Images taken in Argyll and Bute psychiatric hospital – which is still in use.

Over the past few years this word ‘recovery’ has found powerful new meanings within certain groups of people who have been treated within some parts of our health care system. It has become the label for a challenge to the dominant medically driven hegemony within psychiatry in particular, but has also found deep resonance amongst people who have struggled with addictions.

There is a shift at hand in the power dynamics within the system that has the whiff of revolution. All of us who are involved in working with people in some form of mental distress or using some kind of therapeutic process would do well to sit up take notice.

The concept of ‘recovery’ grew out of the lived experience of people who had experienced mental ill health, and perhaps more tellingly, had come through the psychiatric system. They described a process of treatment that often went something like this;

Loss of role and identity

As a result of illness and the separation that the stigma of illness enforces, people experiencing acute mental ill health start down a path of being stripped of who they are.

• First people lose their job/career
• As a result of which they struggle to hold on to possessions- home, car etc
• The stigma of this puts a huge strain on relationships- and so they will lose friends
• Perhaps they may also lose their life partner, and because of this also lose close contact with children
• In all of this, it is incredibly hard to hang on to a sense of personal identity and self worth
• Some people lose the ability to make choices, either through the limiting effects of the above losses, or because these have been taken away by the legal-medical system

New role and identity

For the best of reasons, society sought to find a solution to the mental distress, and so medicalised it- giving the power to detain and to treat primarily to the medical profession. They developed huge institutions, and billions were invested in drugs. The hope was that people might be made better, or if they could not be cured at very least they should be cared for and safe.

So people in mental distress were given a new role and identity-

• They became patients, clients, service users
• If they behaved well, they were ‘compliant’
• If they resisted they were showing signs of  ’challenging behaviour’
• If they tried to play the system they were labelled as ‘manipulative’

Treatment

Meanwhile, the system applied a model of care based largely on other forms of medicine. First your condition is assessed, then it is diagnosed and finally it is treated with scientific evidence based treatments. If you did not get better, then alternative treatments were used. If you still did not get better, then it became a little more problematic. Perhaps we needed higher doses, or more radical treatments. Or perhaps you were treatment resistant, and as such, not much could be done for you and the rest of your days might be lived out in a kind of half life- subject to constant care plans, risk assessments and packages of care.

People who had been through this process – the loss of who they were, then becoming a ‘patient’ – these people started to tell stories to one another. They were convinced that the system was not working- iIt certainly was not working for them. Some even questioned the very core assumptions that psychiatry was based on. They pointed out that despite the so called advances in science, the outcomes for people diagnosed with mental illness were largely unchanged.

Some of this began to gather together around what came to be called the ‘Hearing Voices Movement’.

However, possibly the most significant thing to emerge from this is what has come to be called the ‘Recovery Movement’. Recovery as a personal journey rather than a medical process. A journey based on hope and personal growth both in the presence and absence of symptoms.

The Scottish Recovery Network defines recovery like this-

People can and do recover from even the most serious and long-term mental health problems. Recovery is a unique and individual experience and while there may be common themes and experiences, no two people’s recovery journeys will be identical.

We describe recovery as follows:

“Recovery is being able to live a meaningful and satisfying life, as defined by each person, in the presence or absence of symptoms. It is about having control over and input into your own life. Each individual’s recovery, like his or her experience of the mental health problems or illness, is a unique and deeply personal process.”

This from the Mental Health Foundation-

Research has found that important factors on the road to recovery include:

• good relationships
• financial security
• satisfying work
• personal growth
• the right living environment
• developing one’s own cultural or spiritual perspectives
• developing resilience to possible adversity or stress in the future.

Further factors highlighted by people as supporting them on their recovery journey include:

• being believed in
• being listened to and understood
• getting explanations for problems or experiences
• having the opportunity to temporarily resign responsibility during periods of crisis.

The challenge this presents to professional ‘helpers’; therapists, social workers, nurses and doctors, should not be underestimated. It is not just a change of language that is being proposed, but rather a root and branch change to what we are about. It requires a power shift away from the professionals, and back to the individuals themselves.

What is even more challenging is the idea that the whole system of psychiatric classification, diagnosis and treatment, driven as it has been by the medical model and the multinational pharmacology companies is being re-evaluated. The old divisions between ‘psychosis’ and ‘neurosis’ are being eroded and replaced by a return to ideas of how we might respond to trauma and develop coping behaviours.

As part of this transition, a number of helpful tools have been developed, intended for use by individuals themselves, with support only if they feel this necessary. Here are a selection-

Wellness Recovery Action Planning (WRAP)

Recovery Star

DREEM (Developing Recovery Enhancing Environments Measure)

Loads of free downloads here

SRN Narrative project- stories of recovery and hope

One more resource to mention which might be of particular use to those of us who work for organisations who provide direct support and intervention to people with mental health problems – The Scottish Recovery Indicator is a tool that can be used by staff and users of the service to rate how ‘recovery focussed’ the organisation is. Using it can be rather sobering!

It can open up all sorts of doors.

In May, the American Psychiatric Association will publish the fifth edition of the Diagnostic and Statistical Manual of Psychiatric Disorders, otherwise known as DSM 5. Although originating in the USA, this publication is immensely influential and is likely to form the basis for Psychiatric diagnosis the world over, as with the out going DSM 4.

Does it matter?

Well, my answer to this question is YES.

It matters on an individual level because all of us will be affected by mental disorder. One in four of us will be diagnosed according to one of the classifications above, so even if this is not you it will be someone you love or someone you work with. Lots of us feel a strange relief when distress is given a name – it suggests understanding, companionship, a removal of uncertainty and the possibility of treatment. However, for many these can easily become self perpetuating and destructive as they may have the effect removing responsibility, ownership and even hope, which some never find again.

It matters too on a sociological level. Our societies are increasingly regulated by psychiatry. We medicalise, medicate and plan ‘evidence based interventions’ into all sorts of human variation. This may simply amount to the application of science and knowledge to the alleviation of mental illness, but the question is whether this is ‘healthy’? Are we seeking to make a world in which the mess and gristle of life is edited out, tidied away, chemically suppressed? And is it working?

Psychiatric classification almost always demands treatment, so step forward the drug companies. All those countless drug rep funded lunches, gadgets, even holidays in the name of publicity for the next wonder drug. Even if the drugs do half of what they promise there is no doubt that our population is increasingly medicated. This from here;

Prescription Pricing Authority data shows that more than 30 million prescriptions for SSRIs (selective serotonin reuptake inhibitors) such as Prozac and Seroxat, are now issued per year, twice as many as the early 1990s. Researchers at the University of Southampton found 90 per cent of people diagnosed with depression are now taking SSRIs either continuously or as repeated courses over several years.

Professor Kendrick adds: “Our previous research found that although these drugs are said not to be addictive, many patients found it difficult to come off them, due to withdrawal symptoms including anxiety. Many wanted more help from their GP to come off the drugs. We don’t know how many really need them and whether long-term use is harmful. This has similarities to the situation with Valium in the past.”

Unsurprisingly, there is evidence that the current economic recession is also having an effect. This from the Telegraph;

The number of prescriptions for drugs such as Prozac has risen from 16 million to 23 million since 2006 with many GPs saying patients are increasingly expressing concern about the recession.

Figures obtained by the BBC under the Freedom of Information Act found the number of prescriptions for the most common group of antidepressants rose by 43 per cent during the period covering the banking crisis and housing crash.

If we can agree that in terms of practice, prescription and intervention psychiatry is increasingly involved in our lives, then the emergence of a new set of diagnostic criteria must be a considerable significance to all of us. We should also know then that this classification process, already controversial, is in the middle of a storm of criticism following the release of advance details of the new DSM 5.

Firstly, what could be regarded as the ‘tabloid headlines’. This from here;

Bereavement, which has always been excluded from the mood disorders, will become a mental disorder. Mild forgetfulness will become a mental disorder (“mild neurocognitive disorder”). Your child’s temper tantrums will become a mental disorder (“disruptive mood dysregulation disorder”). Even preferring one of your parents to the other will become a mental disorder! (Yes, really: “parental alienation disorder”).

You will need to display fewer and fewer symptoms to get labeled with certain disorders, for example Attention Deficit Disorder and Generalized Anxiety Disorder. Children will have more and more mental disorder labels available to pin on them.  These are clearly boons to the mental health industry but are they legitimate additions to the manual that mental health professionals use to diagnose their clients?

You can listen to a short Radio 4 Today Programme debate on some of these issues between David Kupfer who chairs the DSM 5 committee for the American Psychiatric Association, and Peter Kinderman, professor and honorary Consultant Clinical Psychologist with Mersey Care NHS Trust about this between on this link.

Then there is the murky world of classification of ‘personality disorders’. Many people regard these as the ultimate examples of how abstract description of patterns of behaviour can become viewed as some kind of unassailable concrete ‘illness’, which then take on a reality in the same way as we might understand influenza or cancer.

DSM 5 complicates this further by adding more categories, for example “Apathy Syndrome,” “Internet Addiction Disorder,” and ”Parental Alienation Syndrome”. This has raised so much concern that the American Psychological Association has begun an on line petition to allow people to express their concerns. This from here;

It is particularly concerning that a member of the Personality Disorders Workgroup has publicly described the proposals as “a disappointing and confusing mixture of innovation and preservation of the status quo that is inconsistent, lacks coherence, is impractical, and, in places, is incompatible with empirical facts” (Livesley, 2010), and that, similarly, Chair of DSM-III Task Force Robert Spitzer has stated that, of all of the problematic proposals, “Probably the most problematic is the revision of personality disorders, where they’ve made major changes; and the changes are not all supported by any empirical basis.”

How about this side of the Atlantic? This from the British Psychological Society (not renowned as a radical organisation) response to the consultation;

The Society is concerned that clients and the general public are negatively affected by the continued and continuous medicalisation of their natural and normal responses to their experiences; responses which undoubtedly have distressing consequences which demand helping responses, but which do not reflect illnesses so much as normal individual variation. (p.1)

We believe that classifying these problems as ‘illnesses’ misses the relational context of problems and the undeniable social causation of many such problems. For psychologists, our well-being and mental health stem from our frameworks of understanding of the world, frameworks which are themselves the product of the experiences and learning through our lives. (p.4)

These comments go to the very heart of how we approach mental distress.

The Hearing Voices Network have been making a case for change for many years. Psychiatrist Marius Romme for example claimed that many people who hallucinate “are like homosexuals in the 1950s — in need of liberation, not cure.”

There is a change underway, akin to that of other great liberation movements pf the last Century and I believe that when we see chains on people it should be the intention and hope of those of us who do therapy to seek to break them.

What is unfortunate is that the classification found in DSM5 do little to break chains; it may yet forge new ones.

How might they be broken then? Here is my reading of (and my hope for) some of the changes that are beginning;

Away from ‘illness’ towards ‘distress’

Away from ‘symptoms’ towards understanding that we develop different  means of coping with this distress.

Away from restrictive labels towards listening to individual experience.

Away from medicalised interventions, towards encouragement and support of individual recovery.

Away from simplistic distinctions between ‘psychosis’ and ‘neurosis’ towards a greater interest and understanding of the effect of trauma.

Away from segregation and ‘otherness’ towards seeing mental distress as an essential part of the human experience and as such, part of all of our experiences.

Away from ‘maintenance’ towards, hope.