Personal Recovery Flashcards
1
Q
What are two types of recoveries?
A
- Clinical recovery
- Personal recovery
2
Q
What are the three perspectives that we can look at recovery?
A
It can be explained from three different perspectives:
- Third person perspective - the ‘external’ object
- First person perspective - the ‘internal’ object
- Second person perspective - the ‘intersubjective’ dialogue
3
Q
The third person perspective
The ‘external’ object
A
- The patient has a disorder or is disordered
- The clinician diagnoses the disorder
- The clinician knows (knowledge is on the side of the clinician) and explains the disorder
- The clinician treats the disorder - treatment given by the clinician to the patient
- The patient needs to follow the treatment
- If the treatment is succesful the disorder is cured = Clinical recovery
↪ What improvement in clinical practice is → e.g. 40% of people with depression will get clinical recovery after 50% reduction of symptoms - Lot of people feel like this definition of how it is to go through treatment/therapy and then back to normal life, is not what it’s about (not just to reduce symptoms)
Picture 1
4
Q
What are the four key features of clinical recovery? What is the intention of such definition?
A
Clinical recovery is an objective, observable state rated by experts and defined consistently across individuals
- Intention for it to be operationalisable - suitable for use in empirical research
5
Q
What is a more socially focused definition of clinical recovery?
A
- Full symptom remission
- Full or part-time work or education
- Independent living without supervision by informal carers
- Having friends with whom activities can be shared
- All sustained for a period of two years
6
Q
What are problems with looking at improvement as a clinical recovery?
A
- The problem arises from treating recovery as an outcome
- Although this allows prevalence questions to be addressed, it also implicitly involves deep assumptions about normality - How many goals must be achieved to be considered recovered? How much life success is considered ‘normal’?’
7
Q
Therefore, we look at recovery from…
The first person perspective
A
- What is the matter with me?
- How did I get this way? Am I crazy?
- What are they telling me? Do they even understand? Can I trust these people?
- The world seems so different now; so ‘black’, so ‘strange’
- Who am I? Where do I belong?
- What will the future bring?
All these questions are essential to how a client experiences their encounter with clinical practice
= Personal recovery?
Picture 2
8
Q
How do professionals and clients regard the relationship between these two perspectives?
A
Both professionals and clients felt disconnect between these two worlds = lead to second person perspective
9
Q
A second person perspective
The ‘intersubjective’ dialogue
A
- Not employ our third person perspective onto the client, rather attunement to the ‘first person’ perspective
- Empathetic understanding of the mind of the other
- Creative collaboration and co-construction - therapist doesn’t always need to know what is going on all the time but with the client they are together trying to figure it out
- Interest in personal narratives and processes of meaning-making - interconnection between the world of the client (the concepts and language of the client) and our own clinical concepts and knowledge
- The school the therapist uses is not as important (as studies show), within schools there are systematic differences in quality of the therapist
- We should not underestimate but neither overestimate the role as a clinician - our role as a clinician is to support and facilitate process of personal recovery
- no one approach works for or ‘fits’ everyone - There is no right way for a person to recover
Picture 3
10
Q
What is recovery in the ‘personal recovery’ framework?
A
‘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.’
- In contrast to the clinical perspective, recovery is seen as a journey into life, not an outcome to be arrived at
- Recovery involves living as well as possible
- It is an individual process - what fits one might not another = there cannot be a single recovery model for services
- Personal recovery removes the unhelpful evaluative element of whether, according to some externally defined criteria, someone has achieved recovery
11
Q
What are the four key domains of recovery
A
-
Hope: What will happen to me? - as a clinician we want to see how much of (realistic) hope, which neccessary for recovery, the client has
↪ Hope leads to action based on approach rather than avoidance motivation - having positive goals, rather than trying to avoid negative outcomes - Identity: Who am I? (e.g. without psychosis, depression…)
-
Meaning (direct): What has happened? Meaning (indirect) What does this mean for me?
↪ construct personal narratives that help them understand their illness
↪ Clinical explanations (e.g., “lack of insight”) can invalidate these personal narratives, reducing autonomy and engagement - Personal responsibility: What can I do? - Last thing we should do as clinicians is to take away the responsibility on the client’s part - we help them to find extra tools but they handle the tools
12
Q
What is an important thing to remember about identity?
A
We never make up our own identity by ourselves rather we develop the self via others
Crucial relationships in recovery narratives:
- A higher being or connection with others (e.g. culture, society)
- Close relationships
- Other mental health service users – ‘experts by experience’
- A specific mental health professional
13
Q
Why do we need to consider the history of personal recovery?
A
- The possibility to visit a psychologist is socially and culturally embedded - the social discourses structure how the interconnection between professional and client is going on (e.g. if social discourse is focused on dsm - that’s what will shape the conversations between the professional and the client)
- And if we have social discourse of personal recovery - that’s what will shape the conversations, interactions and outcomes
- So how it is now is very different from how it was 50 years ago and it’s different to how it will be in the future
14
Q
What is the history behind personal recovery?
A
- In 1945, there were few dominant paradigms: psychoanalysis, institutional psychiatry, behaviourism
- 50s onwards: humanistic and existentialist approaches (Carl Rogers and his client-centered apporach, Rollo May - existentialist) → Within a client there is a natural recovery
- 60s and 70s : anti-psychiatry → lot of strong critique on psychiatry for its institutions, for being authoritarian
- 80s and 90s: due to poor inter-rater reliability of diagnosis between different clinicians, DSM-III was introduced; rise of psychofarmacology and biopsychiatry; RCTs and protocolized treatment; dominance of CBT
15
Q
What were the backgrounds of the recovery movement?
A
- Client-centered and humanistic ideas - went on to develop through 80s and 90s
- Anti-authoritarian impulses (who are you to tell me what my disorder is), e.g. from anti-psychiatry movement
- Dissatisfaction with the dominant discourse since the 80s
↪ DSM, RCT, psychofarmaca, biologized psychiatry - Organizations of clients: ‘it’s going from institutions (psychiatric, universities) to us, just imposing it on us’ - “Nothing about us without us.”
- This influenced how we think about clinical practice and how we operate now
- What this shows is that within any diagnostic approach (dsm, dimensional, recovery-focused, biological…) certain values are embedded
16
Q
Socio-cultural background
What are the ethical questions we should be asking when considering the approach of personal recovery?
A
- What values are embedded in Personal Recovery?
- What is good about it?
- Do you see problems and disadvantages?
- Do you want to work from a Personal Recovery perspective?
17
Q
What are values embedded in personal recovery?
A
- Transparency
- Empathy
- About person, not the disorder = identity
- Autonomy
- Quality of the therapeutic relationship - horizontalism rather than verticalism
18
Q
What are disadvantages with those values and approach?
A
- Some people might prefer vertical relationship (authoritarian approach)
- The client might not want to get better, is lying … - this approach puts trust in the client
- Very strong emphasis on autonomy - especially if it’s individualized autonomy - makes them isolated from a community and they have to deal with it on their own (personal recovery fits with the cultural values of individualization and autonomy)
19
Q
What is reflexivity in personal recovery approach?
A
- We cannot be neutral on values and ethics
- Our values reflect our position in the world
- Our values derive from our personal history
- Our personal history is embedded in family history, social, economic, political situations, cultural histories
We cannot step out of ourselves, but we can expand our horizon - there is not a one objective approach in psychology, but when we know about multiple, we can accomodate ourselves to the ones that we think fit best with us and our clients
20
Q
Scientific background
What are the empirical foundations of personal recovery?
A
The framework of personal recovery is based on lot of qualitative research, especially narrative research - where people are being asked about their experiences in recovery
- Meta-synthesis: combining many perspectives into one big perspective of what people generally bring up when they talk about recovery
21
Q
How does data look like in qualitative research?
A
Picture 4
- Handling such data is a very different process from handling quantitative data → different analyses
22
Q
What are the analyses used in qualitative reserach?
A
- Narrative analysis
- Interpretative Phenomenological Analysis (IPA)
- Thematic Analysis
- Discourse Analysis
- And more…
23
Q
An example of IPA approach to psychotic experiences
A
Interviewes people with psychotic experiences about their experience after the start of medication
Identified themes:
Theme 1: Antipsychotics as external dampening
Theme 2: Shifting of realities
Theme 3: Pace of recovery
Theme 4: Antipsychotics’ impact on identity
Theme 5: Is it truly the antipsychotics?
24
Q
How do the traditional clinical assessment and recovery-focused assessment differ?
A
- Traditional clinical assessment - aims at identifying illness and planning treatment
- Recovery-focused assessment - prioritises promoting personal meaning, amplifying strengths, fostering personal responsibility, supporting a positive identity, and developing hopefulness
25
Aims of recovery oriented assessment
1. Promote and validate the development of personal meaning
2. Amplify strengths rather than deficits
3. Foster personal responsibility rather than passive compliance
4. Support the development of a positive identity rather than an illness identity
5. Develop hopefulness rather than hopelessness
## Footnote
What we don't see in these aims is getting the diagnosis correct - sometimes important
26
Promote and validate the development of personal meaning
1. Validate
→ Reflections, summarizing, using clients own words.
2. Ask open questions on meaning-making:
→ What did it mean to you when….?
→ So, how do you make sense of all this?
→ Do you have ideas as to how you came to feel this way?
→ If we can't make sense of what the client is saying, be honest - translates better since it shows we are really trying to understand, than faking that we do
3. Learn to deal with difficult emotions
→ Shame, guilt, anxiety, resistance, etc.
27
# article
Why do people need meaning according to Baumeister?
- Personal meaning is essential for psychological well-being - it's not enough to simply treat symptoms—patients need a sense of purpose.
- Most people derive meaning from multiple sources (family, work, relationships, faith, hobbies).
1. **Purpose** - connecting current experiences to future aspirations
↪ a person experiencing depression may regain hope by visualizing where they want to be in five years
2. **Values** - belief system that justifies life choices
↪ Clinicians should respect spiritual, religious, and cultural values in treatment
3. **Efficacy**- belief that one’s actions matter
↪ Clinicians should identify past instances where the patient successfully coped with adversity.
4. **Self-Worth**: Seeing oneself as valuable and worthy
↪ Encouraging volunteering, mentoring, and community engagement can help.
28
What is important in the clinician's approach when considering personal meaning for the client?
- Clinicians should focus on the person's search for a meaningful life, rather than imposing their own meaning
- Reflective practice is crucial in this process, as questions shape emergent meaning
- They are encouraged to consider if they know the person as they see themselves and what is meaningful to them, working to support the person's goals and values beyond their illness experience
- There is a danger of **pathologising** individuals' experiences, and a recovery-focused approach aims to normalise these experiences and validate the person's perspective, even if it differs from a clinical one - not aim to make people rational or normal but help them become more fully human
- While a clinical perspective and diagnosis can be helpful for some in containing anxiety, they should be offered tentatively as a resource, not 'the' answer
- **Cultural competence** - a way to avoid imposing culture-based filters of meaning and to work with each person as an individual
29
What are the five cultural tenents identified by the Yale Program for recovery and community health?
1. Working with clients is inevitably a cross-cultural enterprise
2. Becoming culturally competent is a process not an end point
3. A central part of working effectively across cultures is becoming aware of our personal cultural filters
4. Group-specific information can be used as a starting point for exploring individual experiences
5. Stereotyping is a natural part of the human perception process, but is one we need to be aware of and challenge
30
Amplify strengths rather than deficits
1. Open questions in search of strengths
→ How did you get through this difficult period?
2. Think ‘**coping**’!
→ Behaviors, thoughts, actions are ways to make sense of the world and deal with it
→ Ask yourself: “how may this be a way to cope with internal or external obstacles?”
3. Search with the client for internal and external resources
→ What helped you cope with these things in the past? Do you have such resources now as well?
31
What are 4 coping styles?
1. **Emotional avoidance**: Emotionally withdraw from a too-painful reality
2. **Re-framing**: Try to make sense of the situation in a way that fits with current beliefs
3. **Active engagement**: Try to change the world to fit with beliefs
4. **Integration**: Change beliefs, values and goals to better fit reality
Picture 5
32
What are four dimentions that clinical assessment should focus on?
1. Deficiencies and undermining characteristics of the person
2. Strengths and assets of the person
3. Lacks and destructive factors in the environment
4. Resource and opportunities in the environment
33
Why is assessing strengths difficult?
- the dynamic nature of these dimensions
- the ease of focusing on problems
- the mental health system's focus on individual treatment
- the clinician's illusion of only seeing people when they are struggling
- the deficit-focused nature of clinical questioning → deficit-focused discourse reinforces an illness identity; While assessing deficits is important, there is a lack of structured approaches to identify strengths, values, coping strategies, dreams, and goals
↪ Mental Health Assessment is proposed as a corrective to the conventional imbalance of focus on deficits
34
What are the key elements of the Mental Health Assessment [as contrasted to a standard history-taking interview]
- Current strengths and resources [History of the presenting illness]
- Learning from the past [Precipitating events]
- Personal goals [Risk assessment]
- Past coping history [Past psychiatric history]
- Inherited resources [Genetic background]
- Family environment [Family environment]
- Developmental history [Developmental history]
- Valued social roles [Occupational history]
- Social supports [Relationship history]
- Personal gifts [Forensic history, drug and alcohol]
- Personal recovery [Premorbid personality]
35
What is the Appreciative Listening Cycle?
- Contrasts with the Problem Focus Cycle
- Starts with the consumer's passions and focuses on possibilities and growth rather than problems and compliance
- It assumes the patient knows the best solution, with clinical expertise as input
- This cycle emphasises individual responsibility for change
- Picture 6
36
What is another approach to emphasize strentghs?
- uses the concept of character strengths, such as wisdom, courage, humanity, justice, temperance, and transcendence, assessed by the Values in Action Inventory of Strengths (VIAS)
- This can create feelings of pride and a more positive self-perception
- The general principle is to expect to find more than just problems and nurture a non-illness-based identity
37
Foster personal responsibility rather than passive compliance
- Overworking by clinicians can hinder individuals from taking responsibility
- Clinicians need to support the individual's efforts towards recovery, avoiding detached relationships and deficit-focused approaches
38
How should clinician foster personal responsibility?
Clinical communication should focus on personal resourcefulness - person-centred questioning in goal-setting, with clinicians facilitating rather than assuming responsibility for the goal
1. Learn to sit back and shut up
2. Ask open questions that facilitate agency
→ What would make a difference in your life? What would it take to get there? Etc
3. Give suggestions and ask about them
→ Some people say that their moods improve after exercising. What is your experience with that?
39
What can help clinicians overcome the tendency to assume responsibility?
- To use *coaching skills* for supporting partnership relationships: ‘What would it take to meet this goal?’, ‘What would happen if you challenge the rule that says you’re not allowed to do that?’, etc.
- Mental health clinicians need expertise in facilitating, not in doing
40
Support the development of a positive identity rather than an illness identity
- Mental illness changes a person, with some becoming different or better
- Identity changes in recovery involve redefining existing elements (identity re-definition) and developing new ones (identity growth)
- It can be hard to see the person when the illness is prominent
- Approaches include drawing from non-mental-health models, using timelines (putting the person as they are now into the broader context of their own life), and increasing involvement when the person is well
- Assessment at the level of indirect meaning allows the person to process what the illness means for them in a wider social and temporal context, differentiating the person from the illness experience
- Identity transformation involves developing new beliefs related to direct and indirect meaning, leading to increased agency, self-knowledge, normalisation, hope, a coherent narrative, increased self-value, compassion, new social roles, and benefiting others
41
What should the clinician do to support a positive identity?
1. Investigate your own biases concerning mental illness
2. Be curious about what the mental problems mean to the person - to some it may be helpful, but to other it may feel stigmatizing
3. Do not assume it is the same as for you
4. Ask open questions on meaning, e.g.
→ How is it for you to sit here with a psychologist?
42
Develop hopefulness rather than hopelessness
- Hope is fundamental to recovery from mental health challenges, and the assessment process should actively foster it
- Hope is the starting point of recovery, preceding acceptance. Without hope, accepting illness can lead to despair → therefore, assessment should prioritise its cultivation
43
How can the traditional practice be counterproductive to hope?
- For example, a focus on a predefined clinical model contradicts the value of trusting the person's own account
- The concept of insight can be toxic to recovery if it implies the professional is inherently right; in a partnership, the professional perspective does not have automatic primacy → The goal is to find a helpful explanation for the patient
44
What should a clinician do to help develop hope?
1. Don’t give ‘cheap’ hope - people will experience anything as cheap hope if you don't understand the graveness and difficulty of their situation
2. Learn to be present - not to run away from difficult experiences, emotions... but tolerate it and confront yourself with difficult stuff
3. Learn to understand, validate, summarize, etc.
4. Develop patience and a broad, long term view on processes of recovery - recovery takes long time - good to check in: where were you 6 months ago compared to now?
45
How can clinicians actively promote hope?
By adopting specific values, attitudes, and behaviours. These include:
- Valuing the person as a unique individual
- Trusting the authenticity of what the person says
- Believing in the person's potential and strength
- Accepting the person for who they are
- Viewing setbacks as part of recovery
- Listening non-judgementally
- Supporting the person to set and reach personally valued goals
- Facilitating contact with peer role models and self-help groups
- Tolerating uncertainty about the person's future
- Expressing genuine concern for the person's well-being
- Helping the person recall previous achievements and positive experiences
46
Messages to communicate through assessment
- Mental health services can support recovery by communicating messages such as the experience being meaningful, different ways of making sense of it, the person controlling the direction of change, and the importance of effort over miracles
- While these may sound naive to seasoned clinicians, especially in crisis, the patient's perspective may be very different
- The clinical skill in crisis is to provide a map back to hope and responsibility, connecting with the person where they are, offering tentative alternative explanations, providing pointers for the direction of travel, and using professional expertise as a resource without treating it as absolute truth
- The purpose of assessment is to develop goal-oriented action plans
