Recovery is about a focus on resilience and wellness,not a fixation with risk and illness

Recovery is a central theme in mental health policy internationally (Tew, 2013). In Australia, the National framework for recovery oriented health services conceptualises recovery as being able to create and live a meaningful life beyond the constraints of diagnosis. An emphasis is placed upon maximising individual self-determination and self-management of mental health. Organisations adopting recovery-oriented principles are encouraged to acknowledge the strong possibility of a trauma history in people seeking mental health care and to provide services that promote safety, choice, collaboration and empowerment. Health services should concentrate on assisting people to regain control and personal responsibility while reducing coercive practices and increasing opportunities for positive risk taking (Commonwealth of Australia, 2013).

Tew (2013) affirms that population health research indicates social factors, rather than medical interventions, are the main determinants of recovery from mental ill-health. Moreover, medicalising mental health problems potentially has an adverse effect by propagating an illness mentality, lowering expectations, engendering passivity and taking control away from individuals (Tew, 2013).

Conversely, the field of positive health is neatly aligned with the principles of recovery. This ‘asset-based paradigm’ provides an alternative perspective for enhancing resilience and promoting independence by shifting attention away from pathology and dysfunction onto skills, attributes and optimal functioning. Promoting resilience involves concentrating on the competencies, resources and abilities of individuals and communities and recognises that optimism is the dominant cognition of the mentally healthy (Wand, 2013).

Problems with the present paradigm

Mental health service provision is presently dominated by the assessment and management of risk, biomedical models of illness and disorder, an emphasis on pharmacological and physical treatments and the routine use of restrictive measures. However, there are mounting reservations and concerns over the efficacy and the negative consequences of such practices.

While risk assessment and management exerts a heavy influence on clinical decision making, there is an absence of research evidence supporting this approach in reducing risk (Wand et al., 2015). In a recent survey of mental health clinicians, respondents agreed that they regularly resort to the use of restrictive interventions when there is uncertainty around risk, which in turn places patients and staff at increased risk of injury and trauma (Wand et al., 2015). Alternatively, it is argued that risk is reduced when people feel respected, consulted, listened to and valued (Commonwealth of Australia, 2013).

Diagnostic labels for mental illness and disorder are ingrained in the culture of the mental health system, and conditions such as Bipolar Disorder and Schizophrenia are routinely referred to as ‘biological’. Yet, notwithstanding a substantial investment of time and resources, there is still not one specific biomarker associated with any psychiatric diagnosis. Diagnostic systems based on consensus models are inventions (not discoveries) and therefore represent merely one version of the truth. While genetics and biology undoubtedly play a role in mental heath and wellbeing, the degree to which these factors contribute remains a matter of speculation. Unequivocally, however, while mental health challenges reach all corners of society, the concentration is far greater in populations of relative social disadvantage (Wand, 2013).

The prescription and administration of psychotropic medications and the ensuing practices around monitoring for effects and side effects consumes considerable time for clinicians and people taking them. This is despite uncertainty over their effectiveness as well as their potential for enduring and incapacitating side effects. Studies using US Food and Drug Administration data for example, have found that antidepressants are no better than placebo for the majority of people who take them (Wand, 2013). Clinicians need only reflect on the number of individuals they see on antidepressants who remain depressed (often after trialling a number of drugs) to appreciate that such medications are far from a panacea for depression.

The long-term use of antipsychotic medication has also come under scrutiny for the effectiveness versus side effect burden. These side effects are significantly debilitating and include the link between antipsychotic medications and weight gain, metabolic syndrome, electrocardiogram (ECG) changes and increased risk of sudden cardiac death, hyperprolactinaemia associated with sexual dysfunction and reduced bone mineral density, irreversible changes in brain structure and function, and diminished global functioning and cognitive impairment (Wand, 2013).

With regard to electroconvulsive therapy (ECT), an extensive review of the research literature concluded that ECT has ‘no benefits for individuals beyond the treatment period’ and that the cost–benefit analysis for ECT is ‘so poor’ that the practice cannot be scientifically justified (Read and Bentall, 2010). This blunt assessment is compounded by research demonstrating that individuals with rigorously defined endogenous depression have improved following sham ECT.

Incorporating recovery principles into contemporary mental health care

The principles of recovery provide a laudable perspective for promoting mental health and wellbeing regardless of diagnosis or the challenges posed to individuals. However, mental health services are currently illness focussed, and decisions are routinely made for, rather than with, people in their care. There is arguably an obsession with conducting ‘assessments’ in mental health services. These often occur at the expense of any therapeutic assistance. Moreover, assessment formats are predominantly problem, risk and pathology seeking in nature, and far from ‘comprehensive’. An assessment with a recovery orientation would instead pour attention on strengths, attributes, resources, coping skills, past successes, positive intentions, hopes and the broader context of the individual’s life and social circumstances. Rather than re-casting problems of living as symptoms of pathology, a recovery perspective reassures people engaged with mental health services by having their circumstances normalised, not pathologised (Wand, 2013).

There also remains a pervasive view that mental illness is due to a ‘chemical imbalance of the brain’. While holding no scientific foundation, this view has helped to make pharmacological approaches the mainstay of ‘treatment’ in mental health care (Wand, 2013). There are many people who attest to the importance that psychotropic medications have played in their lives; however, it is also crucial that the limitations and potentially damaging side effects are recognised. It must also be acknowledged that medications can impede recovery (Commonwealth of Australia, 2013). Psychotropic medications may be helpful, but the indication is they should be prescribed parsimoniously and for the shortest time possible.

Risk in the mental health field is commonly associated with dangerousness. Alternatively, rather than viewing risk negatively, therapeutic risk taking and allowing individuals the dignity of risk have been promoted as an important part of the recovery process (Wand et al., 2015). Consideration also needs to be given to the potential harms that individuals may be exposed to through involvement in the mental health system, such as being kept in hospital too long, excessive medication and side effects, loss of freedom, privacy and dignity (Commonwealth of Australia, 2013). This highlights the importance of maximising self-determination by encouraging individuals to take control of their lives and to reclaim personal and social power (Tew, 2013). The focus of mental health services should always be on building individual and community capacity, and fostering independence and autonomy, not inadvertently perpetuating a self-maintaining industry of illness.