article, including peer support which hasn’t fulfilled its potential, and in fact has been assimilated into health board cultures where I live. Real peer support and independent advocacy, in mental health settings, should be about standing with the mentally ill person, if need be against the psychiatric system. It will be about taking sides and being unpopular, and could involve speaking out about human rights issues or abuses in psychiatric settings. Which do still happen despite so-called enlightened societies and communities.

    It’s disappointing to have to say this and be critical but my own experience over the last few years, as a carer and advocate for family members in psychiatric settings, has been one of resistance and solidarity, at the sharp edge. Advance directives or statements in Scotland, for example are good in theory but in practice can be disregarded if the psychiatrist considers compulsory treatment is necessary. Doctor knows best. I’m not sure either about Recovery Colleges and suspect they might be another tokenistic endeavour and not the meaningful involvement that’s really needed to bring about a paradigm shift and real system change.

  2. Szasz said it all with “excusing the guilty and punishing the innocent”.
    http://www.mindfreedom.org/mfi-faq/action-alert-to-free-alison-hymes

    Psychiatry is Precrime, just like in the movie “Minority Report”
    From the World Psychiatric Journal linked article it says “238 (Community Treatment Orders) to prevent one arrest.”

    An example of creating the future from the movie “The Matrix”
    Oracle : I’d ask you to sit down…but you’re not going to anyway. And don’t worry about the vase.

    Neo : What vase? *crash*, Neo knocks the vase over while looking.

    Oracle : That vase.

    Neo : I’m sorry.

    Oracle : I _said_ don’t worry about it. I’ll get one of my kids to fix it.

    Neo : How…how did you know?

  3. Ron, the article leaves me with a cold, drained feeling, just like what I felt when I was in State and VA mental hospitals…sitting across from professionals with all the words but none of the heart.

    I may have missed it, but I saw no mention of trauma and the awareness that what is called mental “illness” is in truth a learned dysfunction that one recovers from by gaining support and safety. The stigma and fear that infects one when one is embraced by the mental health systems feeds the nightmare and makes recovery very, very difficult. It is “Big Nurse” saying the right words but draining the will to live from a traumatized person with every breath. Recovery for the traumatized is only possible when one fights back.

    Does “mental illness” exist, other than a collection of learned behaviors? If not, this article is more part of the problem than the solution, as you point out. And if traditional “mental illness” does exist that one needs to recover from, then I should shut up and learn to recover from my…what is the medical word for “refusing to acknowledge one’s disease”?

    When in Northampton VA hospital, diagnosed a chronic paranoid schizophrenic and stumbling around on massive doses of Thorazine, I once wrote “the recidivism rate in this place is 100%, even the staff keeps on coming back” (we were invited to write graffiti on a piece of construction plywood).
    But recovery wasn’t built into the mental health system. Recovery only was a possibility for me when I walked away and detoxified and learned what trauma had done to me.
    Maybe only psychiatric survivors can truly write the book on recovery, and create a system where the recidivism rate trends toward zero. The mental health system needs to recover first before it can hope of being a real agent of health. I know it is trying.
    Thanks for your brave work in advocating for those of us lost in America.
    Hugh Massengill

    • Dear Ron
      Diagnosis and Medication : A Diagnosis like ‘Schizophrenia’ suggests a physical brain disorder that puts someone beyond the pale. Medication has never worked for me – it disabled me.

      I recovered because there were genuine solutions available to the problems I had, and I was able to find them. The solutions were not available within Psychiatry.

  4. There are so many barriers to healing and personal growth and well-being that have become woven into the norm of our fragmented, misguided, and emotionally violent and fear-based society. There are no practical answers in the ivory towers, which are totally disconnected from the reality of streets. Money and power/control, based on survival fears, continue to be the motivating factors of these academic beliefs, and this only serves to transfer social illness onto vulnerable and trusting populations who speak their truth. Not only is this deceitful and unjust, it is emotionally and spiritually murderous. (And, in some cases, physically so).

    Mostly, I feel that, collectively, we suffer from our failure to connect with our true nature and essence. We have strayed so far from that, that we continue to live under a variety of delusions which are the undercurrent of such insane disenfranchisement of human beings. While I so very much respect those who have worked hard to ‘get back into the mainstream,’ which I know is a grand effort for many people, I don’t at all believe that ‘work’ is necessarily a true and accurate measure of anything, other than needing to be accepted by some group or society. Needing to be ‘accepted’ by anything that is inherently out of whack simply puts us all in danger of living in an illusion, which is a house of cards, and only beneficial (in the short run) to some tiny group of self-proclaimed financial elites. From this perspective, our dependence on others only deepens, and this keeps fear alive, and power imbalanced. To me, fear is our number one ill-making culprit.

    Fear is healed when we connect to our inner beings, our spirit voice, and in turn, we learn trust our own process. There are 7 billion individual processes on the planet, one for each individual. We can only know ourselves. By not allowing others to interfere with our innate self-knowledge, knowing how to self-guide and self-heal, we take control of our lives, and we can swim in a sea of integral well-being and personal evolution, naturally. That sounds like good health and life mastery to me.

    Of course, we all know that current mental health practices do not lead us to self-mastery of our lives. In fact, it’s quite the opposite, as we are taught ‘dependence,’ and shamed and punished when we do not learn this twisted lesson.

    It is up to each of us, individually, to choose what it is that feels healthy and balanced to us. Others may not relate, or may judge, and while it could be an opportunity for that society to grow and evolve into embracing diversity, it most often very stubbornly resists this opportunity, which, to me, would be an indication that one may be in the wrong community for themselves. Otherwise, that individual is sure to find themselves marginalized, disabled, and considered ‘ill.’

    The planet is not one big happy family, nor do I feel that this would be natural and reasonable. We are a diverse bunch, with resonant families, and it’s up to each of us to find where we are best supported in our health, well-being, and natural creative process. This would shift the entire framework of what is considered disabled.

    I say it is society which is disabled. What is ‘normal’ to us, is opposite of healthy. To consider an individual disabled–especially permanently disabled–is the grand myth of all time. It saddens me that we continue to operate under these delusions.

  5. Interesting article Ron. I think a lot of this stems from a discussion of what “recovery” means. For those allied with NAMI and the current mental health system, recovery means taking daily medications, integrating into the community and being able to not have severe episodes of distress requiring regular hospitalization. Even if that means having a host of side effects from the meds and health complications.

    I think for people who are critical of psychiatry, recovery means an improvement in health and well being not necessitating large doses of psych meds. It means tolerating or even welcoming divergent symptoms such as voices or even depression as part of the human experience. It means not relying on the medical establishment for managing their well being but developing personal autonomy and finding holistic methods for improving health and well being. It means not believing in a permanent illness model of mental health. It may mean some interaction with the medical community but with much more circumspection and personal agency in those interactions.

    The word “recovery” has been easily co-opted to the point where it’s meaning is fuzzy. Obviously the folks that write this article are invested in the first model of Recovery. From there we have problems.

  6. This nice, ethical, Christian woman was apparently considered a “threat” to an ELCA pastor and his best friend, who wanted to cover up the alleged sodomy of my son; and the denial of my daughter a baptism, a pastoral sin marked throughout eternity at the exact moment the second plane hit the second World Trade Center building on 9.11.2001. “Never forget.”

    I was in denial of the abuse of my son at the time, and trying to understand why the pastor was being so incredibly rude, when a therapist decided majorly tranquilizing me, then having me poisoned via anticholinergic intoxication would be beneficial to me. Yes, as it turns out, this therapist may possibly get lots of sexually abused children recommended to her, to be labeled with psychiatric stigmatizations, by the pastor and his friends. Her neighborhood high school had the highest suicide rate in the country at this time. But in 2001, I was unaware of the fact that the psychiatric profession was in the business of covering up child abuse for sick men.

    Our family PCP was more than happy to oversee this poisoning of me because, as it turns out, she was paranoid of a malpractice suit because her husband had been the “attending physician” at a “bad fix” on my broken bone. I was unaware of her financial motive to oversee the attempted murder of me at the time, however.

    Finally having my family’s medical records handed over by some decent doctors and nurses in 2005, and finding the medical evidence of the alleged sodomy, did help me overcome my denial of the child abuse. But this entire appalling medical cover up of child abuse and the “bad fix” with anticholinergic intoxication poisoning made me a potential “threat” to these doctors.

    So I was medically unnecessarily shipped to another doctor who has now been arrested by the FBI for having many patients medically unnecessarily shipped to him, “snowing” (drugging until only the whites of the eyes show) patients, and performing unneeded surgeries which have resulted in many patient deaths.

    Recovery comes from mentally comprehending the appalling crimes committed against my children and I by pastors and doctors. Denying real life problems and tranquilizing people will never lead to healing. And that is all today’s mindless psychiatrists do.

    And I do not think anyone will ever be able to convince me that an industry that is, and I’ve been told by other pastors has historically been, in the business of covering up child sodomy for religions anything other than pure evil. Although I do know there are individuals within the industry that do actually want to help others.

    Thank you, Ron, for helping to point out that psychiatry is still so misguided. I don’t personally think they will ever be able to actually help anyone without getting rid of the DSM, radically rethinking their use of brain damaging drugs, in essence starting over. Helping people is hard work, takes lots of time, and it can be emotionally taxing. Psychiatrists aren’t interested in that, they want easy money for defaming people with their depersonalized, scientifically “lacking in validity” DSM iatrogenic illnesses.

    I, for one, am telling people I know that the psych drugs cause the symptoms of the mental illnesses, and to stay as far from psychiatric practitioners as possible. Psychiatry doesn’t want to change, but they absolutely should not have a legal right to force belief in their “bible” of stigmatizations upon others, nor rape people with their chemical lobotomy drugs.

  7. Hi Ron,

    I’ve always been perplexed by the idea of ‘recovery’ as it relates to psychosis. There are some that really do ‘recover’ in the sense they have one episode then never see a symptom again. And there is a middle group of those who drift in and out over time of symptoms with periods of ‘recovery’ in between. Then there is the bottom group where recovery means heavily medicated to the point that you are no longer being arrested or sectioned every week and living in a group home, maybe working part time for minimum wage somewhere. It doesn’t make a whole lot of sense to talk about all these trajectories of a psychotic disorder under a single umbrella of ‘recovery’. I feel like most of the dialoguing on this site focuses on recovery of the top two groups and how meds block those who will go on to full or intermittent recoveries. While groups like NAMI, TAC, and the overall social services industry focus on that bottom group where meds are the only standing between a person and incarceration/ destitution/self-mutilation/suicide/accidental death/ etc. And they are all fighting with each other like they are talking about the same thing. When the reality is a psychotic disorder can have any of these three trajectories, and the approach to managing it is very different depending which group a particular individual falls into. I think we must start talking about the trajectory groups before discussing anything that has to do with treatment and recovery. The evidence shows what works best in terms of meds and supports for each group; but the fact that we keep lumping them all together in studies and in public discourse is only confusing everyone. Just my two sense on ‘Recovery.’

    Alexa

  8. Any discussion of recovery should include consideration of whether recovery based systems exist. I think not. It’s over 20 years since Anthony’s article (“Recovery from mental illness. The guiding vision of the mental health service system in the 1990s”) and it appears that recovery is evidenced largely as the stuff of conferences, colloquia, webinars, work groups, seminars, trainings, task forces, and publications. The term has been rendered a meaningless adjective to be added to the name of any initiative or program.

    We’ve been here before. Who can forget that when psychosocial rehabilitation was in vogue everything was predicated on psychosocial rehabilitation. The same was true for the eras of best practices and evidence based practices. Why should it be any different for the Era of Recovery and increasingly the Era of Wellness and Recovery? (see Abuse #1)

    At best recovery based systems are an aspirational goal. At worst it is merely puffery. Sadly, that which is represented broadly is evidenced narrowly, anecdotally or not at all and creates the impression that individuals who fail to recover have failed a system which putatively affords us every opportunity and resource to recover. Afterall, everything is predicated on supporting recovery ….. or not.

  9. Hi Ron,

    While the studies on NEC’s website have long been cited to support the reality that recovery is possible they don’t establish that many are receiving supports and services in an environment which fosters recovery. The broader evidence as related in MIA is that more and more of us are ending up on disability.

    The Mental Health Transformation- State Incentive Grants was a 5-year Federal grant program designed to help States transform their mental health programs into ones that are more effective and that better promote recovery and resiliency. The August 2011 evaluation report is telling,

    Were the grants able to create more recovery-enhancing environments? POC [Proof of Concept] studies were designed to focus on areas in which grantees thought they could effect changes. Limitations of this study were that the intervention fidelity and “dose” were not measured and therefore not statistically controlled. The results from these studies indicated the answer to this question is no. (Executive Summary, page 5, para. 2.)

    Regards,

  10. To me the most important idea touched on here was written by hughmass up above, “maybe only psychiatric survivors can truly write the book on recovery…………

    We write it daily with our lives and our experience .The potential power and truth within us frightens and threatens the many foes ,friends,and family, organizations huge and small ,even governments and robber barons alike. The walls built to contain us, “evidence based” as if our lives and experience are devoid of priceless information that can help others. “Anecdotal” as if we are telling fairy tales of maybe entertainment value only or outright lies or maybe we’re just mad and out of control. We’re all ” so utterly different ” that when we relate our survival strategies they couldn’t possibly be of aid to another because we’re so different . “We must have million dollar double-blind studies conducted by robber baron flunkies so we can have real scientific evidence we can rely on, funded by PigPharma.” Of course there’s more. Give me a break.

    Step aside and give us a chance !

    The merging of the corporation and government with the police military and psychiatry and most of their underlings , robber baron funded, boldly drugging and ect ing even the youngest of children while the population is caught like deer in a headlight and evermore coerced into submission.

    Must of us too broke to travel far to exchange ideas in places not funded by those with coercive or preconceived agendas can clearly see the well paved eugenic road humanity is being marched down by the powerful rulers with the gold.

    I know that collectively we and others hold the tools ,info, and hope to turn this lemming march around.

  11. My view of recovery connects with human development. Human development is complex and multifaceted. Everyone turns out different. But there is a typical agenda, and even though there is a range of capacities, people move through life in stages. In young adulthood people are taking on certain types of social roles, in later life there are others.

    I think recovery connects with restoration of a person to the place they expect to be in life. Social role, meaningful relationships, capacity for expression, economic sufficiency, control of one’s body, all that. This is always complex, and is seldom about technique, or what kind of assistance a person might require, or whether they are obedient to one or another authority.

    So the point of recovery for me is having one’s life back, in some sort of context that makes sense. So what if it’s a struggle! Lots of people struggle. So what if a person zones out sometimes, if there is a way to compensate and still have a family role, and safety, and maybe employment.

    Everyone has a range of capacities, a set of vulnerabilities and certain risks. People who are doing what they must to adjust to all this and move forward in life are “in recovery” while climbing out of whatever hole their medical condition has landed them in. Once they climb out, they’re “better now” or “doing okay.” Recovery has been achieved.

    –pk—