Prologue: What Is Recovery from Mental Illness?
Answer: Probably not what you think
The recovery model says we can be fully well, which isn’t the same as being “normal” because, as we all know, that’s an empty term based on stereotypes, social hierarchies, and power structures. “Well” is subjective, just as mental health is subjective.
Technically, there is no single definition of recovery, but we need a working definition if we’re going to expand insurance coverage and services and change people’s minds (including clinician’s), so we all know that yes, recovery is possible and no, a diagnosis isn’t necessarily a life sentence.
The Substance Abuse and Mental Health Services Administration (SAMHSA), the governmental agency in charge of official policy regarding mental conditions and substance use disorders, defines recovery as “a process of change through which individuals improve their health and wellness, live a self-directed life, and strive to reach their full potential.” SAMHSA’s definition is more extensive than this. It includes four dimensions and ten principles. I’m going to give you the short version.
If you want the really short version, here’s the iconic (at least in my mind) Professor of Psychiatry at Yale Medical College and Senior Advisor to SAMHSA’s Office of Recovery (more on that in another essay) Larry Davidson:
Recovery essentially centers on three basic principles: improving health and wellness, living a self-directed life, and striving to reach our full potential. What do these mean?
Improve our health and wellness
This goes beyond some abstract notion of “mental health” or “mental well-being;” instead, it focuses on
Resilience, which I’ll cover in another essay but which entails having the ability to deal with change and adversity
Living in a safe environment
Maintaining physical health (physical conditions like obesity are closely linked to mental conditions like depression)
Having hope for a better future (or a future—the absence of hope and believing I’d never recover were the primary forces in my suicidality)
Finding purpose and meaning
Notice that eliminating symptoms isn’t on here. Psychiatric “symptoms” like depression and lack of interest and anxiety and ruminations are part of the human condition—even psychosis. (I used to think psychosis was different but as someone I know who hears voices explained, “Ever had a song stuck in your head? That’s not the same, but it gives you an idea.”)
Live a self-directed life
This principle starts with the treatment we receive. We, as patients, are equal partners in recovery, not passive recipients of care. As we say in the recovery community, clinicians are experts on pathologies, theories, and treatments, and we are experts on ourselves. That means our treatment is
person-driven, i.e., as much as possible, we define our own goals, and clinicians provide all the information available (including the fallibility of diagnoses and risks of certain medications and treatments), so we can make empowered decisions and regain control over our lives
strengths-based, so we focus on what’s right with ourselves (our strengths, talents, coping strategies, resources, and values) and our lives instead of what’s wrong
holistic in that it addresses the whole person—faith, race, class, gender, sexuality, socio-economic status, the treatment we’ve received and medications we’ve taken, drug and alcohol use, time, place, social network, environment, personality, genetics, biology, sleeping habits, lifestyle, and diet
trauma-centered, e.g., domestic violence, physical abuse, previous mental health treatments, war
based on respect from our communities, institutions, clinicians, the media, etc.
non-linear and achieved in different ways—just as our experiences of mental illness and emotional distress are singular, our recovery will be too
inviting of peer support—“peers” are those of us who’ve recovered and help others in their recovery
Strive to reach our full potential
This includes
purpose,
relationships,
support,
community, and
culture and cultural background.
Let me break this down.
Finding purpose has nothing to do with being an executive at Google (thank goodness); it can be gardening, going back to school, volunteering, managing our finances, or (say) owning a cat or two or three.
Having relationships doesn’t mean having a lot of friends or being socially at ease or being vulnerable with everyone; I have very few friends (it’s actually delightful—much less pressure and drama), am not close with work colleagues, rely heavily on my family and (yes) my cats, and get a lot of my social contact from my teaching and my role as a certified Mental Health Peer Support Specialist, and I have recovered.
Support will come from different areas: family, friends, mental health peer support specialists, mental health professionals, online communities, and (perhaps) cats.
Community is anywhere we meet others and feel we belong—like, say, the cat-video community on Instagram.
Culture and cultural background are whatever that means to us and often include the values, beliefs, and traditions that guide our decisions and shape what’s important to us.
Recovery isn’t remission. Remission is limited to symptom reduction. It says that you still have the disorder, dysfunction, or diagnosis. Your diagnosis eternally lurks beneath the surface. You and your life are still determined by “symptoms” rather than difficult experiences, thoughts, emotions, and behaviors.
None of this is to imply that we recover simply by deciding to or that mental and emotional suffering is a choice. We don’t just “get over” debilitating psychosis or depression or anxiety or mania. Recovery isn’t a question of will; at the same time, it can’t happen if we don’t know it’s possible.
Some definitions of recovery from mental illness present prohibitively difficult standards. According to the Substance Abuse and Mental Health Services Administration (SAMHSA), the following standards go along with “a full restoration to mental health:”
“Recovery encompasses an individual’s whole life, including mind, body, spirit, and community. Recovery embraces all aspects of life, including housing, employment, education, mental health and medical treatment and services, complementary and naturalistic services, addictions treatment, spirituality, creativity, social networks, community participation, and family supports as determined by the person...Recovery focuses on valuing and building on the multiple capacities, resiliencies, talents, coping abilities, and inherent worth of individuals. By building on these strengths, consumers leave stymied life roles behind and engage in new life roles...with others in supportive, trust-based relationships.”
I love this, but it’s daunting. Does anyone meet this standard? Do the people who wrote the report? Do the clinicians and therapists who diagnosed me?
One Canadian study published in 2019 put forth a model of recovery so unrealistic it borders on absurd. It defined full recovery from generalized anxiety disorder as “excellent mental health,” which required “respondents…to achieve…almost daily happiness or life satisfaction in the past month.” Life in Canada must be amazing because 40 percent of participants attained this seemingly unattainable goal.
Who will get to determine if I’ve recovered? My psychiatrist? A researcher unknown to me? Some other mental health professional?
How will I be scored? Is there some sort of grading system? How many points would they have given me today? Will I get points for having prepared for my class and showing up to teach and connecting with the students? What points would I lose for being nervous before teaching? What about the dread I felt and wanting not to show up? How many points were lost for the pit in my stomach and lack of enjoyment while teaching parts of the class? How many points will be deducted when the inevitable post-first-day-of-class excitement wears off and the emptiness rolls in?
I know mental illness. I know crippling anxiety and panic attacks and mania and depression so deep they take over my body. I understand not being well enough to live on my own. I know suicidality. I know racing thoughts so powerful I feel as though there’s a chorus of people in my head. And depersonalization and derealization so intense my body seems to disappear, and the world has a film around it.
So maybe I’ll know when I’ve recovered, too.
*
Powerful organizations have been trying to tell us that recovery is possible for at least a decade. The Substance Abuse and Mental Health Services Administration (SAMHSA) is one of the most powerful government agencies dictating policies and public health efforts that influence how we think about mental illness and substance abuse. In 2011, it released a definition of recovery: “A process of change through which individuals improve their health and wellness, live a self-directed life, and strive to reach their full potential.”
They outline four dimensions of recovery: health, home, purpose, and community. Health is defined as “overcoming or managing one’s disease(s) or symptoms…and….making informed, healthy choices that support physical and emotional wellbeing.” A home is outlined as a safe, stable place to live. Purpose doesn’t mean having a job you love or believe in, just that you’ve found meaning somewhere in your life. Community entails having positive relationships.
Two popular notions of recovery trouble me. One says that recovery is an ongoing process, the other that we somehow (magically) return to an emotional and mental state we experienced before our struggles started. The first positions recovery as an ongoing battle—a battle we never get to win. It’s an ongoing process. Healing won’t last. The next manic or depressive episode or panic attack lurks in wait.
The second describes it as a “return to normal”—whatever normal is. That would demand time traveling to an idealized version of a life we supposedly had pre-diagnosis. But the past is irretrievable and that idyllic, pre-sickness, pre-distress state an illusion.
Boy. This chapter, an extension of "Pathological," isn't so bad, but Chapter 7, outrightly dissing on group therapy, and Chapter 8, at the core of shape-shifting ... the recovery movement includes medications, but .... ignores why people get those medications? Congrats. My review of "Pathological" just dropped a star.