Recovery Support

Recovery Support

Sandra J. Sundeen

It is estimated that 5% of adults in the United States have a serious mental illness. Nurses care for these people in private and public psychiatric hospitals, psychiatric and medical-surgical units in general hospitals, emergency departments, community-based treatment and rehabilitation programs, primary care settings, and patients’ homes. As patients alternate between community-based and hospital-based care, nurses in all settings share responsibility for their care.


Individuals who have serious mental illnesses, with the provision of appropriate and individualized supports, can recover from their illnesses and lead satisfying and productive lives. One of the eight Strategic Initiatives identified in the 2011–2014 plan of the federal Substance Abuse and Mental Health Services Administration (SAMHSA) is “Recovery Support” (SAMHSA, 2011). One-third of individuals with severe mental illnesses who receive community mental health services after lengthy stays in a state hospital fully recover, and another third improve significantly (SAMHSA, 2009).

Recovery is a journey of healing and transformation enabling a person with a mental health problem to live a meaningful life in a community of his or her choice while striving to achieve his or her full potential (USDHHS, 2006). The components of recovery are described in Box 14-1.


• Self-Determination: Consumers lead, control, exercise choice over, and determine their own path of recovery by optimizing autonomy, independence, and control of resources to achieve a self-determined life. By definition, the recovery process must be self-directed by the individual who defines personal life goals and designs a unique path toward those goals.

• Individualized and Person Centered: There are multiple paths to recovery based on an individual’s unique strengths and resiliencies as well as the individual’s needs, preferences, experiences (including past trauma), and cultural background in all of its diverse representations.

• Empowerment: Consumers have the authority to choose from a range of options and to participate in all decisions—including the allocation of resources—that will affect their lives, and they are educated and supported in so doing. They have the ability to join with other consumers to collectively and effectively speak for themselves about their needs, wants, desires, and aspirations. Through empowerment an individual gains control of his own destiny and influences the organizational and societal structures in his life.

• Holistic: Recovery encompasses an individual’s whole life, including mind, body, spirit, and community. Recovery embraces all aspects of life, including housing, employment, education, mental health and health care treatment and services, complementary and naturalistic services (e.g., recreational services, libraries, museums), addictions treatment, spirituality, creativity, social networks, community participation, and family supports as determined by the person. Families, providers, organizations, systems, communities, and society play crucial roles in creating and maintaining meaningful opportunities for consumer access to these supports.

• Nonlinear: Recovery is not a step-by-step process but one based on continual growth, occasional setbacks, and learning from experience. Recovery begins with an initial stage of awareness in which a person recognizes that positive change is possible. This awareness enables the consumer to move on to fully engage in the work of recovery.

• Strengths Based: Recovery focuses on valuing and building on the multiple capacities, resiliencies, talents, coping abilities, and inherent worth of individuals. By building on these strengths, consumers leave stymied life roles behind and engage in new life roles (e.g., partner, caregiver, friend, student, employee). The process of recovery moves forward through interaction with others in supportive, trust-based relationships.

• Peer Support: Mutual support—including the sharing of experiential knowledge and skills and social learning—plays an invaluable role in recovery. Consumers encourage and engage other consumers in recovery and provide each other with a sense of belonging, supportive relationships, valued roles, and community.

• Respect: Community, systems, and societal acceptance and appreciation of consumers—including protecting their rights and eliminating discrimination and stigma—are crucial in achieving recovery. Self-acceptance and regaining belief in one’s self are particularly vital. Respect ensures the inclusion and full participation of consumers in all aspects of their lives.

• Responsibility: Consumers have a personal responsibility for their own self-care and journeys of recovery. Taking steps toward their goals may require great courage. Consumers must strive to understand and give meaning to their experiences and identify coping strategies and healing processes to promote their own wellness.

• Hope: Recovery provides the essential and motivating message of a better future—that people can and do overcome the barriers and obstacles that confront them. Hope is internalized; but can be fostered by peers, families, friends, providers, and others. Hope is the catalyst of the recovery process.

From Substance Abuse and Mental Health Services Administration (SAMHSA), U.S. Department of Health and Human Services (USDHHS): National consensus statement on mental health recovery, Rockville, MD, 2006, USDHHS, CMHS.

Recovery is the process in which people are able to live, work, learn, and participate fully in their communities. For some individuals, recovery is the ability to live a fulfilling and productive life despite a disability. For others, recovery implies the reduction or complete remission of symptoms. Recovery also involves connectedness, or the capacity for mutual interpersonal relationships, and citizenship, which includes the rights, privileges, and responsibilities of membership in a democratic society (Ware et al, 2007, 2008).

Self-determination is the foundation of person-centered and consumer-driven recovery supports and systems. The most important aspects of recovery are defined by each individual with the help of mental health care providers and the people who are most important in each person’s life. Having hope plays an essential role in an individual’s recovery (Stuart, 2010).

The individual receives recovery supports through activities identified as rehabilitation, which is the process of helping the person return to the highest possible level of functioning. Psychiatric rehabilitation is a combination of services incorporating social, educational, occupational, behavioral, and cognitive interventions aimed at long-term recovery and maximization of self-sufficiency.

It grew out of a need to create opportunities for people diagnosed with severe mental illness to live, learn, and work in their own communities. Psychiatric rehabilitation uses a person-centered, people-to-people approach that differs from the traditional medical model of care as seen in Table 14-1.

Some mental health care providers have concerns that the focus on recovery is not realistic. However as individuals participate in recovery-oriented programs and mental health professionals observe the progress that they make, these concerns are addressed and corrected (Delaney, 2010).

For example, a recovery-oriented approach to providing nursing care to individuals who are taking psychiatric medication would take into account the fact that reluctance to take medication is often related to the person’s illness or refusal to acknowledge a need for medication. The recovery-oriented response is focused on learning about the patient’s reasons for not taking medication and then working with the patient to identify ways to make medication more acceptable based on the patient’s life goals (Roe and Swarbrick, 2007).

There are a number of evidence-based practices that support and enhance recovery including: assertive community treatment, supported employment, illness management and recovery, integrated treatment for co-occurring mental illness and substance abuse, family psychoeducation, medication management, and permanent supported housing. All these practices except integrated treatment for co-occurring mental illness and substance abuse (see Chapter 23) and medication management (see Chapter 26) are addressed in this chapter.

Recovery support in psychiatric nursing care involves working with a multidisciplinary treatment team that can include psychiatrists, psychologists, social workers, counselors, occupational therapists, consumer and peer specialists, case managers, family advocates, employment specialists, or job coaches. It also requires the nurse to focus on three elements: the individual, the family, and the community. The nursing care of people with serious mental illnesses is related to these three elements and the activities of assessment, planning and implementation, and evaluation.


The Individual

The Stuart Stress Adaptation Model can be applied when providing recovery support. Assessment of the person’s recovery goals begins with the initial contact between the nurse and the patient. A comprehensive psychiatric nursing assessment provides information that enables the nurse to help the patient achieve maximum possible functioning.

When conducting an initial assessment, the nurse needs to assist the patient to plan for recovery by first identifying the individual’s life goals. Nurses then identify and reinforce strengths as one means of helping the patient cope. They assess challenges that may block the person’s ability to achieve these goals, as well as services available from the health care system and the person’s social support network that will support strengths and assist in goal achievement.

Characteristics of Serious Mental Illness.

People who have serious mental illnesses are likely to have both primary and secondary symptoms. Primary symptoms are directly caused by the illness. For example, hallucinations and delusions are primary symptoms of schizophrenia, and elation and hyperactivity are primary symptoms of bipolar disorder. Secondary symptoms, such as loneliness and social isolation, are caused by the person’s response to the illness or its treatment.

Behaviors related to primary symptoms may violate social norms and be considered deviant. Society then tries to protect itself from the person’s norm violation. An example of this is community opposition to the establishment of group homes.

As behavior problems become more serious, people increasingly identify themselves as mentally ill. They begin to relate to society in terms of this identity rather than others, such as wife, mother, husband, father, or worker. This is sometimes referred to as self-stigmatizing behavior. The person’s acceptance of mentally ill status and adjustment to society in terms of this role are accompanied by the secondary symptoms of serious mental illness.

Behaviors Related to Serious Mental Illness

Roadblocks to the recovery of individuals with severe mental illness include poverty, victimization, and stigma. People with serious mental illnesses are often unemployed, are less likely to be involved in close relationships, and tend to have fewer financial resources than their peers.

The exact causes of these characteristics have not been identified. Some could be related to primary and secondary symptoms or disabilities of the illness and others to society’s reaction to the person with mental illness (Pope, 2011).

Attitudes that could contribute to this reaction are illustrated by the list of myths and facts about people with mental illness seen in Box 14-2. None of these myths is true, but they are commonly believed and stigmatize people with mental illness. They also can prevent people with mental illness from gaining access to needed services and opportunities.


Myth: Psychiatric disorders are not true medical illnesses like heart disease and diabetes. People who have a mental illness are just “crazy.”

Fact: Brain disorders, like heart disease and diabetes, are true medical illnesses. Research shows genetic and biological causes for psychiatric disorders, and they can be treated effectively.

Myth: People with a severe mental illness, such as schizophrenia, are usually dangerous and violent.

Fact: Statistics show that the incidence of violence in people who have a brain disorder is not much higher than it is in the general population. Those suffering from a psychosis, such as schizophrenia, are more often frightened, confused, and despairing than violent.

Myth: Mental illness is the result of bad parenting.

Fact: A genetic susceptibility, combined with other risk factors and stressors, leads to a psychiatric disorder. In other words, mental illnesses have a physical cause.

Myth: Depression results from a personality weakness or character flaw, and people who are depressed could just snap out of it if they tried hard enough.

Fact: Depression has nothing to do with being lazy or weak. It results from changes in brain chemistry or brain function, and medication and/or psychotherapy often helps people recover.

Myth: Schizophrenia means split personality, and there is no way to control it.

Fact: Schizophrenia is not split personality or multiple personality disorder. Schizophrenia is a brain disorder that robs people of their ability to think clearly and logically. The estimated 2.5 million Americans with schizophrenia have symptoms ranging from social withdrawal to hallucinations and delusions. Treatment has helped many of these individuals lead fulfilling, productive lives.

Myth: Depression is a normal part of the aging process.

Fact: It is not normal for older adults to be depressed. Depression in the elderly is often undiagnosed, and it is important for seniors and their family members to recognize the problem and seek professional help.

Myth: Depression and other illnesses, such as anxiety disorders, do not affect children or adolescents. Any problems they have are just a part of growing up.

Fact: Children and adolescents can develop severe mental illnesses. In the United States, one in five children and adolescents has a mental disorder severe enough to cause impairment. However, only about one third of these children receive needed treatment. Left untreated, these problems get worse and continue into adulthood.

Myth: If you have a mental illness, you can will it away. Being treated for a psychiatric disorder means an individual has in some way “failed” or is weak.

Fact: A serious mental illness cannot be willed away. Ignoring the problem does not make it go away, either. It takes courage to seek professional help.

Myth: Addiction is a lifestyle choice. People with a substance abuse problem are morally wrong or “bad.”

Fact: Addiction is a disease that generally results from changes in brain chemistry. It has nothing to do with being a “bad” person.

Myth: Electroconvulsive therapy (ECT), formerly known as “shock treatment,” is painful and barbaric.

Fact: ECT has given a new lease on life to many people who suffer from severe and debilitating depression. It is used when other treatments such as psychotherapy or medication fail or cannot be used. Patients who receive ECT are asleep and under anesthesia, so they do not feel anything.

From NARSAD (National Alliance for Research on Schizophrenia and Depression): Research Newsletter,13, winter 2001/2002.

Stigma experienced by those who are mentally ill has been linked to self-esteem. Thus, the effects of stigma, poverty and victimization should be included in patient assessment and treatment planning.

Low self-esteem

Self-esteem is the feeling of self-worth or regard for oneself. It is difficult to maintain high self-esteem when a person is aware of low achievement compared with cultural expectations. Lack of ability to maintain employment, live independently, marry, and have children contributes to low self-esteem. People who have serious mental illnesses often feel cheated of the life experiences they expected to enjoy before they became ill.

One mental health professional who also has a serious mental illness describes her experience of being diagnosed with schizophrenia during adolescence (Deegan, 1993):

I was told I had a disease that was like diabetes, and if I continued to take neuroleptic medications for the rest of my life and avoided stress, I might be able to cope. I remember that as these words were spoken to me by my psychiatrist it felt as if my whole teenage world—in which I aspired to dreams of being a valued person in valued roles, of playing lacrosse for the U.S. Women’s Team or maybe joining the Peace Corps—began to crumble and shatter. It felt as if these parts of my identity were being stripped from me. I was beginning to undergo that radically dehumanizing and devaluing transformation from being a person to being an illness; from being Pat Deegan to being a schizophrenic.


Failure to take medication is a common cause of rehospitalization. It is important to assess the reasons for nonadherence. There may be a denial of the illness or a lack of understanding of the reason for the treatment regimen. Sometimes the person wants to comply but needs help, such as transportation to a pharmacy or advice about obtaining a medical assistance card. Some patients do not like the side effects of their medication, but they may not be assertive enough to tell the prescriber about their discomfort.

The nurse can help patients by developing a therapeutic alliance with them, educating them about their illness and the beneficial effects of their treatment including medication, and engaging them in the treatment plan. Teaching patients to write notes about their medicines and to keep lists of questions for the provider also may increase adherence. Linking the benefits of medication to the achievement of personal goals is especially important.

Living Skills Assessment

The nursing assessment of a patient with a serious mental illness should include an analysis of the physical, emotional, and intellectual components of the skills needed for living, learning, and working in the community. Table 14-2 presents skills required for successful functioning in the community.

The nurse may use these examples in working with the patient to identify strengths, establish goals, and set priorities for skill development. Such a model provides a basis for assessing the patient’s readiness to function productively in the community. It also provides objective information on quality of life that can be shared with other mental health care providers.

The Family

Most people with mental illness are involved with their families and have frequent contact with family members while they are living in the community. Approximately 65% of people who have mental illnesses live with their families. Therefore, family resources must be assessed when a recovery plan is being developed.

Families and other caregivers can be a major source of support for individuals who have serious mental illnesses. They can help by identifying potential problem areas and enhancing the patient’s adherence to the treatment plan. Caregivers should be educated about the patient’s condition and involved in the treatment process. Families should be viewed as resources, caregivers, and collaborators by psychiatric nurses (see Chapter 10).

Unfortunately, families are often overlooked and not provided with education about mental illness. This is frustrating and interferes with their ability to assist in the patient’s recovery. Although issues of confidentiality and respect for the patient’s wishes regarding disclosure of treatment information must always be primary, nurses should strive as much as possible to include family members as partners in the treatment process.

Components of Family Assessment.

The nurse who assesses the family as part of a recovery plan should consider the following aspects of family dynamics:

Some of this information may be obtained from other members of the treatment team. However, it is the nurse’s responsibility to be available to the family.

Family Burden

The mental illness of a family member affects the entire family. This impact is often called family burden. It can be related to worry about the future, poor concentration, upset household routines, feeling guilty about not doing enough, feeling trapped, and being upset by changes in their family member.

Burden may be objective or subjective. Objective burden is related to the patient’s behavior, role performance, adverse effects on the family, need for support, and financial costs of the illness. Subjective burden is the person’s own feeling of being burdened; it is individual and not always related to objective burden. For instance, a patient may lack ambition and remain in a dependent role well into adulthood. Family members who value success and upward mobility may feel more subjective burden related to this situation than members who are comfortable with nurturing and supporting someone.

By assessing burden the nurse can work with the family to identify concerns with which they would like help. Several responses are frequently noted in families who have members with serious mental illness. It is helpful to consider these when assessing subjective burden.

Grief is common and is related to the loss of the person they knew before the illness, as well as loss of the future that they expected to share with the ill family member. Because serious mental illness is usually cyclical, grief tends to be recurrent; it subsides during remissions and returns during exacerbations. This is especially difficult for families to handle. In addition, social support systems may not recognize or respond to their need because of discomfort with the situation or the related stigma.

Guilt is another emotion that families may experience in relation to their relative’s illness. It is common for those who are close to a person with any serious illness to wonder whether they could have done something to prevent it. For instance, the wife of a heart attack victim may think she could have prevented it if she had not encouraged him to shovel snow. Similarly, parents of a depressed woman may believe that they could have prevented her depression if they had not shared their own worries with her.

In neither of these situations did relatives cause the illnesses, but they feel guilt because of their interpretation of the situation. Another source of guilt for relatives of people with mental illness is the need to set limits on the patient’s behavior at times. For instance, the family of a patient who is physically agitated may need to arrange hospitalization to keep the patient safe.

Anger may be directed toward the patient, but it is more often felt toward other family members, mental health care providers, or the entire health care system. Anger within the family relates to differing perceptions of the patient and varied ideas about how to manage the illness. Prolonged stress results in irritability that is often taken out on those to whom one is closest. Anger at the system often is justified because it is related to deficiencies in the accessibility or acceptability of needed mental health services.

Powerlessness and fear often result from families’ realization that they are dealing with a long-term recurrent illness. Most people believe that the health care system should cure illnesses. When this does not happen, they feel powerless and frustrated. This can result in fear about the future of the ill family member, as well as fear for themselves.

Powerlessness and fear are especially troublesome for parents who are aging and worried about care arrangements for their mentally ill child when they can no longer provide care themselves. Some families also fear ill members who may become dangerous if they stop adhering to their treatment.

Feb 25, 2017 | Posted by in NURSING | Comments Off on Recovery Support
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