Moving Mental Health Recovery Toward Meaningful Participation

Mental health recovery involves not only finding employment but also holistic and meaningful participation in communal life.

Micah Ingle, MA
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A recent article published in Psychiatric Services argues that mental health recovery should not be measured solely by an ability to return to work or find employment. Instead, measures of recovery should account for participation in activities that are personally and socially meaningful. The authors explore frameworks that can lead to this reconceptualization, the need for targeted interventions, and the moral or social justice imperative linked to this shift in vision.

Disability scholar Terry Krupa, from Queens University in Canada, and her co-authors, Sandra Moll and Ellie Fossey, argue for a return to a holistic understanding of recovery, writing:

 “In her seminal article, Patricia Deegan described recovery as a process to ‘re-establish a new and valued sense of integrity and purpose within and beyond the limits of the disability; the aspiration is to live, work, and love, in a community in which one can make a significant contribution.’ This rich, multidimensional image of recovery speaks to the value of active engagement in not only employment but also in maintaining social connections, establishing identity, and contributing to community.”
Photo by Benjamin Combs on Unsplash

The need to rethink the meaning of recovery in mental health has been on the horizon for many clinical professionals and service users. Critics have noted that psychiatry’s emphasis on returning individuals to work can serve as a support to capitalism, rather than focusing on the health and well-being of people.

In a recent MIA Spotlight, critical psychologist Ian Parker stated: “Therapy on its own will solve nothing. We need broader social therapy that will change the world and the conditions that give rise to so many forms of distress.”

To move away from a strictly economic or work-based understanding of recovery, Terry Krupa and co-authors argue for the necessity of expanding recovery to include other dimensions of meaningful involvement in life, such as social relationships and contributing to one’s community. They discuss the practical and ethical implications of such a shift in understanding.

The authors recommend the Canadian “Do-Live-Well” framework as one potential alternative to the prevailing model. This framework consists of eight dimensions that can help psychiatric professionals understand recovery differently:

  • Activating one’s body, mind, and senses
  • Connecting with others
  • Developing and expressing personal identity
  • Contributing to community and society
  • Building security and prosperity
  • Taking care of oneself
  • Developing capabilities and potential
  • Experiencing pleasure and joy

This framework is said to emphasize “choice, meaning, balance, and routine” while avoiding black and white understandings of participation as good or bad, but simply as having the potential to add to or detract from well-being.

Second, the authors argue for the importance of specific interventions that can facilitate this alternative approach to recovery. They note that there are significant barriers to meaningful life participation for many who are experiencing psychological distress, such as diminished motivation, fear of failure, poverty, victimization, and stigma. Any practical interventions must take these factors into account.

They discuss two approaches that can help individuals to overcome these barriers. The first is called the “Action Over Inertia” (AOI) initiative, which is a manualized treatment encouraging individuals to reflect on the meaningful change they want, followed by “supporting individuals in activity and participation experiments and longer-term commitments aligned with their personal preferences and performance needs.” The AOI also emphasizes connecting people to service organizations.

The second example they discuss is Temple University’s “Collaborative on Community Inclusion” program, which aims to research and facilitate individuals’ meaningful involvement with communities. The collaborative is said to emphasize “community, social, and civic life” while prioritizing “activity and participation in natural environments with natural supports.”

The authors state that peer support models may be a useful avenue for implementing these kinds of interventions into existing services, given that peer support can promote community-based opportunities for engagement and mutual care.

Finally, the authors propose that this shift in vision around recovery has an important moral element. Social and economic obstacles can make it more difficult for individuals to live meaningful lives. Offering a social justice orientation, they explore the “capabilities frameworks” of economist Amartya Sen and philosopher Martha Nussbaum.

A capabilities framework can help to view recovery as fundamentally an issue of avoiding “indignity, exclusion, and deprivation,” to which every human being has the right. Nussbaum argues for ten dimensions, which she links to living a life of dignity and well-being. Among these dimensions are: having the agency to plan one’s life, having attachments to material objects as well as other people and animals, being able to play and enjoy recreation, and having sociopolitical agency, as in voting and owning property.

Perspectives like these can help shift the discussion in psychiatry away from managing people as workers, toward a more holistic picture of people’s lives, including the need to dismantle socioeconomic barriers and work toward achievable goals in meaningful community with other human beings.

The authors conclude:

“It is time to attend more directly to overlooked dimensions of health, well-being, and recovery that are grounded in opportunities for engagement in health-promoting activity and participation and to hold the system accountable for addressing challenges to accessing these important opportunities.”

 

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Krupa, T., Moll, S., & Fossey, E. (2020). Beyond employment: A broader vision linking activity and participation to health, well-being, and recovery. Psychiatric Services. (Link)

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16 COMMENTS

  1. I wonder about this when one considers the way Key Performance Indicators (KPIs) have been used in the health system.

    My first KPI is that the sun will rise, and when it does I’ve met my first KPI for the day …… end of the week it looks like I’ve done a whole heap of work because statistically i’ve met my hundreds of KPIs.

    The best example being the statistics of how long it was taking for people to be seen by medical staff in the Emergency Depts of hospitals. By putting a nurse on the door to greet people on the way into the Emergency Dept, and then leaving them waiting for hours in the waiting room, the statistics showed the hospital had reduced waiting times by massive amounts. Which of course was used to justify the massive increases in wages.

    Could this be done with these ‘dimensions’?

    “Connecting with others” Spoke to the receptionist on the way in, the other staff nodded in the general direction of the ‘patient’, there were 4 people in the waiting room, passed a large number of people in the street ……. and the other side of the coin, the bis was empty, staff were off today ……. I could introduce you to a filthy ‘verballing’ Community Nurse who could train people in how to make what are clinically insignificant matters sound like the require forced drugging and incarceration.

  2. “A recent article published in Psychiatric Services argues that mental health recovery should not be measured solely by an ability to return to work or find employment. Instead, measures of recovery should account for participation in activities that are personally and socially meaningful.”

    (sigh) “psychiatric services”…are a busy bunch. I’m glad they found new “measurements”. I wish they would make up their minds. The most conbubulated practice. And what does “solely” mean? Like we are allowed other markers and measurements? But I see they are still doing the ASSessments.

    critical psychologist Ian Parker stated: “Therapy on its own will solve nothing. We need broader social therapy that will change the world and the conditions that give rise to so many forms of distress.”

    What we need is for psychiatry to admit their jerkass behaviour and quit projecting their crap onto vulnerable people.

    “Perspectives like these can help shift the discussion in psychiatry away from managing people as workers, toward a more holistic picture of people’s lives, including the need to dismantle socioeconomic barriers and work toward achievable goals in meaningful community with other human beings.”

    No, it’s not shifting, it’s meant to keep the idea of “management” going strong. Get the dirty paws off people, practice humility by first stating truth, stop hiding. Stop managing distress because on the whole, you can see that psychiatry has NO clue about humanity. The most uneducated bunch of wannabee managers.

    • The main “outcome measure” used by most “mental health services” these days are whether people “have symptoms” or are “on their meds.” I have rarely seen employment used as an outcome measure by any such agency, in fact, they often seem to discourage efforts of clients to find employment, encouraging them instead to get on disability for life. As for quality of life, it doesn’t even enter into the discussion in most situations.

      • I’m pretty certain some psychiatrists do look at employment, Steve. Since I had medical records handed over that stated I was “unemployed.” Despite the fact that the force treating psychiatrist never asked me what I did. And since I was a full time mom, very active volunteer – including co-chairing a 250 volunteer strong school art program, village planning commissioner, Boy Scout pack Charter rep, et al. Plus, I was an artist working on my portfolio, and had already paid for my half of my family’s home. My husband was supposed to work to pay for his share of our home. I would never in a million years have told that psychiatrist I was “unemployed.”

        But psychiatrists illegally nosing themselves into people’s private finances may help to explain why there are so many artists who are being misdiagnosed and neurotoxic poisoned by the psychiatrists. They don’t know what we’re doing, so they incorrectly assume we’re “unemployed.” Now I’ve got a portfolio that is so “too truthful,” “insightful,” “work of smart female,” and “prophetic” that a psychologist recently tried to steal all my work. He fears I’ll some day be known as a “Chicago Chagall.”

        “Perspectives like these can help shift the discussion in psychiatry away from managing people as workers, toward a more holistic picture of people’s lives, including the need to dismantle socioeconomic barriers and work toward achievable goals in meaningful community with other human beings.”

        That should never have been the role of psychiatrists. And they shouldn’t have been neurotoxic poisoning those of us who did “work toward achievable goals in meaningful community with other human beings.” Merely because the psychiatrists are ignorant of who people are, and all of what we do. Or they “not believed by doctor” people, when we truthfully tell them about our fulfilling lives.

        When did it become illegal to save up money, so one may be a stay at home mom, active volunteer, and artist working on her portfolio? I missed that psychiatric announcement. And who placed them in the position of “managing people as workers,” in our supposedly free society? When were the psychiatrists handed the right to dictate to other people what professions they have a right to do, or not do? And why does the medical community have a right to shut down our entire economy, claiming certain jobs are non-mandatory?

        I’ve got a child graduating with his masters, moving, and starting a “mandatory job” in July, and thankfully he’ll finally be back in the same state as me. Yeah! But he needs furniture, et al for his new place. Yet all the furniture store, estate sales, antique stores, everything is closed down. We have to do “virtual tours” of apartments, this is nuts. Medical tyranny for the whole country now. Pardon my frustration and disgust at the staggering lack of respect given now to all people who don’t work in the medical field.

        But I absolutely agree, Steve, the psychologists and psychiatrists do “discourage efforts of clients to find employment, encouraging them instead to get on disability for life. As for quality of life, it doesn’t even enter into the discussion in most situations.” “Quit all your activities and concentrate on the meds,” was some of that insanely stupid advice from a psychologist, that I did not bother to take.

        I couldn’t agree more, sam, both psychology and “psychiatry [have] NO clue about humanity.” Or if they do, they always utilize their knowledge for evil. Although, after reading all my medical records, and my other obnoxious dealings with them, I’d say you’re likely correct, most are likely stupid, not to mention staggeringly unethical.

  3. “The first is called the “Action Over Inertia” (AOI) initiative, which is a manualized treatment encouraging individuals to reflect on the meaningful change they want, followed by “supporting individuals in activity and participation experiments and longer-term commitments aligned with their personal preferences and performance needs.” The AOI also emphasizes connecting people to service organizations.”
    I really hope that “manualized treatment” actually stays true to what the “service-user” wants, and not what the agency thinks they should want. And I really hope that last sentence “…connecting people to service organizations,” doesn’t just mean ‘you, service-user, need case management in your life so we are going to connect you with that type service organization.’
    If this is meant to be a real shift, then I hope it is not filtered through the lens of narrow scope of the system already in place.
    “The authors state that peer support models may be a useful avenue for implementing these kinds of interventions into existing services, given that peer support can promote community-based opportunities for engagement and mutual care.”
    That sentence just reads ridiculous to me. “…may be a useful avenue…” May be?
    If what this article is saying is ‘Here’s a great idea for a way to re-define and reshape the way “service-providers” approach and practice with the people they work with’ then of course peer support is part of that – that is what peer support is, that is how peer support functions – not as an extension of pre-packaged treatment, but it offers the unique perspective of someone who’s been there/is there and who understands the importance of holistic approach and the importance of community, in all the ways that that can be defined

  4. Being employed either as a wage earner or an entrepreneur need not be divorced from a person’s ability to find purpose and meaning. The two are not mutually exclusive or at odds with one another. The missing element that young adults are lacking is ‘vocational discernment.’

    Vocational discernment as practiced by the Catholic Church is spiritually focused and not ‘market’ focused (i.e. obsessed with the highest wages that society will reward you for your skills and aptitudes) Some kind of spin-off of this approach, as opposed to vocational rehabilitation, a loathsome segway into repetitive and meaningless work—would be helpful as well as safety nets for young or elders getting re-integrated after a protracted crisis or period of institutionalization– a form of universal income or at the very least, health care coverage while they explore creative options or public service options

  6. Can anyone please cite a program(s) which can empirically establish that it fosters recovery by any definition? It’s dismaying that decades into the Era of Recovery providers broadly assert that they foster recovery but can evidence it anecdotally, narrowly or not at all. Provider evidence typically begins and ends with “Let me tell you the story of Billie” at best.

    My peers and I now suffer the added burden of failing a system which ensures the resources and approaches necessary to aid in recovery. We’ve been here before. We can remember when medication was always safer and more effective and we could be accused of failing our medication. When one putatively transformational era flowed into another: Psychosocial rehabilitation, evidence based services, best practices, recovery, wellness. The impact was no more then when we went from being patients, to recipients, to clients, to consumers.

    It would have been nice if the vision of Deegan, Anthony and so many others had become our reality.

    • One of the problems I see with the concept of “recovery” is that it is a co-opted term that presumes that “mental illnesses” are real, scientific entities which can be “treated.” The truth is, “depression” and “anxiety” and “psychosis” are just descriptive terms that don’t reflect any known pathology. What this means is that the “solution” may be totally different for each person, even if they have the same “diagnosis.” So when these “disorders” are studied, no “treatment” will be shown to be generally effective, because we’re not “treating” any kind of unified condition or illness. So it is that some people who “have depression” thrive in therapy, others find it useless or damaging. Some people benefit from nutritional approaches, some need thyroid treatment, some just need to get a new job. Some have to escape from violent relationships, some need time to grieve, some need to move away from their parents, some need to learn how to manage their children’s behavior more effectively. Some need more money or healthcare, some are old and their bodies are deteriorating and they need to move on to the next life. ALL of the above people could be classified as having “Major Depressive Disorder!” Do we REALLY expect each and every “depressed” person to respond to the same “treatment,” when I have just listed over a dozen possible causes/approaches that are completely unrelated to each other? Of course, lumping them all together does meet the interests of one particular group: pharmaceutical companies. Because if you only look at “symptoms,” and measure all “treatments” of these issues, pharmaceuticals will have an advantage, since they are focused only on making the symptoms go away rather than detecting fixing anything that’s actually amiss.

      So I’d say, don’t wait around for the “mental health” industry to come up with answers. There are too many conflicts of interest involved. I think each of us has to find our own path, except that we ALL need to work together to reduce poverty, racism, sexism, and other social ills, and to challenge the institutions of this society to become more humane and just. Beyond that, I think what “helps” is only going to be determined by the person seeking help, and anyone claiming to be able to “fix” our problems is immediately to be distrusted.

      • Time to re-post the Bonkers Institute iteration of depression and its causes:

        Understanding depression and its causes

        Depressive disorders often co-occur with anxiety or substance abuse and are a leading form of disability in the United States. Depression may strike any time without warning. Researchers have identified the five primary causes of mild, moderate and severe clinical depression:

        1. Imbalance of key chemical neurotransmitters in the brain;
        2. Chronic low-grade hopelessness generated by early childhood trauma;
        3. Marriage to the wrong person;
        4. Sudden realization of the essential absurdity of life;
        5. Ecological catastrophe on a scale never before seen in human history.

        Other factors which might trigger a depressive episode include

        * having either too much or not enough of something;
        * being trapped in an utterly hopeless situation with no way of escape;
        * remorse, guilt, shame, failure, disappointment, frustration, grief, heartache, pain or loss of some kind;
        * infestation of household pests such as termites or rodents;
        * omega-3 deficiency from not eating sufficient quantities of cauliflower and other vegetables;
        * leaky faucet, clogged drain or similar plumbing problem;
        * global economic collapse, thermonuclear war, mass starvation, genocide, etc.

        http://www.bonkersinstitute.org/asymptomatic.html

      • “One of the problems I see with the concept of “recovery” is that it is a co-opted term that presumes that “mental illnesses” are real, scientific entities which can be “treated.”

        Umm yep. I get real uncomfortable around certain words.
        I wish “therapists” watched their language and worked on that language use, perhaps it can even change their views

  7. We need broader social therapy that will change the world and the conditions that give rise to so many forms of distress.”

    So the new euphemism for revolution is “social therapy”?

    There actually used to be a NY based marxist-oriented group called the “Institute for Social Therapy and Research.” Don’t know if they still exist. Has “social therapy” become a “thing”?

  8. A great way to measure outcomes is money earned, income. After all, that’s how the rest of society judges your worth.

    Is your income roughly the same as people with the same age, demographics, and education?

    But it’s one simple number that is pretty easy to measure, and already being measured in many settings.

    • By that token Corinna, if a person were to work as a waiter they mightn’t have recovered.

      Dependency on the Psychiatric System might imply non recovery. But dependency on the system and treatments could be as a result of the system and the treatments.

      • They often say that the man in the street is the best judge of mental illness or recovery.

        In 1986 I went to see a priest/’social worker’ in London who I had previously visited in 1980 prior to admission to the Maudsley Psychiatric Hospital, and who knew me.

        The Priest asked me in 1986 if I was still taking drugs, I told him that I took a little medication. He said he didn’t mean medication, that he meant illegal drugs. I told him I had never taken illegal drugs, but the priest didnt believe me. The notion of Mental Illness had never occurred to him!

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