Historically, recovery from mental illness has been viewed from a medical model that focuses on the primary treatment goal of symptom control through medication management. However, people who experience and live with a psychiatric disability describe a very different view of recovery and what promotes that process. Their focus is on the desire to lead active, fulfilling lives. They value clinicians who instill hope, encourage individual efforts, and provide opportunities to pursue life goals.
Since Peplau (1952) first emphasized the "nurse-client relationship" in the nursing process, psychiatric nurses have approached clients as active participants in their recovery. The psychiatric rehabilitation model provides a context for nurse-client relationships that enables client empowerment, selfgrowth, and the recovery process.
This article describes psychosocial rehabilitation principles that guide a community-based faculty nursing practice. Key concepts of psychosocial rehabilitation, the recovery process, and hope as a critical factor in nurseclient relationships are examined. Nurse-clinician and consumer experiences illustrate integration of these concepts and offer a practice model based on collaborative partnerships within the community in a managed care environment.
The primary tenet of psychosocial (psychiatric) rehabilitation advocates viewing the mentally ill as people with disabilities who share the same aspirations as other persons (Palmer-Erbs & Anthony, 1995). People with psychiatric disabilities want safe, affordable housing, the opportunity to work for fair wages, the opportunity to learn, time to enjoy social and leisure activities, involvement in the communities where they live, and most of all, families and friends who love and care about them.
The "psychiatrie disability" metaphor
Most people are familiar with the concept of rehabilitation for physical injuries (such as a spinal cord injury) and physiologic conditions (such as myocardial infarct and cerebrovascular accident). The same metaphor may be applied to psychiatric rehabilitation for persons with a psychiatric disability (Palmer-Erbs, 1995; Palmer-Erbs & Anthony, 1995).
Rather than viewing a person with a mental illness as destined for life-long suffering and decline in functional abilities, the metaphor of "psychiatric disability" creates a sense of possibility for overcoming the challenges of a disability and for living to one's maximum potential. A psychiatric disability consists of the functional limitations and handicaps created by the mental impairments and symptoms, rather than the mental impairment alone (Anthony, 1993).
Physical rehabilitation services are targeted to help people develop skills that enhance adjustment to their living environment and develop environmental supports that facilitate successful community living (Wright, 1960). Psychiatric rehabilitation likewise focuses on the same areas of intervention - improving a person's knowledge and skills to maximize levels of functioning and develop resources within the community to support successful living. The Principles of Psychosocial Rehabilitation, as shown in Table 1 , provide guidelines for facilitating the recovery process.
The Recovery Process
Deegan (1988) draws a distinction between rehabilitation and recovery. Rehabilitation encompasses the services and resources made available to people with disabilities to facilitate adaptation to their world. Recovery encompasses the lived experience of people as they meet and overcome the challenges of the disability. Psychiatric rehabilitation is not a passive process wherein a person is rehabilitated. Psychiatrically disabled adults who choose to embark on a recovery process "become active and courageous participants in their own rehabilitation project" (Deegan, 1988). This active participation component corresponds with the view of the nurse-client relationship as a collaborative partnership.
A radical notion
Although the concept of recovery from a physical illness or disability is well known, the concept of recovery from mental illness represents a radical notion. Consumers and clients of mental health services have been the most active in advancing this approach (Deegan, 1988; Spaniol & Koehler, 1994; Unzicker, 1989). They describe a process, as shown in Table 2, that is universal to anyone who has experienced a catastrophic loss, including those associated with mental illness.
Principles of Psychosocial Rehabilitation
Deegan (1988) portrays a moving parallel between her experience, which involved being diagnosed with schizophrenia during late adolescence, and that of a friend, who experienced a cervical spinal cord injury and subsequent paralysis. Both individuals recalled the initial shock of their respective disabilities and the ensuing denial and rage, which was later recognized as the first two stages of the recovery process.
Months and years of denial gave way to "despair and anguish" over whether life would ever hold anything more meaningful man days of watching soap operas, smoking cigarettes, tolerating side effects from medications, or watching caretakers move and bathe immobile limbs. Self-pity became a daily past-time for both. Sadly, this third stage of depression can last a lifetime if the critical element of a caring other is missing in the despairing person's life.
The fourth stage of recovery is characterized by the "birth of hope" which springs from within the individual. Both the paralyzed friend and me woman with schizophrenia recalled the experience of having persons in their lives who did not give up on them, and remained hopeful despite their own despair. Those who cared about and loved them despite their own sense of hopelessness and powerlessness did not force unrealistic goals or plans. They simply provided emotional support and belief in possible changes (Deegan, 1988).
The glimmer of hope becomes a turning point followed by a willingness to act (Deegan, 1988) and to try small steps that sometimes meet with success and sometimes meet with failure. The ability to keep trying despite failures requires personal strength and encouragement from others.
Although the schizophrenia and the spinal cord damage cannot be cured, the recovery process becomes one of defining new possibilities and finding new meaning and purpose in life. As individuals begin to accept the limitations of what they cannot do, they begin to discover what they are able to do and to look forward to a new beginning. The disability or catastrophic loss is no longer the focus of life, but ramer the pursuit of new interests and new relationships becomes foremost.
Recovering From the Stigma
Recovery from the stigma of mental illness is also part of the journey. This may be difficult because of negative public attitudes about psychiatric treatment and people with psychiatric disabilities, despite educational efforts designed to change perceptions. Public knowledge about mental illness is largely shaped by media images linking psychiatric patients with violence or labeling them as fundamentally different (Wahl, 1995; Yankelovich, 1991). Friends, acquaintances, employers, even family members, all avoid and withdraw from persons with psychiatric disabilities. It is not uncommon to hear people describe that "dealing with depression (or schizophrenia) is not nearly as difficult as dealing with the stigma and the rejection."
Recovering from the stigma of a psychiatric disability is a slow and erratic process that lasts a lifetime. Even for persons who have succeeded in establishing careers and meaningful friendships and family life, and who publicly acknowledge their psychiatric disability, mere are daily reminders of prejudice about their disabling condition.
Consumer self-help groups are one important source of healing this wound. Discovering that the disabled person is not alone in experiencing subtle slights and overt rejection validates the recovering person's perceptions. Discussing ways to cope with various forms of prejudice engenders courage to act individually and collectively.
Having role models who are further along in the recovery process also provides hope to those who have abandoned their dreams of being normal. Someone who is not ashamed to say, "I have schizophrenia, and at times my thoughts become jumbled and suspicious ... my friends know this and still accept me ..." is a role model to others who continue to struggle in shame about their disability. Someone with bipolar disorder who participates in weekly poetry readings at a local bookstore models creativity. Someone with recurrent psychotic depressions who starts a part-time job bagging groceries and is promoted to cashier models tenacity. Each time a person in the general public has a positive encounter with someone who acknowledges their psychiatric disability, stigma is diminished.
Hope: The Critical Factor
Hope is the anticipation of a desired event or condition - the expectation of something good happening in the foreseeable future. Hope springs from a sense of "the possible."
When people struggle with daily reminders of physical, mental, emotional, social, or environmental limitations, imagining the possibility of attempting a different approach or new behavior is difficult. So, how do people with disabilities begin to imagine something as possible? The answer lies in those around them - through other people in their world. Meeting someone with the same disability who is successful at school, at keeping a job, or at learning to drive inspires hope. People with disabilities value the success of peers and can begin to imagine that they, too, might develop similar skills and achieve similar goals.
Stages in the Recovery Process
Having someone who believes in you and can envision you accomplishing personal goals is the second source of imagining the possible. People with disabilities value persons who respect their unique limitations and help create and encourage alternative approaches. The willingness to try something new requires courage, and the ability to try again in the face of failure requires persistence and encouragement from others. The success of meeting even a small goal brings with it feelings of empowerment.
Strategies that instill hope in the psychiatrically disabled person need to be implemented by clinicians. Building a therapeutic relationship that values the client as a person, conveys respect and acceptance, and fosters meaning and hope in life engages the client in his or her own recovery. Facilitating success, connecting to successful role models, managing the illness, and educating clients and the community are all identified as areas that enhance hope for clients (Kirkpatrick et al., 1995). These strategies should never be overlooked or devalued; mey are essential components of a comprehensive treatment plan. These strategies can easily be incorporated into a variety of practice settings which promote recovery.
- Anthony, W.A. (1993). Recovering from mental illness: The guiding vision of the mental health service system in the 1990s. Psychosocial Rehabilitation Journal, 16(4), 11-23.
- Deegan, P.E. (1992). The independent living movement and people with psychiatric disabilities: Taking back control over our own lives. Psychosocial Rehabilitation Journal, 15(3), 3-19.
- Deegan, P.E. (1988). Recovery: The lived experience of rehabilitation. Psychosocial Rehabilitation Journal, 11(4), 11-19.
- Kirkpatrick, H., Landeen, J., Byme, C, Woodside, H., Pawlick, J., & Bernardo, A. (1995). Hope and schizophrenia: Clinicians identify hopeinstilling strategies. Journal of Psychosocial Nursing and Mental Health Services, 33(6), 15-19.
- Palmer-Erbs, V. (1995, October). Living and coping with schizophrenia: A psychiatric rehabilitation approach for psychiatric-mental health nurses. Paper presented at the American Psychiatric Nurses Association Conference, Philadelphia.
- Palmer-Erbs, V.K., & Anthony, W.A. (1995). Incorporating psychiatric rehabilitation principles into mental health nursing: An opportunity to develop a full partnership among nurses, consumers, and families. Journal of Psychosocial Nursing and Mental Health Services, 33(3), 36-44.
- Palmer-Erbs, V.K., Connolly, P.M., Bianchi, R., & Hoff, L. A. (1996). Nursing perspectives on disability and rehabilitation. In K.N. Anchor (Ed.), Disability analysis handbook (pp. 173201). Dubuque, IA: Kendall/Hunt Publishing Company.
- Peplau, H.E. (1952). Interpersonal relations in nursing. New York: G.P. Putnam.
- Spaniol, L., & Koehler, M. (Eds.). (1994). The experience of recovery. Boston: The Center for Psychiatric Rehabilitation, Sargent College of Allied Health Professions.
- Unzicker, R. (1989). On my own: A personal journey through madness and re-emergence. Psychosocial Rehabilitation Journal, 13(1), 7177.
- Wahl, O.F. (1995). Media madness: Public images of mental illness. New Brunswick, NJ: Rutgers University Press.
- Wright, B. (1960). The psychosocial aspects of disability. New York: Harper and Row.
- Yankelovich, D. (1990). Public attitudes toward people with chronic mental illness. Princeton, NJ: Robert Wood Johnson Foundation.
Principles of Psychosocial Rehabilitation
Stages in the Recovery Process