The recovery model, a paradigm shift in the approach to mental health
Summary
Activism in the first person, the world of associations in mental health and its representatives, demand a change that goes beyond the way of understanding treatments and care.
The recovery models go through talking about resilience, capacities and own resources and the environment, social inclusion, care based on rights and taking early decisions.
Currently in Catalonia, as in other territories, we are in a moment of paradigm shift in the understanding and approach to mental health and psychosocial ailments. Since the creation of Integral plan of mental health and addictions 2017 - 2019 and the Strategies of the Plan Director of mental health and addictions 2017 - 2020, the strategic planning of mental health in Catalonia is oriented (or seeks to be oriented) from the recovery model . In the creation of these plans, for the first time we had the activist movements in the first person, constituted by people who are or have been users of mental health services. Perhaps thanks to this participation, these plans include care based on human rights as one of their strategic axes.
The main epistemological shift introduced by the paradigm shift (Pilgrim, 2008) is that the approach to mental health problems no longer focuses on the control of symptoms (biomedical model), nor on the functional adaptation of the person to the society (psychiatric rehabilitation model), but in the development of a satisfactory life and a life project according to people's own preferences and values, regardless of whether or not there are symptoms. This means changing the approach: from the pathological to the resilience, to the capacities and resources of our own and of our environment that people have within our reach to lead a full life, despite the difficulties that having or having had a mental health problem or psychosocial distress. Now, the focus must be on personal health and well-being, and not on illness.
Joan Alvarós Costa
Likewise, the new paradigm highlights the importance of building a non-diseased identity. Assuming the role of the patient (Parsons, 1951), building a defined identity from psychiatric diagnoses, chronifies people. Professional work must ensure that this identity is not strengthened. Relating with others based only on the diagnosis, operating in exclusive spaces for diagnosed people, activities centering around diagnosis, are all barriers to recovery.
The devices should encourage participation in non-sanitary or mental health spaces, reciprocal relationships or not marked by the diagnosis, and activities that make us feel valuable as people.
Ideally, we should abandon the current system of categorical diagnoses (that separate types of beings) and return to dimensional systems (that explain what happens to us and in what intensity). At our disposal we already have models like the one offered by the British Psychological Society (Johnstone and Boyle, 2018); But while we continue with the current diagnostic system, it would be essential to be explained that psychiatric diagnoses are only heuristic, an action guide for interventions. Giving them an ontological value has strong identity effects and is the foundation of stigma and self-stigma.
It should also be borne in mind that, although the recovery model was born from the civil rights movements and, especially, from the movements of survivors of psychiatry, critical of the violation of Human Rights, in practice this dimension does not it has always been considered. The experience of Anglo-Saxon countries teaches us that when the recovery model is attempted without a human rights perspective, distortions are generated that end up being barriers to people's recovery processes and, often, aggravate suffering and problems. mental health.
Mental health professionals tend to intervene from a biological and psychological perspective, focused on the individual, neglecting the context and living conditions of people. This is one of the main criticisms that the model receives in its applications in the Anglo-Saxon world: the co-responsibility of our recovery process and the need to empower ourselves does not mean neglecting the real life conditions that condition our existence.
Professional care must consider that there is no recovery without social inclusion, it is necessary to have decent living conditions.
Homelessness or exclusion make it impossible to recover. There is also no recovery without a community, it is necessary to strengthen or rebuild the network of family ties, friendship, neighbors, etc. Loneliness and isolation make it impossible to recover. And there is no recovery without respect for diversity, it is necessary to bear in mind the cultural, religious and social factors present in people's lives. Cultural exclusion, anomie (the lack, incongruity or degradation of social norms) and social asylum (make believe that it is not possible to achieve or satisfy the majority of human needs or motivations, when in fact it is ) make it impossible to recover. Being denied or having to deny our values, beliefs and identity generates suffering that is difficult to manage. All of these are possible conditions of a recovery process. Before proposing any other intervention, the professionals have to see if we can cover our basic needs, if we have a network of significant affective ties and if the interventions respect our diversity (cultural, sexual, religious, etc.). A recovery process cannot be proposed without taking into account all the forms of violence and exclusion to which many of us are subjected: machismo, racism, xenophobia, capacitism, classism, etc.
Among the forms of violence that generate, perpetuate or aggravate psychological suffering and psychosocial disability, the violence itself (historical and current) of the psychiatric system itself stands out. In our country, and in all Western societies in general, the mental health system has been based on the structural and systematic violation of human rights: involuntary admissions, forced medication, mechanical restraints, guardianships and conservatories, sterilizations and miscarriages, etc., are all practices that violate them. In this sense, the World Health Organization itself speaks of an "unresolved global crisis" (Drew et al., 2011) in the violation of human rights of the people of our group. A good part of the practices that are the historical foundation of the mental health system in Spain and Catalonia violate the Convention on the Rights of Persons with Disabilities (CRPD), and must be eradicated both from the assistance devices and from the system's legislative framework mental health. This has been made clear by the Committee on the rights of persons with disabilities in its Concluding Observations on the combined 2nd and 3rd periodic reports of Spain. (CRPD, 2019)
This need to eradicate coercive and involuntary practices not only lies in ethical and moral issues, but also in health. In a systematic way, academic research concludes that promoting and supporting people diagnosed with a mental disorder in the exercise of the rights and responsibilities of citizenship is a condition of possibility for their recovery, a prerequisite and not a consequence: «Supporting people with mental disorders in the exercise of their rights and responsibilities of citizenship can be a precondition for their recovery, and not a contingent, eventual reward, if the person first overcomes their disability ”(Pelletier et al, 2015). In this sense, it should be noted that, as a society and as people (professionals and non-professionals), we have the obligation to promote the exercise of citizenship of those who are experiencing or have experienced mental health problems.
Precisely, we are in a historical and social moment in which, for the first time, changes are being introduced in the institutions that go along this line of respecting and promoting the citizenship rights of psychiatrized people as a way to their recovery.
Among the changes, at the level of new tools and resources, we can mention:
- Advance Decision Planning (Ramos et al., 2020), a decision-making support resource aimed at facilitating our autonomy and legal capacity, which favors respect for our will and preferences, especially during a mental health crisis .
- The Manual for the Recovery and Self-Management of Well-being (Sampietro et al., 2018) with information, guidance and strategies that we can use to develop a personalized plan to face psychological suffering and to carry out a recovery process according to our own preferences.
At the legislative level, we highlight that they are currently in process:
- The reform of the Civil Code of Catalonia, in terms of support for the exercise of legal capacity, to adapt the law to the Convention on the Rights of Persons with Disabilities, especially its article 12, "Equal recognition as a person before the law" .
- In Spain, the Draft Law that reforms the civil and procedural legislation, for the Support of people with disabilities, in the Exercise of their legal capacity. Legislative change that eliminates legal incapacities and guardianships.
- Proposal for a Law on Rights in the field of mental health, dated March 8, 2019, which collects the historical claims of activist movements in the first person and the recommendations of the CRPD.
In short, although we still have a long way to go for the recovery model and rights-based care to move from paper (strategic plans) to practice (real care in mental health services), we are already working on it. This path, collaborating to achieve the necessary changes with the Administration, service providers and associative movements.
Because recovery requires self-determination, respect for one's own preferences, exercise of citizenship rights and inclusion in the community.
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