Understanding Recovery

By Stuart Sorensen - RMN

Since the nineteenth century, when psychiatry was just beginning, a furious argument raged between people with very different opinions about the nature and course of mental disorders. On the one hand, psychiatrists like Eugene Bleuler believed that recovery was possible and indeed likely for the vast majority of people suffering from serious mental disorders like schizophrenia (then called dementia praecox).

On the other hand, psychiatrists such as Emil Kraepelin insisted that recovery was impossible and that sufferers would never recover. Indeed he believed that their condition would get worse throughout their lives. Kraepelin won the debate and the idea of permanent illness and disability has formed the basis of mental health services ever since.

People with ... schizophrenia and bipolar affective disorder can and do recover and go on to lead useful and fulfilling lives.

Many people argue that this was a mistake. People with serious mental disorders such as schizophrenia and bipolar affective disorder can and do recover and go on to lead useful and fulfilling lives. This handout provides a brief overview of current thinking about recovery.

The International study of Schizophrenia (Harrison G. et al 2001) is a long term study of the nature and outcome of schizophrenia in many countries across the world. It ran for around 25 years and has produced some remarkable results.

It seems that the rich industrialised nations of the developed world, in spite of our sophisticated treatments and drugs, have some of the worst records in terms of recovery rates from serious mental illness. Other places such as rural India have much higher recovery rates, as much as 90% in some places. It is not possible to say with confidence exactly why this might be but there are a number of possibilities which seem to fit the research.

People who live in cultures where they are expected to recover tend to be much more likely to do so. In the West, where we tend to expect people to deteriorate they tend to do worse. It seems that whatever a person is encouraged to think about themselves will probably come true. This is called a 'self-fulfilling prophecy' and is a regular theme in this series of handouts.

It's much easier to live a relatively stress-free life in a society which accepts us. Cultures which accept or perhaps even value people who have suffered episodes of mental disorder (shamanic cultures for example) tend to have much higher recovery rates.

By way of contrast, popular Western culture, fuelled by misleading media hype about people labelled as 'mad, bad and dangerous', tends to avoid and isolate people with diagnoses of serious mental disorders. This makes it much harder for them to develop effective social networks and make friends.

Occupation and work
People are much more likely to recover if they are engaged in productive work. Apart from the effect that this has on a person's self esteem it provides them with something to think about other than illness. Work also gives people the opportunity to mix with others who may not have had mental health problems, thus helping them to maintain links with mainstream society.
Recent studies in Britain have shown that people diagnosed with serious mental disorders tend to find it extremely difficult to find work. In fact the trend is for people to lose employment after diagnosis rather than gain it.

For every person distressed by their voices there are many others who aren't.
Everyone has good and bad days and normal mood fluctuation is a part of life. However people diagnosed with serious mental disorders often believe that the slightest change in mood is evidence of relapse. This can also be true of their families who sometimes become extremely sensitive to even normal changes in mood or behaviour.

Often people become so worried about these normal fluctuations in mood that they become extremely stressed and so bring on an episode of illness which wouldn't otherwise have happened. Cultures which are more likely to accept people's changes in mood tend to have the best recovery rates.

People who live in cultures where they are expected to recover tend to be much more likely to do so.

Even the more serious 'symptoms' of mental disorder such as voice-hearing don't necessarily mean relapse. A recent study in Holland (Romme M. & Escher S. 2001) found that although many people heard voices only a fraction had a problem with them. To put it another way, for every person distressed by their voices there are many others who aren't. The handout on hearing voices in this series has some interesting information about how and why people can cope with their voices.

Three types of recovery
It's important to be clear about what we mean by recovery. Many people would argue that there are actually three types of recovery and if a person can achieve any two of the three then they have recovered. The three types of recovery are:

1. Social recovery
This is to do with acceptance by the community in which a person lives. If the people around us don't have a problem with us then we have achieved social recovery. We become productive members of our society and contribute to the social structure around us.

2.Psychological recovery
If we are not distressed by our 'symptoms', such as the voice hearers in Holland, then there is no problem. This is known as psychological recovery.

3.Medical recovery
This is to do with the signs and symptoms which doctors use to diagnose mental illness. If we are free of symptoms of mental disorder then we can be said to have recovered, so long as the symptoms do not return. This is why mental health professionals who are interested in recovery work hard on 'relapse prevention'. If a person never has a relapse of their mental health problems than that must equal recovery.

British outcomes
In Britain, as in many other developed countries, the course of illnesses such as schizophrenia and bipolar affective disorder can be divided roughly into three equal groups:

  • About a third of people recover completely.
  • About a third of people continue to have the occasional relapse without getting any worse.
  • About a third of people do indeed deteriorate throughout their lives and never really become well.

  • This is much less positive than the outcomes in the developing world, possibly for the reasons outlined above.

    What can we do about it?
    If we believe in the possibility of recovery and actively work toward it who knows what could happen?

    It's extremely difficult to have any real impact upon the culture as a whole. However there is a great deal that can be done to change the outcome for individual sufferers. By working on interpretation and expectation it is possible to greatly impact the effects of illness. Work aimed at helping the person find an accepted place in their community, perhaps with meaningful employment to boot, is likely to make a huge impact upon their individual outcomes.

    The important thing is not to accept the old ideas. If we believe in the possibility of recovery and actively work toward it who knows what could happen?
    This has been a very brief overview of the notion of recovery from serious mental disorder. Further information can be found in the work of recovered 'schizophrenics' such as Rufus May, clinical psychologist or Ron Coleman, founder of the Keepwell organisation.

    Harrison G. et al (2001) Recovery from psychotic illness: a 15- and 25- year international follow up study British journal of Psychiatry Number 178 pp.506-517
    Romme M. & Escher S. (2000) Making Sense of Voices MIND Publications, London

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