Jean Pierre Wilken

Version July 2024

A deeply personal, unique process

One of the first descriptions of personal recovery in people with mental illness, and still the most quoted worldwide, is that of William Anthony (1993, p. 527), one of the most famous in the 1980s and 1990s. pioneers of psychosocial rehabilitation in America:

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 Anthony’s time, hardly any research had been done into how people themselves experienced their condition, what their experiences were with care, let alone how they dealt with their vulnerability and how care can connect with it. But a great deal has now been published about this. All these studies show that Anthony’s definition still contains important elements of recovery, although the mental illness is less central today. We are using more the notion of vulnerability which both entails mental issues as well as its interaction with external factors. These may be related to a particular condition, but also to what may have preceded it, often involving serious traumatic experiences.

What is recovery?                      

Recovery can be defined in four different ways: as personal recovery, medical or clinical recovery, functional recovery, and social or societal recovery (Van der Stel, 2017).

Personal recovery is about the recovery process as experienced by a person. Granting meaning and getting a grip on one’s own life are important aspects here. An essential aspect of personal recovery is making sense. This concerns past, present and future. If there have been serious disruptive experiences and their consequences, this must be processed. Questions such as: what happened? why did this happen to me? Interpretation and acceptance seem to be important elements in this processing process. However, another element is to become aware of resilience. Apparently, I’ve been able to get over the situation! The next question is then: What can I do with these experiences, now and in the future? Can I use my powers to work on a future. In this way an interpretation is sought for a meaningful life.

For a long time, health care recovery was seen only as clinical recovery.

Medical or clinical recovery occurs when there are no longer any signs of disease to a lesser extent. In the case of a mental illness, for example, depressive or psychotic symptoms disappear. There is eventually a cure. The diagnosis can then no longer be made.

Functional recovery refers to the restoration of functions that are impaired or impaired as a result of the condition. There is a connection here with clinical recovery. This particularly concerns the so-called executive functions, such as being able to keep an overview, to be able to plan, to motivate yourself and to exercise self-discipline. These executive functions are necessary for self-regulation. Self-regulation is the mechanism for managing yourself and your behaviour in such a way that you can take responsibility, keep control and take control of your life. In this way you are also able to meet the basic needs of autonomy, connectedness and personal development. Self-regulation presupposes the ability to connect with ourselves, with our emotions, feelings, thoughts, needs, motivation and behaviour, and is the operative mechanism for setting goals and working towards achieving them (Van der Stel, 2013; 2017). It is also a condition for self-determination: being able to fulfil basic natural needs, experiencing yourself as competent and feeling connected to others (Wolf, 2017). If self-regulation is impaired, this hinders social recovery. Social or civic or recovery refers to the improvement of the person’s position in terms of housing, work, income and social relations.

The above meanings of recovery are generally components of personal recovery. You could say that in the process as the person experiences and shapes it, aspects of disease recovery, recovery of self-regulation and social recovery come together.

Stages in a recovery process

A number of authors have described the course of a recovery process by identifying stages (Andresen, Oades & Caputi, 2003; Ochocka et al., 2005; Spaniol et al., 2002; Young & Ensing, 1999, Wilken, 2010). The most cited classification is that of Spaniol et al. (2002), who speak of ‘being overwhelmed by the disability’, ‘struggling with the disability’, ‘living with the disability’ and ‘living beyond the disability’.

Another way to describe the course of a recovery process as it emerges is ‘from crisis to stabilisation’, ‘from stabilization to reorientation’ and ‘from reorientation to reintegration’. In the first phase, the main task is to gain control over the condition. In the second phase, an important task is to find explanations for understanding the experience of the disease and the crises, and to develop a positive future perspective. The person will work on psychological recovery. This period includes determining what the core (intact or healthy) of the personality is, such as one’s own values and qualities. People may find it important to learn about psychiatric illnesses or to look for suitable care. People can join self-help groups and seek out fellow sufferers. The person is working on a positive identity. This means setting goals that are important to the person himself, sometimes revising old goals and values. During this period, people take responsibility for managing the condition and taking control of their own life. It means that risks are taken, that relapse can take place and that people have to get back on their feet. This is the preparation for the third phase. In this phase, the person takes on roles that are meaningful and valued. The different phases and transitions between the phases are summarized in the following overview.

1. Stabilization Disintegration/disconnection of the self and society → stabilization/reconnection with the self at a basic level of functioning	2. Reorientation Reorientation/reconnection to the self on a psychological level → reorientation to the community	3. Reintegration Reintegration /reconnection at a social level → connection with the community → integration
Focus: control symptoms and reduce suffering; recovery of self-regulation	Focus: exploring the implications of the condition for the near future; re-identify; explore how to get back to a normal life	Focus: restoring meaningful activities, relationships, and social roles

Figure 2.3. Phases and transitions in the recovery process

When people begin to recover, they report that they are increasingly able to take responsibility for their self-care, such as their own hygiene, and maintaining a daily routine of eating and sleeping. Taking care of one’s own living environment is also seen as aspects of restoring self-regulation (Van der Stel, 2017).

Many people report that the most effective way to prevent their condition from draining all energy and time is to participate in various adapted activities. These activities yield other gains, namely an increased sense of competence and a greater sense of well-being. The activities most frequently mentioned in the studies include exercise such as sports, (volunteer) work and participation in various mental health care programmes.

A dynamic process

The ‘road to recovery’ is not a linear process. The boundaries between the phases cannot be drawn exactly and there are up and down movements within the same phase and between the phases. The pace of recovery can vary from person to person.

Recovery can be considered a learning process. People face a number of challenges in their recovery process:

1. Learning to deal with vulnerability in such a way that a new balance is found and maintained. This concerns self-regulatory competences, both to gain and maintain a grip on daily life, and also to make adequate use of resources. Since vulnerability can also be formed by stigmatisation and discrimination, these are also things to deal with.
2. Processing the cause of the vulnerability. This is what Detlef Petry (Petry and Nuy, 1997) once called re-historicization: the reconstruction of personal history in order to understand what happened and give it a good place, in order to heal life history, as it were. Slade (2009) calls this a process of framing.
3. Developing a positive identity. This involves, among other things, separating the vulnerability (for example, the mental health issue or functional limitation) from the other aspects of the personality, the healthy side, the strengths, for example qualities like personal knowledge, experience, skills and talents.
4. Develop (or resume) meaningful activities and social roles.

Five clusters of recovery factors                       

Leamy et al (2011) have identified five elements of recovery, which they brought together in the CHIME model. The letters CHIME stand for: Connectedness, Hope and optimism about the future, Identity, Meaning in life and Empowerment.

These elements correspond with the clusters of recovery factors as revealed by the meta-analysis of Wilken (2010). In the CARe model these are called ‘the 5 pillars of a recovery process’:

1. Factors that strengthen personal motivation to work on recovery, such as hope and optimism about the future, meaning and positive relationships.

2. Factors associated with self-regulation: skills to take care of yourself, to take responsibility, to keep control and to be able to direct one’s own life.

3. Factors that contribute to the reconstruction and reinforcement of one’s own identity. This also includes the overcoming of self-stigma.

4. Factors that lead to connection and social participation, such as meaningful social roles.

5. Support factors that serve as resources for recovery (both personal and material support). It concerns the support of peers (peer support), family members and other relatives, and professionals, and all kinds of material resources.

Click here [jpw1] to find an infographic.

Summary

Recovery can be defined as a development process that can be sketched on a continuum from disintegration to integration, or from a state of disconnection to a state of connection and connection. In a personal recovery process, recovery plays a role on a physical, psychological, existential and social level. All these aspects are connected in some way. Integration and connection relate to two entities: the person or the self, and the environment, community or society. In the course of this process, the focus gradually shifts from the person to the environment, i.e. from the inside out.

The recovery process is driven by a desire to move ‘forward’. In the stabilization phase, the direction can still be vague and there may be nothing more than the desire to get rid of the repressive nature of a situation that causes a lot of suffering. In the reorientation phase, the desired future perspective becomes clearer and can take shape in the form of concrete goals. In the reintegration phase, specific steps are taken to achieve these goals. All studies show that the support of other people is indispensable. People who give hope and encouragement, who (help to) understand what is going on, and who give practical help.

The four core acts of the CARe model can also be interpreted as parts of a personal recovery process, as dimensions of ‘the recovery story’. Connecting is about restoring the connection with one’s own core, one’s own identity, but also about restoring self-confidence, competences and social connections. It takes ‘understanding’ about what happened and what is happening now. Understanding how you are put together, and that you are more than a condition or disability. Ensuring refers to working on safety and restoring and preserving stability. Finally, ‘strengthening’ concerns all those aspects that contribute to empowerment, such as hope, optimism, self-confidence, talents and skills.

---

 [jpw1]Insert link to multidimensional model