These days people are talking about recovery from mental illness. This is a great step forward. Even using the word recovery in a field too long dominated by the goal of stabilization is refreshing. But whose vision of recovery are people talking about? I thought we were all talking about the same view of recovery. I see two distinctly different visions of recovery emerging, however. We will call these the Rehabilitation and Empowerment views of recovery. It is especially important to clarify what recovery means in each model because many states and counties nationally are proposing to create recovery-centered policies and services. Distinctly different policies would result depending on whose picture of recovery those policies are based on.
Rehabilitation View: Recovery of Function Despite Still Having the Permanent Impairment of Mental Illness
According to this view, mental illness is seen as a primary, permanent impairment similar to a spinal cord injury resulting in paralysis. This impairment causes a disability depending on the degree to which it interferes with a person’s capacity to function in a major social role such as worker, parent, or student. The rehabilitation view of recovery from spinal cord injury is that, with supports, a person can once again function in society. Their impairment, however remains permanent. As William Anthony, from the Boston University Center for Psychiatric Rehabilitation states, “a person with paraplegia can recover even though the spinal cord has not. Similarly, a person with mental illness can recover even though the illness is not ‘cured.'” (Recovery from Mental Illness Psychosocial Rehabilitation Journal, 16:12-23, 1993). The rehabilitation view of recovery from mental illness is that people can regain some social functioning, despite having symptoms, limitations, medication, and remaining mentally ill. Though this rehabilitation view works in describing recovery from the effects of physical impairments, it does not help explain how people can recover from mental illness. Whereas in paralysis a person’s spinal cord is injured, separating their functioning head from the rest of their poorly functioning body, in mental illness the whole person is separated from the people around them. They are considered less than human. They experience a loss of civil rights. Once a person is labeled mentally ill, they are discredited and disqualified from full membership in society solely as a result of that label. Therefore, to say that the person’s mental illness is a permanent condition is to forever ostracize the person from society and say that they will never be able to regain a major social role. No wonder there is such a high rate of unemployment (85-90%) among those labeled with mental illness. The label defines the person as being incapable of work. No wonder so many people labeled with mental illness lose their children; the label itself defines the person as being an incompetent parent.
A New Vision of Recovery: the Empowerment Vision
In contrast to the Rehabilitation View of Recovery, people who have recovered from mental illness have an empowering view that full recovery is possible for everybody. According to this Empowerment Vision, people are labeled with mental illness through a combination of severe emotional distress and insufficient social supports/resources/coping skills to maintain the major social role expected of them during that phase in their life. The psychosocial nature of mental illness is highlighted by the common experience most consumer/survivors have gone through of having had a variety of diagnoses. In fact, the degree of interruption in a person’s social role is more important in affixing the label mental illness to someone than their diagnosis. Recovery is possible through a combination of supports needed to (re)establish a major social role and the self-management skills needed to take control of the major decisions affecting one. This combination of social supports and self-management help the person regain membership in society and regain the sense of being a whole person. Self-help and peer support are fundamental elements in this journey of recovery because often the only people who can truly understand the feeling of exclusion are those who have also been labeled. The diagram summarizes our view of recovery. The usefulness of this model is seen in the description of two young adults in this issue. They were equally distressed but one boy found the belief, social supports and resources to heal his emotional distress while the other lacked the necessary beliefs, supports and resources. The first boy was able to maintain a social role of student while the second boy was not able to remain a student and was labeled with mental illness.
According to this vision, one is capable of recovering from the mental illness itself, not merely regaining functioning while remaining mentally ill. This distinction is critical in a person’s motivation to improve as well in the attitudes of society towards people who have been labeled. Ideally this recognition will be the first step towards finding a way to provide benefits, such as social security, for people whose functioning is compromised by emotional difficulties without needing to first reject them as members of society. We realize that the idea that people can recover from mental illness will create more work on the part of entitlement programs. Instead of a single, once-in-a-lifetime determination of disability, episodic periods of disability will need to be supported. We also realize that people will fear they will lose their social security before they are able to live without it. Hopefully Social Security can be reformed to provide the needed gradual transitions back to work. (Some of these issues are addressed in an accompanying article.)
In this model, treatment is part of self-managed care. The goal of treatment here is assisting people in gaining greater control of their lives and assisting them in regaining valued roles in society. The primary goal of treatment should not be to control the person’s behavior. The use of medication does not itself mean that a person has not recovered from mental illness. It depends upon the degree to which the person and those around them see the medication as constantly needed. Ideally, each person should learn to take medication on an as-needed basis, after having learned to self-monitor. Many people also embrace holistic health as an alternative to medication.
In addition, people regain a valued social role through support services in housing, work, education, and parenting. As many of these services as possible should be run by people who have recovered. These services are as vital to recovery as any medical procedure.
This model also differentiates between recovery from mental illness which involves a limited number of people over limited periods of time, and the nearly universal healing and transformation from emotional distress and trauma which can occupy a lifetime.
Role of Work in Recovery
Psychiatric disabilities are unique because the label of mental illness itself creates a barrier to people returning to work. Perhaps more than any other label in our society, mental illness indicates to the person and those around them that he/she will never be capable of work. This may explain why so few people labeled with mental illness are working in competitive jobs. Therefore, to truly remove this barrier to people returning to work it is necessary to recognize that people recover from mental illness and that work helps in that process.
In this new vision of recovery, work plays an important role in recovery from mental illness. In many cases, loss of work plays an important role in a person being labeled mentally ill. In addition, boring, unfulfilling work can lead to stresses which contribute towards mental illness. Without work, or another equivalent social role (parent or student), a person loses membership in this society and the identity which accompanies membership. It then becomes necessary to assume a new identity as a consumer. The movement to find jobs for people labeled with mental illness as mental health providers helps many of us to regain an identity as worker and member of society and thereby recover from the mental illness. (NEC has produced a video on this topic.)
Recovery from mental illness does not mean that the person no longer needs support. In fact, those continued supports are often critical in the person’s recovery. Though working persons, with a history of mental illness, may no longer need cash benefits, they continue to need other benefits such as health insurance (see article in this newsletter) and housing. According to our new vision of recovery many people have recovered from mental illness, although they and those around them still think they have not. They are, however, carrying out important social roles and have learned to take control of their own lives. They still experience at times severe emotional states, but they and the people around them have learned to cope with them. They are surprised to learn that they are now dealing with the states that many people never labeled with mental illness go through. They seem to go through a combination of relief and fear at the idea that they are no longer mentally ill. We hope that this model will raise this topic of discussion about recovery being a goal which can be achieved in a period of time rather than it needing to be a life-long process.