The Theory of Recovery Psychology/The Recovery Model/Chapter Three

What is mental health recovery?

The President's New Freedom Commission On Mental Health defines recovery as "the process in which people are able to live, work, learn, and participate fully in their communities. For some individuals, recovery is the ability to live a fulfilling and productive life despite a disability. For others, recovery implies the reduction or complete remission of symptoms"

John M. Kane, M.D. Treatment Strategies to Prevent Relaspe and Encourage Remission from The Journal of Clinical Psychiatry Volume 68 2007 Supplement 14 p.27-30 states that: Recovery, in general, refers to sustained asymptomatic functioning without relaspe. This will drastically conflict with others concepts of recovery.

Liberman RP, Kopelowicz JV, Ventura J, et al. Operational Criteria and Factors related to Recovery from Schizophrenia International Review of Psychiatry 2002 volume 14 p.256-272 speaks of UCLA recovery criteria which is made up the following domains symptom remission, appropriate role functioning, daily living skills, and social interaction (similar to Partnership In Recovery.)

The idea of creating a recovery criteria is seen as being upsetting to some, while seen as beneficial to others. The question that is seen as valid by these persons is how does a clinician know that their work is done if recovery can not be as noticed as was the illness.

Various people will define recovery as something different, although most agree on certain principles which are the same. Recovery is living a meaningful quality life, despite a psychiatric condition. To many it is about a reduction in prescribed psychiatric medication. While to some degree it is about those who use the mental health services having a voice as in any other form of consumer psychology. It may address issues of mental freedom.

Recovery Theory

To discuss recovery, we must first discuss remission. Remission is the state of absence of disease activity in patients with known chronic illness. It is commonly used to refer to absence of active cancer or inflammatory bowel disease. The term can be used incorrectly with mental illness when the illness is under control and a doctor may say it is in remission when in fact it is merely being controlled.

With schizophrenia clinical psychology often discusses positive and negative symptoms, positive symptoms being abnormal behavior or symptoms that are present as a result of the disorder and negative symptoms being being the lack of normal behavior which present as symptoms. Positive symptoms are things like hallucinations, delusions, and formal thought disorder. Negative symptoms are things like anhedonia (lack of pleasure seeking behavior), affective flattening (lack or decline in emotional response), alogia (lack or decline in speech), or avolition (lack or decline in motivation). Negative and positive symptoms are mostly discussed in the context of schizophrenia, however all persons with all psychological disorders have negative symptoms and positive symptoms.

Remission of a psychological disorder is about the ceasing of abnormal behavior (positive symptoms.) Recovery is about is also about remission, but it is more about ceasing of negative symptoms, or the begining of normal behavior. Recovery is action. Remission is an inaction.
Elisabeth Kübler-Ross, M.D. was a Swiss-born psychiatrist and the author of the groundbreaking book On Death and Dying, where she first discussed what is now known as the Kübler-Ross model. The Kübler-Ross model describes, in five discrete stages, a process by which people allegedly deal with grief and tragedy, especially when diagnosed with a terminal illness. The stages are known as the "Five Stages of Grief". These stages are Denial, Anger, Bargaining, Depression and Acceptance.

Recovery is the normal adaption process that follows a devastation just like grief follows loss. Often the two processes compliment one another. The recovery process can also be viewed in terms of stages, like the Kübler-Ross model of the five stages of greiving. These fluid stages of grief-denial, anger, bargaining, depression and acceptance were first described in the complex term of death and dying, but have been have applied to other types of serious losses. In their book The Recovery Workbook: Practical Coping and Empowerment Strategies for People with Psychiatric Disability LeRoy Spaniol, Martin Koehler and Dori Hutchinson list seven phases of the recovery process; 1. Shock 2. Denial 3. Depression/Despair/Grieving 4. Anger 5. Acceptance/Hope/Helplessness 6. Coping 7. Advocacy/Empowerment
Mark Raggins lists four fluid stages for the recovery process: 1. Hope-Some idea that things are going to get better. 2.Empowerment-To move forward, people need to have a sense of their own capability, their own power. 3. Self-responsibility-At some point in a persons recovery, they come to the realization that nobody can recover for them, and that they must take charge for their own recovery, 4. Meaningful and productive role in life.-ultimately to recover a person must achieve some meaningful role for themselves other than a person with an illness.

Patricia Schiffer has developed a theory of the recovery process that involves a pyramid; in this paradigm there are three types of recovery that take place simultaneously:

1. Symptomatic recovery-Managing the illness to control symptoms is a foundational component of recovery. The more successful we are at managing the illness, the greater the degree of symptomatic recovery we attain. The more symptomatic recovery we achieve, the less the illness obstructs functional and role recovery. This presupposes that we are working toward a greater degree of symptom remission, rather than just stability. This approach is predicated on the belief that it is possible for us to help people achieve symptomatic improvement. We don’t dismiss severe symptoms as a person’s “baseline” but strive to improve symptom remission through a variety of illness management strategies. Effective treatment can remit acute symptoms and reduce the frequency, intensity, and severity of persistent symptoms. However, symptomatic recovery does not necessarily mean symptom free. Our objective is to control the illness so the illness no longer controls the individual. For many people, symptomatic recovery means reducing the severity of persistent symptoms to the point that the illness is no longer an impediment to attaining personal life goals. Identification of personal life goals is what gives symptomatic recovery motivation and focus. We don’t work to control illness as a goal in and of itself, but we work to facilitate achievement of role recovery. Research suggests that cognitive and negative symptoms may be even more important than positive or mood symptoms in limiting functional and role recovery. Therefore, specific attention to multiple symptom domains is critical. To some degree, symptomatic recovery allows functional recovery. Some functional improvement may be achieved through medication as atypical antipsychotics help improve cognitive and negative symptoms. As symptoms remit, the individual may find it easier to do everyday things. It may become less difficult to interact, initiate, concentrate, think clearly, complete tasks, follow instructions, comprehend, retain, plan, initiate, prioritize, problem solve, and process. However, rehabilitation is an essential strategy that enables more people to attain both functional and role recovery.

2. Functional recovery-However, role recovery can commence even though functional recovery is not fully attained. It is important to avoid the mistake of endlessly preparing for role recovery. Risk taking is often necessary to move forward. Recent supported employment research suggests that there may be advantages to helping people get a job first, them develop job skills while working. This approach reverses the more traditional process of requiring extensive functional skills training before pursuing employment. Functional recovery is facilitated by case managers, nurses, assertive community treatment teams, prescribers, day treatment programs, psychosocial rehabilitation programs, job coaches, therapists, family, residential staff, peers, and many other members of the treatment/rehabilitation team.

3. Role recovery-At the pinnacle of our pyramid, the main focus is role recovery. However, it is often important to begin by identifying role recovery goals, which serve as the motivation for optimizing symptomatic recovery. The point of role recovery is for people to choose, pursue, renew, and sustain the roles in life to which they aspire. Individuals more definitively move beyond patienthood and the impaired role into personhood. The illness is not the sum total of their identity or their existence. Multifaceted role aspiration, role identification, and role performance help define individuality and wellbeing. The person affirms being an individual in his or her own right. Inherent in role recovery is a sense of personhood which is both experienced by the individual and perceived by others. Pride, satisfaction, strengths, and accomplishments eclipse illness and impairment in defining self.

Recovery is not remission

Positive symptoms are the behaviors or features that are present as a result of a psychological disorder. Negative symptoms are behaviors or features that are absent as a result of a psychological disorder. Remission is the absence of positive symptoms in psychological disorders, meaning that a person’s abnormal behavior(s) has stopped occurring. Where as, recovery is more about the return of normal behavior(s) or the absence of negative symptoms. Remission is a clinical term for a state of absence of disease activity in patients. This does not describe a qualitative feature that is recovery in terms of psychosocial factors. If a person is "in remission" from a serious mental disorder, they are for the most part temporarily asymptomatic with regards to positive symptoms; recovery is concerned with both positive and negative symptoms. This does not mean that any of the conditions or consequences of sociological determinants of mental illness have sudsided. A person who is no longer delusional, hallicinating or depressed may still not have social skills, employment, or meaningful purpose, but may very well be in remission. Although some may mistakenly dilute the meaning of the word recovery.

A good article to read that makes this point is: Harding, C. (2004). Remission vs. recovery: Two very different concepts. Conference presentation at Reclaiming Lives: What Professionals Need to Know About Assessment, Planning, and Treatment for People Who Appear to be Stuck on the Road to Recovery, Boston University Center for Psychiatric Rehabilitation at the Sargent College of Health and Rehabilitation Sciences, April 13, 2004.