Claire Hilton, Consultant old age psychiatrist
25 January 2010

We fail to see what all the fuss over the ‘Recovery Model’ is about. Nor can we appreciate why it has been so powerful in ‘influencing mental health service development around the world’. Working with older people, especially those with dementia butalso those with functional disorders, 'recovery' has been the style of ourwork long before it became a jargon term.

Our day assessment unit aims to give both the patient and their relatives as much autonomy as possible despite progressive mental disability. Enhancing wellbeing and giving meaning to people’s lives, empowering patients and carer to make decisions collaboratively, and enabling activities salient to the patient and carer have been integral toour work for years. We run inhouse educational courses and support groups for carers. Some carers’ courses have continued as informal groups, meeting and supporting each other even after the relative they arecaring for has died. An upmarket chain coffee emporium offers free drinks for one peer support group organised by a patient with a history ofbipolar affective disorder, which meets in their café; perhaps some would say this is unwarranted charity: the group does not think so. A ‘drop-in’at a local church hall is popular. Carers contribute to our educational programme for staff.

To us, the recovery model represents standard high quality old age psychiatric practice. So often we can see the quality of life of patientsand their relatives improve, despite progressive illness and disability, as understanding and coping mechanisms increase. Scientific evidence is not always necessary, especially when it is measured in economic rather than person-centred terms. The recovery model is a humane, self-esteem, self-respect approach, perhaps one which all psychiatry can learn from older people’s services. We will not become complacent in our practices even if services for younger people are catching up with us. ... More

Conflict of interest: None Declared

George J. Lodge, Consultant Psychiatrist
13 January 2010

I would not argue against the underlying principles espoused in the two leading articles in the first issue of The Psychiatrist 1,2. The principleof working with patients to help them to make informed decisions about options for their health care is embodied in the General Medical Council’s guidance: “Good Medical Practice” (GMP) 3, which says that doctors must work in partnership with patients, listen to patients and respond to their preferences.

Many psychiatric disorders are exacerbated or precipitated by stress.

Autonomy of action is associated with enhanced self esteem, reduced stress

and improved health. Meaningful employment contributes in many ways, giving: a sense of purpose and value; enhanced social status; structure and stability; opportunities for social interaction; and improved leisure and social opportunities as a result of greater disposable income.

Those working with sufferers from mental illness should be aware of these principles and, seek to incorporate them in the care they offer. In practice, however, professionals nominally subscribing to a “recovery model” may have a poor understanding of its complexity. An inappropriate application of the concept of empowering patients can lead to a laissez faire approach of simply endorsing the patient’s choice. This can result in justifying patients discontinuation of treatment and withdrawal from engagement with professionals. Such withdrawal can lead to relapse and a deteriorating prognosis and may itself be indicative of incipient relapse.

Professionals do not enjoy a monopoly of wisdom. We cannot reliably predict the course of a patient’s illness or how they might respond to treatment. Those with capacity have the right to decide not to accept treatment or to

deal with their illness in ways which professionals may consider unwise. However, GMP also says that doctors must provide effective treatments based on the best available evidence. The doctor’s duty to provide the best advice may include advising a patient that their intended course of action is likely to lead to an adverse outcome. It is incumbent upon us to inform patients of the probable consequences of their decisions and to continue efforts to engage

them, when we consider them to be at significant risk of deterioration or relapse.

Additionally, UK and European law takes a special view of mental disorder and allows for the patient’s autonomy to be over-ridden. It is a matter of judgment, governed by legislative safeguards as to when this should occur.

Such powers are generally only exercised when the patient’s ability to understand is so impaired as to render them incapacitated but a decision to override the decision of a capable patient may be made when the protection

of others is in question.

It is right to be adopt a positive approach, hopeful of recovery, after a first episode of psychosis. However, rather than adopt unqualified optimism, we should refine our approach using our knowledge of factors favouring a good

prognosis. Such features include: acute as opposed to insidious onset; clear and proximate psychogenesis; and the presence of marked affective features

in the symptomatology. Several interventions can improve the prognosis and

reduce the risk of relapse. Richard Warner points out the more favourable prognosis in less developed countries. One explanatory hypothesis is that the recovering patient is more likely to have a valued occupational role. Continued anti-psychotic medication reduces the risk of relapse. Psychosocial interventions to assist the patient in better understanding the illness and its behaviour, and work to modify family attitudes and environments appear to help. Complete resolution of symptoms encourages optimism about prognosis, but hopes for a meaningful and lasting recovery

need to be underpinned by appropriate support and treatment to reduce the risk of relapse.

Despite the advances made in treating the acute symptoms of schizophrenia and preventing acute relapse, social recovery rates do not appear to have improved since Eugen Bleuler coined the term schizophrenia 4. Richard Warner quotes a 40% social recovery level but, at the start of the 20th century, Bleuler considered that 60% of his patients showed only “mild deterioration”, that is: had preserved the ability to pursue an occupation.

While, therefore, I accept that significant numbers of patients with schizophrenia can remain symptom free and that others lead reasonably productive lives, it is still the case that the majority will experience a degree of impairment of function and many will suffer frank relapses of their positive symptoms or chronic levels of such symptoms.

Psychiatrists should strive to achieve that those diagnosed with schizophrenia are treated so that they become as free as possible of symptoms (including

adverse effects of treatment) and that they, their families and carers have as good as possible an understanding of the nature and behaviour of the illness, so that they can make effective informed decisions about their future healthcare. True empowerment requires the individual to have the best information available and the fullest command of their intellectual abilities in order to reach considered decisions based on that information. Suffering from psychosis is traumatic and bewildering experience. The course of the illness is unpredictable and frequently fluctuating. Sufferers should have

ongoing advice, support and treatment to cope with this.

1Sugarman P, Ikkos G, Bailey S. Choice in Mental Health: participation and recovery. The Psychiatrist 2010; 193: 1-3.

2Warner R. Does the scientific evidence support the recovery model?The Psychiatrist 2010; 193: 3-5.

3Good Medical Practice. General Medical Council, 2006

4Bleuler E. Dementia Praecox or the Group of Schizophrenias. New York. International University Press, 1950.

George Lodge was formerly Consultant Psychiatrist, with an interest in rehabilitation and is currently a Fitness to Practise chair for the General Medical Council and part-time medical member of the Mental Health Tribunal, e-mail: george.lodge@doctors.org.uk ... More

Conflict of interest: None Declared