On-line version ISSN 2078-5135
SAMJ, S. Afr. med. j. vol.104 n.1 Cape Town Jan. 2014
CONTINUING MEDICAL EDUCATION
MB BCh, FCPsych (SA) OPD, Outreach and Medium Term Services, Lentegeur Hospital, Division of Public Mental Health, Department of Psychiatry and Mental Health, University of Cape Town, South Africa
Traditionally, recovery has referred to absence of disease, or cure. This makes sense when applied to a short-lived condition such as tonsillitis, but its relevance in more enduring or chronic conditions, such as high blood pressure, an amputated limb or mental disorders, is questionable.
We are all aware of many successful business people with high blood pressure and some very famous Olympians with amputated limbs. In the traditional sense, they can never recover from these conditions, but we don't think of them as sick people or 'cripples'. Yet, with mental illness, our understanding and resultant attitude can be very different. This has a powerful effect on how healthcare is provided and it also breeds a sense of hopelessness, which dramatically decreases the chance of the person ever getting better. If there is no hope, why bother even trying?
However, long-term follow-up studies increasingly show that the vast majority of people with mental disorders can get better over an extended period of time, particularly when they receive the right kind of support. This applies to even the most severe of disorders, such as schizophrenia. Furthermore, from the perspective of the philosophy of recovery, recovery in the short term is also possible.
A new understanding of recovery
The new understanding of mental illness recovery begins with a conceptualisation of recovery as a journey, rather than an endpoint. This journey begins with recognition of the existence of a mental health problem and the desire to set out on a path to healing. The focus is on acceptance of the reality of the illness, but also on the fact that one is still a whole person, with the possibility of a satisfying life, full of hope and meaning, regardless of whether symptoms are present or not. This also involves the realisation that recovery is about the whole self and not just the illness. As we all have our own way of seeing the world and our own ideas of what it means to live a positive, meaningful life, the definition of recovery is unique for each person.
For many people with mental illness, this can be a fundamentally empowering realisation. After all, the struggle to find happiness and meaning in life is a universal one, not something limited to people with mental illness. The idea that there is a clear line between those who are 'normal' and those who are not, is therefore immediately challenged.
This new understanding of recovery is summarised in the 2004 consensus statement of the US Substance Abuse and Mental Health Services Administration: 'Mental health recovery is a journey of healing and transformation, enabling a person with mental health problems to live a meaningful life in a community of his or her choice, while striving to achieve his or her full potential.''31 Such understandings have given rise to a global movement that seeks to make this view of recovery a core principle around which mental healthcare is organised.
Making recovery a reality
The philosophy of recovery views mental illness recovery as a personal process that can be aided by support services. Jacobson and Greenley have emphasised that four 'internal conditions' need to be present for recovery to take place:
- Hope that recovery is possible, generating a frame of mind that allows this to occur.
- Understanding that healing is different to cure, and that the emphasis is on self rather than illness and control.
- Empowerment as a corrective for the sense of helplessness and dependency that comes with severe mental illness and with traditionally paternalistic services.
- Connection with society and knowledge of one's roles in it.
For these conditions to exist, Farkas adds that services need to promote four key values:
- Person orientation. Seeing a patient as a whole person, rather than as simply someone with an illness.
- Person involvement. Involving people who have experienced mental illness in the design, planning and delivery of mental health services.
- Self-determination or self-choice. Understanding that the patients need to decide the meaning of 'better', set their own goals, make their own plans for how to achieve them, and take responsibility for the outcome of their decisions.
- Hope. Recognising the tremendous harm that is done when services are provided in a negative, cynical environment, and the enormous healing benefits of a positive atmosphere.
Recovery in South Africa
This vision of recovery is critical for the further development of mental health services in South Africa where resources are poor and levels of public knowledge and concern are even worse. The recovery movement involves a wide range of role-players, including patients, their friends and family, NGOs, and state services, all of whom need to pull together to make the necessary changes. Indeed, as awareness improves and stigma is challenged, it will become apparent that improved mental health is everyone's business and achieving it involves the kind of empowerment and transformation that is the dream of our young democracy.
1. Harding CM, Brooks GW, Ashikaga T, et al. The Vermont longitudinal study of persons with severe mental illness: I. Methodology, study sample, and overall status 32 years later. Am J Psychiatry 1987;144:718-726. [ Links ]
2. Bellack AS. Scientific and consumer models of recovery in schizophrenia: Concordance, contrasts, and implications. Schizophr Bull 2006;32(3):432-442. 'http://dx.doi.org/10.1093/schbul/sbj044] [ Links ]
3. Substance Abuse and Mental Health Services Administration (SAMHSA). National Consensus Statement on Mental Health Recovery Definition. http://mentalhealth.samhsa.gov/pub-lications/allpubs/sma05-4129 (accessed 18 July 2012). [ Links ]
5. Farkas M. The vision of recovery today: What it is and what it means for services. World Psychiatry 2007;6(2):68-74. [ Links ]