By the end of this learning package you will:

  • discuss Recovery and Social Inclusion theory
  • appreciate the significance of Recovery and Social Inclusion theory to the lives of people who experience mental health problems
  • consider the global reach of the Recovery movement and how the concept has become embedded in policy in much of the English speaking world and beyond
  • discuss commonest recovery models used in mental health services
  • appreciate the significance of inequality to social exclusion

There are many books and journal articles about Recovery and Social Inclusion. Most are in the English language. Indeed, the Recovery Approach has been adopted in mental health policy in much of the English speaking world. How much of this has been rigorously translated to practice however, is not known.

One of the early proponents of Recovery is Patricia Deegan. In this short video she explains how she “became a schizophrenic” and also how she decided to become a new person to bring about change in psychiatric services. It is a useful introduction to the Recovery concept:

One widely accepted and early definition of 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 with limitations caused by the illness. Recovery involves the development of new meaning and purpose in one’s life as one grows beyond the catastrophic effects of mental illness." (William Anthony, 1993)

In the USA, Dan Fisher (2008), Director of the Empowerment Centre places a great deal of emphasis on empowerment. For him, people experiencing mental health problems need to have choice, be self-determining, and have a voice in order to experience recovery from mental distress.

Higgins (2008:7) describes personal recovery as: ‘a journey of discovery’ where the person develops “…personal resourcefulness...control, a positive sense of self...and rediscovers their voice and belief in their ability to live a meaningful life, despite the presence of challenges”.

In work commissioned by the Scottish Recovery Network, Brown and Kandirikirira (2007) identified twelve elements necessary for recovery. Six are referred to as ‘internal elements’ and six are referred to as ‘external elements’.

  • Being able to develop a positive identity and belief in one’s self
  • Having a knowledge that recovery is possible
  • Engaging ion meaningful and purposeful activities
  • Being able to develop positive relationships
  • Increased understanding of the experience of mental distress, health and well-being
  • Maintaining strategies to help stay well and deal with setbacks and periods of distress
  • The support of friends and families who promote and stimulate a sense of self-determination and autonomy
  • Others who believe in one’s recovery and are able to share this with the person
  • Feeling that what one does is valued and respected by others
  • Experiencing appropriate support that is not rigid but sensitive to the person’s needs
  • Being viewed by others as more than a person with illness and diagnosis
  • Being surrounded by people who support one’s choices and having actions validated by others.

For people to experience a sense of recovery, they may move on from the ‘patient role’ which is often disempowering and stigmatised. Recovery is an active process and rather than being dependent on mental health services, people can find supports amongst family, friends and communities whilst at the same time taking responsibly for their own recovery (Jacobson and Curtis 2000). As people take control and responsibility for their own lives they may also experience increased confidence and trust in their own judgement and capabilities.

Some English speaking countries have developed their own frameworks and common understandings:

In the country where you live, find out what mental health policy exists that supports a Recovery approach? How does it compare to some of the countries’ policies above?

Recovery has also been defined academically. In their 2011 systematic review and narrative synthesis on personal recovery in mental illness, Leamy et al., reviewed 97 academic papers and constructed a conceptual framework as a result. They came up with the acronym CHIME (connectedness; hope and optimism about the future; identity; meaning in life; and empowerment). We loosely use these themes when we consider our central narrative: JOHN

The Leamy et al., article is available free here.

All recovery narratives reveal that people are not just recovering from the life circumstances that gave rise to their mental distress or ‘mental illness’, but are also recovering from the consequence of the loss of rights and voice. Many people experiencing mental health problems and labelled ‘mentally ill’ do not have access to the normal experiences of citizenship, and suffer social exclusion, discrimination and victimisation as well as structural discrimination at the level of access to housing, education and employment. In addition, a recurring theme within recovery stories is that people who have encountered the mental health services have to recover from the impact of coercive, oppressive and paternalistic practices. Similarly, care that is focused on risk avoidance, medication compliance and symptom reduction, seriously diminishes the autonomy, agency and power of the person.

The word “recovery” in mental health contexts has various meanings and the concept of recovery is spoken of as a movement, a philosophy, a set of values or principles, a paradigm, and a policy.

There are four ways that Recovery is discussed in the literature:

  1. Clinical recovery. Treatment aims at reduction, remission of symptoms and, if possible cure.
  2. Functional recovery. Improvement of physical, psychic and social functions.
  3. Social recovery. Working for a better social and cultural position including stigma reduction.
  4. Personal recovery. The person sets out to change him/herself and his/her situation (identity, values, goals, hope and meaning making).

Try to identify the philosophical and theoretical origins of the recovery paradigm. Is there any relationship between a Recovery approach and Positive psychology? If so, what are the differences and similarities? NB – there is a great deal of literature to assist with this inquiry.

It has been said that the recovery movement in mental health has its origins in people’s narratives of their own survival, following the closure of large asylums in the western world. Conduct a study looking at people’s narratives; there are many books and journal articles to help you.

What are the perceived potential and actual difficulties in working in a Recovery–orientated way in statutory mental health services? How can mental health nurses balance their role of custodians and use coercion whilst maintaining a Recovery approach?

There are various Recovery models that have been specifically developed to help bring about change in practice. Here are a few of them:

  1. Wellness Recovery Action Plan® (WRAP®) and find out about WRAP®.
  2. The Tidal Model
  3. The Recovery Star
  4. There is also a “Checklist of Good Practice”. There are 16 questions that practitioners can ask themselves to determine whether or not they are offering good practice according to recovery principles.

Answer these questions:

  • What do these models have in common?
  • What makes them different?
  • Search in the academic literature and see what research has been conducted using these models.

To complete this short study on the background to recovery, visit this website where people give their own definitions.

To promote social inclusion implies that “social exclusion” exists. The term may refer to individuals, groups or entire communities, but is invariably associated with poverty, unemployment, inequality and disadvantage.

The European conceptualisation of exclusion implies that there has been a breach of social justice (Silver and Miller, 2003).

In the UK, the Social Exclusion Unit defined social exclusion as:

...a shorthand label for what can happen when individuals or areas suffer from a combination of linked problems such as unemployment, poor skills, low incomes, poor housing, high crime environments, bad health and family breakdown. (SEU, 1999).

In the country where you live, find out what equality laws exist that may protect people with mental health problems relating to their social inclusion.

The work of Richard Wilkinson (2005) and others (Marmot, 2010; Wilkinson and Pickett, 2010) highlight that it is not simply poverty that causes exclusion and associated pathologies, but rather poverty in relation to unattainable wealth in unequal societies. The Marmot Review can be downloaded here.

This is supported by Friedli (2009) who also observes that it is difficult to differentiate between the causes and effects of mental health problems and social exclusion. Friedli’s report for the World Health Organisation can be downloaded here.

Davies (2005) however takes issue with the legitimacy of labelling individuals and groups as “socially excluded” because, he argues, by doing so, they become further side-lined from mainstream society and further stigmatised.

Illich (1975) has argued that medical classification itself determines loss of autonomy and social separation and subsequent exclusion is an inevitable consequence of medical categorisation.

Levitas (2004) also identifies that people with mental health problems like many of the groups labelled as socially excluded are those who may be perceived to challenge the established social order and status quo.

Over the last 20 years Recovery and social inclusion have become key concepts in mental health in the English speaking world and beyond. There are many policy directives and examples of good practice. Social exclusion is a complex phenomenon and it is difficult to separate mental health problems from their social causes and psychological consequences. This is especially true of economic inequality.

In the country where you live, find out the proportion of those diagnosed with a mental health problem who are from lower social classes.

In the country where you live, find out if ethnic minorities are over-represented amongst those diagnosed with a mental health problem.

Think about the results from your inquiry; what does this tell you about the society in which you live?

In the country where you live, find out what laws exist that enforce the rights of people who specifically experience mental health problems. How do these laws compare with the protection offered to other disadvantaged groups?

To what extent does the media maintain social exclusion for people with mental health problems? Access and read this article by Corrigan et al (2005)

It identifies what it refers as “structural stigma”. “This type of stigma is formed by sociopolitical forces and represents policies of private and government institutions that restrict the opportunities of the groups that are stigmatized.”

Social exclusion therefore can be experienced on a very personal/local level, but there are also structures in society that maintain the exclusion of some people.

Anthony, W.A. (1993) Recovery from mental illness: The guiding vision of the mental health service in the 1990’s. Psychosocial Rehabilitation Journal. 16: pp.11-23.

Brown, W., & Kandirikirira, N. (2007). Recovering mental health in Scotland: Report on narrative investigation of mental health recovery, Scotland, Scottish Recovery Network.

Corrigan, P.W., Watson, A.C., Gracia, G., Slopen, N., Rasinski, K. and Hall, L.L. (2005) Newspaper stories as measures of structural stigma. Psychiatric Services. 56(5):pp. 551-556.

Davies, J.S. (2005) The social exclusion debate: Strategies, controversies and dilemmas. Policy Studies. 26(1): pp.3-27.

Fisher, D. B. 2008. A new vision of recovery, Boston, National Empowerment Center

Friedli, L. (2009) World Health Organisation: Mental Health, Resilience and Inequalities. Copehagen: World Health Organisation.

Higgins, A. (2008). A recovery approach within the Irish mental health services: A framework for development Ireland, Mental Health Commission.

Illich, I. (1975) Medical nemesis: the expropriation of health. London: Calder & Boyars.

Jacobson, N. & Curtis, L. 2000. Recovery as policy in mental health services: Strategies emerging from the states. Psychiatric Rehabilitation Journal, 23, 333-341

Leamy, M., Bird, V., Boutillier, C., Williams, J. and Slade, M. (2011) Conceptual framework for personal recovery in mental health: systematic review and narrative synthesis. British Journal of Psychiatry. 199: pp.445-452

Levitas, R. (2004) Let’s hear it for Humpty: Social exclusion, the third way and cultural capital. Cultural Trends 13(2): pp. 41-56.

Marmot, M. (2010) Fair Society, Healthy Lives: The Marmot Review. London: Crown.

Wilkinson, R.G. (2005) The impact of inequality : how to make sick societies healthier. London: Routledge.

Wilkinson, R.G. and Pickett, K. (2010) The spirit level: why equality is better for everyone. London: Penguin.

Silver, H. and Miller, S.M. (2003) Social exclusion: The European approach to social disadvantage. Indicators 2(2): pp.1-17.

Social Exclusion Unit (1999) What’s it all about? Cabinet Office Website. Social Exclusion Unit.

The European Commission support for the production of this publication does not constitute an endorsement of the contents which reflects the views only of the authors, and the Commission cannot be held responsible for any use which may be made of the information contained therein.