Unfortunately, mental health professionals are a major source of stigma towards people with mental illness. Recovery-oriented practice is one possibility for transforming mental health care into a less stigmatizing place, so let’s talk about what that might look like.
What recovery is
Personal recovery, also known as psychosocial recovery, is a different can of tuna from the remission of symptoms of illness. Remission is a clinical term that refers specifically to illness symptoms; you can find examples of specific definitions of remission here for depression, bipolar, and schizophrenia.
Rethink Mental Illness uses this definition of recovery from Anthony (1993):
“Recovery is described as 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 also explains that recovery is more than just recovering from the illness itself; it can also involve recovery from stigma, negative experiences of treatment, and loss of opportunities. Recovery from those things may actually be more difficult than dealing with the illness itself. Recovery isn’t something mental health professionals do to/for a patient; they can only support patients as they forge their own paths and determine what their own version of recovery is going to look like.
Recovery is about the process rather than being something that’s measured in terms of outcomes. That process can happen even if symptoms are ongoing. However, that doesn’t stop people from talking about it as if it’s an outcome that involves freedom from illness. I’ve written before about my concerns about “recovery is a choice” messaging, and I think there’s a problem when people start to expect some endpoint of recovery rather than accepting that different people may be at very different places in their illness/recovery journeys.
What recovery-oriented practice is
Recovery-oriented practice looks different from traditional mental health care practice in a number of ways. It emphasizes:
- empowerment
- choice
- self-determination
- hope
- personal meanings and purpose for the individual with mental illness
- developing a positive identity and valued social roles
- recognizing people with mental illness as experts by experience
- focusing on the person rather than the disorder
- care is adapted to the individual rather than the other way around
- transformation rather than a return to normal
The Mental Health Commission of Canada has published Guidelines for Recovery-Oriented Practice. According to these guidelines, “A key source of hope comes from looking beyond the challenges that may accompany illness to see people’s unique strengths, character, innate abilities and potential for growth.”
They add: “Recovery is nurtured by working with people to help activate their internal resources so they are able to retain and deepen a belief in their abilities, strengthen their sense of personal agency and acquire control over their journey of recovery and well-being.” The focus is on strengths and what people can do rather than their limitations and barriers.
How this relates to stigma
Stigma among health professionals often involves stereotypes related to incompetence. This can lead to the belief that health care providers need to take a paternalistic role. Other common issues include pessimism around recovery, seeing the illness rather than the person, and having an us vs. them mindset that frames patients as being fundamentally different from health care providers.
Recovery-oriented practice turns a lot of that on its head. The basic principles, like hope, empowerment, and choice, really aren’t compatible with stigma. While stigma is about stereotypes, recovery-oriented practice is about seeing individuals as unique beings with strengths rather than just weaknesses. It’s a shift in attitude that’s a change in the right direction if we’re going to be able to stop the stigma in mental health care.
Getting it right
However, to go in that right direction, attitudes actually have to change. Lip service to recovery does nothing to reduce stigma, and it may be used as an excuse for health care providers not to engage in self-reflection around the impact of their own practices. An attitude of “there can’t be stigma because we’re recovery-oriented” doesn’t help anyone.
Actual recovery-oriented practice, on the other hand, could make a big difference. I think that the only way to ensure high-fidelity implementation is to have people with mental illness involved in the implementation and evaluation. Unfortunately, far too many of the people in power don’t get there by being committed to truly helping people with mental illness. I would like to hope that that’s a quirk of the system where I’ve worked, but I doubt it. Recovery-oriented practice can’t be successfully implemented by people who are riding high on their own power trips.
Does recovery-oriented practice sound like something you think would be helpful? Do you see it as something that could successfully be implemented throughout the mental health care system, or is that just a pipe dream?
References
- Anthony, W. A. (1993). Recovery from mental illness: The guiding vision of the mental health service system in the 1990s. Psychosocial Rehabilitation Journal, 16(4), 11-23.
- Mental Health Commission of Canada:
- Rethink Mental Illness: 100 Ways to Support Recovery
My latest book, A Brief History of Stigma, looks at the nature of stigma, the contexts in which it occurs, and how to challenge it most effectively.
You can find it on Amazon and Google Play.
There’s more on stigma on Mental Health @ Home’s Stop the Stigma page.
I like Anthony’s more inclusive, well-rounded definition of recovery.
I’m sorry the last facility you worked that claimed to be recovery-oriented were more interested in sounding good rather than practicing what they preach.
I know there are many problems with people on the ground, from mental health facilities to general hospitals, but I also think a huge part of the problem is with the top of the hierarchy. All too often, decisions on everything from budget to treatment plans are made by those who don’t have a clue.
Sadly, so true.
Very true!
I have been working with my therapist and prescribing doctor toward recovery since 2008. I’d like to make a distinction between working toward recovery and actually making a recovery. There are so many steps along the path toward recovery but many of those steps occur before you reach the destination of recovery. Do you still call it recovery work if you only have made it 5 out of 10 steps in the process? Is recovery a final outcome or a step in the process?
For me, it’s all about the process. Recovery as a final outcome doesn’t look like it will ever be a possibility, but the process of me trying to make the most of what I’ve got is ongoing.
Agreed. Recovery feels like a very big mountain to climb – I think I can I think I can…… Does the word remission have any place in this conversation? Is being in remission a thing? Something to achieve before or on the way toward recovery?
The concept of psychosocial recovery is supposed to be distinct from remission, with recovery being about personal meaning and purpose, and remission being a clinical term referring to the absence of symptoms. The idea is that even if people’s illnesses don’t allow for remission of symptoms, recovery is still a journey that one can be active in. I think that has to do with the fact that remission is a psychiatric term and the notion of recovery originated with the consumer/survivor/ex-patient movement.
Personally, I used to achieve full remission between depressive episodes, and at that stage of my illness, recovery and remission were the same thing to me. Now, it’s been 5 1/2 years since my illness was last in remission, so the recovery journey for me now looks very different from remission, because being symptom-free just doesn’t seem to be in the cards.
Thanks for the explanation. I am sorry to hear that your latest journey toward recovery has been 5 1/2 years in the making. I tend to use the phrase remission to mean I have been hospitalization-free not necessarily symptom-free. Maybe that is a misnomer I need to address….?
Hospitalization-free isn’t the clinical definition of remission. The specific definitions vary depending on the diagnosis, but here are examples for depression, bipolar, and schizophrenia:
https://www.icsi.org/guideline/depression/has-patient-reached-remission/
https://pubmed.ncbi.nlm.nih.gov/18007564/
https://library.neura.edu.au/schizophrenia/illness-course-and-outcomes/remission-and-recovery/
I agree with this type of approach. I have just started therapy and am hoping my therapist uses this approach. I feel I have a lot of strengths to help me through my issues and that is the primary focus of my therapy.
That sounds like a very good thing to focus on.
In my opinion and in answer to your questions:
Does recovery-oriented practice sound like something you think would be helpful?
Yes I do. I see (from personal experience too) a problem with the implementation of such a thing though. I’m working with a therapist currently who is dedicated to that sort of idea. And she makes ME do the hard work of figuring out how I can start to recover (and we’ve made more strides than all the years with other therapists – eight years now) have done. I’ve been seeing her for three-four months. Maybe I was prepped to take that next step already, but her pushing me to figure it out made the difference. Many of the therapists that I’ve seen have an attitude that comes across to me (with my borderline personality disorder yet) as wishy washy. They don’t follow through, they would give me work to do, but never seemed interested in the RESULTS, even if I went to great lengths to do the work. So I got lazy. I let the therapist lead the path and was content to trot along behind, giving lip service where required. And things for me didn’t change much.
Do you see it as something that could successfully be implemented throughout the mental health care system, or is that just a pipe dream? I think it could be implemented through Canada’s health care system more easily than it could down here in the States. Reason? Our health care system isn’t just broken, it’s smashed into tiny pieces. Greed is the foremost motivation for health care insurance certainly, but many providers are on that gravy train too. The patient gets a right fucking (sorry for the crude language). We suffer for their greediness by getting providers who are incompetent, who don’t give a fig about achieving a wellness goal with a patient, and who further damage the system. The ones who do have principles and who do good work and try to actually BE health care providers (mental or physical) get burned out as a result, because the patients figure out who IS competent and who is a fraud, and they flock to the competent ones. Or they slip through the cracks. I’m there with my physical health care right now and I can’t say I care either. I’m tired of platitudes, health plans that are unrealistic for me and my situation, and having more and more pills shoved down my throat because the provider is too lazy to figure out what’s actually WRONG and address it.
I got lucky with this latest therapist and even though it’s a big trial to make my appointments and do the work, because I AM lazy and have learned so many bad habits over the years, she gets results. I see progress. It’s amazing.
Now if we could get those ‘in charge’ to listen up, hmmm?
It seems like those in charge are fucked in the head on both sides of the border, although the money train isn’t such a motivator here. It bugs me that the kind of people that rise to the top are those who tend to make things worse for patients. On an individual level, there are definitely good ones out there, of which your current therapist sounds like a good example, but they can only do so much in a system that seems designed to screw patients over. Not that I’m jaded and bitter or anything…
Phenomenal article! I wish I had been educated when I began my journey. I agree about recovery being a hopeless goal. I’ve just haphazardly found my way to recovery-oriented practice without realizing it is a thing. Through the research of my own, my individual preferences, and the knowledge my diagnoses are forever, I created my path to where I am today. It was never suggested or encouraged by professionals rather “take this pill”. I recently stayed a stint in the hospital to stabilize, however, my last hospitalization was 10 years ago. I’m quite proud of that.
That’s definitely worth being proud of.
Recovery for me and my system mates will be integration. With the aim of healthy multiplicity without trauma impairments, amnesia, etc. We might always have trauma impairments of some form. Not just PTSD stuff but the wider issues of mistrust, and fear of vulnerability.
Integration is not to be confused with fusion and final fusion. Some achieve that (Looking at “Multiplicity and Me” on YouTube) but it can’t be forced without harm. And of course, we can split again. That happens, wg Carolyn Spring.
Psychiatry has a poor track record, in our opinion, with treating OSDD-1/partial DID/DID, that includes with experts in the field. They tend to be paternalistic. Gee, even ISSTD’s “latest” guidelines dated 2011 still thinks final fusion is the best blah blah. There’s limitations for many people globally whatever the diagnosis. So I don’t get why they think a unified personality is ideal. It eorld for some (case studies) but not everyone can spend 10 years in therapy integrating and then going for final fusion (more years in therapy), then the long relearning process (another bunch of years in therapy!) of how to cope without dissociation. To achieve “stable” final fusion. Which can fall apart with new trauma. How many people can afford that even if they want to?
I think health professionals need to realize that they shouldn’t get to decide what the goal is for an individual. Everyone is unique and should have the right to decide what the best outcome for them is.
Yup ❤❤
Reading this, I wish I could have continued with therapy. I had a great therapist and we had started EMDR but then covid struck and I couldn’t go in person anymore, which defeats the purpose of EMDR. I don’t like teletherapy because I am never honest/candid talking to the screen. I made great strides but I still need some more help to get to the stage of recovery where I’d like to be. But judging from what you write here, I can see that my therapist had a recovery model in mind.
I suspect the move to teletherapy/telehealth ended up fucking over a lot of people. It’s been convenient for some people, but it’s been a huge barrier for others.
It’s hard when you’re doing something requiring physical proximity like EMDR or if someone is like me and needs to be in the presence of the therapist to keep an eye on my body language so they can call me out.
Yeah, there’s a lot that just isn’t doable virtually.
I’m still trying to heal from stigma and being misunderstood to the point of a serious cyber incident where I had to phone the police 😳 It destroyed me at the time and the other party got others involved and they all took sides. No-one approached me and asked anything, I felt like a snail hiding in her shell from the burning rays of the sun. Other people VS mental health issues can be terrible and reinforcement of stigma.
You provide helpful support and encouragement to all who read your amazing work.
A hug for you and your piggies 💚
Thank you, and hugs right back at you. ❤️
Stigma can cause so much harm, and when people start taking sides, it never seems to be the side of the person dealing with mental health issues.
I like this concept: recovery-oriented practice. Good to see you speaking up about this:)
I appreciate Anthony’s ideology and framework. It seems an awareness is placed ( where it should be) on the strengths of the individual with solid respect for the dignity of the person. I would imagine to achieve this system wide the institutions and individual professionals involved would have to understand and value this approach. And, I think that would require each professional at each level of the system to do their own introspective work. I often think this is a large part of the problem. Providers don’t always value, understand, or have avenues to work toward this for a variety of reasons.
I agree. Introspection is hard, but it’s necessary for real change.