After engaging with this material you will be able to

  • summarise what the contribution of hope is to the process of recovery and social inclusion
  • describe the connection between hope and the process of giving meaning to life
  • give an operationalisation of the concept of hope
  • tell how the concept of self-efficacy is related to hope
  • describe what goal readiness is (3 elements)
  • describe how living according to one’s values in life, hope and goal-finding are interconnected
  • relate the Strengths Approach to goal readiness
  • explain what the role is of narrative in the process of meaning-giving
  • describe the role of stress in the concept of Sense of Coherence
  • differentiate between linear approaches in supporting goal-finding and non-linear approaches, which apply more creative resources (derived from arts)
  • describe how the metaphor of the journey ties in with the application of arts in facilitating recovery programs
  • demonstrate how the Strengths Approach was central to the "Just Look At Me!" intervention with photography

Facilitating and supporting recovery and social inclusion has become a new paradigm in mental health care, one that permeates acute and medium-term care. How does this inform mental health nursing? There is a need for both unifying central concepts ánd practical tools. Central concepts can help us legitimize the direction of newly developed nursing interventions and also steer us in operationalising them in concrete tools for our professional praxis. Commencing with the CHIME-framework (Leamy et al.) we can identify domains of recovery that we as workers should address when we organise nursing care and rehabilitation programs. These domains are:

Domains Subjects
Connectedness including social inclusion
Hope human potential, positive psychology, strengths, resilience
Identity including the social identity
Meaning to life including theology, spirituality and human philosophy
Empowerment -

In the vignette of John we will reflect on the contribution of hope and meaning to Life as aspects of well-being to the process of recovery and social inclusion. How are they connected with each other on a conceptual level and what is the causal relationship between recovery and social inclusion as an outcome and process? To be able to answer these questions we must first define the concept of hope and meaning to Life. Hope can be seen as something that is present in people in high or low levels. Someone develops feelings of hope when he/she is able to make estimations of his/her chances and possibilities that adverse developments or conditions will turn for the better. Take John for instance: how does he estimate his chances to get a job and earn a living? There is a passive and an active variant of hope. In relation to recovery we are interested in the active variant that focuses on how people can have hope that they can change their lives themselves. The more realistic this estimation is, the higher the level of hope in the individual will be. How is this for John? He may have the hope to get a job and work, but he does not know how to realize that in the face of ‘being threatened on a daily basis’. He would like a girlfriend, but doesn’t know how to get one. So, the hope remains a passive wish for him.

Hope in its active variant is seen as a motivational drive that: builds on an accurate assessment of the actions necessary to realize a goal; develops the strengths, means and assets needed to perform. Goal finding is an overarching concept.

Without a goal or ambition in life there can be no hope. Seen in this light ‘hope’ plays an important role in all stages of recovery. Young and Ensing's (1999) qualitative analysis of recovery narratives identified having hope as a significant component of the first phase in service users' accounts of the recovery process. The authors refer to this as overcoming “stuckness”. Can you identify in what respect John is still stuck in his situation? How could you, as a professional, help him to make his hope more realistic and ‘active’? We will deal with these questions and the underlying concepts in the following sections:

Further reading:

Hope is strongly related to another key concept: self-efficacy. Self-efficacy is about one's beliefs in being able to perform successful actions that are needed to realize a desired outcome. On the one hand there is the confidence that one will attain a certain goal and on the other hand there is the belief that one can perform the skills and strengths needed for realizing the goal. It concerns the individual’s agency. Is John very confident that he can keep up a job if he gets one?

What values can you infer from John saying: “It was really embarrassing still living at home”? And from his wish to earn a living of his own?

The strengths-approach (Rapp) has been developed at the university of Kansas(USA) to provide professionals with tools to facilitate and support recovery process of service users. It focuses on making an inventory of strengths (talents, skills, strong beliefs, community contacts) together with the service user, prioritizing a domain of living for goal setting and then building a plan that uses one of the strengths to connect to the action.

Further reading:

As you will have learned after studying the material it is the narrative that plays a signficant role in recovery oriented mental health nursing. Be it as photo story (see 'Recovery in Images') or any other form that storying one’s experiences and life can take as the vehicle for constructing a coherent life story is the narrative. The narrative must convince its narrator and his public. This is the dialogical setting and the social context that lends the story its realism. In the Sense of Coherence Theory by Antonowsky the need for a coherent story to make sense of one's life is seen as something that helps the individual to cope with stress. This is explained in the following section:

Further reading: The process of Meaning Giving in Recovery

This text 'The process of Meaning Giving in Recovery' pulls together all strings of concepts and approaches we have discussed until now and in this way also serves as a summary.

After having done the further reading you will have assembled enough knowledge to better understand the overall framework of Mike Slade’s 100 ways to support recovery. A guide for mental health professionals.

Read and study this guide and identify where the hope, values, meaning and the narrative comes in. Can you connect what you read about strategies for promoting hope with the other texts? How would you now approach John to find meaning in his life and develop hope?

Narrative

Narrative holds a central place in facilitating recovery. Although there is more than one theory about how people construct narrative (Labov and Waletsky, 1967; Schroots, 1996, Rubin, 1999) we ‘ll focus here on the classic approach of Burke (1945), because goal formulation (an important aspect of hope) plays a central role in it . According to Burke the story structure consists of five elements (the pentad): in a story we always have an agent (actorship), an action, a goal, a setting and an instrument. In a story something happens and is made to happen by the main character(s). That‘s what we call the action. The main character (agent) acts in order to realize his goal or at least there is some intention in his acts. There must be a drive behind the story. Usually there is some kind of trouble that triggers the story to take its course (Bruner, 2001). This can be anything from suffering, death, struggle, whims of fate, shame and guilt. In the case of people with mental health distress, an important drive can be inferred from the struggle to survive mental health problems, including hospitalisation. This struggle involves suffering, be it a suffering from decreased self-esteem, or be it from the stigmatising influence from others.

People with mental health problems often have to cope with a self-image that lies under attack. They may feel the need to re-story their lives and find a new relation with their suffering. The suffering often has a parallel in narrative where a mismatch between elements of the pentad may occur, for instance when a person can’t explain his suffering without compromising his agency. This may be the case when accepting a diagnosis with a mental disorder may victimize someone as someone who does not know what he is doing because he is considered a psychiatric patient. A ‘good’ story however strikes a match between the narrative elements that restores credibility in one’s owns eyes and those of others. When it comes to the integration of a proven vulnerability into the self-image, then a too realistic estimation of deficiencies and impairments because of mental health problems may forestall a hopeful narrative. A hopeful narrative may be wished for more than a narrative true to life.

Burke's Dramatic Pentad

Hope

Mental health care aims at empowerment and raising hope in patients who recover from mental illness. Empowerment as a concept was developed within consumer run projects in the patient movement and focused on an increase of self-esteem and self-efficacy beside a social activism. Self-efficacy may be considered the core principle of empowerment because it integrates cognitive, emotional and behavioral aspects. Self-efficacy is not only confidence that one can successfully realize plans and can trust one’s capacities to do so; it is also the actual performance that counts. What triggers people to act? First there must be some feeling of urgency, a stimulus to respond to. Then there must be some motivating drive: anger, revenge, lust, etc. In the context of supporting recovery it is foremost hope that dominates. Without hope life is just a miserable passage from birth to death. The presence of hope can predict whether a treatment will be successful in psychotherapy (Hubble et al, 1999; Frank, 1991) and is probably just as important for the success of institutional care programs. Martin Seligman emphasized the importance of positive thinking which is akin to having hope (Seligman, 1990). Snyder operationalized the concept of hope and embarked on studies in validating it from empirical evidence (Snyder, 2000).

Snyder postulated that hope consists of three dimensions: goal formulation, path-finding and agency. Hope means hoping for something to happen. There is the passive wait and see that can have strong hope elements. Snyder focused on a more active hoping. People have higher hope levels, he claims, as they can have personal goals they want to realize in life. There must be something to strive for that makes life worth living. Having a goal is however not enough in itself. It must be a realistic goal that can be attained, otherwise it gives false hope that in the end will disillusion people. Besides, one must have some idea of the way how one’s goals can be realized. This is path-finding and consists of having knowledge of the different options that lead to a goal and then being able to pick the option that is best fitted to the job. What option is best fitted to the job depends on an understanding one’s motivation and personal qualities and skills. One can have an attainable goal in life, know how to get there, but may stumble without necessary skills and equipment for the journey. Or, in other words, one needs a credible coherent story in which the elements of Burke’s pentad are attuned to one another in order to succeed in the journey. This is what is called for in the sessions of recovery peer-groups where participants learn from each other to (re-)construct their life-story and integrate mental health problems into their story without letting those difficulties dominate their lives. We aim at supporting service users in becoming aware of their values in life. Re-storying their lives involves distinguishing core values from the impact of mental health problems and the stigmatizing influence of treatment. Thus enabling people to reformulate ambitions, wishes and goals that are connected with this deeper and personal core of values.

Hope can be seen as something that is present in people in high or low levels. The degree of hope people have tells us about how individuals envisage the likelihood of positive/negative developments in their mental health or conditions. There is a passive and an active variant. In relation to recovery we are interested in the active variant that focuses on how people can have hope and that they can change their lives themselves. The more realistic this estimation is the higher the level of hope in the individual will be. Would assessing the level of hope at the outset of a trajectory of supporting John in his recovery and again after some time, help professionals to measure the effect of their work?

The following text is a fragment from an article by Choe (2013):

"The Snyder Hope Scale, Herth Hope Index, and Miller Hope Scale are the most frequently used with psychiatric patients. Although these tools are reported to have good reliability and validity, none have been validated for people with severe mental illness (Schrank et al. 2012b).

Read the following article: Copic, V., Dean, F.P., Crowe T.P. and Oades, L.G. (2011). Hope, Meaning and Responsibility across stages of Recovery for Individuals Living with an Enduring Mental illness. Australian Journal of Rehabilitation Counselling 17(2), 61-73.

Hobbs & Baker (2012) interviewed eight people with experience of recovering from mental health problems.Interesting is that they found that the non-linear course of a recovery trajectory complements the linear routes in which there is a direct line from goal formulation through pathfinding to performance. These linear models however lie close to what nurses and other professionals are familiar with: the interventionist approach (problem identification goal-setting and action-planning), but which are not always suitable for persons recovering from severe mental illness.

Recovery is a journey. Photograph by Chris. Recovery is a journey. Photograph by Chris.

Hobbs & Baker found that a journey metaphor was prominent in participants’ accounts, associated with the image of travelling down a road. There were bumps, set-backs and reverses along the road, but the idea of “catalysts to hope” incorporating talk of “sparks” and “turning points” associated with significant increases in hope for recovery made the journey variable, rather than being smooth and continuous. The metaphor of the journey has been the starting point for the application of arts in facilitating recovery programs, as for instance in ‘Just Look at Me! Recovery in Images’ where photography is used to support service users in their recovery trajectory.

Read the following text on stages of recovery and the role of hope as one of the four components of recovery (based on Andresen, 2006). Then relate what you have learnt to the case of John.

The definition of recovery that was given by the mental health consumer movement describes it as a psychological recovery and as a search for a meaningful life, finding a positive sense of identity, based on hopefulness and self-determination. Four key component processes can be identified:

  • finding and maintaining hope
  • the reestablishment of a positive identity
  • finding meaning in life
  • taking responsibility for one’s life.

These processes take place over time. Five stages of recovery can be distinguished (the following text is a fragment from Andresen, 2006):

  1. Moratorium: A time of withdrawal characterized by a profound sense of loss and hopelessness.
  2. Awareness: Realization that all is not lost, and that a fulfilling life is possible.
  3. Preparation: Taking stock of strengths and weaknesses regarding recovery, and starting to work on developing recovery skills.
  4. Rebuilding: Actively working towards a positive identity, setting meaningful goals and taking control of one’s life.
  5. Growth: Living a full and meaningful life, characterized by self-management of the illness, resilience and a positive sense of self.

"This stage model of recovery, consisting of the four component processes and five stages, combines these findings in a model of the personal experience of psychological recovery. The stages are sequential, with the ‘Growth’ stage representing the outcome of the recovery process. The component processes represent the psychological state of the person as he or she progresses through the stages of recovery. Due to the highly personal nature of recovery, the model is purposely flexible in terms of the timeframe and the means by which the person moves through this process. That is, each individual finds his or her own sources of hope and ways of finding meaning and building a positive identity."

Andresen R, Caputi P, Oades L. (2006). Stages of recovery instrument: development of a measure of recovery from serious mental illness. Australian and New Zealand Journal of Psychiatry 2006; 40:972–980.

The stage of moratorium: a sense of loss and hopelessness. Photograph by Annelies The stage of moratorium: a sense of loss and hopelessness. Photograph by Annelies

Read also: Young, S.L. and Ensing, D.S. (1999). Exploring recovery from the perspective of people with psychiatric disabilities. Psychiatric Rehabilitation Journal 22(3): pp. 219-232.

Stage of awareness. Half full or half empty. Photograph by Annelies. The stage of awareness: half full or half empty. Photograph by Annelies.

  • In which of the stages do you think that John is in, taking into account the four components of recovery?
  • How hopeful do you think John is about his future?
  • How could John be helped to develop a positive identity and where does this conflict with a medical approach to his recovery?
  • What may be for John the psychological trauma inflicted from his mental health problems?

Pieter compared his suffering from mental problems with this mouldered tree he photographed.Pieter compared his suffering from mental problems with this mouldered tree he photographed. Photograph made by Pieter.

Case study of how photography can facilitate recovery and hope.

Service users may be invited to show us (literally showing us in pictures) what they think that is important in their lifes. Our interest in their pictures is a strong acknowledging power that carries the message that we see service users as persons. We called the method of using photography in this way 'The Photo-instrument' (Sitvast, 2011).

More information can be found here.

The photo-instrument is a potentially strong medium that makes visible what otherwise may remain hidden. Awareness of values in life and what one holds as dear tend to be buried under daily routines and overwhelming burdens of illness. The photo-instrument focuses on meaning making. We therefore consider the photo-instrument a hermeneutic instrument. In nursing research hermeneutic photography was first used by M. Hagedorn, but as an aesthetic technique for generating data. Photography can be used for therapeutic ends because of the potential of photographs to mirror the personal history of the person who has made the photograph. In the Photo-instrument service users made their own photographs. In another variant a professional photographer photographed service users while they were in action: Just Look at Me! recovery in Images (see the introduction Recovery in Images). Both are forms of hermeneutic photography in which the photographs are not just an anecdotal report on activities that were performed, but invite a person to see himself as part of a story, an inner discovery journey during which meaning was given to experiences in the life world. Reflecting on the pictures afterwards helped service users to recognize how certain things impacted their lives and how they could integrate them in a broader meaningful context and develop a new perspective.

There are many more possibilities of using photography to help service users to tell their story in images that invite the person to find meaning in a narrative that belongs to the pictures. The photo-instrument resembles the photovoice method that has been developed by the Boston Rehabilitation Center in the USA.

Consult the Phototherapy Manual: Finding your Identity. Phototherapy Training Course, by Lietta Granato. Retrieved february 2015.

Hope is strongly related to another key concept: self-efficacy. Self-efficacy stands for beliefs in being able to perform successfully actions needed to realize a desired outcome. On the one hand there is the confidence that one will attain a certain goal and on the other hand there is the belief that one can perform the skills and strengths needed for realizing the goal. It concerns the individual’s agency. On the cognitive level self-efficacy presupposes a good understanding of one’s potentials ánd also what options there are to choose from that will lead to successful goal attainment. This has to do with agency and actorship. Goal formulation is also bound up with cognitive skills, but not only with cognitive skills. There is a strong attitudinal/emotional aspect too: goals are connected with values in life. Only when we are able to remember and are aware of the values we have and the good that we cherish in life and the people/pets/habits/beliefs we hold dear, we can formulate goals that are truly ours. Harassed by setbacks in life and beset by illness we may have developed a low self-image that prevents us to live our life as a valued life with value-based goals to strive for. Then we can need the help of professionals to overcome shame and connect again with our deeper and whole core. And develop a greater goal readiness. How can we, as professionals, assist service users in these difficult tasks?

Hope is strongly related to another key concept: self-efficacy. Self-efficacy stands for beliefs in being able to perform successfully actions needed to realize a desired outcome. On the one hand there is the confidence that one will attain a certain goal and on the other hand there is the belief that one can perform the skills and strengths needed for realizing the goal. It concerns the individual’s agency. On the cognitive level self-efficacy presupposes a good understanding of one’s potentials ánd also what action options there are to choose from that will lead to successful goal attainment. This has to do with agency and actorship. Goal formulation is also bound up with cognitive skills, but not only with cognitive skills. There is a strong attitudinal/emotional aspect too: goals are connected with values in life. Only when we are able to remember and are aware of the values we have and the good that we cherish in life and the people/animals/habits/beliefs we hold dear, we can formulate goals that are truly ours. Harassed by setbacks in life and beset by illness we may have developed a low self-image that prevents us to live our life as a valued life with value-based goals to strife for. Then we can need the help of professionals to overcome shame and connect again with our inner-most selves. And develop a greater goal readiness. How can we, as professionals, assist service users in these difficult tasks?

Four sources of self-efficacy that nurses can use in their work with service users may be distinguished (Washington & Moxeley, 2013): 1 learning from example, role modelling 2 helping service users to become aware of their self-defeating and productive emotions in coping with situations 3 verbal persuasion: influential people encouraging and supporting change 4 performing new behaviour and find out that it works The integration of these sources will activate and sustain change processes. It will strengthen self-efficacy.

From: Washington, O.G.M. and Moxeley, D.P. (2013). Self-efficay as a unifying construct in nursing-social work collaboration with vulnerable populations. Nursing inquiry 20(1): pp. 42-50.

One of the sources of self-efficacy is: performance in which recipients practice new behavioral forms, enact new behaviors in relevant settings and accumulate evidence for the efficacy they need to face life challenges or to achieve goals. Performance presupposes goals that can be attained. Goalfinding and goal formulation are also the elements of hope, in the operationalization by Snyder.

In the following research summary, published by RRTC-EBP. Retrieved here. you can read about goal attainment:

"Many factors contribute to adjustment to disability; however, people with higher hope have been shown to adjust better to disability and the challenges that come with it. Often in rehabilitation counseling it may be difficult to understand why one client has successful outcomes, while another one does not. Since goals are what drive hope, and identifying and reaching goals are a key component to successful rehabilitation outcomes, understanding clients' level of hope is critical. Snyder's Trait Hope Scale is an effective tool to measure and understand clients' levels of hope, including those with depression."" [...]

Coduti, W.A., and Schoen, B. (2014). Hope Model: A method of goal attainment with rehabilitation services clients.. Journal of Rehabilitation 80(2), 30-40.

One may wonder how the interventions mentioned in the summary above can also be realized in self-help peer-groups, or in other words: how can service users develop effective strategies for goal setting and attainment in a self-directed trajectory of learning (that would match better with self-efficacy than a too dominant role of professionals). After all, recovery is an unique discovery journey and professionals need a more facilitative approach. It is here that the approach by the name of Wellness Recovery Action Plan (WRAP) is very promising.

One may wonder how the interventions mentioned in the summary above can also be realized in self-help peergroups, or in other words: how can service users develop effectieve strategies for goal setting and attainment in a self- directed trajectory of learning ( that would match better with self-efficacy than a too dominant role of professionals). After all recovery is an unique discovery journey and a more coaching stance or facilitating methods in stead of directing ones are more appropiate for professionals to adopt. It is here that the approach by the name of Wellness Recovery Action Plan (WRAP) is very promising.

In the following fragment of an article by Sadaaki Fukui et al (2011) you can read about WRAP:

“. WRAP is a peer-based program in which participants identify internal and external resources for facilitating recovery (Cook et al., 2010). These resources are then used as tools to develop an individualized self-management plan. The goal of participation is health-related behavioral and attitudinal change, emphasizing the acquisition of new information and skills to better manage symptoms and maintain increased levels of health and functioning (Cook, 2005). The premise of WRAP is to allow individuals with severe and persistent mental illness to: (1) improve their ability to effectively take responsibility for their own wellness and stability, (2) manage and reduce mental health symptoms using a variety of self-help techniques, and (3) effectively learn skills to reach out and use support (Copeland, 1997; 2004). To achieve these objectives, WRAP users create individualized plans to assist them in recognizing the progression of symptoms and plan, in advance, how to self- manage these symptoms. In addition to learning the aspects of a WRAP plan, groups also provide an introduction to key recovery concepts, exposure to a variety of self-help techniques, and specific concerns that may need to be addressed in order to complete and use a plan effectively (e.g., trauma recovery, general health care, medications, and suicide prevention). Thus, by participating in a WRAP group and developing a WRAP plan, individuals can gain a sense of hope and empowerment while learning effective self-management skills to better control their symptoms, and become an active participant in their own recovery.”

The research conducted by Fukui et al had an experimental design with a follow-up measurement after six months. The findings indicated that there was a reduction in psychiatric symptoms in the participants that had completed the WRAP intervention. Their sense of hope had significantly improved.

From: Fukui S, Starnino VR, Susana M, Davidson LJ, Cook K, Rapp CA and Gowdy EA. Effect of Wellness Recovery Action Plan (WRAP) Participation on Psychiatric Symptoms, Sense of Hope, and Recovery. Psychiatric Rehabilitation Journal 2011, Volume 34, No. 3, 214-222.

  • Why is the WRAP approach concomitant with self-efficacy?

  • How could you use the four sources of self-efficacy in the case of John?

  • Argue why the following statement is true or false:

"Thus, by participating in a WRAP group and developing a WRAP plan, individuals can gain a sense of hope and empowerment ment while learning effective self-man- agement skills to better control their symptoms, and become an active participant in their own recovery"

There are the regular, linear ways of supporting persons in a recovery trajectory to rebuild a positive identity with a focus on formulating goals to start action planning. These approaches fail where service users have cognitive problems or communicative difficulties. Alternative approaches must be developed then, using more creative means. One example is the use of photography.

Read about a project in mental health care in the Netherlands, by Sitvast & Bogert (2012) Just Look at me. Recovery in Images:

Recovery and Recovery Oriented Care

We asked a professional photographer to portray people with mental health problems who are dependent on care and support. The photographs show us images of how they engage in recovery. What is recovery? How do people recover? How can caregivers support them in their recovery?

“Recovery is something that clients must do themselves. It is a search for answers to the question how to cope with the psychic handicap, how to get a grip on it and how to take direction of life again in one’s own hands. Recovery is not the same as cure. The psychological problems do not go away, but compel someone into a long learning process.” (Boevink et al, 2003)

Recovery is an individual learning process. How can caregivers support clients in this process that they have to undertake themselves? Recovery Oriented Care can build on the rehabilitation-approach that has been the guiding principle for the support of clients in chronic care from the beginning of the nineties. What is new however, is the focus on the resilience of clients and how clients utilise this power. By utilising their resilience, clients will feel strong and that will help them in answering the question of how to take life in their own preferred direction. Making an inventory of one’s own strengths first can be useful. Strengths are more than talents and skills alone. There is a strength in strong opinions and convictions as is also the case with memories of events in life that were experienced as good. A motivational power can be attributed to a longing to become someone different from who you are now. The same may be true for a wish to engage in a job or a hobby. Last but not least there is the support that clients experience from relatives, fellow men and caregivers. This support often gives clients the power to go on in life. Autobiographic narrative accounts of persons who report on their own recovery-trajectory describe how important it was that there were people who did not lose faith and kept believing in them, even in the darkest hours of crisis.

Recovery oriented care involves the health professional and client working together to look for possibilities and starting points in identifying the client's strengths. This approach starts with a moral appeal for people's lives not to be dictated by their mental health problems, but for people to salvage life from the restrictions of mental health disorders. Caregivers can help clients recognise their potential: the authentic person who lies waiting behind the person and his disturbed behaviour, even where this is only present in potentiality. The role of the caregiver is not that of an expert, but much more that of travelling companion who helps the client to make the journey. Let go of the familiar role patterns and undertake this journey together with the client, without knowing on beforehand where you will end or what the outcome will be! If you succeed in doing so then there will be a moment that the client will turn to you for an expert advice on how to cope with challenges of the journey. Giving advice uncalled for does not befit a travelling companion, because travelling together suggests a reciprocal relationship. What matters is that caregivers should believe in their client because otherwise they cannot stand beside the client in their search for a life with more quality and more direction.

That’s where the shoe pinches. Most caregivers are inclined to solve problems: the so called reparation reflex. Caregivers offer help where the client asks for it. Treatment plans and nursing plans usually start from patient problems and shortcomings that need to be repaired or that should at least not become worse. Caregivers therefore think in a problem-oriented and problem-solving way. This is okay most of the time, especially with clearly defined and delimited problems. However, in the phase of recovery another approach is more fitting, namely one in which the caregiver follows the lead of the client. Of course there is no clear demarcation line between the phase of treatment and a phase of recovery. Recovery starts from the first accommodation and adaptation to a crisis. We cannot say: it is the one or the other. As a caregiver you follow the client one moment and the next moment you take the lead.

As a caregiver it remains difficult to detach oneself from the linear problem-oriented way of thinking when rehabilitation plans are drafted. Client’s wishes tend to be translated into problems for which goals are formulated and problem-solving actions to work towards. The rational model that characterizes nursing and treatment planning impedes caregivers to think out of the box and approach client’s wishes and ambitions as chances and possibilities that still need to be discovered. They are unable to let go of their impulse to control the situation. Even a method based on the inventory of strengths, the Strengths-approach (Rapp & Goscha, 2006) that nowadays is considered to be a most valuable update of the rehabilitation approach (anyway in the Netherlands), runs the risk of resulting in too much time spent talking and planning and too little doing and sharing experiences. However, this is a search and a journey of discovery. What a client will discover cannot be predicted beforehand, which can make formulating a goal difficult. What it takes is the will and intention to engage on the journey. To speak in terms of another metaphor than the image of a journey: it is a dance during which you tune your movement to your dancing partner, alternately leading and then again following. Dancing the tango is something you have to learn. The same goes for supporting someone in his recovery.

A method

We developed a method that has been based on the inventory of strengths. However, we did not start with first making an inventory of strengths, but considered this as an outcome of our efforts. First we intend to create an experience that proceeds from a meeting between the caregiver and the client in their shared search for sources of strengths.

When the journey is undertaken and the travelling companions are on the road then there may be a moment that they feel the need for making a stop and reflect on what we they have experienced so far and see if the experience inspires the client to wish for follow up activities and may-be even formulate goals to realise them. The client takes direction here and the caregiver follows. His role is to create conditions. One of the conditions is to make visible what happens. On crucial moments photographs are made. This can be done by a professional photographer. However, this may also be done by the caregiver himself or by an amateur-photographer who works as a volunteer or by the client himself.

Together the photographs make a story that shows where someone comes from, what journey was undertaken (activities) and where the journey led the client. This is a report with images that may function as a beacon for the client and that reminds him of his journey and will stimulate further reflection on the things that are important in life. The journey commences with asking oneself one question or, actually a number of questions:

What activities make my life worthwhile? What makes me feel alright about myself? What are the things I enjoy most throughout the week? What helps me feel better when I am down?

The fact that we illustrate the answers in a photo-report changes the perspective, because it invites clients to join a game of seeing and being seen. The question changes in:

When I make photographs of the things I enjoy (or that give me strength), then what you see is the following:………

This becomes the point of departure for the journey: ‘This is me!’ The client is portrayed in his daily routine: the activities and household chores, the setting where he lives, the hobbies he enjoys, etc. During this photography sessions it often occurs that a client discovers what activity he would like to engage in for the second session. In the second étape of the journey we embroider further on the issue of the good things in life. This entails a question that, as we saw before, can be put in more than one way: it can be formulated as strength, as something that can be enjoyed or that makes you feel good, etc. But we put the question as one that inquires after potential possibilities:

Do you have a wish for something that you want to do: may-be something that is on your mind for some time? Or Is there something that you have done in the past and that you would like to do again? Or What do you like ánd find important to do?

Menno loves to paint. He would very much like to attend a workshop given by Jack, the graffiti artist. Photograph by Guido Bogert. Photograph by Guido Bogert.

These questions connect expectations and memories of what people find important in their lives. The message it contains is: get doing what you find important! The only condition we put forward is that it must be a new activity, something that takes guts and courage to overcome reticence to make a first move. We make a demand on clients, expecting them to reach beyond normal routine. We do so because we believe that people can do more than they usually have been demonstrating, pampered as they often are by overprotective caregivers. That’s why we ask not only what a client likes to do, but also what he thinks is important to him. To find out just this someone must go out of his normal way, and in the case of institutionalised clients, literally out of the terrains of the institute. This journey of discovery explores the person's own roots in a search for whom they want to be or what they want to mean as a person to others in this world. Within the context of the photo story this exploration usually keeps a light touch, because it is a game of seeing and being seen. On the more basic level it is about how someone wants to look like to others. Photographs offer clients an opportunity to feel accepted for positive valued aspects of their personhood. We will avail of the photo stories to this end by exhibiting them in the residential home or somewhere else. Photographers will tour visiting guests along the photographs on an opening night and explicate their meaning. Additionally, clients will receive their own album and an extra copy to share with relatives. Visualising an activity in the context of recovery will promote expression and ownership. Some of the more expressive images- those invested with pride for instance- may become mental icons that linger on in the mind. In this way they function as reminders that invite clients to follow up the intention associated with the photographed action. They then may become scripts for further recovery.

The trajectory

There are three photo sessions. Actually the word photo-session is not correct, because it is about activities in the context of recovery in the first place. Photographs are made unobtrusively, with the exception of the portrait photograph at the beginning. The photographer tries to prevent that the sessions becoming a photoshoot, although he may enter into a dialogue with the client. The third and last session focuses on possible gains or results. Did the recovery activity effect a change with the client? Did the contact with caregivers or relatives improve? The gain may not necessarily be in relation greater participation in social roles. It may be that the most important benefit is that some clients develop a greater self-esteem or find renewed strength to face life.

Clients can engage in the project without precisely knowing what it is that they want to photograph. They may choose from three pre-mediated trajectories or propose one of their own. The three given options are the following:

  • ‘Walking on native soil’: return to your roots in the town or village where you spent your youth.
  • ‘Face up to the confrontation’: Who are you now? Who do you want to be and who do you not want to be or become (not even in your worst nightmare)?
  • ‘What can you mean to others?’(what do I have to offer others in terms of being warm, supportive, neighbourly or loving?)

The project also aims at making caregivers more sensitive to an agenda of recovery and provide them with a method to realize recovery oriented care. For them guidelines and worksheets with instructions have been developed.

Bogert, G., Bogert, I. and Sitvast J. (2012). Kijk Mij Nou! Herstel in beeld. (Just Look at Me! Recovery in Images). Private Publication.

Reflective questions - John

  • How can the arts connect John with his social environment?
  • How might John profit from expressing himself artistically?
  • How might photographing John while he is engaged in his daily activities or when invited to show the things in life he thinks are important to him contribute his nurse mentor understanding him better?

The Strengths approach

How can professionals help service users in (i) finding and maintaining hope; (ii) the re-establishment of a positive identity; (iii) finding meaning in life; and (iv) taking responsibility for one’s life (the four components of recovery)? Are there a practical tools for professionals in mental health care that assist them in supporting their clients? How can we help John to (re-)construct a more positive identity and find hope and new meaning in his life?

Adopting a strengths based approach we no longer focus on clients’ deficits, but instead we honour their skills, competencies and talents. Rapp (2006) described the Strengths Approach (or Model) as a new and creative way to work with clients and focus on strengths and resilience. Different questions are asked:

  • Why do people survive the problems of life at all?
  • What resources do people draw on that would account for their resilience?
  • Why do a significant majority of people diagnosed with mental health problems not just survive but often live well despite their problems?
  • What are the protective factors that support recovery?
  • What meaning do individuals ascribe to their experiences, their suffering, and their triumphs?

(Questions mentioned by McCormack (2007) in a paper published by the Scottish Recovery Network (SRN) about the principles of the strengths based approach in mental health care).

Professionals can help clients to discover their strengths. They do not deny that serious symptoms and problems exist. Clients often have huge problems, suffer from mental distress, and face severe difficulties, but that is not the whole story. There is another side that often can be highlighted as well: for instance when a client is homeless, he or she will probably has developed street survival skills; a client resisting interventions by the professional also means that someone believes in using own strategies. There are hidden strengths that can be brought to daylight because they are potentially the key to more self-efficacy, more self-esteem and may-be the solution for certain problems. Making an assessment together with the client of his/her strengths may be very empowering. “Strengths based practice uses these skills and personal strengths as the platform on which recovery will be built.”(McCormack, 2007). Building from an inventory of client’s strengths and connecting it with a person’s values, dreams and ambitions (which can also be considered as a kind of strengths, because they can be strong motivating powers for action) professionals can assist clients in taking steps towards recovery.

Below here you can read a fragment from McCormack, J. (2007) Recovery and Strengths Based Practice. SRN Discussion Paper Series. Report No.6. Glasgow, Scottish Recovery Network. Retrieved from http://www.scottishrecovery.net/Related-documents/related-documents.html (paper 6). “Assessment is conducted in a conversational and engaging manner, and the language used documenting it, is from the service users’ perspective and in their own words, paying attention to the metaphors and images used by the client. Strengths based assessment is viewed as ongoing and evolving. This leads to another key feature of a strengths based, solution oriented approach, the explicit recognition that the client is the expert. This approach respects and honours the individuals lived experience and involves the worker in relinquishing the role of expert or teacher in favour of that of collaborator working towards recovery in partnership with the service user. This allows the worker to be open, respectful and curious, thus avoiding a prescriptive or dogmatic approach.”

Andre: “My dogs helps me to have physical exercise.” Photograph by Andre. “My dogs helps me to have physical exercise." Photograph by Andre.

Find the text by McCormack on internet and summarize in a short essay what he writes about Solution Focused Therapy and how it principles can be used in a strengths based approach.

Reflective question-John:

  • How could you reframe/ de-pathologize some of John’s problems and show the strengths that John must have to survive them? Make a scheme just like the one in the text above.
  • Explain how ‘deficit thinking’ triggers a ‘repair reflex’ in professionals.
  • How would ‘what if’ questions have to be framed to rekindle a sense within John of having permission to dream of an attractive inspiring future, based on his values and ambitions?

As we can learn from studies on stages of recovery (see the introductory text on that topic) it is important for service users to rebuild an identity that is not solely determined by symptoms, illness and treatment history, but departs from one's values in life and which is based on ambitions, wishes, preferences, talents and skills besides resources like family ties (and other social ties). In other words: how to live a valued life that connects with one strengths (see the introductory text on the Strengths Approach). This supposes a continuous process of meaning giving. It will be a process in which one arrives at a new comprehension of how mental illness affects one's life and how to deal with or cope with symptoms and illness consequences. It entails the delimitation of the part of one's life that is affected by illness from the deeper 'whole' core of one's identity. In this process life becomes coherent again. It runs parallel with increasing powers of coming to terms with illness, managing its consequences and as a result being able to live a life as intended, with goals to go for. Can someone comprehend what happens to him (also life's inequities), manage its consequences (for instance practice disease self-management) and experience that life has meaning? The overarching concept may be found in The Sense of Coherence (SOC) theory, developed by Antonowsky (1979).

The following fragment on the Sense of Coherence is from an introductory text by Collingwood (2006) on the website of PsychCentral:

The concept of sense of coherence (SOC) was put forward by Aaron Antonovsky in 1979 to explain why some people become ill under stress and others stay healthy. It arose from the salutogenic approach, that is, the search for the origins of health rather than the causes of disease. The SOC gained widespread attention and has since been linked to health outcomes in many studies.The SOC is defined as: “The extent to which one has a pervasive, enduring though dynamic, feeling of confidence that one’s environment is predictable and that things will work out as well as can reasonably be expected.” In other words, it’s a mixture of optimism and control. It has three components – comprehensibility, manageability, and meaningfulness. Comprehensibility is the extent to which events are perceived as making logical sense, that they are ordered, consistent, and structured. Manageability is the extent to which a person feels they can cope. Meaningfulness is how much one feels that life makes sense, and challenges are worthy of commitment. Professor Antonovsky believed that, in general, a person with a strong SOC is more likely to feel less stress and tension, and to believe that he or she can meet demands. The SOC was developed to apply across cultures, and versions of the questionnaire have been used in at least 32 countries.The concept interacts with a person’s natural coping style, upbringing, financial assets, and social support – the extent to which these [resources] are available is a major determinant in the development of a strong or weak SOC.

"A person with a strong SOC is more likely to feel less stress and tension, and to believe that he or she can meet demands." "

[...]

Depression

Having a strong SOC may protect against depression, so SOC may be useful for identifying people who may be helped by psychological interventions. A strong SOC also improves life satisfaction, and is linked with reduced fatigue, loneliness, and anxiety. [...] It is possible that, rather than signifying patients’ previous personality, serious health problems are a large enough stressor to lower SOC levels. It is not surprising that those with serious health problems score lower on meaningfulness, and their sense of manageability may be eroded by high levels of pain. Is SOC the cause or the effect of the symptoms, or is it a parallel issue? When both are assessed simultaneously, no firm conclusion can be drawn. Another consideration is that symptom questionnaires and the SOC questionnaire often are both self-reported, so could be picking up on the same characteristics. Both might be measuring a tendency to dissatisfaction, for example. An additional drawback is that SOC may not be as stable over the lifetime as first envisioned. Antonovsky believed the SOC remains relatively stable as long as “radical and enduring changes in one’s life situation” do not occur. Some studies appear to confirm this, although in one large study, SOC was significantly lower in the youngest age group and increased with age. In the same study SOC was highest in the highest social classes. The relationships between SOC and childhood conditions, adult social class and adult health were examined further to investigate how SOC inequalities arise. The study concluded that the association between SOC and illness is likely to be causal. Questions remain about what SOC actually measures. However, it may be useful in clinical practice to identify people who are particularly vulnerable to depression, even when they are not clinically depressed. Counseling and stress management could then be considered. But knowledge about how SOC changes, and how it can be influenced, remains incomplete.

Colingwood, J. (2006). Your sense of Coherence .

By Lindstrom and Eriksson (2006):

The Sense of Coherence (SOC) is the capability to perceive that one can manage in any situation independent of whatever is happening in life. SOC is flexible, not constructed around a fixed set of mastering strategies, like the classic coping strategies (Antonovsky, 1993b). One could say that SOC functions as a ‘sixth sense’ for survival and generates health promoting abilities. In the original text:

The SOC is defined as a global orientation that expresses the extent to which one has a pervasive, enduring though dynamic feeling of confidence that (1) the stimuli deriving from one’s internal and external environments in the course of living are structured, predictable and explicable; (2) the resources are available to one to meet the demands posed by the stimuli; and (3) these demands are challenges, worthy of investment and engagement. (Antonovsky, 1987)

In a wider analysis of SOC Antonovsky describes its key components as follows: (i) comprehensibility—the cognitive component; (ii) manageability—the instrumental or behavioural component; and (iii) meaningfulness—the motivational component. People have to understand their lives and they have to be understood by others, perceive that they are able to manage the situation and deepest and most important perceive it is mean-ingful enough to find motivation to continue.

Lindstrom, B. and Eriksson, M. (2006) Contextualizing salutogenesis and Antonovsky in public health development. Health Promotion International 21(3).

In the first stage of Recovery service users often find it hard to see that their life may be different from the situation they are in now, harassed by illness symptoms, having endured losses (work, relations, etc.) and sometimes being hospitalised. Having hope that things may turn for the better or being able to remember the things as they have been in the past can save service users from despair. Only then they can set out on the long route of recovery and find the motivation to overcome a predicament of being 'stuck' in life. Hope translates into finding goals to aim for (read also the introductory texts on Hope). Goal formulation is bound up with cognitive skills, but not only with cognitive skills. There is a strong attitudinal/emotional aspect too: goals are connected with values in life. Only when we are able to remember and are aware of the values we have and the good that we cherish in life and the people/animals/habits/beliefs we hold dear, we can formulate goals that are truly ours. Harassed by setbacks in life and beset by illness we may have developed a low self-image that prevents us to live our life as a valued life with value-based goals to strive for. Then we can need the help of professionals to overcome shame and connect again with our deeper and whole core and develop a greater goal readiness.

How can professionals assist service users in these difficult tasks? The strengths-approach (Rapp) has been developed at the university of Kansas (USA) to provide professionals with tools to facilitate and support recovery process of service users. It focuses on making an inventory of strengths, which are the broad array of everything that can be considered to be resources to the individual: values, talents, skills, strong beliefs, community contacts. The Strengths approach clients and professional together prioritizing a domain of living for goal setting and then building a plan that uses one of the strengths to connect to the action to realize goals (read the introductory text on the Strengths Approach). The resources it builds on are the same as in the theory on salutogenesis. There they are called Generalized Resistance Resources (GRR) because individuals need them to resist the impact of stressors and manage their lives.

  • How does a Sense of Coherence (SOC) overlap with the concept of self-efficacy?
  • Describe in the case of John how the three components (comprehensibility, manageability and meaningfulness) apply to his situation.
  • Do you think that SOC is a stable feature? What arguments are there to say the SOC is changeable? How would that be for John?
  • How does disease self-management and coping with illness symptoms fit in the salutogenesis theory?

We can conclude that hope, operationalised as goal readiness, may serve as an overall theoretical framework from which the components can be connected with key competencies that persons with mental health problems must have in order to go forward with their recovery. These components are: goal formulation, path finding and agency. Goal formulation depends on how a person gives meaning to his life, usually by means of constructing a narrative (aided potentially by pictures or photographs). In the Sense of Coherence theory this ties in with 'comprehensibility' and 'Meaningfulness'. Path-finding has everything to do with 'Manageability'. The concept of self-efficacy comes in here: does a person know what action options there are to choose from? The person's agency is involved here: the belief that one can perform and that one possesses the skills and strengths needed for walking the path that leads to goal attainment. We found that the Strengths Approach may help professionals to assist persons with mental health problems to connect again with their own strengths and use these for recovery. In the Sense of Coherence theory the strengths are called 'Generalized Resistance Resources' and they can be used to handle situations and maintain or restore your health and be resilient. This is what 'Salutogenesis' comes down to.

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