Suggestions for the Effective Psychosis Recovery Program Models
Mental health and wellbeing are of major importance due to the vital role in which they play in everyday life. This can be shown in the prevalence, with mental health affecting approximately 1 in 4 people in the UK each year. (1) Good mental health allows the individual to cope with ‘varying life stressors, learn, feel, express and manage a range of positive and negative emotions, form relationships and cope with uncertainty’ (17). However, mental illness can be defined as “clinically diagnosable disorder that significantly interferes with an individual’s cognitive, emotional or social abilities” (3). We all have varying levels of mental health and just like physical health we need to seek treatment and recognise when it needs attention.
Psychosis is a mental health condition that ‘causes people to perceive or interpret things differently from those around them’ (NHS). This might involve hallucinations or delusions’ (18), other symptoms can also include disorganised thinking, abnormal motor behaviour and negative symptoms such as reduced emotion. The importance of ‘recovery’ from mental illness such as psychosis is not only important to the individual but for healthcare and social services, although recovery does not have a clear definition it can be thought of like the belief that it is possible for someone to regain a meaningful life, despite serious mental illness” (2) However, a full recovery in mental health may not be a ‘complete’ process such as one associated with physical health, is this is often due the dynamic nature of recovery.
Recovery is thought of dynamically because of the continuous process of growth, discovery, and change throughout (Stocks, 1995) (4). These definitions show the personal aspect of recovery with the outcome often being judged by the individual as it is personal to those involved. Recovery to an individual could be developing a new goal or purpose in an individual’s life as they move beyond the effect of mental illness they have been experiencing. Therefore, a co-produced approach with the individual could be vital in returning power and control to individuals aiding recovery from conditions such as psychosis.
A good program of recovery consists of numerous people coming together to provide a network of support, this often includes health care professionals, family, friends and the individual. The characteristics of a positive recovery journey often consists of various factors such as a unique and personal journey, an ongoing experience and not the same as an endpoint or cure and a nonlinear experience with both setbacks and achievement (5). The concept of recovery has been discussed co-productively with service users and a concept diagram created. This included key points such as lived experience leading to resilience, strength, optimism and hope on the inner circle, the middle circle containing recovery strategies such as support, treatment, advocacy, acceptance, connection and inclusion of an induvial and finally the outermost circle contains support networks such as services, practitioners, peer specialists, community, friends and family (6).
Previous examples of conceptual models of recovery can also be seen to follow similar approaches as shown by Glover (2012) who suggested taking an active approach to recovery and not a passive one allows the individual to regain sense of self-worth playing an important role, the approach follows similar patterns throughout once again focusing on what the individual can do for themselves and not becoming sedentary in their journey to recovery. This active approach to recovery can be a positive one, with it being a move away from the traditional approach of health care professionals providing support and leads the individuals to take an active role instead, this new approach to recovery allows control to be once again to be taken over the individual’s life instead of being passive.
Despite this, previous studies show the difficulty in defining and measuring ‘recovery’. This can be shown Jääskeläinen (2012) (7) with only 1 in 7 individuals meeting the criteria for recovery. Therefore, the dynamic nature of mental illness such as psychosis will be influenced by various stressors of both social and psychological natures which makes defining and measuring recovery extremely difficult. Furthermore, the nature of psychosis may lead to individuals not to seek the help of healthcare professionals. An individual suffering with hearing of voices, may often be reported amongst those with previously good psychological health and with no history of mental health service contact leading to not only difficulty in diagnosis but therefore difficulty in receiving treatment (7). Despite this people living with psychosis may not be in contact with service providers for varying reasons. These can include varying reasons such as already having an existing positive support network, valuing the voices or choosing not to disclose the nature of the voices, this could be due to the fear being stigmatised if they are given a diagnosis of a mental illness. These factors can lead to difficulties in working towards the concept of recovery, once again showing the dynamic nature of recovery and the journey one must travel in order to reach their desired destination.
One of the main principles in relation to recovery is the ladder of change, it can be thought of as having five main principles to bring about positive change. The first level of the ladder consists of being ‘stuck’, this is where an individual is on the beginning of their journey often unwilling to accept support or accept their mental health situation this, therefore, may then causing harm to ourselves or others leading to isolation or not being aware of the problems present. Following the ladder of change, acceptance of help plays an important role in creating real change, it consists of engagement with both people and service providers when then creates the next step which is believing. Believing consists of a sense of what it is we want to achieve in addition to what we are moving away from, learning how to do this comes next with support in order to keep us moving in the right direction. Finally, self-reliance is the final step which allows the individual what works in terms of recovery from themselves, it also helps facilitate the use of support services if the individual knowing when they need extra support and how to access it when required to avoid a crisis.
In addition to the ladder of change, a similar holistic and personalised concept can be used – the mental health recovery star (9). This approach allows the individual to get a general overview of where they are on their journey to recovery and therefore areas of improvement throughout the journey of recovery. The 10 areas of the recovery star consist of managing mental health, self-care, living skills, social networks, work, relationships, addictive behaviour, responsibilities, identity and self-esteem and finally trust and hope. Overall, these ten categories allow for clear understanding and measurement, both for the service provider and the individual with the later identifying where they need to strengthen in order to reach their end goal of recovery. The Mental Health Recovery Star has shown to be a useful measure of outcomes and clinical importance for a co-produced recovery-focused service. Additionally, the instrument assists service users to identify their key goals for recovery and track their progress in their recovery journey (15)
Recent developments into psychosis have shown increased use of strength-based interventions, this approach focuses on amplifying strengths and therefore relies heavily on effective interpersonal processes (8).
When it comes to recovery, it has been shown that a strength-based approach is often helpful in reaching the end goal of recovery. Strength-based approaches do not discount the problems that the individual is experiencing but more importantly, focuses on the strengths instead. The approach discussed allows for a proactive approach to recovery, this, however, is difficult as individuals suffering from psychosis may be socially isolated and lacking self-esteem. Previous research finding 24% of the people with psychosis scored low on self-reported self-esteem (10). In addition, those reporting lower levels of self-esteem are more likely to perform badly in the community and relapse, therefore, slowing down their recovery (11).
Further research was carried out by Tse et al (12) who found that the ‘‘utilisation of a strength-based approach is effective for yielding desirable outcomes, including ‘hard’ outcomes such as duration of hospitalisation, adherence to treatment and employment/educational attainment, as well as ‘soft’ outcomes such as self-esteem, self-efficacy and sense of hope’’ this suggests that a strength-based approach is a viable option when used in psychosis recovery. This approach focuses on the individual and what they can do with the healthcare professionals being considered facilitators of the recovery process, this then allows the individuals to be the source of change and recovery.
In addition to previously discussed approaches, the Wellness Recovery Action Plan (WRAP) is an additional program to aid facilitation of recovery. WRAP is a structured process that allows for the monitoring of psychosis during periods of relapse with coping strategies formulated with responses that you have planned during times that the individuals were well. The key factors of WRAP consist of various factors such as a daily maintenance plan, a good understanding of triggers and how to manage them, identifying early warning signs and an action plan, recognising relapse and an action plan to combat this, crisis planning and post-crisis planning (13). The idea of hope can also be an important factor when facing difficulties, Deegan (1988) considers hope as a ‘turning point in the process of recovery, which must be followed by a willingness to act. Hope seems to be an attitude, which is inviting or encouraging making changes for the better’. This then allows the belief that things will get better, increasing the self-esteem of individuals and therefore leading to a quicker recovery.
Another indicator of recovery can be indicated by the ‘recovery rates’ of individuals with psychosis. Lally et al, 2017 carried out a systematic review and meta-analysis of remission and recovery of first time psychosis, it consisted of 79 studies with 19072 participants with a follow up at 5.5 and 7.2 years. They found that 58% of patients met set criteria for remission and 38% the criteria for recovery. The findings showed high levels of ‘statistical heterogeneity’ and overall offer valid measures of recovery and remission. However, various confounding variables such as treatments over the follow up period and lifestyle factors over the course of the follow up could be an issue (14). In addition, sampling bias when recruiting participants could also be a confounding factor, participants who are extremely unwell or those who are fully recovered quickly after an episode maybe less likely to consent and participate. (14)
In conclusion, the recovery of psychosis is a dynamic process and is one best judged by the person with lived experiences. The nature of recovery allows the individual to move freely from states of ‘in recovery’ or ‘not in recovery’ this could be due to social and psychological stressors. This further suggests that the term recovery is formed by the person it is effecting and is personalised, what one individual’s definition may not be the same as another. In addition, this further emphasises the importance of a person-centred approach. Recovery will not just happen, it needs a co-productive approach, support and partnership between individuals in order to foster hope and change.
The suggestion of a strength-based approach focuses mainly on this. It suggests that the idea that the power has shifted from the traditional medical model of recovery, one where it solely focused on solving the problem, to one of empowerment, self-worth, and participation. These factors are all associated with a strength-based approach that will ensure the individual moves towards recovery. This new way of working will require a shift of attitudes from both individuals and service providers, however, a successful implementation from all involved parties could lead to greater success in recovery from psychosis and other mental illnesses. Recovery from psychosis is possible, however not an easy one which will require real commitment and management from the individual to see real change in their lives.
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