What kinds of recovery might we be hoping for? There are many definitions and understandings of recovery from mental illness. Davidson et al. (2006) compare recovery from mental illnesses to recovery from physical illnesses. They note that recovery can be a full return to functioning after one episode, with little residual impairment, as in recovery from an acute medical condition. If the person feels vulnerable to future episodes, recovery can be compared to that from a heart attack. For those who recover over a period of many years, recovery can be compared to that of long-term medical conditions, such as asthma. For many, there is also recovery from the trauma of being treated as a mental patient, and others are in dual recovery from both mental illness and substance abuse. Additionally, a common conception of recovery has been spurred by the Independent Living Movement (for people with physical disabilities) and popularized by Dr. William Anthony of the Boston Center for Psychiatric Rehabilitation: “Recovery from mental illness does not mean cure. It means regaining control over one’s life if not one’s illness. It means leading a useful, satisfying life even though symptoms may reoccur” (Anthony, 2007). As Davidson et al. note,
"Even if we achieve conceptual clarity in these distinctions between various forms of recovery, confusion is reintroduced by virtue of the fact that a person may experience more than one form of recovery at any given time, as well as move in and out of different forms of recovery over time. So robust is the heterogeneity found in mental illness, and so little is known about what determines individual outcomes, that there is considerable fluidity between these various forms of recovery." (2006, para. 13)
In an effort to reduce complexity for the purposes of guiding professional practice and formulating policy, Davidson et al. (2006) propose focusing on Anthony’s definition, arguing that it the most inclusive because it avoids leaving out those whose symptoms may not remit but who may otherwise regain a functional life.
Like Davidson, et al. (2006), I also advocate that persons whose symptoms do not remit should have their place in the definition of recovery, but I believe that restricting our understanding of recovery to the experience of some cannot be called “the most inclusive.” I have felt excluded and had my own experiences invalidated when I have been brave enough to share that recovery means more to me than what is dreamt of in Anthony’s vision. Many people I know believe that there is no course for psychosis other than lifetime disability; in fact, 75% of those with first-episode psychosis recover completely within a few months or years (Cullberg, 2006). Even schizophrenia, generally considered the most disabling disorder, shows significant improvement or full recovery in a significant percentage of persons (see Fisher, Langan, & Ahern, 2003). Hope plays a vital role in recovery, as described later, but one cannot hope for what one does not know exists. Therefore, I believe we need an approach which leaves room for multiple dimensions of recovery.
Keyes’ Mental Health Continuum emphasizes the distinction between two dimensions: the absence or presence of mental illness, and low or high well-being/mental health (Figure 1.1).
Figure 1.1. The Mental Health Continuum. Keyes’ Mental Health Continuum emphasizes the distinction between two dimensions: the absence or presence of mental illness, and low or high mental health/well-being. Smith, S. & Saari, D. (2013). Wellness: Grappling with its simplicity and complexity. Retrieved from http://www.heretohelp.bc.ca/visions/wellness-vol7/wellness-grappling-with-its-simplicity-and-complexity
An adapted version of Keyes model that I've constructed (Figure 1.2) can support the understanding of different dimensions of recovery from mental illness.
Figure 1.2 Dimensions of Recovery from Mental Illness.
Figure 1.2 Dimensions of Recovery from Mental Illness.
The vertical purple arrow represents Anthony’s vision of recovery as a return to a satisfying life, whereas the horizontal purple arrow represents the traditional medical vision of recovery as a reduction or remission of symptoms. The diagonal green arrow represents movement along both dimensions, from surviving with mental illness to thriving without it. This was my personal experience of recovery. For an inclusive vision of recovery, imagine that the green arrow has flexibility between the two purple arrows, from due East to due North on the compass. It is the counselor’s job to support movement along this flexible green arrow. The red arrow represents treatment that reduces symptoms at the expense of overall well-being. Sadly, this has happened frequently in the history of the treatment of mental illness, particularly when “treatment” has been focused on quieting the patient for the benefit of others, rather than improving the patient’s inner experience of well-being (Whitaker, 2002). Sometimes, such a reduction may be temporarily necessary. For a client in manic psychosis engaging in life-endangering behaviors, the right dose of the appropriate medication might reduce his subjective experience of well-being yet subdue this client into safety. Sadly, many with mental illness live out their lives on overly-high doses of medication, which reduce overt symptoms yet may also reduce physical and even mental well-being (Whitaker, 2002).
Many people’s understanding of recovery from mental illness is limited to that represented by either the horizontal or vertical purple arrows in Figure 1.2. Some do not realize that studies show that a significant portion of persons with the most severe mental disorders recover completely from symptoms (see Fisher, Langan, & Ahern, 2003). Daniel Fisher, once diagnosed with schizophrenia and now a psychiatrist and executive director of the National Empowerment Center, is a prominent figure out of many individuals who have experienced this phenomenon (Fisher, 2006). Others do not realize that another significant portion of persons with severe mental illness can live completely fulfilling and satisfying lives in spite of the continuation of symptoms. Lawyer Elyn Saks, who lives with schizophrenia and is the author of the riveting book The Center Cannot Hold: My Journey through Madness is a prominent example of one such person (Saks, 2007). Yet both of these dimensions of recovery are real and are not limited to prominent individuals such as Fisher or Saks or to an otherwise lucky few. It is important to remember that recovery is not a linear process, and never moves consistently forward along a straight line or arrow. Relapses are normal, and should be coped with without shame. Slade’s caveat about stage models of recovery from mental illness applies to Figure 1.2:
"it can easily become seen as a model for what should happen, with consequent feelings of failure incurred for people who do not seem to be recovering. The response to these concerns is to distinguish between a map and route. Providing a map of the terrain does not prescribe the best way through it. Similarly, providing a synthesis of the kinds of domains and processes involved in the recovery journey of others has value in a general way, but does not provide an individualized list of instructions to follow. Each person needs to find their own way forward." (2009, p. 80)
Maps of recovery processes can be helpful, however, by promoting therapeutic optimism, and helping clinicians support progress and make sense of both progress and a lack thereof (Slade, 2009, p. 81). I also contend that a more inclusive understanding of recovery will support the eradication of stigma. In a misguided effort to reduce stigma, messages about mental illness being a biological “disease like any other” have actually been found to increase stigma (Cevalios, 2010). While mental illnesses do have biological factors, limiting our understanding of them to the biological realm, a choice not supported by the scientific evidence, has been detrimental to the clarity and compassion with which we view mental illnesses. Similarly, limiting our understanding of recovery to only one dimension, a choice also not supported by the scientific evidence, may also be clouding our view in a way that harms rather than helps.
As a foundation for recovery-based therapy for psychosis, I offer a modified understanding of recovery as defined by the President’s New Freedom Commission on Mental Health. According to this commission, recovery
"refers to 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. Science has shown that having hope plays an integral role in an individual’s recovery." (2003, p. 7)
I propose adding the following to the definition, prior to the final sentence: The process of recovery may even transform a person into a state healthier than prior to their illness (Martens, 2010; Williams, 2012; Galuska, 2001). The flexible green arrow of recovery need not halt upon return to the person’s prior level of functioning. Psychosis can itself be a means to self-actualization or transformation, a “transitional stage between a fruitless, unhealthy emotional and mental condition and a new condition that is characterized by increased social-emotional, cognitive, intrapsychic and spiritual adequacy and enhanced well-being” (Martens, 2010). This was my experience, and has also been noted by Karl Menninger, among others:
"Menninger noticed that some of his very sick (psychotic) patients surprised him by getting well even without much of 'treatment.' Some of them did something else even more surprising. They kept improving, got 'weller than well,' better behaved and more comfortable or reasonable than they were before they got into that 'sick' condition. Menninger reported that the kind of the 'sickness' he had observed seemed to be a kind of conversion experience, like trimming a fruit tree, for example. Persons increased their productivity, they expanded their life and its horizons. They developed new talents, new powers, new effectiveness . . . transcendence did occur." (as cited in Martens, 2010)
The therapist’s job is to be open to, hopeful for, and supportive of all dimensions and types of recovery. In each dimension, therapy must provide the right level of challenge, noting that “the good life is not achieved by simply lowering expectations... but nor is it achieved by raising expectations too high -- recovery should be a journey, not a treadmill” (Slade, 2009, p. 130). If the expectations are too low, the client may not be motivated to face her pain; if too high, she may not be able to tolerate facing her pain (Schwartz & Summers, 2009).
Anthony, W. (2007). Toward a vision of recovery for mental health and psychiatric rehabilitation services. Boston: Center for Psychiatric Rehabilitation.
Cevalios, M. (September 16, 2010). Mental health messages actually increase stigma. Orlando Sentinel. Retrieved from http://blogs.orlandosentinel.com/health/2010/09/16/mental-health-messages-actually-increase-stigma/
Cullberg, J. (2006). Psychoses: An integrative perspective. New York: Routledge.
Davidson, L., O’Connell, M., Tondora, J., Styron, T., & Kangas, K. (2006). The top ten concerns about recovery encountered in mental health system transformation. Psychiatric Services, 57(5). doi: 10.1176/appi.ps.57.5.640. Retrieved from http://ps.psychiatryonline.org/article.aspx?articleID=96652
Fisher, D., Langan, T., & Ahern, L. (2003). A PACE/Recovery reader: Personal assistance in community existence: Recovery at your own pace. Lawrence, MA: National Empowerment Center, Inc.
Fisher, D. (2006). A new vision of recovery. Lawrence, MA: National Empowerment Center.
Galuska, J. (2001). Healing of psychoses in transpersonal understanding. The International Journal of Transpersonal Studies, 20: pp. 67-77.
Martens, W. H. J. (2010). Positive functions of psychosis. Journal of Phenomenological Psychology, 41: pp. 216-233.
New Freedom Commission on Mental Health. (2003). Achieving the promise: Transforming mental health care in America. Final Report (DHHS Pub. No. SMA-03-3831). Rockville, MD: Government Printing Office.
Saks, E. (2007). The center cannot hold: My journey through madness. New York: Hyperion.
Schwartz, W. & Summers, F. (2009). The role of the therapeutic alliance in the treatment of seriously disturbed individuals. In D. Garfield, D. Mackler, (Eds.), Beyond medication: Therapeutic engagement and recovery from psychosis (pp. 50-64). New York: Routledge.
Slade, M. (2009). Personal recovery and mental illness: A guide for mental health professionals. New York: Cambridge University Press.
Smith, S. & Saari, D. (2013). Wellness: Grappling with its simplicity and complexity. Retrieved from http://www.heretohelp.bc.ca/visions/wellness-vol7/wellness-grappling-with-its-simplicity-and-complexity
Whitaker, R. (2002). Mad in America: Bad science, bad medicine and the enduring mistreatment of the mentally ill. New York: Perseus Books.
Williams, P. (2012). Rethinking madness: Towards a paradigm shift in our understanding and treatment of psychosis. San Rafael, CA: Sky’s Edge Publishing.