HOW SOCIAL WORKERS SHOULD PROMOTE RECOVERY FOR ADULTS WITH SEVERE MENTAL ILLNESS
General overview/abstract/Rationale for choice
During the past few decades, advocacy for people with severe mental health has developed as an important factor in mental health policy both in UK and in America. However, the recovery model which has at its heart person centred approaches is being seen as not completely suitable for people with severe mental health problems who have not recovered from their ailment. The main case study will critique this group which supports more evidence based practices. In America, an example of this group is the National Alliance for the Mentally Ill who focuses on the needs of people with severe mental health problems. The case study example champions a hybrid theory which integrates evidence based practices with the recovery model, thereby maximising the virtues and minimising the weaknesses of each model. This will suggest that, while the degree of illness remain high in evidence based practice, is important for the patient to receive the right treatment; but, as the patient recovers, he is allowed more autonomy, and greater input about the type of treatment and services he receives. The hybrid theory was suggested in 2001, and, while it appeared rational and effective, the focus of this research will be to revisit the recovery model and promote it as the desired option for supporting people with severe mental health issues, whilst looking at new approaches and ideas. The recovery model is more person centred and supports a more humanistic approach; therefore, the challenge for this study will be to demonstrate its efficacy and effectiveness. The methodological approach will be the case study. Multiple case examples are preferred as this arguably enriches the data analysis and improves validity.
Introduction
The goal of the study will be to establish the parameters which can be applied to all research provided it meets the established objectives. The generalisation of results will then be made to theory rather than to the populations. The methodological approach to be used will be the case study. Rather than solely relying on statistics, the case study will explain the conditions through the perspectives of the participants. The case study is a qualitative approach. The unit of analysis is the recovery model, and how to promote this, though the main target group is people with severe mental health problems. This is a multi-perspective analysis meaning that the research will not just consider the voice and perspective of the participants, but also the relevant group of actors and the interaction between them. It resolves anti oppressive and anti discriminatory practices by giving a voice to the powerless and voiceless (Feagin, Orum and Sjoberg, 1991).
The goals of the study include demonstrating that the recovery approach can work for people with severe mental illness, and therefore will support inclusion. The research questions are:
- What evidence exists for the preference for evidence based approaches to supporting people with severe mental illness?
- What evidence exists for the preference for a mixed approach to supporting people with severe mental illness?
- What evidence exists for the preference for the Recovery approach to supporting people with severe mental illness?
- Which model is most suitable and how will this be promoted?
The secondary literature source will be used to address these questions. This will be made up of journals, magazines, internet sites and text books. Data from these sources will be analysed; further, this data will then be analysed interpreting the theoretical propositions, and linking this back to the data. The findings will be evaluated to sift evidence for a best practice model in supporting people with severe mental illness. Conclusions, findings and recommendations will be proffered at the end of the study.
Methodology
The qualitative research to be used for this proposal will be the case study method. Case study will make it possible to incorporate the views of those involved in the case (Zonabend, 1992). I will use the case study approach because quantitative methods are limited in terms of analysing the phenomenon. To be generalised it needs to have more than one case. (Hamel et al, 1993). The main case example will come from Frese et al (2001).
There are three types of cases exploratory, explanatory and descriptive. This will be a descriptive case, which begins with a theory, and then using a pattern matching theory to link the cases. For instance, the evidence based approach will link the case supporting treatment and scientific approach, then the hybrid theory will link the case supported by Frese et al (2001), while a number of data are in support of the person centred approach of the recovery model such as SCIE, Falloon and Fadden (1995) and De Paulo (2002).
The research will aim at explaining a phenomenon (the recovery model) in depth and in a holistic manner taking an interpretative stance (Gall, Borg and Gall, 1996). I will look at multiple cases concentrating on a particular case example from the literature and using other research to interpret the data by looking at patterns and themes. I will develop a profile of the case, placing it in context (background), giving examples and linkages to broader issues (Yin, 1994). For future study, purposeful sampling will be used since it is generally used for case studies. This sampling procedure targets a particular group of people – those with severe mental illness (Creswell, 1998). Social workers, as support staff, are another part of the population being sampled, as their role in promoting the recovery model is important. The limitation with this study is that I will not be able to recruit those from other parts of the population (Wadsworth, 2005). I have therefore studied a similar case in another country (US) to establish validity. The data will be drawn from one primary source, a journal, and analysed from multiple perspectives, methods and sources of secondary information from the literature (Cohen and Manion, 1994).
Literature review
I will look at a case study of a model that demands for a more evidence based approach, critically analysing this and use arguments in favour of the recovery model from the literature to demonstrate that this approach will be more relevant. So the main case study used will look at two conflicting models. America in the 1990s saw the advance of scientific approaches to the treatment of mental illness increase dramatically. I will pick one of the research studies done in America as a case example and make a comparative case study on how recovery in the UK can be promoted to benefit people with severe mental illness.
Before the turn of the century, determining how psychiatrically disabled people perceive their needs was a new area in mental health since those with schizophrenia and other serious mental illnesses were generally seen as so cognitively impaired that they were incapable of providing substantive input about their care. In America, the National Alliance for the Mentally Ill (NAMI) developed as the largest mental health movement made up of people recovering from mental illness and affecting policies around the subject. They developed an eight point blue print for recovery which included access to new medication, employment incentives for people with severe mental illness, access to safe affordable housing with appropriate community based services and equitable health care coverage and participation by the recipient and their family (Ross, 1999). Frese et al (2001) stated that those with mental health problems have significant differing needs for various types of treatment and services. Therefore, the authors suggest that the degree of support for evidence based practice depends largely on the severity of the ailment. Therefore, mental health advocates are more likely to support treatment for people who are severely disabled while those whose health problems are not as severe are more likely to support the recovery model.
The purpose of this case example is to integrate evidence based practice with the recovery model and suggest a hybrid theory which maximises the advantages and reduces the disadvantages of both models. In supporting the evidence based practice model, Torrey et al (2001) have called for treatment approaches that are scientifically grounded. Under this concept greater reliance on scientific evidence is being added to treatment approaches that are supported by psychological and sociological evidence, as well as by findings through biological research. Frese et al (2001) believe that it is important to prescribe medication along specific parameters, self-management training of illness, community treatment, supported employment and integrated treatment for co-occurring substance use disorders. However, mental health services for persons with severe mental health illness should reflect the goals for such people. Mental health services are not expected to focus only on traditional medical treatment or rehospitalisation but should be mixed so that people can be involved in employment, develop relationships and have good quality lifestyles. Those with severe mental health have a right to intervention that is seen as effective. Therefore, evidence based practices do not provide the answers for everyone with mental illness. “Nothing about us without us”, is a slogan that expresses the wishes for more dignity and autonomous control for those with mental health illness (Pelka, 1998). Frese et al (2001) therefore sees the Recovery model emerging at the same time of that of evidence based approaches which it called more personalised and subjective. Anthony (1993) notes that recovery is a deeply personal, unique process of changing ones attitude, values, feelings, goals and skills. It is a way of living a satisfying, hopeful and contributing life, even with limitations caused by the illness. Sullivan (2004) offers another definition of recovery which involves the development of new meaning and purpose in one’s life as one grows beyond the problems of mental illness and develops empowerment and self directedness. Objections to the Recovery model have included: it being obstructive to medical treatment because psychotic illnesses and other severe mental illnesses can affect the thinking processes to the point that the patient’s self is overtaken by the disease (Peyser, 2001). Therefore, the recovery model which focuses primarily on hope, phenomenological, subjective experiences, empowerment and Human Rights will not be effective. The two models will conflict under many circumstances; therefore treatment decisions should involve both medical facts and choices based on values (Frese et al, 2001). The key skill for practitioners will be to work out the right balance of medical treatment and value principles, or switching from medical treatment to person centred approaches when the patient is on the road to recovery. There are different value judgements of the different approaches. A major issue of this case example is whether the two different major approaches to manage mental illness can co-exist, and if expanding evidence based approaches can co-exist with the philosophical pursuits of the recovery movement which will be a challenge. Frese et al (2001) believes that the insights of the recovery movement should be accommodated in order to gain support for medical treatment.
One method of integrating the two models is suggested by Munetz and Frese (2001) regarding combining the traditional medical model (scientific) with the social model (subjective) being pursued by the Recovery model. At first glance this appears difficult as the two models seem diametrically opposed. The medical model is highly paternalistic, emphasising weakness, illness and limitation rather than the potential for growth. Advocates for people with mental health problems also feel that doctors are too powerful and oppressive acting out of misguided beneficence. Munetz and Frese (2001) makes it clear that those who are severely ill in their decision making capacity will not be able to determine what is in their best interest, therefore the medical approach is relevant for such people because individuals can be so ill that they do not have the capacity to understand that they are not healthy, and leaving them in this state amounts to neglect. But once benefitted from this approach a shift can then be made towards recovery. Csernansky and Bardgett (1998) divide serious mental illness in ranges from severe, refractory psychosis to less serious, responsive psychosis and normality. While this researcher may not agree with labelling the ranges listed demonstrates that recovery can begin to occur at the responsive psychosis stage.
In terms of the socio-political setting, the development of community based approaches has replaced the medical model, where people are encouraged to live in their own homes rather than long stay hospitals. Falloon and Fadden (1995) noted that when support is given to those with severe mental illness it will lead to rapid recovery of functioning and a healthy and productive lifestyle. Social workers should therefore promote a coordinated strategy to include assessing needs, setting goals, allocating resources, implementation reviewing progress and assessing outcomes. More sympathy and support is needed to demystify the illness as stated in Edwards (2003). In 2002 the Department of Health released its paper on the National Suicide Prevention Strategy for England, laying out strategies to reduce suicide rates in England. This was preceded by the defeat depression campaign, which sought to reduce the stigma associated with depression. Both these reports focused attention on prevention through education so that depression can be diagnosed early and people who are depressive must be empowered to identify their needs and experiences, and press for improved treatment and public awareness; neither report focused on doing anything about the possible causes of depression (e.g. divorce and family breakdown).
Legislation protects people from unfairness, such as at work, for instance, getting time off work for a depressive disorder – in theory, at least. This improves anti oppressive and anti discriminatory practices. De Paulo (2002) said patients should be given something positive to think about. Social workers should be careful about what they say to patients, even when patients have relapsed. This is important for the patient in terms of care delivery. “I always tell patients, you’ll look better before you feel better. The inner symptoms of hopelessness and low self esteem take more time to recover than vitality and physical condition.” De Paulo (2002, p245).
Community care (2008) reviewed a research carried out by the Social Care Institute for Excellence (SCIE) on their findings about recovery from mental health. The interest in recovery arose from the experiences of people with severe mental health problems. Since then professional bodies, health care agencies and governments have become more interested in adopting recovery as the guiding principle for mental health policy, practice and services. In mental health services recovery has three main meanings: a spontaneous and natural event – overcoming problems without intervention, the intended consequence of the skilful use of the full range of effective treatments, and finally, personal recovery that can occur in the context of continuing symptoms or disabilities. The first usage relates to resilience and robustness though it is poorly understood. The second meaning is the focus of evidence-based practice and treatment guidelines and the third is about recovery of hope and ambition for living full and purposeful lives whatever the circumstances. It is this definition that is informing some current thinking on direction in mental health services, and among social workers.
An emphasis on personal recovery focuses on collaboration, partnership working and self-directed care, all of which lead to choice and control for people who use services, their families and other supporters. Recovery is the process of regaining active control over one’s life. This may involve discovering (or rediscovering) a positive sense of self, accepting and coping with the reality of any continuing distress or disability, finding meaning in one’s experiences, resolving personal, social or relationship issues that may contribute to one’s mental health difficulties, taking on satisfying and meaningful social roles, and calling on formal and/or informal systems of support as needed (Community Care, 2008).
Recovery involves a process of empowerment, finding meaning in and valuing personal experience. It is positive about cultural, religious, sexual and other forms of diversity as sources of identity and belonging. Recovery is associated with social inclusion and being able to take on meaningful and satisfying social roles in society and gaining access to mainstream support such as housing, adequate personal finances, education and leisure facilities. Treatment is important but its capacity to support recovery lies in the opportunity to arrive at treatment decisions through negotiation and collaboration. Recovery-based services emphasise the personal qualities of social work staff as much as their formal qualifications, and seeks to cultivate their capacity for hope, creativity, care and compassion, acceptance and resilience.
To promote personal recovery, social workers need to move beyond preoccupations with risk avoidance and a narrow interpretation of evidence-based approaches towards working with creative risk-taking and what is meaningful to the individual and their family. Interaction between social workers and clients continues to be an understudied aspect of interventions. Recovery places an emphasis on therapeutic relationships, demanding that providers collaborate closely with each consumer to discover their unique path to healing. As a result, researchers must also reorientate their focus from the structure of services to the processes that take place during service delivery (Stanhope and Solomon, 2008).
In evaluating the research question from the secondary source material, evidence based practices of the traditional medical model is seen as forcing dependency on treatment and others, devaluing and isolating people and creating institutionalisation. In the second research question, Frese (2001) looks at a more hybrid theory from America where evidence based approaches is supported when people are very ill, and the recovery model used when they begin to achieve normalisation. This appears to be a popular notion. However, this research supports the fourth research question, where the recovery model is generic and holistic, developing relationships and support to help people recover, maintaining their recovery in the community and fostering a positive personal outlook to overcome barriers.
Conclusion
In summary, the main case example from Frese et al (2001) is that service users, who are more severely disabled, particularly in their decision-making capacity, can best be treated with evidence-based approaches, and perhaps with less attention to recovery-model considerations. However, for those whose mental illnesses become less disabling, the principles of the recovery model become increasingly applicable. Frese et al (2001) called this the hybrid theory. The recovery model emphasises that responsibility for and control of the recovery process must be given in large part to the person who has the condition. Indeed, some advocates for the recovery model have stressed that overdependence on others prevents recovery.
This study is a critical case because it can be generalised to other cases and can be compared using multiple case example from secondary source materials (Patton, 1990). The advantage is that there will be better representation from the population but the disadvantage is that it limits the depth with which each case may be analysed (Creswell, 1998). The source of evidence or data used included documents such as journals, magazine and text books (Stake, 1995). The analytical strategy used was to analyse the evidence based on the theoretical propositions (evidence based approach, person centred approach and hybrid theory).
Recommendation for future study
For the sake of triangulation of evidence, the documents will serve to confirm the evidence from future interviews of the population (people with severe mental illness and social work practitioners). The focused interview will be used where the respondent will answer a set question used to confirm data from the literature review. The rival theories (evidence based and hybrid theory) will then be used to add quality control to the case study. The data will be analysed by evaluating the case example then interviewing the participants, analysing the transcripts, looking for recurring themes (findings), patterns and categories, thereby moving from more general to more specific observations (Silverman, 2000). External validity will be tested to ascertain if other studies agree with the conclusions, and generalisable beyond the immediate case. Triangulation will exist from the ethical need to confirm validity of the processes using multiple sources of data to establish meaning (Stake, 1995). Pattern matching linked the data to the theoretical proposition.
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