Essentially, recovery is defined as the “process of change through which individuals improve their health and wellness, live a self-directed life, and strive to reach their full potential” (Puryear 2012, p.43).This premise has applied across various healthcare disciplines, including mental healthcare. However, besides this general premise, the specific constituents of recovery vary depending on the perspective one takes. For instance, there is no consensus on the definition of recovery in relation to anorexia, although it includes physical, behavioral and psychological elements (Bardone-Cone et al. 2015; Dawson et al. 2015). This variability in the definition of recovery, argue Dawson et al. (2015), is one of the major limitations in mental health care. Regardless, in relation to mental health in general, the concept of recovery has emphasized the consumer self-help, and this has been evident in mental health care practice from the 1930s. The underlying premise in this approach is that those with severe mental illness can get well enough to live full and productive lives (Leamy et al. 2011; Aston & Coffey 2012; Puryear 2012; Leese 2014).
There is a new way of conceptualizing what recovery means from mental health perspective and is a shift from the traditional approach which largely sidelined self-management and wellness (Sterling et al. 2010; Leamy et al. 2011; Kidd et al. 2015). This re-conceptualization of recovery may largely be attributable to the many landmark federal reports over the last decade and a half that have increasingly suggested radical transformation of mental health care. Indeed, over the years, though, there has been a constant regeneration of recovery thinking. These have resulted in the birth of new ideas and truths that have been modeled into new paradigms, each with their own integrity and distinct values, beliefs and practices (Aston & Coffey 2012; Gale & Marshall-Lucette 2012; Puryear 2012; Leese 2014).
Ultimately, although the essential premise of mental remains, there are small differences across the various mental health disciplines: psychiatry, psychology and nursing, and even from the perspective of the consumers. This paper aims to examine the definition and conceptualization across these disciplines.
Definition and Conceptualization
- Psychiatry and Psychology Perspectives
Traditionally, many health care practitioners are not trained to offer recovery-oriented care. However, a recovery-oriented care has become an increasingly major focus across the various disciplines within mental health care practice (Sterling 2010; Leamy et al. 2011).
The term ‘recovery’ within the recovery model refers to various things: process, vision, outlook as well as guiding principle. For psychiatrists, recovery is not necessarily about the remission of clinical symptoms. Rather, the term in this case comes to cover a wider concept that entails the person’s total adjustment to life. In this respect, therefore, a recovery approach seeks to support a patient through their own individual development, which includes building one’s self-esteem and identity as well as finding a meaningful role in the society (Allott & Loganathan 2003). This definition follows on Anthony’s (1993; 2000) description of the recovery as a process that involves changing a person’s values, attitudes, feelings and objectives/goals as well as roles and skills. This is particularly true for many mentally ill persons. Several mental illnesses may not be cured. In fact, many mental illnesses tend to remain permanent throughout one’s life.As Roberts and Wolfson (2004) put it, the illness is not cured and the recovery proceeds even in the presence of continuing symptoms and disability. In other words, recovery in this case is not synonymous with cure. Still, it is considered recovery depending on one’s changed values, attitudes, beliefs as well as goals (i.e. setting realistic recovery goals) (Roberts & Wolfson 2004). In other words, the main premise here (as slightly pointed out in the introduction) is that a patient can still live a satisfying and hopeful life and even contribute to society despite the limitations of illness (Roberts & Wolfson 2004).
The psychology perspective also believes in this mental or cognitive adjustment of a person. In other words, psychologists also believe that recovery in mental health care has more to do with changed perception of illness and recovery rather than cure per se. However, psychologists seem to have a different opinion about to achieve this perception of recovery (Allott & Loganathan 2003).
There are a number of personal and ideological standpoints that the recovery movements incorporate in relation to illness and recovery. One central issue of contention, especially between psychiatric and psychology perspectives are the continued use of medication as part of the recovery process.
For some, full recovery means that there no longer is the need for medication; that it no longer maintains wellness. Fisher (2003) (a practitioner), for instance, argues that he has never had to rely on medication to deal with the symptoms. Moreover, even most importantly, Fisher (2003) says he is a recovered schizophrenic. In other words, he also believes that realistic goals about recovery for the mentally ill do not necessarily have to exclude cure because, as far as he is concerned, cure is also a possibility.
Fleck et al (2005) examine extensively this issue of medication, especially how many patients abide by the prescriptions they are given and how this may affect their treatment and recovery. While the authors admit that medication is not necessarily a predictor of recovery, they still do show that failure to take medication can still affect negatively on recovery. For example, they cite studies showing that failure to take medication increases risks of increasing symptoms and relapse, among others.
Of course, many psychiatrists would not agree that medication could be excluded entirely from the treatment and care process even after recovery. Medication is also often considered an important part of the recovery process, especially as part of a person’s self management plan. This focus on rehabilitation is said to be a central distinguishing point that separates psychiatrists from psychologists (Deegan 1998, cited in Deegan et al. 2008).
For instance, Deegan (1998), a clinical psychologist, was one of the first recovery ideologists to cite the difference between the meaning of recovery to psychiatrists and psychologists. Writing a person account of her illness and experience in recovery, Deegan (1988, cited in Deegan et al. 2008) recovery is not similar to the psychosocial rehabilitation processes of psychiatry. She argues that rehabilitation- and psychiatry for that matter- focuses more on services and technologies. However, she further argued, recovery is more about lived and real experiences of a person as he/she accepts and overcomes challenges of disability.
These different viewpoints about the role of medication in the recovery of the mentally ill imply two perspectives about the cause of mental illness. One perspective seems to hold that mental illness is purely psychological and that once these psychological aspects are put in check- so that, for instance, the person can live a meaningful life despite their differences- then all is well. However, another perspective seems to imply that mental conditions can result from physiological conditions. Therefore, continued medication is supposed to offer support (by impacting on the potential and known physiological risk factors) to the psychological aspect of it (Puryear 2012).
Most importantly, the recovery models places emphasis on self-management as well as the development of recovery strategies. In this regard, the patient is believed to play an equally vital role in the recovery process rather than waiting on doctors to do it. The patient is expected to have faith in their abilities to take control of and manage their recovery and lives. Patients are, therefore, expected to learn to not depend on others to do everything for them (Puryear 2012).
Generally, in psychology, recovery has largely been a niche interest area for those psychologists carrying out research on or providing treatment for people with severe mental illnesses. However, psychologists have had to change their notions of and play new roles in recovery, especially within the framework of recovery movement, which places emphasis on “integrated health-care models, meaningful patient-centered outcomes and collaboration with community stakeholders and others” (Puryear 2012, p.43), including
In this new model, psychologists play new roles, including as providers of integrated mental health care systems, facilitators of patient-centered planning, which is considered as the basic foundation of patient-centered teams.
- Nursing Perspective
According to Leese (2014), The Nursing and MidWifery Council, NMC (2010) support the National Institute for Mental Health Excellence’s, NIMHE (2005) principles of recovery-oriented practice. For NIMHE- and, therefore, for NMC, recovery mainly focuses on hope, but also reintegrating service users back into society and their former productive life before they were diagnosed with mental illness (Gale & Marshall-Lucette 2012). In this regard, the principle goals of care and toward recovery are similar to the premises promoted by both the psychiatrist and psychological perspectives. Moreover, for nursing, there is a major focus on the possibility of relapse. In this respect the nurse focuses on the factors that could impact on a person’s recovery and find ways to implement these goals, but only in line with the patient’s unique needs andcircumstances. Ultimately, Leese (2014) finds three main issues related to the notionsof recovery in nursing practice: hope; patient-centered care; and the consideration of the perspectives of the service-users.
One of the issues that nurses have to deal with has to do with medications. Indeed, nurses can face major dilemma when dealing with patients who choose not to take their medication as prescribed by the physician and this is hindering the patient’s effort to attain their own recovery goals. The first step in dealing with such a difficult situation- and in line with patient-centered approach- is to develop a trusting rapport with the patient. Such trust facilitates dialogue, which would help the nurse understand the patient’s preferences and attitudes towards medication and goals for personal recovery (Leese 2014). Indeed, Fleck et al. (2005) do agree that the interpersonal relationship between the nurse and the consumer plays a vital role in promoting personal choice directed towards engaging in activities that would help provide the consumer with meaning and purpose.
Considering their constant interaction with patients, nurses are in a strategic position to empower the consumers of mental health care to care and sustain their recovery goals, including psychiatric medications where necessary. Generally, in relation to the conceptof patient-centered care, nurses may employ various strategies to help patients take the prescribed medication. These include, first, empowering the patients to ask questions about things they do not understand or would like to know more about (Fleck et al. 2005). Second, the nurse can also help the patient to prepare their medication appointments, which involves helping he patient prepare ahead of time for a meeting with the prescribing doctor or nurse. The nurse may also role-play to prepare the patient psychologically (Sainsbury Centre for Mental Health 2008; Williams & Tufford 2012). Third, the nurse can also practice coping strategies with the patient. These may include helpingpatients deal with delusions, voices, self-injury, paranoia, flashbacks, depression, obsessive thinking, etc (Williams & Tufford 2012). Moreover, the nurse may also help the patient learn how to use various non-drug coping strategies that would help minimize the amount of medication they may need to take. However, the nurse may also simply teach the patients about medication so they (the patients) do not feel intimidated by the big names. This may involve providing a written fact sheet that describes the drugs and what the drugs do, as well information on likely side effects and precautions (Mueser et al. 2002; Fleck et al. 2005; Sainsbury Centre for Mental Health 2008; Williams & Tufford 2012).
These are only some of the ways that nurses’ practice can meet the requirements of patient-centered approach, which is a major factor in the realization of both the patients’ and practitioners’ recovery goals and outcomes.
- Consumer Perspective
Consumers, patients most especially- although the carers are also considered- have their own definitions of recovery. Consumers do not necessarily perceive recovery in the same way as the practitioners of mental health care across the various disciplines. Moreover, each patient has unique view of recovery, including what they believe will help or hinder their recovery. Ultimately, these perceptions determine their journeys to recovery. Because of these unique patient perceptions, patient-centered places emphasis on the need to work with personal recovery goals of patients. In other words, patients do not necessarily see recovery as just about getting well, but also what steps are taken towards it (Aston & Coffey 2012). They consider recovery as a process that entails various elements, all of which build up to the ultimate goal. Australia’s Mental Health Foundation, for instance, outlines some of the elements that patients consider important in their care and recovery (Aston & Coffey 2012). First, patients like to be understood as having unique experiences even when they suffer from the same illnesses. Secondly, patients respond better to treatment and care when they are treated with respect and allowed their basic human rights (Gale & Marshall-Lucette 2012). Thirdly, patients respond better to treatment and care when they are listened to and understood. Fourth, patients like to have their concerns taken seriously, including the side effects of medication. This is a very vital point, especially in influencing the treatment and care decision of the physician. For instance, the physician may take an upper hand and remain adamant that they have to administer certain drugs for care. However, it is important to consider how these drugs- even if considered the very best- impact upon the patient (Leese 2014).
Often, patients may be allergic to an ingredient and react to a drug one way or another. Patients would like to have these concerns taken seriously. However, this is not to say that the physician must always do what the patient asks. If the doctor feels that he/she is making the right decision, then- fifth point- patients like to be calmed and involved in decision-making rather than coerced into a treatment or care method (Gale & Marshall-Lucette 2012). Sixth, patients also like to be educated about their illnesses, so that they can be directly involved in their treatment and care by making informed decisions. Seventh, patients may also like to be part of support groups within their communities. Last but not least, patients also like to know their rights (Aston & Coffey 2012; Gale & Marshall-Lucette 2012; Puryear 2012; Leese 2014).
Ultimately, though, the experience of recovery from a mental illness is defined from an individual perspective and is more than just the remission of clinical symptoms and signs. Because of these reasons, it is important that researchers develop more sophisticated measures of outcome which would reflect this broader viewpoint of recovery. According to Anthony (2001), as a result of the traditional narrowness of the outcome measures used to validate treatments, evidence-based practice could help maintain the same traditional ways of delivering mental health services and fail to accept or validate newer, promising ways of delivering services such as recovery based services. Anthony (2001) is only part of the bigger debate over the recovery paradigm, particularly how to reconcile evidence-based practice.
This paper examined how recovery is viewed across different disciplines in mental health care: psychiatry; psychology; and nursing, and also the perceptions to what recovery means to service-users or patients. The common denominator in all these perspectives is that, when it comes to mental health care, recovery is not necessarily synonymous with cure- although cure may not necessarily be rules out. This premise mainly rests on the fact that many several; mental illnesses never cure. The idea, therefore, is to set realistic goals and objectives for recovery. Most of the time, the best realistic goal is to have the patient change their attitude about their illness and life, including their ability to go on and live a full life and contribute positively to society regardless of the limitations they experience as a result of their illness.
However, one of thepoints of contention is the use of medication as a support for recovery. While some groups do not agree that medication use must accompany care and recovery, others are concerned that failure to take medication can have negative impacts on recovery, including the possibility for relapse. Ultimately, though, and despite these differences, when it comes to practice, all these disciplines agree on taking a patient-centered approach. This approach essentially refers to the involvement of patients in their care. This includes taking their feelings into consideration, and involving them in the process of decision making over their care or involving a trusted family member or friend they prefer to make key decisions on their behalf when they are in no position to do it themselves. The premise here is that people respond better to treatment and care when they feel they have control over the processes (Aston & Coffey 2012; Gale & Marshall-Lucette 2012; Puryear 2012; Leese 2014).
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