RECOVERY AND RECOVERY ORIENTED PRACTICE
SFNSW RESOURCE
‘…recovery is what the individual does; facilitating recovery is what the clinician does; and supporting recovery is what the system and community does.’ (Townsend and Glasser, 2003)
The Fellowship’s motto,Succeeding Together,adopted in 1991, underpins our ongoing commitment to supporting recovery. This discussion paper aims to open a dialogue about what we currently do, and will do,to support recovery. It is intended as a practical guide to help us reframe and rethink recovery and determine priorities in relation to how we can support and assist people living with mental illness across all Fellowship services.
People can and do recover from mental illness. Agrowing literature, definitions and models of recovery from around the globe provide multiple starting pointsfrom which to begin to think aboutthe implications of this reality. The term ‘recovery’ itself is evolving and being reinterpreted so quickly that it is bestunderstood as a moving target.Given that this is the case, we have an important opportunity to continually reframe our understanding of this elusive term and critically rethink the meanings we give to it.
Consumers, families, carers, service providers and members of the broader community all view recovery very differently. Seen from diverse consumer perspectives, personal recoveryoften involves personal experiences and differing interpretations of experience.[1] Common goals of being in recovery arewide-ranging, and may include personal empowerment, self-determination, social inclusion, general healthand holistic quality of life considerations among other personal goals.
In contrast, viewed from a much narrower medical perspective, clinical recovery from mental illness may mean that the symptoms of an illness are being managed or are no longer present. This perspective does not recognise the importance of personal or individual goals or the significance of the journey being undertaken. Any use of the term recovery therefore needs to be qualified and premised on the understanding that the same word can mean many differentthings.
The Fellowship’s priorities are determined primarily in relation toconsumerdefinedpersonal recovery perspectives. These are sometimes referred to as empowerment perspectives and theyoutline various individual centredprocesses, pathways and journeys towards recovery that focus on hope, individual choice, self-determination, strengths, living well and developing a positive sense of self. These meanings highlight what a person can and may need to do to determine his/her own pathwaythrough mental health difficulties. Our aim then, is to determine how recovery oriented perspectives and practiceswithin the Fellowship can bestsupport recovery, as defined by consumers and their carers and families.
Contemporary consumer defined meanings of recovery frequently show thata significant goal of improvingmental health is social inclusion and a return to full life in the community. To this end, ‘recovery’ can be seen to offer a range of modes to empower each person to take an active role in learning about, dealing with and overcoming the effects of their condition, in order to determinelife aims and priorities. These diverse definitions all highlight that it requires a ‘whole person’ to diligently practice self-care and to bein recovery in the face of ongoing challenges. Recovery builds on each individual’s strengths and fosters a sense of hope, dignity, control and capacity for resilience.
Over the course of the last twenty years, both in Australia and internationally, the rhetoric of recoveryorientation has become embedded within policy direction and spoken of asa core aim of service delivery. However, there is still a lack of understanding about what this means in practice for consumers, carers and service providers.[2] Just as being in recoveryis a process, so the challenge for service deliveryis in making recovery oriented practice more than simply a hollow phraseor an excuse for system failure. To be meaningful, any genuine ‘recoveryoriented practice’ must grapple with the complicated understanding that service delivery must continually adapt and respond to thecomplex, changing individualneedsand preferences of real people who want to experience all that life has to offer.
Viewed in these terms, recovery is a way of seeing, an approach, a guiding principle. For people living with mental illness and their carers, recovery is a personal process that needs to be renegotiated day by day or even hour by hour.Collaborative practice, that is, working alongside people who are the experts in their own recovery, means providing supports that are respectful, hopeful and recovery-conducive. Recovery oriented practices arenecessarily aspirational, allow no room for complacency, and must be continually open to rethinking, reframing, innovation and improvement, as well asrigorous evaluation by consumers themselves.
Theoverview that follows is intended to outline some of the broad historical shifts, changing definitions and guiding principles thatform our current understanding of what recovery means.It concludes with a brief outline of what the Fellowship does and will do to support recovery as well as a quick quiz.
Recovery is a moving target. For this reason, recovery oriented practice is described here as an ongoing process, theshifting goal towards which the Fellowshipstrivesevery day.
The Origins of Recovery
The most powerful and irrefutable evidence of recovery lies in the narrative accounts and personal stories of people with mental illness who do recover.Since the 1970s, consumer and carer advocates have continued to explode the myth that mental illness is for life, that it is inescapable. Individual narratives and personal stories continue to highlight the importance of lived, subjective experiences, and of the need to share individual recovery stories with others.
Consumer driven recovery movements in mental healthemerged first in the United States and United Kingdom in the 1960s and 70s, and lateraround the globe. These werefirst and foremost civil rights movements, influenced by the awareness-raising successes achieved by women’s, gay and black liberation, peace and anti-war movements.
Led by people in recovery themselves, advocates saw a need to reclaim their right to full citizenship, community membership,as well as self and meaning,by making their own decisions in all aspects of their lives, including health care. Many of the founders of recovery movements had been the victims of mental health systems of the mid to late twentieth century, medicated against their will, suffering a range of indignities, humiliations, deprivations and abuses in custodial institutions.Ex-patient advocates denounced the ‘system of care’ that had made their advocacy necessary. They identifiedthe ‘medical model’ as taking an overly narrow focus on the biological aspects of mental illness and highlighted that medication aloneoffered a dangerously inadequate mode of care.
Simultaneously, clinical frameworks for recovery, developed by health professionals and academics in the 1980s reinforced models of psychiatric rehabilitation, and these models influenced service contexts in Australia and elsewhere. In Australia, for example, the Second Mental Health Strategy, launched in 1998, referred to recovery, and subsequent strategies have claimed to place recovery at the centre of service provision.And yet a recent position statement by the National Mental Health Consumer and Carer Forum noted a ‘lack of progress around the adoption of a recovery orientation in mental health services to date.[3][i]’ Only when the invisible barriers to change are identified and overcome, can areal paradigm shift in mental health policy and practice begin.
Since the 1990s, consumer groups, supported by the non-government sector, began to exert real influence in changing the policy context from one imposed by others to one determined by consumer perspectives. These groups continue to draw into question psychiatric and medical models. They show that these models fail to recognise non-medical approaches, the role of consumers as active partners, and the role of communities in contributing to wellness.
Recovery advocates, informed by lived experience, continue to play a vital role in requiring mental health practitioners and service providers to approach their practices from the perspective of the person with the condition, understanding that s/he is a person first, the driver of the process and the key decision maker. This requires practitioners, service providers and carers to see whole people, and not just people with a mental illness. It requires services to assess, explore, understand and assist as requested in all areas of a person’s life in which s/he is experiencing distress or dysfunction.
Decades of research confirm the wide-ranging benefits of self-determined care, that is, of care decided on by the consumer themselves and supported by those around them. In seeking to become recovery oriented, good mental health practice must return power and self-determination to the consumer. Each recovery pathway is as unique as the destination sought.
Consumer advocatesand NGOs continueto demand shifts in service delivery, including community-based alternatives to long-term hospitalisation and re-hospitalising. They emphasise that ‘recovery approaches minimise reliance on acute services and improve quality of life by strengthening consumer and carer autonomy or personal control.[4]’ They reinforce the understanding that full, meaningful and self-determined life in the community can only happen with advocacy that promotes hope and facilitates optimism. They also remind us that social connections, good relationships and social support are important for good mental health for everyone. Social engagement and inclusion provide a sense of agency and hope, opening up possibilities for recovery.
Social responsibility, community and an inclusive society, all contribute to recovery. Social, economic and political commitment makes recovery a matter of human rights, social justice and anti-discriminatory practice. Wellness must be enhanced by removing obstacles to recovery, such as stigma, discrimination and social exclusion.
The Fellowship is committed to recovery oriented practice in its fullest sense. We recognise that service transformation means that we must constantly re-evaluate our attitudes, values, relationships, explanatory theories, models of practice and organisational structures.
Recovery as a concept is a moving target, and this understanding has implications for the work that we do.The following section will explore some existing definitions of recovery and suggests the need for the Fellowship to devise our own.
Definitions
Multiple definitions of recovery exist and yet none of them adequately conveys what ‘recovery’ means. Working definitionssuggest that recovery is an individual process, shaped by unique experience and the meanings that each individual attaches to these meanings (see Meehan 2008, p. 178, Ministry of Health, New Zealand, 2008). Recovery is often defined as a non-linear journey, a series of experiences and stages in which recovery becomes possible. Recovery means living well in the presence or absence of mental illness.
Recovery orientation in service delivery ensures that people living with mental illness and their carers receive the services that best meet their needs, and that continue to meet their needs as these change.’ [5]
The Fellowship as an organisation needs to devise our own working definition of recovery.Listed here are some helpful working definitions that might assist us inthis aim. The list begins with definitions created in the late 1980s and 90s and moves forward into our present time:
Recovery is a process,…not a perfectly linear process…The need is to meet the challenges of the disability and to re-establish a new and valued sense of integrity and purpose within and beyond the limits of the disability. The aspiration is to live, work and love in a community in which one makes a significant contribution…’(Deegan, 1988, p. 15).
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 with limitations caused by illness. Recovery involves the development of new meaning and purpose in one’s life as one grows beyond the catastrophic effects of mental illness.
(Anthony, 1993, p. 527).
Recovery is…a subjective experience of having regained control over one’s life. (Knight, 2000)
It is important to remember that recovery is not synonymous with cure. Recovery refers to both internal conditions experienced by persons who describe themselves as being in recovery—hope, healing, empowerment and connection—and external conditions that facilitate recovery—implementation of human rights, a positive culture of healing, and recovery-orientedservices. (Jacobson and Greenley, 2001, p. 482).
Recovery means regaining mental health and achieving a better quality of life (HAFAL, 2006).
…being ‘in recovery’ can mean learning how to live a safe, dignified, full and meaningful life, at times in the presence of symptoms of mental illness. (Davidson, Drake, Schmutte, Dinzeo & Andres-Hyman, 2009, p. 324).
Recovery is … a process in which you take an active part in getting as well as you possibly can be: accepting unavoidable limitations and focusing on the many possibilities of what you can do to lead a satisfying life (‘Getting Better’ SANE Australia Factsheet 18, 2010).
(Recovery is) a process of change through which individuals improve their health and wellness, live a self-directed life, and strive to reach their full potential(The U.S Substance Abuse and Mental Health Services (SAMHSA) 2011 Working Definition of Recovery)
Guiding Principles of Recovery
Recovery oriented practices are empowering and multiple. The principles suggested here areextracted and modified for the Fellowships purposes from the U.S Substance Abuse and Mental Health Services (SAMHSA) Working Definition of Recovery from Mental Disorders and Substance Use Disorders, 2011.
Recovery emerges from hope: The belief that recovery is real provides the essential and motivating message of a better future – that people can and do overcome the internal and external challenges, barriers, and obstacles that confront them. Hope is internalised and can be fostered by peers, families, providers, allies, and others. Hope is the catalyst of the recovery process.
Recovery is person-driven: Self-determination and self-direction are the foundations for recovery as individuals define their own life goals and design their unique path(s) towards those goals. Individuals optimise their autonomy and independence to the greatest extent possible by leading, controlling, and exercising choice over the services and supports that assist their recovery and resilience. In so doing, they are empowered and provided the resources to make informed decisions, initiate recovery, build on their strengths, and gain or regain control over their lives.
Recovery occurs via many pathways: Individuals are unique with distinct needs, strengths, preferences, goals, culture, and backgrounds, including trauma experiences that affect and determine their pathway(s) to recovery. Recovery is built on the multiple capacities, strengths, talents, coping abilities, resources, and inherent value of each individual. Recovery pathways are highly personalised. They may include professional clinical treatment; use of medications; support from families and in schools; faith-based approaches; peer support; and other approaches. Recovery is non-linear, characterised by continual growth and improved functioning that may involve setbacks. Because setbacks are a natural, though not inevitable, part of the recovery process, it is essential to foster resilience for all individuals and families.
Recovery is holistic: Recovery encompasses an individual’s whole life, including mind, body, spirit, and community. This includes addressing: self-care practices, family, housing, employment, education, clinical treatment for mental disorders and substance use disorders, services and supports, primary healthcare, dental care, complementary and alternative services, faith, spirituality, creativity, social networks, transportation, and community participation. The array of services and supports available should be integrated and coordinated.
Recovery is supported by peers and allies: Mutual support and mutual aid groups, including the sharing of experiential knowledge and skills, as well as social learning, play an invaluable role in recovery. Peers encourage and engage other peers and provide each other with a vital sense of belonging, supportive relationships, valued roles, and community. Through helping others and giving back to the community, one helps one’s self. Peer-operated supports and services provide important resources to assist people along their journeys of recovery and wellness. Professionals can also play an important role in the recovery process by providing clinical treatment and other services that support individuals in their chosen recovery paths.
Recovery is supported through relationship and social networks: An important factor in the recovery process is the presence and involvement of people who believe in the person’s ability to recover; who offer hope, support, and encouragement; and who also suggest strategies and resources for change. Family members, peers, providers, faith groups, community members, and other allies form vital support networks. Through these relationships, people leave unhealthy and/or unfulfilling life roles behind and engage in new roles (e.g., partner, caregiver, friend, student, employee) that lead to a greater sense of belonging, personhood, empowerment, autonomy, social inclusion, and community participation.
Recovery is culturally-based and influenced: Culture and cultural background in all of its diverse representations including values, traditions, and beliefs are keys in determining a person’s journey and unique pathway to recovery. Services should be culturally grounded, attuned, sensitive, congruent, and competent, as well as personalised to meet each individual’s unique needs.
Recovery is supported by addressing trauma: The experience of trauma (such as physical or sexual abuse, domestic violence, war, disaster, and others) is often a precursor to or associated with alcohol and drug use, mental health problems, and related issues. Mental Illness in itself can create trauma.Services and supports should be trauma-informed to foster safety (physical and emotional) and trust, as well as promote choice, empowerment, and collaboration.
Recovery involves individual, family, and community strengths and responsibility: Individuals, families, and communities have strengths and resources that serve as a foundation for recovery. In addition, individuals have a personal responsibility for their own self-care and journeys of recovery. Individuals should be supported in speaking for themselves. Families and significant others have responsibilities to support their loved ones, especially for children and youth in recovery. Communities have responsibilities to provide opportunities and resources to address discrimination and to foster social inclusion and recovery. Individuals in recovery also have a social responsibility and should have the ability to join with peers to speak collectively about their strengths, needs, wants, desires, and aspirations.