Formulación en régimen plástico

While the focus of recovery shifts from that of objectivity to one of subjectivity a more enlightened model of recovery continues to emerge. Contemporary models of recovery are structures or tools designed by patients based on their subjective experience of living with mental illness. Subjective experiences include instillation of hope, empowerment, development brought about by the mental illness, professional support and that which comes from significant others, and support for human rights (Warner, 2009). For example, in a study in the UK, SUs

identified 100 elements which promoted their recovery. A conceptual framework was then developed, Personal Recovery Framework (PRF), based on these subjective elements and was subsequently adapted for practice (Slade, 2009). However, in keeping with the ideology of contemporary models of recovery this can only serve as a guide to supporting theprocess of recovery from mental illness, as the journey is one that is unique to each individual.

1.6.2.1 Wellness Recovery Action Plan (WRAP)

WRAP is a step by step self-supportive plan that was developed in 1997 by patients living with mental illness in the USA, who wanted to recover from the illness. The patients were supported by Dr Helen Mary Copeland, who also confessed to have benefited from using the tool (U- Tube audio, Copeland, 1995-2015). Patients using the tool take ownership of their destination, goals and desires, they develop a plan of action on daily bases, acknowledge triggers of becoming unwell and how best to cope, they also delineate early warning signs along with indicators of when things are getting out of hand. They then develop an action plan. Patients also devise a crisis plan and how they would cope after a crisis (Copeland, 1995-2015). WRAP is based on five key concepts: hope, personal responsibility, education, self-advocacy, and support (Copeland, 1995-2015).

1.6.2.2 Recovery: An Australian Perspective

An Australian team of researchers, Andresen et al. (2003), conducted a critical study of personal narratives of psychiatric patients, from which they came up with a conceptual model of recovery, consisting of the following:

a. Finding and maintaining hope b. Re-establishing a positive identity c. Building a meaningful life

d. Taking responsibility and control

In an autobiographical account Helen Glover reiterated her own journey of recovery from mental illness. Glover was a teacher before she was diagnosed with mental illness, however, after becoming unwell, the department of Education in Queensland did not feel able to continue her employment because she was diagnosed with a mental illness. With her optimistic attitude, she changed career and graduated as a social worker, where she did not only enjoy working with people living with mental illness, but recognised it was also an opportunity for her to recover, as she interacted with empowering professionals (Glover, 2012). As a result of her experience Glover, identified five developmental stages which she believes are evident in those in the process of recovery. Because of her experience, Glover asserts that the following are important in helping survivors regain direction of their lives (Glover, 2012, p. 8-9):

a. From passivity to an active sense of self: where, rather than depending on others’ input and initiative, the patient survivor has the energy to us her strength, abilities and initiative in the process of recovery

b. From hopelessness and despair to hope: instead of giving up, one realises that there is a bright future ahead

c. From others’ control to personal control and responsibility: being responsible for one’s actions and destiny, versus blaming others or situations

d. From alienation to discovery: using the past to positively influence the future, or learning from past experience

e. From disconnectedness to connectedness: social inclusion and involvement with the rest of the community, as a citizen, instead of isolating or being isolated as a result of living with mental illness.

1.6.2.3 The Star Recovery

In the UK, the Mental Health Providers Forum (MHPF) developed a tool to accomplish two purposes: to be used in implementing recovery for patients, and as a measurement of their prognosis. The outcome measurement tool was developed using recovery based academic information, as well as evidence from patients’ accounts of their recovery from mental illness, and this lead to the development of core areas of a recovery journey (Dickens et al., 2012; Killaspy et al, 2012). The ten core areas of the recovery journey from mental illness are: i) Managing mental health; ii) self-care; iii) living skill; iv) social networks; v) work; vi) relationships; vii) addictive behaviour; viii) responsibilities; ix) identity and self-esteem; and x) trust and hope. The service user works alongside his/her key-worker to score the level of achievement at each of the ten core areas, using the ladder of change. The ladder of change has five steps which map a person’s position in the journey from being unwell to recovery, so that a patient who identifies him or herself as being in level five (in one of the core areas) indicates being much better that one on level one or two, of the same core area. Starting from the bottom to the top of the ladder an individual may be stuck with a problem, where they are unable to accept its existence; or they be on level twowhere they acknowledge that a problem exists and look and accept help to get it resolved. In level three one my believe that she or he can be an urgent of change to the problem, by either doing something him or herself, or even finding help from others in an attempt to achieve their set gaol(s); or move on to level four where they learn

and put into practise different strategies to achieve their goals implement. In level five individuals identify themselves as self-reliant and feel that they can manage their problems independently. The ladder helps patients in identifying areas that need improvement and working on. Additionally, using this tool in recovery assist patients to gain confidence in talking about issues they would otherwise not be able to discuss (Mental Health Providers Forum, 2008).

Although patients were involved in the design of the tool, the Forum acknowledged that this was limited. This was also pointed out during a research seminar on the Star Recovery, where it was recommendation that patients should be highly involved in the design and formulation of the recovery tool (Recovery Star Research Seminar, 2013). A survey undertaken by Killaspy et al., (2012) indicated that almost 90% of patients and close to 90% staff using the Star Recovery model stated that it is a very useful tool.

1.6.2.4 The Recovery Star modified

The Mental Health Providers Forum (2008) conducted a pilot study amongst two groups of Black, Asian and Minority Ethnic (BAME) group, where the star recovery tool was tested to ascertain if it addressed the issues of race and culture to those who experience mental health problems. More than 80% of participants said they found the tool enjoyable, and gave them a better understanding of their intended goals. Half of the participants stated that it was difficult to read and understand the tool, mainly due to language barrier. In the first group more than 60% felt that the tool did not cover some aspects of cultural identity (possibly due to the issue of language), yet 37% of the second group felt the same. The majority of participants also indicated that most of the ten core areas of the tool were related to them (Imonioro, 2009). However, they made a few recommendations which led to the modification of the recovery tool.

The BAME group felt that issues around religion, culture, the role of the family in promoting recovery, language, additive behaviours and identity and self esteem, needed to be either modified and/or included in the tool. To clarify and promote understanding of the tool pictures

were created for each of the core areas and the steps of the ladder. Secondly, the area of language has been included in a number of core areas. For example under ‘Living Skills’, patients are to indicate that they are attending literacy classes as a way of improving their English language. Excessive hand washing and self harm were incorporated under the core area of addictive behaviours. In the modified recovery model, patients can now score and talk about their ‘identity and self-esteem’ in relation to how they feel about their culture, spirituality and religious beliefs (Mizock et al., 2012)

The last step of the ladder, ‘self-reliance’ has been modified, following participants’ feedback that its definition did not reflect a similar meaning to them. Most BAME felt that self-reliance is defined within the parameters of social relationships, and not as an autonomous individual. Consequently, additional statements to include support from family and significant others have now been added, to reflect the communal support from various social groups.

1.6.2.5 A comprehensive model of recovery

Patients indicated that one of the influences of their recovery from mental illness was the way mental health services are designed, and the support given to them by professionals. Consequently, recovery lead services have been identified as enhancers of recovery, and this is predominately reflected in the organisations’ practise documents, such as the policies and procedures, and philosophies (Deegen, 1988; Anthony, 1993; Glover, 2012).

In an attempt to come up with a unified international conceptual framework, Le Boutillier et al., (2011) reviewed 30 international documents of recovery-focused services. Thematic analysis was used to identify commonly emerging themes, and these were merged into sixteen dominant themes. These were then grouped into four domains applicable to practice.

Figure 2 below summarises the conceptual framework that came out of this study. While these were taken from developed countries (England, Scotland, USA, Denmark, New Zealand and the Republic of Ireland) the conceptual framework could be used as a source of reference and to develop further research (Le Boutillier et al., 2011).

Figure 2 A recovery focused service by SCN, adopted form Le Boutillier et al., 2011

•WORKING RELATIONSHIP •SUPPORTING PERSONALLY DEFINED RECOVERY •ORGANIZATIONAL COMMITMENT •PROMOTING CITIZENSHIP

seeing beyond the service user, her

rights, social inclusion, meaningful occupation recovery vision; workplace support structures; quality improvement; care pathway; workforce planning partnership; inspiring hope individuality; informed choices; peer support; strengths focus; holistic approach

1.6.2.6 Basic assumptions of recovery from mental illness, adopted from Anthony (1993)

Recovery can occur with, or without professionals. As such, professionals must be aware that patients are the leaders in their journey of recovery. This becomes important in the formulation of service user centred care planes, as opposed to a ‘one size fits all’ (South London and Maudsley NHS Foundation Trust and South West London and St George’s Mental Health NHS Trust, 2010). Some of the important facets of recovery include the following;

• Patients have acknowledged the importance of support given by others during the journey of recovery. Meaning that recovery was promoted by encouragement from those who believed in them.

• Recovery from mental illness is not determined by its cause, whether physiological or psychological. Recovery can still occur even if the physical condition is present or becomes worse.

• The reoccurrence of symptoms of mental illness is not an indication that an individual is not recovering.

• Recovery is associated with a reduced frequency and duration of symptoms. So that even if symptoms reoccur, their interference to the service user’s daily life is much less than the previous reoccurrence.

• The recovery journey is not a straightforward one, even to the individual who experiences it. So that while there are episodes of rapid growth and development, insight into progress; there may also be hindrances, periods of confusion, lack of insight, and possible growth retardation.

• The loss of one’s ability to perform certain task and the loss of self-esteem, following being mentally unwell are the two issues which hinders the process of recovery. It is therefore important not to rely on the absence of symptoms, as measure for one’s

recovery. Patients play a central role in informing others of their position in the recovery journey.

• Those who have recovered from mental illness must have had a real experience of the illness, and not just mimic being mentally unwell.

1.6.2.7 The Medical Model and Recovery from Mental Illness

Despite attempts to make the voice of mental health experts louder by promoting and implementing the recovery values, there remains a constant tension between the medical perspective of mental illness and the use of the recovery model (Roberts &Wolfson, 2004). This is due to their different values. As already discussed, recovery is subjectively defined by those who experience the mental illness. On the contrary, evidence and objectivity is associated with the presence of illness, diseases and treatment. One of the distinctive features of these paradigms is that recovery focuses on the patient as an expert, because of his or her experience of illness, so that he or she becomes the central tenet of interest; while the medical perspective focuses on the disorder or illness, viewing health professionals and their instruments as experts and the main source of information about the illness, management and treatment; with limited consideration of patient contribution (Ralph et al, 2002; May, 2004; Roberts & Wolfson, 2004). A number of authors have highlighted significant distinguishing issues between the two paradigms, attributing this to their use of language (Ralph et al., 2002; Allott et al., 2003; May, 2004). A discussion on some of the contrasting phrasing delineated by the authors above is discussed below.

The recovery model perceives illness as a distressing experience, while the medical model focuses on psychopathology; a scientific study of mental disorders. The experts’ account of his

of one’s live and the influence of the illness in that life) enhance others’ understanding of the illness. The medical model gives a label of a ‘diagnosis’ to the illness, while recovery describes the illness in terms of the experts’ ‘personal meaning.’ Recovery uses terms such as choice, growth and discovery; in contrast to the use of compliance with treatment in the medical domain.

Although similar to a certain extent, Shean (2010) introduced another perspective to the perspective of schizophrenia and recovery, based on the causes of schizophrenia. Within the biomedical model schizophrenia is said to be caused by genetic defects which results in biochemical changes to the brain; so that pharmaceutical interventions is paramount to reversing the defects. On the contrary, the focus of the psychosocial model advocates that schizophrenia is triggered by interactions in society and, along with the genetic influences, medication is unable to address the causes of the illness. The diathesis-stress model addresses the weaknesses of each of the two former models; integrating in the bio-psychosocial contributions to the triggers of schizophrenia to develop effective strategies that enhance recovery from schizophrenia (Shean, 2010). The Schizophrenia Patient Outcomes Research Team (PORT) developed evidence based bio-psychological guidelines for promoting recovery of people living with schizophrenia; these consist of 16 psychopharmacological treatments and 8 psychosocial interventions (Kreyenbuhl et al., 2010).

The outcomes of living with mental illness leads to transformation in the recovery model, yet in the medical perspective talks about returning to normal function. The focus of this study is the recovery perspective; where contributions from people living with mental illness is highly valued, and the intention is to find new insight into the lived experience of women diagnosed

with schizophrenia by attentively listening to their biographies, and interpreting them in order to develop supportive strategies which will be congruent to their needs.