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4.3 Severe Mental Illness in Urban Context Samenvatting Week 3
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Samenvatting van alle te lezen literatuur van week 3 en colleges van het vak 4.3 Severe Mental Illness in Urban Context van de master Klinische Psychologie aan de Erasmus Universiteit Rotterdam (EUR). Behaald tentamencijfer: 8.0. Literatuur is in het Nederlands samengevat en colleges zijn voornamel...

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  • 15 februari 2021
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1


WEEK 3: Recovery paradigm

Lecture 5 (video lecture): Recovery paradigm

In today’s lecture you will be introduced to the recovery paradigm. This is a paradigm or perspective that this to
formulate a counter argument/answer to certain problems that are experienced in the current default perspectives
in psychiatry.

Expert by experience Brenda Froyen (2015): ‘We will definetly see her back’. She often heard this, what implies
that she will not recover and has to come back to psychiatric care. She experienced this as that there is no hope.
Slade (2009): Hope is central to personal recovery. […But] hope is a problem in mental health services. […] The
possibility of a good future is rarely communicated by mental health professionals. It is therefore all too easy for
people using services to develop the belief that they will never recover. […] This lack of hope has toxic
consequences. The self-fulfilling nature of being told by an expert that you’ll be never able to work, or live
independently, or have children, or be treatment-free is profoundly damaging. The reason that clinicians should
never make these statements (either explicitly or – more commonly – implicitly) is not some vague notion of
withholding damaging information. It is because these statements are often wrong.’

Postive outcome bias
 Positive outcome psychosis (see Goluksuz & Van Os, 2017): there a plenty of people that recover from
psychotic episodes, especially if they have only experienced it once. But even after several incidents it can
balance out. In scientific literature, however, less attention is given to people that recover. This scientific
bias can lead to us and patients thinking change and positives outcomes are rare or even not possible.
 Symptom reduction (Harding & Zahniser, 1994):
o Myth 1: Once a schizophrenic, always a schizophrenic Heterogeneity in outcome (is
overlooked because of bias and the ones that recover don’t come back)
o Myth 2: Schizophrenia is an homogeneous diagnostic category Diagnostic diversity
o Myth 5: People with schizophrenic symptoms have to use life-long medication
25-50% can come off meds
 Recovery > cure (recovery and being able to live happily is more important than to be cured or to be
completely symptom free) & symptom reduction (Harding & Zahniser, 1994):
o Myth 4: Don’t bother with psychotherapy (only medication works ) Experiential integration
It’s necessary to understand what the patient is experiences, which means psychotherapy is
worthwhile for people with schizophrenia even though it does not completely fit in the cure
paradigm, it is important for recovery
o Myth 6: Low-level jobs if jobs at all is possible for people with schizophrenia Limitations
by stigma (means that perhaps their chances at a job are more reduced because of stigma than by
their actual competencies)
o Myth 7: Families cause schizophrenia (bio/psycho) Critical collaborators
Even though family can have negative ‘effects’ on schizophrenia, however they are often an
important support system and can contribute positively to the course of patients with schizophrenia.
It is important to integrate the therapy with real life, in which family can play a huge positive role.
Otherwise, after treatment the effects won’t sustain and relapse becomes more of a risk.
 Recovery is not only ‘about symptoms, but about the relationship with the symptoms’ (Slade,
2009, p. 43)

‘Founding father’ Anthony
 The founding father of this way of thinking (recovery instead of cure) was Anthony. According to him there
are for domains that are effected by severe mental illness (SMI):
o Impairment: any loss or abnormality of psychological, physiological or anatomical structure or
function. E.g. hallucinations, delusions, depression
o Dysfunction: any restriction or lack of ability to perform an activity or task in the manner or within
the range considered normal for a human being. E.g. lack of work, lack of social skills, lack of ADL
skills, lack of adjustment skills. Regards limitations in the way people can fulfil tasks or activities
that are required in social situations, such as work, in social encounters with colleagues, friends
and family or societal services.
o Disability: any restriction or lack of ability to perform a role in the manner or within the range
considered for a human being. E.g. unemployment and homelessness. refers to the lack of ability
to perform in roles necessary for employment or renting a house, for example.

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o Disadvantage: a lack of opportunity for an individual that limits or prevents the performance of an
activity or the fulfillment of a role that is normal (depending on age, sex, social, cultural factors) for
that individual. Regards the opportunities of finding a meaningful place in society . E.g.
discrimination and stigma
 Medical discourse focused on impairment:
o Typified by ‘avoidance motivation’: the motivation to prevent symptoms
o Too little emphasis on ‘approach motivation’: motivation on meaningful future (Slade, 2009, p.
52). In this approach the other three domains described above are also taken into account instead
of only the impairment domain

Medical model terminology
 States of illness: complaints experienced by the patient e.g., pain, itching, loss of mobile functions.
 Disease: the cause of states of illness (ontological state or mechanism, often on biological level). We
assume a disease is touchable or traceable.
 Symptoms: the observable effects or manifestations of the disease, e.g. sadness in depression. The
symptoms are not necessarily the states of an illness. The most prominent system does not have to be the
symptom that bothers a patient the most. When you are talking to patients, you are talking with them about
complaints, not symptoms (if you consider the recovery paradigm approach).
 Cure: reverse the condition by eliminating the difference making symptoms
 Cure is understood as reversing the condition – the disease – by eliminating the difference making
symptoms. This is quite important, because I just addressed the fact that symptoms and states of illness
are not the same. So, if we say we want to reverse the difference making symptoms, keep in mind we are
talking about what we as health care professionals take as difference making symptoms. For example, in
schizophrenia, we take the hallucinations as difference making symptoms. That is not to say that for the
person sitting across you, these hallucinations are in fact experienced as the difference making symptoms!
It may very well be that if the hallucinations are somewhat stable or even positive, such as reported in the
Fenekou & Georgaca paper, it is rather the anxiety or the motoric restlessness that for the person are the
difference making symptoms! So, “cure” is understood mainly from the perspective of the health care
worker. And behind that, of course, our scientific approach.
 The medical model has found its way in psychiatric thinking and psychiatric care. This medical model has
consequences for how we perceive mental illness.

Experiences consequences of medical discourse
 According to this medical perspective on mental health and treatment…
o Your experiences are a disease. Consequences experienced by the patients are:
 Society condems your experiences by labelling it as abnormal or deviant (stigmatization)
 You condemn your own experiences (self-stigmatization)
o The doctor is an expert in your disease. Consequences experienced by patients are:
 You are detached from your own experiences
 You become dependent to the other
 You lose control over your life
 You adhere to your patient role
o And recovery means to be cured from your disease. Consequences experienced by patients are:
 You survive despite your disease, no cure implies no recovery
 You cannot further develop as a person (people feel stuck)
 Psychiatric focus on impairment puts focus on internal organization of individual (Anthony, 1993)  you as
the individual or the body of the individual is the focus of psychiatry
o Ignores embeddedness of complaints in external circumstances. Mental illness happens within a
context, e.g. society, your family, and community.
o Overlooks strengths and helpful aspects in circumstances for recovery
 “The assumption that treatment involves the clinician doing something to the patient constrains possible
solutions” (Slade, 2009, p. 24-25).

Principles of recovery according to the recovery paradigm (Anthony, 1993)
 Recovery can occur without professional intervention
 Presence of people who believe in and stand by the person in need of recovery
 A recovery vision is not a function of one’s theory about the causes of mental illness … people can recover
even though the physical nature of the illness is unchanged or even worsened
 Recovery can occur even though symptoms reoccur (goes against the cure paradigm)

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o E.g., “individuals who hear voices for a long time tend to enter a stage of stabilization, whereby the
voices become integrated in the hearer’s life.” (Fenekou & Georgaca, 2009, p. 138).
 Recovery changes the frequency and duration of symptoms
 Recovery does not feel like a linear process
o Recovery is a dynamic process involving (Drake & Whitley, 2014):
 Familial & social network (part of your identity and finding meaning)
 Work/societal perspective, beyond stigma & prejudice
 Agency (you are the decider of your life), dynamic growth
 Sense of self (identity) beyond disease
 Autonomy & indepence of health care services
 Recovery from the consequences of the illness is sometimes more difficult than recovering from the
illness itself (dysfunction, disability, disadvantage)
o “People in recovery are not necessarily defined as persons whose psychiatric symptoms have
decreased or dissappeared (clinical recovery) but rahter as individuals who despite the presence
of symptoms can reconstruct a positive sense of identity and a meaningful life (personal
recovery)” (Spector-Mersel & Knaifel, 2018, p. 300). Personal recovery is not completely distinct
from clinical recovery. You need some clinical recovery to experience personal recovery.
 Recovery does not mean that one was not mentally ill.
 Expert by experience Jeroen Zwaal (2018): ‘I recovered from three psychoses, mostly because I put an effort
in my job.’

Medical versus recovery perspectives
Medical perspective Personal recovery perspective
Your experiences are a disease (objectivity) Your experiences are not wrong, but meaningful, personal
and, personal, and worthy to be known (subjectivity)
The doctor is the expert in your disease You are the expert on your experiences and you can and are
(generalizable) allowed to take the lead over your own life (unique)
Recovery means to be cured from your Recovery means to develop a new meaning, new goals, at
disease (mollifiable) your own pace beyond mental suffering (holistic and
integrated within your personal frame of meaning)

Recovery is] 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.’ (Anthony, 1993, p. 15)

Four key processes in personal recovery (according to recovery paradigm)
 Hope: future-oriented perspective on a meaningful live
 Identity: develop personal identity beyond mental illness (c.f., me-it difference)
 Meaning: making sense of ‘mental illness’ & integrate in personal meaning framework (i.e., direct and
indirect meaning)
 Personal responsibility: stay in the driver seat (i.e., self-management, case-based treatment planning,
shared decision making)

Shared decision making
 Difference in perception between patients and health care professionals (Drivenes et al., 2020)
 To regard the patient as equal in the patient-clinician dynamic and decision-making processes is a medical-
ethical imperative for good practice (Goldenberg, 2013). This is an interpretative rather than just a
humanistic imperative:
o Humanist approach: clinician takes the patient’s perspective into consideration and then applies a
certain approach or decision to the patient. It still the clinician who decides what the next steps will
be. If a treatment does not work, you can ‘blame’ the patients. In this way, shared decision making
does not work according to its core valued.
o Interpretative approach: does not prioritize one interpretation over the other
 Shared decision making as dynamic between professional and patient, with varying leadership roles over the
course of treatment (Brown & Salmon, 2018). Autonomy of the patient should increase over time and the
perspective of the patient should be taken into account.
 Professional-patient dynamic is narrative context (Greenhalgh, 1999; see next weeks’ classes)

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