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Disability is where we start, recovery is our destination, and rehabilitation is the road we travel.Robert Paul Liberman
Approaches to the treatment of severe mental illnesses (SMIs), such as schizophrenia, schizoaffective disorder, bipolar disorder, obsessive-compulsive disorder, and substance use disorder, have moved beyond the mere control of symptoms and prevention of relapse to include functional recovery, social and vocational reintegration, and enhancement of the quality of life of the patients (1,2,3). In each of these illnesses, the absence of symptoms does not indicate return to a fully normal life. Therefore, recovery from any severe mental illnesses, besides achieving symptom remission, should include participation in work or school and in social, family, and recreational activities. Because patients with SMI mostly suffer from a long lasting disability and are often dependent on family members or assisted-living facilities and are poorly integrated into the community, low functional capabilities of these patients can cause a significant burden to their families and society.
Although there is no concise definition or consensus on the concept of recovery, there are two perspectives for recovery. One is a clinical, service-based, or objective definition, and the other is a user-based, subjective, or personal recovery. The first perspective comes from the concept of remission as an improvement in symptoms and other deficits to a degree that they would be considered within normal range and implies a long-term goal of psychosocial functioning with fever or no relapses. The second perspective focuses on a personal growth and development, regaining control, and establishing a personally fulfilling and meaningful life with a mental illness (4,5). The service-based definition of recovery reflects the state of people who return to a premorbid functioning at least for some time. In this context, recovery is seen as a long-term goal of remission (6). The user-based definition of recovery includes symptom remission or a return to normal functioning to some extent. However, recovery is seen as a process of personal growth and development and involves overcoming the effects of being a mental patient, with all its implications, to regain control and establish a meaningful life (4). This definition refers to the achievement of a personally acceptable quality of life regardless of the state of their illness or health and that people with SMI can have hope, feel capable of expanding their personal abilities, and make their own choices. As Liberman and Kopelowicz pointed out, the recovery from SMI is the process of recovering and not recovery as an outcome. The processes and stages of recovering are seen as preparations for recovery. Individuals can take many pathways to recover depending on the varied factors that influence the process, such as personal attributes, economic conditions, social environment, continuity and quality of treatment, and subjective experiences (2). In the process of recovery, the greater the person’s symptomatic and functional improvement, the more would be expected subjectively experienced qualities such as hope, optimism, empowerment, self-responsibility, self-esteem, and life satisfaction. For a patient, participation in daily activities, routines, and normative life processes, such as going to work, taking a course, taking part of any activity, are frequently considered as both facilitators and indicators of recovery.
The main dimensions of recovery, substantially based on the optimal effective treatment of the illness and rehabilitation of a patient, are knowledge about mental illness and services, independent living, life satisfaction, hope and optimism, empowerment, and employment. As depicted in Figure 1, these dimensions should be evaluated and carefully considered when designing comprehensive, coordinated, and community-based services and service systems for people with severe mental illness to recover from disability because all these dimensions are reciprocally related to each other (7,8).
Patients’ knowledge about their mental illness and multiple types of conventional services, including day hospitals, community mental health centers, crisis intervention services, assertive community treatment services, legal services, and having a social worker and case manager who are available to them in their needy conditions is an important dimension for recovery (2,7). Not only having knowledge about mental illness and services, but also having an opportunity to easily access the services routinely and as necessary is an important factor leading to recovery in patients with SMIs. The ways for recovery should always be open for patients and their caregivers.
Independent living includes being productive in work or school, social relations, family life, and recreational activities. The main aspect of this dimension is the ability to take care of one’s personal needs without assistance. Whether or not the individual is living apart from the family, independent functioning could be defined as managing one’s own medication, health, and money without regular supervision (2). All treatment and rehabilitation services to reach the achievement of the level of living independently should be available and ready for patients.
A strong relationship between symptoms and quality of life has been consistently represented. The severity of symptoms and side effects of medication are obstacles on the way to recovery. Thus, recovery orientation services should emphasize the aggressive treatment of symptoms and side effects of medications for obesity, diabetes, and other comorbid medical conditions. Other psychosocial variables related to life satisfaction, such as family, social network, living arrangements, community, and safety, should also be taken into considered (7).
Greater risks for a sustainable recovery are hopelessness and pessimism. Resulting from the debilitating course of the illness, these psychological components are found to be related to increased risk of poor outcome of vocational rehabilitation, and decreased quality of life (7,9). An important component of the journey of recovery is the fostering of hope for the future, hope for achieving one’s goals, and being surrounded by a reliable treatment team, peers, and family members who share realistic optimism and hope (7). Hope can serve to fuel motivation for change and active participation in clinical services or self-help groups, which are stepping stones toward recovery (10).
Empowerment refers to an empowered feeling to take responsibility of making one’s own decisions and to take responsibility for treatment as well as feeling that one’s treatment and treatment providers are in concordance with one’s own treatment goals (7). Empowered patients can manage their sense of powerlessness and dependence resulting from traditional treatment approaches.
Employment is a primary goal for a majority of unemployed patients with SMI. Sustained employment is associated with reduced health care use and cost and increased levels of self-esteem and satisfaction (11,12). As traditionally known, work may play an important role in the process of recovering by engaging a person into a feeling of being able to work as a sort of existence (13).
Recovery-oriented approaches currently appear to be the dominant expression in psychiatry with regard to a patients’ functionality in society. They are independent from the medical model and focus on the integrity and strengths of an individual rather than on the illness. Patients with SMI, even though they have some residual symptoms, generally want to live independently, be in society with dignity, have a job with self-esteem, have a partner for love and affection, have a house for safety, hope for a future, and having all civil rights like all other individuals. In this sense, the main purpose of recovery-oriented services is to provide an effective treatment for the patients with SMI that makes them obtain satisfaction in the following areas: continuing symptom relief, daily functioning, social relations, family relations, occupational or academic functioning, independent living and autonomy, goal attainment, satisfaction, and possession of common objects (14). By implementing recovery-oriented services in community settings, besides improving a patients’ wellness, it is expected to decrease the burden of illness (lost income, stigma, disordered social relations, re-hospitalizations, family stress, treatment expenses, etc.) on families, caregivers, and friends, health care systems, and society as a whole.
Unfortunately, all treatment and rehabilitative services and approaches that foster recovery are not routinely available in many places. For recovery to become completely integrated into a mental health care system, widespread systemic changes may need to be done. These include the implementation of services that promote financial, residential, and personal independence, as well as normative adult roles, such as employment and social connectedness (3). Clearly, a clinician cannot manage all problems related to sustain the recovery of patients with SMI alone and will need to look for additional resources to become a partner of the patient and to coordinate and maximize the clinical effectiveness of the treatment and rehabilitation.
It is arguable that systemic factors, such as high patient loads, time constraints in clinical encounters, lack of or limited availability of ancillary professionals, management resistance to change, and most importantly, lack of training in recovery, can act as impediments toward a recovery orientation in psychiatry. As such, currently integrating a recovery orientation into psychiatry involves much more than attitudinal shifts among individual psychiatrists. Establishing the recovery orientation services must involve multi-level systemic changes as well as changes in medical education (15).