Critical Factors in Recovery

Focus on Users Prof. Shula Ramon, Recovery Centre Hertfordshire University Hatfield, UK Tel Aviv January 2008

The new meaning of recovery is to a large extent the outcome of users’ own work in countries such as the US, New Zealand, and the UK. In which way do previous professional – led and current user-led definitions differ?

Table 1: The innovative elements in the new meaning given to recovery

It is not about going back to a previous pre-illness state; Instead it is about forging a new way of living controlled by the newly found self agency of users; Recovery is from the trauma of psychosis (McGory, 1992, Davidson, 2003), treatment, stigma, lack of skills and opportunities for valued activities (Wallcraft, 2005);Inter-dependency and self help are an integral part of it; other people can be a source of support and confirmation of self worth;Hope is a core component (Repper & Perkins, 2003);Developing one's own coping strategies sits side by side with strategies for giving to others;It requires a systematic effort, which entails risk taking, as well as risk avoidance;The right to fail is an integral part of the new meaning (Deegan, 1996);Unlike the original meaning of the term recovery, the new meaning is partly created by users and adopted by them, and has transformative implications (Wallcraft, 2005);It entails a move from a deficit model of living with mental illness to a strengths perspective (Rapp, 1998) which Davidson (2003) aptly called living outside of illness..

Existing evidence The evidence on recovery rates from Schizophrenia is more than double the rate quoted in psychiatric textbooks of 25% existed since the middle of the 20th century (Bleuler, 1978, Ciompi, 1980, Huber et al, 1980, Jabelnsky et al, 1992, Warner, 1985, Harding, 1987, Harrison,2001), ranging between 50-65%.

Yet many professionals, users and carers seem not to have this information, or not to believe in it.

In summary, if recovery is about:

Reintroducing hope that there is life beyond one’s mental illness That one has abilities, and not only disabilities, after experiencing mental illness (the strengths approach) Chronicity is not a given!

Being mentally ill is not the totality of one’s identity: living with a hybrid identity Regaining control over one’s life Rebuilding identity Rebuilding valued social roles Questioning professional wisdom Then what is the challenge for all of us, but particularly for users?

To get rid of the belief in chronicity, an understanding of where the belief in chronicity comes from might be useful: Tooth et al. (2003) asserts that chronicity was seen as essentially being a feature of the disorder whereas it has come to be seen more recently more as a product of professional intervention and community stigma. Professional explanations of the meaning and nature of schizophrenia, such as the idea that it is incurable, can all too readily become self-fulfilling prophesies (Allott et al 2004).

What sustains the belief in chronicity

?

The belief in the genetic origin of mental illness as though it was fate and not an indicator of vulnerability It is reinforced by observing the lives of many users professionals work with, assumed to be solely the impact of mental illness.

However, genetics is about higher probability and about vulnerability, but not about fate! Social Stigma Internalised identity as doomed by the illness, unpredictable, potentially dangerous to others and self, should be doing what one is told by professionals Protective (or over-protective?) attitudes adopted by professionals and relatives The fear of professionals of the risk of giving the message that everyone can recover: aimed at not inflating users’ hopes and expectations as well as covering one’s back.

Lack of opportunities to engage in valued activities, in activities the person would like to do (need vs. wish as a motivating force)

Is it possible to reverse the identity of someone who has been both traumatised and devalued? A. Examples of approaches which have tackled successfully the reversal of devalued identities Without using the term recovery, the Italian Psychiatric Reform (Ramon, 1989) and Social Role Valorisation (Wolfensberger, 1983; Ramon, 1991), developed in the 1970s and the 1980s, left behind the focus on cure from symptoms&chronicity.

These approaches focused instead on:

Changing public and professional approaches Providing users with opportunities to lead a more fulfilling and socially inclusive life, even with a number of symptoms remaining. So did the focus on users' own strategies of living with voices, developed and nurtured by Romme and Escher from Maastricht in the Netherlands, and transferred into a successful network of local self help groups in the UK (Romme and Escher, 1993).

The user-led frameworks developed by Colman&Smith (1999) and Copeland (1993) demonstrate the implications of applying the strengths approach by users and their supporters to recovery work, as does the work of Rapp (1998), a social work professor, in care management.

Users fears of recovery The need to begin to think differently: Users’ Role a.Can there be positive aspects to being

different from one’s peers?

Developing the potential positives: having an understanding and knowledge which most of one’s peers do not have being more tolerant of people’s weaknesses looking for, and finding, new solutions learning to overcome adversity

b. The role of self-help groups

c.The role of users as mentors in the recovery of other users (Copeland, 1997, Allott, 2004)

d.Use of everyday knowledge about how personal

change can come about:

In their stories about recovery users come time and again to the point when it became worthwhile for them to take responsibility for their lives, to struggle to control their lives, to look for better solutions and options.

Frequently this happened when they felt that someone was genuinely interested in them as a human being, and ready to support them on their own terms. That someone could be another person with mental illness, a professional, a family member, a friend.

Changing the balance of power

If we want users to take responsibility, they need to have more control over their lives They can get together and think about the recovery-led services they would like to see implemented They can also do so with like-minded carers and professionals “Easily said than done, because they have come to be so dependent in their vulnerability”

Learning from the dimensions emerging from user-led research on recovery

Rogers et al. (1997) identified through a ‘Making Decisions Empowerment Scale’ the relevance of self- efficacy/self esteem,

power/powerlessness, community activism, righteous anger and

optimism/control over the future as the key components.

Ridgeway (2001) compared four early users’ recovery narratives, which confirm the importance of most of the dimensions already outlined above:

Table 3: Users’ recovery dimensions (Ridgeway, 2001)

Recovery as the reawakening of hope after despair; Breaking through denial and achieving understanding and acceptance; Moving from withdrawal to engagement and active participation in life; Active coping rather than passive adjustment

Case study Please work in small groups of 3-4 people for the next 10 minutes in considering what would you do as J in her journey towards recovery.

Please write down the most important four elements and be ready to share them with the larger group.