From spotlight - Winter 2019 - recovery for all
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In the same year as the NHS was formed, the World Health Organization (WHO) defined health as 'a complete state of physical, mental and social well-being, not merely the absence of disease or infirmity'. (1)
This definition pioneered, within modern healthcare, a recognition of holistic health and the rounded, multifaceted nature of human well-being. Yet, it still stipulated a need for a medical cure (dictating a need for an 'absence of disease'). Despite recognising 'holism', it allowed healthcare to remain illness-focused.
Historically, psychiatric care took this illness-focused approach and asserted 'cure' as the gold standard, often at the cost of very unpleasant side-effects, social isolation and near-punitive therapies. It wasn't until the late 1980s when Pat Deegan, amongst others, began to promote an alternative approach to be taken in the delivery of care to those struggling with mental illness. This seminal work became the conceptual basis of what we now know as the recovery approach; the model of care, all mental health services are encouraged to embrace today. (2)
the recovery approach
There is no single definition of the concept of recovery for people with mental health problems. Recovery may be considered a journey of well-being. Deegan describes recovery as 'a process. It is a way of life. It is an attitude and a way of approaching the day's challenges'. (3) The recovery approach is established on three main principles: hope, agency and opportunity. (4) It encourages healthcare staff to look at those in their care holistically, seeking to improve quality of life through social inclusion, as well as promoting community connectedness and community living.
Hope is foundational to recovery and probably impossible without it. (5) This hope is the belief that it is possible for someone to regain a meaningful life, despite serious mental illness.
Agency focuses on the individual taking responsibility for, and control over, their own care. The recovery approach emphasises that, whilst individuals may not have full control over their symptoms, they can have a sense of control over their lives. (6) Recognising the expertise of both the patient and the practitioner, it promotes collaborative working to establish goals based on what 'being well' means to the individual.
Opportunities for social inclusion; supporting people in the roles they already have (such as family member, student, in their work) as well as gaining new experiences and developing new skills is key to recovery. Together, they seek ways to facilitate patients to take part in mainstream activities and opportunities along with everyone else.
One of the constant burdens of working in the healthcare profession is the recognition that although you may have treated a patient's primary presenting complaint, you cannot rescue them from all the difficulty and pain they are experiencing at that time.
Furthermore, we cannot rescue people from the consequences of their actions, or what we may perceive as unwise decisions. Clinical competence rarely feels sufficient when we are faced with the suffering we see daily filling our wards and caseloads. In its nature, the recovery approach acknowledges that we will not be able to 'cure' all pain, but through partnership with the patient they can find meaning and hope within life's struggles. The recovery approach addresses the individual as a whole person, taking into consideration the stage they are at in life and their place in community.
From the very beginning of nursing training we are taught about holistic care. The NMC stipulates that it is a standard of competence for all fields of nursing that nurses should practice in a holistic manner. (7) The phrase 'holistic care' litters policy and guidance documents and is considered paramount in the delivery of high quality patient-centred care. As a final year, dual field adult and mental health nursing student, I have been able to experience a wide variety of practice areas in both medical and psychiatric worlds during my training. Increasingly, I see great value in applying the recovery approach when planning and delivering care in both fields.
Obviously, we should not apply the recovery approach in a reductionist sense when transferring to the physical healthcare setting. When we can alleviate pain and suffering from injury or disease, we should! However, seeing patients through the lens of the recovery approach enables us to see them as so much more than an illness.
God's model of care
As a believer, the recovery approach reminds me of God's model of care towards his children. Faith, like recovery, has long been compared to a journey. This metaphor not only reminds us that we are travelling somewhere, but that the journey itself is a process during which we will be refined as we move towards our destination. God's love gives us hope, agency and opportunity.
In Jesus's death and resurrection, we have the greatest hope of all; a hope that if our trust is in Jesus as our Lord and Saviour, we are free from the power of sin over us. We can look forward with hope to an eternity with God; confident that we will be made new and will be free from all physical, mental and spiritual suffering. We will be free to enjoy Jesus fully and will see him face-to-face.
Patient agency focuses on the contribution that patients can make to their own care. Through collaborative work, the recovery approach seeks to challenge and change the mindset that a patient is defined by addiction or mental illness and that their life is controlled by its symptoms and limitations. Similarly, we as Christians need not live as if sin continues to control our lives. In Romans, Paul addresses just this point, stating 'we should no longer be slaves to sin' (Romans 6:6). Through Jesus's redemptive blood, we are saved from the eternal penalty of our sin, but not spared the everyday presence and potential of sin.
As such, we are not 'cured' of sin in this life. Until the new creation we will still experience present symptoms of sin: separation and suffering. Sin, like addiction and mental illness, is a persistent enemy we must battle daily. Much of this battle is a change of mindset. Let us pray, as Paul did, that we will be transformed by the renewing of our minds to live lives worshipping God and not idols. (8) Saving grace is where our relationship with God begins, but salvation is not where his grace ends. In our lifelong sanctification God calls us to continue on under his grace rather than move on from it. (9)
How marvellous, that when we come to know Jesus we are adopted (10) into his ever-growing, international family. As part of the body of Christ, we are each given a role to play and through the power of the Spirit we are equipped with gifts to serve God and his church. (11) Each of us are commissioned to share Jesus's love and the good news of salvation with those around us. (12)
Working in healthcare, we are given opportunities daily to share Jesus's love to those in our care. Often it may not be possible for us to speak openly about faith, but we do have the opportunity to pray for all those we meet. We know prayer is powerful. I encourage you to pray for as many patients as you can. These prayers don't have to be long, complicated or noticeable to those around you. But I do encourage you to pray; you may be the only person who has ever prayed for them.
Let us pray not just for our patients, but also for our colleagues, family and friends who may similarly have an ongoing struggle with poor mental health with no 'quick fix' cure. Pray that they would know fresh hope, agency and opportunity, both in earthly and spiritual terms.
What a hope we have in Jesus; what a dignity that we are given the choice to live for him each day and what a privilege to have the opportunity to share the good news with those around us. That is essential to true 'holistic care'.
Rachel Denno is a final year, dual field adult and mental health nursing student
1. Constitution of WHO: principles. WHO 1948. bit.ly/2nmQ7iL
2. Jacob K S. Recovery Model of Mental Illness: A Complementary Approach to Psychiatric Care. Indian J Psychol Med. 2015 Apr-Jun; 37(2): 117-119. bit.ly/2zDlBqN
3. Deegan P. Recovering our sense of value after being labelled. Journal of Psychosocial Nursing. 1993; 31(4): 7-11.
4. Boardman et al. Recovery is for All Hope, Agency and Opportunity in Psychiatry. South London and Maudsley NHS Foundation Trust and South West London and St George's Mental Health NHS Trust December 2010 bit.ly/2AWeevC
5. Deegan P. 'There's a Person in Here' (transcript). The Sixth Annual Mental Health Services Conference of Australia and New Zealand. Brisbane, Australia. 16 September 1996. bit.ly/2Por8eQ
6. Miller E. Clinical: The recovery approach to life-changing conditions. Nursing in Practice 18 April 2017. bit.ly/2qyEhD8
7. Nursing and Midwifery Council. Standards for competence for registered nurses. NMC 10 October 2018 bit.ly/2cjMEil
8. Romans 12:2, 1 Corinthians 12:2
9. Romans 6:14
10. Ephesians 1:5
11. 1 Corinthians 12:12-27
12. Matthew 28:18-20