Uses and Abuses of “Recovery” – A Review

The World Psychiatric Journal just published an interesting article, Uses and abuses of recovery: implementing recovery-oriented practices in mental health systems .  It is available in full at that link.

One of the things it does is to outline “7 abuses of the concept of “recovery”.”  I think this effort to identify problems in the use of the term “recovery” is important, even though I believe their list of abuses is much too short, and some of their reasoning about those abuses, and what should be done instead, is flawed or incomplete.

One interesting issue they define as a problem is thinking that “RECOVERY IS ABOUT MAKING PEOPLE INDEPENDENT AND NORMAL”  They state that

But 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 (33). 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” (34).

It is true that all humans need support, and the exact kinds of support vary by individual, and sometimes people’s problem can be simply that the society fails to provide the kind of support they need, or they haven’t yet been able to find it, even though such support exists here and there.  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 link up with a subculture that provides necessary supports needed by that person due to their sensitivity.

But it’s also true I think 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.)  I think we would do best to see that recovery comes in different varieties or flavors, sometimes it seems more about learning to live better with a particular disability, and sometimes learning how to no longer have that disability.  So I think 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 of the problems in the article’s perspective on this begins with the definition of recovery that they use, which is

“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” (1).

It seems to me that when I meet up with people who have fully recovered, 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 big problem, and are often seen now 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 that

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 (71

It would have been much better if the article had  been able to acknowledge the ways that diagnosis and medication can often be a very real barrier to recovery.  For example, I heard Oryx Cohen describe how when he was given a major “mental illness” diagnosis, he felt he had just lost his membership in the human race – this kind of 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.  And we know from the studies Robert Whitaker has cited, and from the more recent Wunderink study, that medications are likely to make recovery less likely for many.

The article does at least question the widespread use of forced treatment, which I appreciated.

I’m curious to hear more thoughts about these issues.  I look forward to reading your comments and perspectives.