Module 3: The Recovery Paradigm
Ch 3: What is Recovery?
One Word, Two Meanings
The term clinical recovery – refers to recovery in the sense of cure
The term personal recovery – refers to individuals self-reporting as being recovered, even
when they experience ongoing symptoms
Meaning (1) – Clinical Recovery
The first meaning of recovery has emerged from professional-led research – and has four key
features:
1. It is an outcome or a state – generally dichotomous
2. It is observable – in clinical parlance, it is objective, not subjective
3. It is rated by the expert clinician – not the patient
4. The definition of recovery is invariant across individuals
Various definitions of recovery have been proposed – such as that recovery in SZ can be
defined as:
1. A reliable previous diagnosis of SZ
2. Criteria for diagnosis not fulfilled at present
3. Out of hospital for at least 5 years
4. Present psychological functioning within a ‘normal’ range
5. Not on antipsychotic medication or only on low dosage
The intention with this definition is that it is operationalizable – suitable for use in empirical
research
- It contains diagnostic, service use, functioning and treatment elements
,Each of these can vary for reasons not related to the individual – and whether they are
recovered
1. Diagnostic criteria can change
2. Hospitals close and home treatment operate – so admission thresholds alter
3. Functioning is dependent on the opportunities in the environment
4. Medication regimes are influenced by prescriber beliefs
A more socially focused definition is proposed – such that recovery is characterized by:
1. Full symptoms remission
2. Full or part-time work or education
3. Independent living without supervision by informal carers
4. Having friends with whom activities can be shared
5. All sustained for a period of two years
Their conclusion is that – “it is now realistic to set as a goal the feasibility of recovery from
SZ for half or more individuals with first episode”
Issues with Clinical Recovery Definition
Only 11% of individuals with severe and enduring mental health issues remain unrecovered
and deep in the system
- This is much less than the clinical rule of thirds – where a third recovers, a
third fluctuates in course, and a third never gets better
Empirical data challenge the applicability of a chronic disease model to mental illness – with
its embedded assumption that conditions like SZ are necessarily life-long and have
deteriorating course
Sometimes recovery has been in spite of – rather than due to – mental health services
Perhaps the problem arises from treating recovery as an outcome – as it implicitly involves
deep assumptions about normality
, Meaning (2) – Personal Recovery
Early individual accounts of recovery provide ecologically valid pointers to what recovery
looks and feels like from the inside
The understanding of recovery which has emerged from these accounts has a different focus
from clinical recovery
- E.g., emphasizing the centrality of hope, identity, meaning and personal
responsibility
The understanding of recovery as personal recovery – reflects its individually (1) defined
and (2) experienced nature
Emerging Themes
There is no right way for a person to recover – but there are some themes that have emerged:
First – A first clear point of divergence from the clinical perspective – is that recovery is seen
as a journey into life – not an outcome to be arrived at
Recovery is not about “getting rid” of the problems – it is about seeing people beyond their
problems – as in their abilities, possibilities, interests and dreams
- And recovering the social roles and relationships that give value and
meaning
Many definitions of recovery have been proposed by those who are experiencing it – the most
widely used one is as follows:
1. Recovery is a deeply personal, unique process of changing one’s attitudes, values,
feelings, goals, skills and/or roles – it is a way of living a satisfying, hopeful, and
contributing life even within the limitations caused by illness
- Recovery involves the development of new meaning and purpose in one’s life
as on grows beyond the catastrophic effects of mental illness
This definition is consistent with another – less widely used definition – stating that recovery
involves:
, 1. The establishment of a fulfilling, meaningful life and a positive sense of identity –
founded on hopefulness and self-determination
- Recovery involves living as well as possible
Implications of These Definitions
One implication is that personal recovery is an individual process
1. There is no one right way to do or experience recovery
2. Something that helps an individual at one point in their life – may not help them at
another
A focus on promoting personal recovery – means there cannot be a single recovery model for
mental health services
A recovery-focused service – is an approach, a way of thinking, a set of attitudes and values
put into practice by skilled MH practitioners
Key Elements of a Recovery Approach
, Personal recovery has high ecological validity – it emerges from the narratives of people
with mental illness – who describe themselves as recovered or in recovery
- It removes the unhelpful evaluative element of whether – according to some
externally defined criteria – someone has achieved recovery
A disadvantage of personal recovery – is that it makes operationalization of the concept and
empirical investigation problematic
1. If recovery is an ongoing, idiosyncratic process – unclear how to get a reliable idea of,
or demonstrate, positive change
Recovery orientation – recovery can be identified using four domains allowing the prevalence
of recovery orientation among service users – and the impact of interventions on this
orientation – to be investigated empirically:
(1) Empowerment, (2) hope and optimism, (3) knowledge, and (4) life satisfaction
Are Clinical Recovery and Personal Recovery Incompatible?
Two overlapping, but different, understandings of recovery have been proposed – and three
definitions of recovery have been proposed:
1. Spontaneous Recovery – recovery is a naturally occurring phenomenon – some
people who meet diagnostic criteria for a serious mental illness are able to overcome
their disabilities and fully enjoy a life in which their life goals are accomplished –
without any kind of treatment
2. Clinical Recovery – as with other medical illnesses, people can recover from mental
illness with proper treatment – others who do not enjoy spontaneous recovery from
mental illness are able to achieve a similar state of goal attainment and life
satisfaction as a result of participating in variety of services
3. Personal Recovery – recovery reintroduces the idea of hope in understanding serious
mental illness – it means that even though a person is diagnosed with a serious psych
disorder, his/her life need not be limited by institutions
A primary focus on personal recovery will fundamentally change the values, goals, and
working practices of MHS
Personal recovery encompasses the three types of recovery listed above:
Ch 3: What is Recovery?
One Word, Two Meanings
The term clinical recovery – refers to recovery in the sense of cure
The term personal recovery – refers to individuals self-reporting as being recovered, even
when they experience ongoing symptoms
Meaning (1) – Clinical Recovery
The first meaning of recovery has emerged from professional-led research – and has four key
features:
1. It is an outcome or a state – generally dichotomous
2. It is observable – in clinical parlance, it is objective, not subjective
3. It is rated by the expert clinician – not the patient
4. The definition of recovery is invariant across individuals
Various definitions of recovery have been proposed – such as that recovery in SZ can be
defined as:
1. A reliable previous diagnosis of SZ
2. Criteria for diagnosis not fulfilled at present
3. Out of hospital for at least 5 years
4. Present psychological functioning within a ‘normal’ range
5. Not on antipsychotic medication or only on low dosage
The intention with this definition is that it is operationalizable – suitable for use in empirical
research
- It contains diagnostic, service use, functioning and treatment elements
,Each of these can vary for reasons not related to the individual – and whether they are
recovered
1. Diagnostic criteria can change
2. Hospitals close and home treatment operate – so admission thresholds alter
3. Functioning is dependent on the opportunities in the environment
4. Medication regimes are influenced by prescriber beliefs
A more socially focused definition is proposed – such that recovery is characterized by:
1. Full symptoms remission
2. Full or part-time work or education
3. Independent living without supervision by informal carers
4. Having friends with whom activities can be shared
5. All sustained for a period of two years
Their conclusion is that – “it is now realistic to set as a goal the feasibility of recovery from
SZ for half or more individuals with first episode”
Issues with Clinical Recovery Definition
Only 11% of individuals with severe and enduring mental health issues remain unrecovered
and deep in the system
- This is much less than the clinical rule of thirds – where a third recovers, a
third fluctuates in course, and a third never gets better
Empirical data challenge the applicability of a chronic disease model to mental illness – with
its embedded assumption that conditions like SZ are necessarily life-long and have
deteriorating course
Sometimes recovery has been in spite of – rather than due to – mental health services
Perhaps the problem arises from treating recovery as an outcome – as it implicitly involves
deep assumptions about normality
, Meaning (2) – Personal Recovery
Early individual accounts of recovery provide ecologically valid pointers to what recovery
looks and feels like from the inside
The understanding of recovery which has emerged from these accounts has a different focus
from clinical recovery
- E.g., emphasizing the centrality of hope, identity, meaning and personal
responsibility
The understanding of recovery as personal recovery – reflects its individually (1) defined
and (2) experienced nature
Emerging Themes
There is no right way for a person to recover – but there are some themes that have emerged:
First – A first clear point of divergence from the clinical perspective – is that recovery is seen
as a journey into life – not an outcome to be arrived at
Recovery is not about “getting rid” of the problems – it is about seeing people beyond their
problems – as in their abilities, possibilities, interests and dreams
- And recovering the social roles and relationships that give value and
meaning
Many definitions of recovery have been proposed by those who are experiencing it – the most
widely used one is as follows:
1. Recovery is a deeply personal, unique process of changing one’s attitudes, values,
feelings, goals, skills and/or roles – it is a way of living a satisfying, hopeful, and
contributing life even within the limitations caused by illness
- Recovery involves the development of new meaning and purpose in one’s life
as on grows beyond the catastrophic effects of mental illness
This definition is consistent with another – less widely used definition – stating that recovery
involves:
, 1. The establishment of a fulfilling, meaningful life and a positive sense of identity –
founded on hopefulness and self-determination
- Recovery involves living as well as possible
Implications of These Definitions
One implication is that personal recovery is an individual process
1. There is no one right way to do or experience recovery
2. Something that helps an individual at one point in their life – may not help them at
another
A focus on promoting personal recovery – means there cannot be a single recovery model for
mental health services
A recovery-focused service – is an approach, a way of thinking, a set of attitudes and values
put into practice by skilled MH practitioners
Key Elements of a Recovery Approach
, Personal recovery has high ecological validity – it emerges from the narratives of people
with mental illness – who describe themselves as recovered or in recovery
- It removes the unhelpful evaluative element of whether – according to some
externally defined criteria – someone has achieved recovery
A disadvantage of personal recovery – is that it makes operationalization of the concept and
empirical investigation problematic
1. If recovery is an ongoing, idiosyncratic process – unclear how to get a reliable idea of,
or demonstrate, positive change
Recovery orientation – recovery can be identified using four domains allowing the prevalence
of recovery orientation among service users – and the impact of interventions on this
orientation – to be investigated empirically:
(1) Empowerment, (2) hope and optimism, (3) knowledge, and (4) life satisfaction
Are Clinical Recovery and Personal Recovery Incompatible?
Two overlapping, but different, understandings of recovery have been proposed – and three
definitions of recovery have been proposed:
1. Spontaneous Recovery – recovery is a naturally occurring phenomenon – some
people who meet diagnostic criteria for a serious mental illness are able to overcome
their disabilities and fully enjoy a life in which their life goals are accomplished –
without any kind of treatment
2. Clinical Recovery – as with other medical illnesses, people can recover from mental
illness with proper treatment – others who do not enjoy spontaneous recovery from
mental illness are able to achieve a similar state of goal attainment and life
satisfaction as a result of participating in variety of services
3. Personal Recovery – recovery reintroduces the idea of hope in understanding serious
mental illness – it means that even though a person is diagnosed with a serious psych
disorder, his/her life need not be limited by institutions
A primary focus on personal recovery will fundamentally change the values, goals, and
working practices of MHS
Personal recovery encompasses the three types of recovery listed above:
