Development of the recovery model in the mental health field, Part 1

rsz_emil_kraepelin_1926A recovery revolution is occurring in both the addiction and mental health arenas that is challenging practices within both fields. In various places in different countries, recovery is becoming the concept around which addiction and mental health systems of care are being organised.

A transformation of systems of care is underway, shifting away from systems based on pathology to ones that promote wellness and recovery. Hopefully, these changes will also see a much needed bridging between the addiction and mental health fields.

Where did this interest in recovery arise? And why do we feel that we need to change our present systems of care? In this, and in following blogs, I will look briefly at the development of the recovery model in the mental health field.

Impact of Kraepelin’s model of schizophrenia
Our story starts at the end of the 19th century, with the identification by Emile Kraepelin of the illness, or family of illnesses, we currently consider to be schizophrenia. Classical symptoms of schizophrenia are delusions (often paranoid in nature), hallucinations, and disorganised speech and thinking.

Kraepelin used the term “dementia praecox” (premature dementia) to distinguish schizophrenia from manic depression, with the difference between these forms of major psychosis being their course and outcome. 

Manic depression was considered to be an episodic, cyclical disorder responsible for a moderate degree of impairment alternating with period of intact functioning. On the other hand, schizophrenia was considered to have a chronic, unremitting course, leading to progressive deterioration and death.

Kraepelin, whose conclusions were based on clinical observations of inpatients during the era of long-term institutional care, assumed that schizophrenia was an organic disorder that attacked the brain, leaving the person who was affected with little hope of a life beyond neurological degeneration and irreversible dementia. People did not recover from schizophrenia, according to Kraepelin.

This understanding of schizophrenia as a neurobiological disorder had a massive influence for over a century, and has formed the basis for the development of a number of approaches to tackling the illness, ranging from involuntary frontal lobotomies and insulin shock treatments earlier in the 20th century, to the more recent use of psychoactive drug treatment.

Advocates for this approach do not believe that schizophrenia is necessarily caused solely by genetic or biological factors. The popular stress-vulnerability model considers schizophrenia to be caused by a complex interaction of genetic disposition, neuronal dysfunction, stressful life events, and inadequate coping responses to these events.

However, although this model acknowledges the role that social environment and coping play in schizophrenia, it fails to address the variations between people in their ability to manage the illness.

Nor does it allow for the possibility that can people can recover from schizophrenia. The most one can hope for is containment of the damage caused by the illness and a degree of control over one’s ongoing symptoms. It is believed that the illness and the person’s underlying vulnerability will persist for

the remainder of their life, requiring active treatment and rehabilitation for the person to preserve remaining areas of independent functioning.

Kraepelin’s model has not only formed the foundation for various treatments of schizophrenia, but also has informed social policy and community attitudes towards people with schizophrenia and other mental health problems. It has perpetuated the stigma of mental illness and justified the continued exclusion of the ‘mentally ill’ from social debates about their fate.

“The legislation, policies and programming that dictate the locus of care and the practices of mental health professionals have been decided with little or no input from the people most directly affected by these decisions: the patients themselves. Based on the perceptions that the person is lost to the illness, others have stepped in to make decisions and speak for the person.” Davidson (2003)

In fact, psychiatry has differed from most other parts of medicine in that it has extended its authority to include most aspects of the person’s life, including where they live, with whom they associate, what they eat and what they do with their time. Whilst there has been a move away from the large mental hospitals in which many patients spent a good deal of time, the psychiatric system stills impacts on the impoverished lives of many people with mental health problems living in the community.

Contrary to what is often portrayed by the popular media, the majority of people with severe mental health problems do not pose any particular public health or societal risk that merits the degree of segregation and control by others that predominates. Nor do many of these people require the long-term custodial care or clinical supervision that is often assumed to be needed.

This picture remained unchallenged for many decades before two related developments began to reveal an alternative view of mental illness. The first of these developments was the emergence of the Mental Health Consumer / Survivor movement.

The second was the emerging impressive outcome research conducted by scientists who were skeptical of Kraepelin’s certainty about the inevitability of a chronic course and poor outcome for schizophrenia.

This blog is based on the writing of Larry Davidson in Living Outside Mental illness: Qualitative Studies of Recovery in Schizophrenia. This is a book well worth reading.