I recently read a very interesting and mostly helpful document by the UK charity Rethink, 100 ways to support recovery. However, I had some reactions to their approach to defining recovery, and I thought I would share them here.
According to Rethink “Clinical recovery is an idea that has emerged from the expertise of mental health professionals, and involves getting rid of symptoms, restoring social functioning, and in other ways ‘getting back to normal’.”
Rethink contrasts this with Personal recovery, which they define as “an idea that has emerged from the expertise of people with lived experienced of mental illness, and means something different to clinical recovery. The most widely used definition of personal recovery is from Anthony (1993): “…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 one grows beyond the catastrophic effects of mental illness.”
Rethink further states that “It is generally acknowledged that most mental health services are currently organised to meet the goal of clinical recovery” and then goes on to advocate for a shift to a focus on personal recovery instead.
I would argue that most mental health services for what the system calls “serious mental illness” are really not organized around any kind of recovery at all, but are organized instead around a desire to keep people out of acute crisis so they are less of a burden on the community. Most services don’t even seriously contemplate the possibility of recovery once people have been in the system awhile, and indeed people are often told to expect that they will always be “mentally ill.”
However, recovery and reorganizing the system to work toward recovery is at least being talked about more, so it is important to decide what recovery really is. While I believe that Rethink correctly asserts that there are serious problems when or if people are led to exclusively focus on clinical recovery, there are also real problems caused by simply shifting to a focus on “personal recovery” instead.
One of those problems is that fact that personal recovery is usually defined as accepting the limitations of the “illness” and finding ways to live within those limits. Unfortunately, this suggests that people should give up on attempts to transcend any such limits, and as a result, the focus on “personal recovery” has been used as part of the movement to redefine recovery as “doing a bit better while continuing to be mentally ill.”)
I believe a better conception of recovery would frame efforts at clinical recovery and at personal recovery as both important, and as capable of supporting each other. Working together like this, they could be like the two “legs” of full recovery. Full recovery would be seen as including the components of both clinical and personal recovery, and as definitely involving no longer being “mentally ill.”
When people focus on clinical recovery alone, they feel defined by their mental health problem, and this focus can actually exacerbate the problem, while leading the person to neglect other areas of their life which might otherwise be cultivated and lead to improved wellbeing. And since clinicians often identify as “illness” experiences like hearing voices which could be accepted and integrated in a way where they become no longer problematic, a focus on clinical recovery may lead to wasted effort trying to get rid of personal idiosyncrasies which could actually be personal assets if understood and worked with in the best possible way.
But if people focus on personal recovery alone, they might settle for overly restricted lives, forced to stay within limits caused by mental health problems which otherwise might be resolved. A person with a high level of paranoia for example might decide that working in an environment that triggers the paranoia will always be impossible, or might decide that taking a high level of medication to offset the paranoia will always be necessary, when in fact if the person did psychological work focused on resolving the paranoia (clinical recovery) it might be found that the paranoia could be overcome & the person could return to the environment that used to trigger paranoia, eventually without using any medication.
Since full recovery involves both personal recovery and clinical recovery, it makes sense that while working toward full recovery, one at times may be more focused on personal recovery, at times more on clinical recovery, depending on what is more possible and what is more desired at the time. Progress in one area of recovery can later be leveraged to support progress in another: for example a person who succeeds in a job despite the presence of critical voices (a success in personal recovery), might later use the confidence resulting from that job success to change the relationship with the voices and to reduce the self doubts that generated the voices (so creating a success in clinical recovery.) This success in clinical recovery might then open doors to more possible life accomplishment, or more personal recovery.
Why is this important? Because restricted definitions of recovery make it more likely that people will feel stuck with a definition of themselves as “mentally ill” or at best “always recovering.” They will fail to notice that many people have already accomplished both personal and clinical recovery, and this is possible for them as well. And they may feel stuck with either restricting themselves to whatever is possible within limits set by their mental health symptoms, or stuck with medications that may suppress those symptoms, but often at a cost of many more problems, including some that may be fatal.
In contrast, when full recovery is seen as possible, it also becomes more likely, because people will then work toward that possibility. What is really needed is for the mental health system as a whole to recognize this possibility and reorient toward helping people work toward it, rather than envisioning lifelong disability, which too often becomes a self fulfilling prophecy.
Thanks for this piece. It explains the tension.
“Why is this important? Because restricted definitions of recovery make it more likely that people will feel stuck with a definition of themselves as “mentally ill” or at best “always recovering.”
The document summarizes a very positive step in the treatment process. This conceptual framework is a marked improvement over the current approach to treatment. While it appears to be written within a context that suggests medication is a preventative tool to avoid relapse it is also less coercive with respect to the absolute need for medication compliance.
I will suggest that personal recovery, in most cases, is a necessary precursor to clinical recovery and either term might mean any number of things to different people. In some respects focusing on the distinctions of personal versus clinical recovery is symantic.
Clinical recovery cannot mean anything less than recovery without the need for ongoing medication and an absence of symptoms. It is possible, even for schizophrenia. In this instance the individual is “cured” or has recovered sufficiently so that his or her prior condition is not an impediment to their full functional capability in society.
Anything less than full recovery can be defined as having the condition and that condition being in some state of control that allows the individual some level of functional capability, perhaps even near normal, though the individual still has the condition. In this case the individual either is being prescribed medication to control symptoms or experiences symptoms but does not take medication.
Recovery is transformative! It is in the realm of “what I had that limited me before has now been transformed. It is gone. I am complete. My life presents a new state of possibility.”
I think clinical recovery as is often still defined by psychiatrists is having symptoms under control with the aid of meds. This is explained in the article too.
The concept of full recovery is so important and many consultants do not expect this and the view that the patient is deficient in either chemicals or genes prevails. If that is so, the why do some make full recoveries.
Personal recovery goes further than clinical recovery since you go to a recovery stage which you yourself expect, as opposed to what consultants expect of you, which unfortunately due to their training and lack of personal experience of the illness is not much.
Therefore full recovery should be sought after and strived for by the patient, but all too often this involves a battle with the mental health system and at some point, non-compliance. This is sad when the support of a consultant to aim to full recovery may be the difference between making it and not.
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