Mental health articles

OF mental health care and mentally ill

Principles of recovery and rehabilitation

If people with serious mental health problems are to make the most of their lives, then they need access to a range of services, including: crisis support; interventions to help reduce and manage symptoms; a range of housing options including supported accommodation and intensive outreach support at home; help to access a range of work and education opportunities; support to maintain and develop relationships; and support from family and friends. However, the simple presence of this range of components does not guarantee facilitation of recovery in those whom they serve. Critically important are the principles and values of these services.

Recovery is about people’s whole lives – not just their symptoms

There are a variety of different ways in which people may gain relief from distressing symptoms: these include medication, psychological therapy, counselling and a range of complementary therapies. However, people’s problems extend well beyond the expertise traditionally found within mental health services. Difficulties with housing, money, employment, education, relationships, social and leisure activities are typically more important in the recovery process than are the mental health problems themselves.

It should not be expected that a single practitioner or agency can provide the full range of interventions, supports and assistance that a person needs. First, it is highly unlikely that a single worker/provider can simultaneously be an expert in welfare benefits; vocational rehabilitation and liaising with employers; individual psychological therapy and family interventions; the impact of various drug treatments; and putting together MFI furniture or making a washing machine work. Second, everyone needs the opportunity to be different people in different relationships and situations. We may be competent at work, delinquent with our friends, inadequate and needy with our nearest and dearest. In a single relationship with a ‘key worker’ or ‘care coordinator’ it is not possible for someone to simultaneously address their fears and problems, use/extend their skills and abilities, and achieve the social relationships on which most people rely so heavily for mutual support in their day-to-day lives. However, if a person is receiving help and support from a range of different individuals and agencies then effective coordination is required in order to ensure that the person gets all the assistance they need.

Therefore, if they are to facilitate recovery, then rehabilitation services need to:

Adopt a team approach: If responsibility for the provision of all support rests with a single individual then the provision of effective support/ intervention across diverse domains is jeopardized; and

Ensure continuity across providers: If people receive input from multiple agencies and individuals then these must work effectively together.


Recovery is about growth

It is very easy for people with mental health problems to become nothing other than the array of symptoms that characterizes their illness: ‘a schizophrenic’, ‘a manic depressive’. ‘Schizophrenia is an “I am” illness, one which may take over and redefine the identity of a person’. If practitioners’ focus is limited to symptoms and deficits simply then this process is reinforced. People are always more than their ‘illness’. Recovery involves redefining identity in a way which includes these difficulties, but enables the person to grow, develop and move beyond them. However, growth is often limited not by characteristics of the person, but by the barriers imposed by discrimination and exclusion. ‘My recovery was about how to gain other people’s confidence in my abilities and potential … in my own experience the toughest part was changing other people’s expectations of what I could do. Combating a disempowering sense of being undervalued …’. The traditional focus of services is helping the individual to change: reducing their symptoms, helping them to develop new skills, helping them to adjust to what has happened. These may all be important in facilitating recovery, but it is important that practitioners also attend to reducing the external barriers that they face. Growth is not possible if you are debarred from doing the things you want to do. Therefore, if they are to facilitate recovery, rehabilitation services need to:

Be strengths-based: It is not possible to help people to rebuild their lives without focusing on their skills, interests, abilities and assets and helping people to make the most of these; and

Focus on changing the environment, not simply changing individuals: A person’s ability to access the things they want to do depends on the dynamic interaction between the individual and their environment. Changing the environment – providing support and adaptations to increase access – is at least as important as changing individuals to ‘fit in’.

Recovery does not refer to an end product or a result

Recovery is a process, not an end point or destination. Recovery is an attitude, a way of approaching the day and the challenges I face … I know I have certain limitations and things I can’t do. But rather than letting these limitations be occasions for despair and giving up, I have learned that in knowing what I can’t do, I also open up the possibilities of all I can do. (Deegan 1993) People cannot be ‘fixed’ or ‘rehabilitated’ as one might mend a television or refurbish a building. If recovery is a continuing journey, then rehabilitation must be seen as a continuing process of supporting people in that journey. And this must involve not only helping the person to move forward, but also helping them to maintain what has already been gained. The original work on ‘assertive outreach’ of Stein and Test (1980) demonstrated that people did not simply require ‘training in community living’ but needed ongoing support to sustain their community tenure and the lives they had built for themselves. Likewise, there is now a wealth of evidence which demonstrates that people with mental health problems can be successful in open employment if they are provided not only with help to get work, but also ongoing, time-unlimited support, to sustain their employment. The critical yardstick of success is not whether the person can be discharged and function unaided – this may or may not be possible or desirable– but what they are able to achieve in their life in the presence of support. In the context of other impairments the efficacy of, for example, a wheelchair would never be judged in terms of whether it could be removed, but in terms of what it enabled the person using it to do. It is also important to accept that recovery will not be a linear process there will be problems and setbacks along the way. ‘The recovery process is … a series of small beginnings and very small steps. At times our course is erratic and we falter, slide back, re-group and start again …’ (Deegan 1988). Relapse is not ‘failure’, but a part of the recovery process. However, if a person is not to become dispirited or give up, they need people around them who can ‘hold on to hope’: believe in them and their possibilities, during those times when they are not able to believe in their own worth and future. Therefore, if they are to facilitate recovery, rehabilitation services need to:

Focus on maintaining, as well as optimizing functioning: Throughput models are inappropriate in the context of ongoing problems. The efficacy of an intervention/support should be judged in terms of what it enables a person to achieve, not whether it enables the person to be discharged from the service.

Adopt a long-term perspective: If recovery is an ongoing process then people may require continuity of help and support, and over long periods of time.

Offer continuity of support over time: If support over longer periods of time is to be effective, then it cannot be subject to the presence of a single member of staff. It is inevitable that practitioners will go on holiday, take sick leave, and move on to other jobs. In order to reduce the disruption and discontinuities to which this can lead, it is preferable if people know and trust a number of different team members, so that when one person leaves some continuity can be preserved. A team approach does not mean that individual relationships are unimportant, merely that everyone needs several such relationships.

Accept setbacks and relapse as part of the recovery process: Practitioners must be willing to help people to persevere. We must be able to continue to believe in people even when everything seems to be going wrong.

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