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While most of the existing action research projects on SDM have focused on medication decisions, projects looking at the wide range of social recovery decisions—such as family relations, education, employment, housing and leisure activities are beginning to emerge [ 24 , 25 ].

Given that the scope of such activities is much wider in the context of the recovery journey than that of medication, it is central that SDM will be practiced within this area too. Shared decision making in mental health is hardly implemented in everyday practice [ 26 ], even though it has the potential to support co-production and active citizenship of service users, and thus contribute to changing the existing power differential between service users and providers, as well as the social place of this group of people. Co-production as an important dimension of recovery has begun towards the end of the 20th century, but has developed further in the 21st century [ 27 ].

It is based on the belief that service users have not only strengths to share in a joint project, but that co-production can enhance the power they have within such an undertaking, and with it their social standing and identity, as well as enriching any given project. Participation as equals in the management of projects is a good example of co-production see an example in The Haven initiative, [ 28 ]; or in co-training and co-researching in mental health shared decision making of young people and adults [ 23 , 25 ].

The power parity is evident in these examples, as well as the value given to the contributions made by the different participants. Roper, Grey and Cadogan [ 29 ] look at the principles, problematic aspects, and necessary conditions for the success of co-produced projects in mental health, providing a number of useful examples from Australia and the UK.

They perceive co-production to be based on social justice and community development, even though it comes originally from economics [ 30 ]. For them, the essence of such an approach in mental health is reversing the existing power imbalance by enhancing the power and leadership of service users to enable them to share their unique knowledge and experiential expertise. The necessary conditions for the success of co-production include giving support and time for service users to become better able to act as leaders and knowledge providers, focus on the process of co-production, and for all participants to be open about differences and potential conflicts, rather than to sweep these under the carpet.

A high degree of openness is asked not only from service providers. In the example given service users who are trainers and object to taking medication need to be ready to understand the perspective of those who wish to take medication and accept it as their legitimate choice [ 29 ], p. The recognition that co-production requires a lot more time to complete a project than a non-co-produced one is a reflection of the need for a process in which suitable modes of communication are found to fit with the emerging power, leadership and contribution to the project by the service users. Likewise, a process of readjustment is necessary also for the non-service users, who may be professionals or representing established organizations [ 30 ].

THE RECOVERY PROCESS

Examples of co-production projects in practice include developing a tool for dialogue on ECT between service users and providers to support the beginning of a consultative process, in which the service users were encouraged to ask all of the questions they had, make them comfortable when asking, and encourage more informed choices to be taken up by them [ 29 ], p.

Critical elements for co-production include having everyone on board, support for the initiative before it begins, willing to take risks, and access to co-production expertise and support if needed. Participatory action research PAR is another way of enabling co-production [ 31 ]. It enables the acquisition of new skills and interests, such as learning what is research, which are the relevant methods for a PAR design, how to do it, how to contribute to data analysis, write up and presentation of research findings.

An interesting example is provided by Mahone and her colleagues of a PAR study between a public mental health clinic and a university nursing department [ 32 ].

A DIFFERENT PERSPECTIVE ON RECOVERY

Co-production has the potential to generate a higher degree of social inclusion, but also new knowledge and evidence. For a number of service user groups co-production is perceived to be insufficient in redressing the power imbalance, and they aim at separate organizations which include only service users [ 33 ].

The attraction of such an arrangement is easy to understand in terms of being finally in full control and having the power to decide on their own with whom to share their activities. Developed by service users initially, the new meaning of recovery has been an empowering concept in particular for this group.

However, the focus on the uniqueness of any one group may prevent the full use of the expertise which exists beyond one group, hence preventing opportunities for genuine co-production. In summary, co-production is neither easy nor simple to achieve, given a history of institutionalization, prevailing perception of mental illness as only a bio-medical issue, lack of joint work history, and a belief that having a mental illness renders people unable to have a meaningful contribution to offer, which all too often becomes also an internalized identity.


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Putting in place processes of shared decision making in mental health, in dyads or triads person and clinician, person, clinician and carers [ 23 , 26 , 34 ] and in networks e. The concept of active citizenship in the context of social recovery in mental health relates to the wider discussion of biological citizenship [ 35 ], medicalization and de-medicalization, as well as to the social model of disability [ 36 ].

Given the contested nature of mental ill health and its likely underlying causes, this issue is often fudged by formally applying to it bio-psycho-social lenses. However, in our social reality which is dominated by the belief in science and medicine, both the psychological and the social aspects of mental ill health receive less attention than the assumed bio-medical base. The biological citizen, a concept focused on being governed and of taking an active part in self-governing, encourages up to a point the individual aspect of self-governing.

The latter is accentuated within certain social ideologies, such as neoliberalism, to the point of blaming individuals for failing to succeed economically and otherwise, by ignoring the impact of social structural factors, and acting as a justification for the destruction of protective frameworks, and often demonizing the citizen who is perceived as a failure [ 37 , 38 ].

Addiction Among Physically Disabled Individuals

The social model of disability [ 36 ], which is of relevance to the new meaning of recovery and to social recovery, provides an example of citizens self-governing as against being governed by society. It highlights the role of society in the stigmatization of people with disabilities and in erecting a number of barriers they face in leading an ordinary life. The new meaning of recovery straddles a complex path in following mainly a non-medicalized approach, without denying the place of medication within the range of mental health intervention.

It seems to accept without discussion the multiplicity of underlying causes leading to mental ill health, though the writings of recovery oriented thinkers often favor psychological and social factors, such as trauma, abuse, stigmatization and social deprivation over biological factors [ 40 ]. It also focuses on care and not on cure, and emphasizes leading a meaningful life with the illness and beyond it. A meaningful life beyond the illness includes fostering personal and collective responsibility towards oneself and others. The strong belief in the potential and actual strengths of people with the lived experience of mental ill health, and the empirical evidence supporting this belief [ 21 , 22 ] provide the basis for the assumed abilities this group has with which to achieve such responsibility.

The social recovery dimension emphasizes the place of social structural factors as impacting on the range of individual and collective choices available to people in their recovery journey, which in turn impact on their self-governing capacity. By advocating active citizenship as a recovery-oriented objective, social recovery widens the scope of individual and collective governing.

Empirical research has demonstrated that those service users who develop their citizenship activities increase also their level of recovery [ 9 ].

At present, good correlations between these two variables are noted, rather than a clear causal relationships. Pelletier et al. Becoming an active citizen is not a dimension that mental health service providers can do for people using the service; the latter need to do this themselves. Yet there is a range of opportunities and networks which facilitate this achievement which providers can support. This process is exemplified in the Barcelona development of active citizenship there, where a variety of local and EU mental health initiatives have led to creating a sound base for this development [ 41 ].

Rowe et al. Both shared decision making and co-production are enablers of active citizenship. In the context of mental health there are two key facets related to employment:.

Existing evidence highlights that once in work the diagnosis attributed to the person does not matter in terms of predicting likelihood to stay at work [ 1 ] and that given the right support employees with mental ill health tend to be more devoted to the workplace than those without this experience [ 43 ]. Availability of work for this group is higher when economic market success is higher, than when it is lower [ 1 ].

Recovery approach - Wikipedia

The rate of employment among people with the lived experience of mental ill health is poor in most countries [ 43 ]. People who do not work need to explain to themselves and to others the reasons for this state, and are often perceived as unproductive members of society. This attitude is prevalent in all countries which have embraced the neoliberal ideology, clearly expressed in treating unemployed people with a disability as a burden to society, and hence as a socially undeserving group.

This approach is reflected in the yearly decrease in the real value of disability benefits, and in the largely controlling way this group is treated by those responsible for administering the benefits to them. It takes a long time to re-instate the payment of benefits, and in the meantime people—and their dependents—may be literally starving.

This seems to be an additional layer of the stigma attached to people who experience mental ill health, instead of changing the inflexibility of the existing state system to enable people a gradual move to employment without losing their right to housing, or to other benefits, if they work more than the specified number of hours per week.

1. Introduction: What Is Social Recovery?

Housing is the most costly element of the financial benefits available to people with a high level of disability, including mental ill health [ 48 ]. Most jobs, even if full time, do not provide an income level that would cover the cost of housing. Thus people are faced with the dilemma of losing their housing benefits with no alternative housing solution or staying on benefits.

This problem cannot be resolved by individuals who use mental health services, but by governments and local authorities.

Hence to blame these individuals is not only unjust, but is adding to the stigma they already live with. IPS Individual placement and support is a scheme focusing on supporting people to enter competitive employment by providing individualized long term support in the workplace [ 46 ] for people with all types of diagnoses. Originating in the US, it has proven to be the more successful way of becoming and staying employed [ 49 ], not only in the US, but also in Europe [ 50 ]. The outcomes of people entering competitive employment and staying there, while in parallel not being in need of frequent hospitalization episodes, are accounted for by the individualized nature of the scheme, its main location within the employment base, and by the readiness of the employer and other employees to foster it.

Schneider [ 52 ] explains and exemplifies the key reasons which are mainly located at the inter-organizational meeting point. To be a success, IPS requires co-location and joint work of IPS training team with the clinical team throughout the duration of the scheme.

Such joint work is not easy to achieve even if the teams are physically located in the same building, because of differences in status and perspectives on mental health and the capacity of people with long term mental ill heath to work successfully in a competitive environment. Changing professional mentalities usually requires a lengthy process and competent, dedicated, leadership, one that does not match the logic of a time limited project.