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.