A Staff Perspective
By Stephen Epp, Occupational Therapist
Someone I know could be labeled a client, a co-worker, a teacher, and, most importantly, an inspiration. I have heard her story, watched her facilitate groups, participated with her on a committee, and visited her in an acute psychiatric ward. She has a mental illness, receives assertive community treatment, and, most importantly, she has a life. She is not an isolated example. I regularly witness people with incredible stories of trauma, victimization, and severe mental health symptoms demonstrate resilience, recover, live beyond their illness and develop a purposeful life.
As we know, mental illnesses can be devastating to the individuals affected and also to their families. These illnesses create serious barriers to quality of life. For people with mental illness, the client and family recover by reclaiming, regaining, and recovering the roles in their lives that lead to social inclusion, meaningful engagement in life, and participation in their communities. That is the goal.
At Strathcona Mental Health Team, I have found that the severity of a mental illness does not seem to predict a person’s ability to make friends, build connections, and create a life of which they are proud. The largest barriers to increased quality of life and reclaiming valued roles in society seem external to the illness. I see societal attitudes, stigma, a lack of public examples of successful recovery, and a lack of a belief in and an expectation of recovery being the greatest barriers to recovery for people with mental health issues. Health care clinical effectiveness is typically defined in “terms of correctness of diagnosis and appropriateness and efficacy of treatment and care provided.” However, for real recovery, the data no longer supports the dated model of an expert therapist guiding a naïve client towards the light of mainstream society. To become recovery oriented, we need to help “clients” become responsible citizens. We help them by modifying expectations within the environment in which they live.
The term “recovery,” means many things to many people. There are comparisons to the human rights/civil rights movements of African-Americans in the 1960s. There is a comparable gap in basic human rights, a lack of a power and voice, under-employment, social problems, lack of peer stewards, learned helplessness, the same token representation, and similar misrepresentation in the media. The current medical model also tends to place responsibility for change predominantly on the individual with the mental illness. In his book, The Careless Society: Community and Its Counterfeits, John McKnight writes, “revolutions begin when people who are defined as problems achieve the power to redefine the problem.”
How do we empower individuals, establish a voice, enable responsibility, and achieve steps toward recovery given the environmental barriers?
First, we need to acknowledge the expertise that the client brings. As Occupational Therapists, we espouse client-centered practice. We are required to consider and provide interventions related to the interplay among the individual, their environment, and their occupations. This affords the client a level of choice to select the direction of change based on their motivation, their perspective on the problems, and their definition of success. Our goal as therapists is to enable the individual and the family to build confidence, explore options and achieve successes, under the overarching belief that there is an expectation of recovery.
Second, we need to believe that all clients can exercise responsibility to establish recovery. The only way to learn responsibility is through responsibility. We can not wait until the client is “cured” or “fixed enough” before we place the expectations of citizenship and the responsibility to create a life. We start as we mean to finish.
To achieve this goal, therapists and clients both need to close the gap on how success is defined. A client may come from a place of complete dysfunction and in the process of treatment, progress towards a stable environment with shelter, better mental health and increased social participation. This progress may be perceived as a wonderful success story — and it is. However, in a full recovery, a “successful” story will include social inclusion in the mainstream community, friendships within and outside the mental health system, and employment.
In contrast with our Western society, people with schizophrenia living in “developing” countries appear to have higher quality of life, lower severity of symptoms, greater social inclusion and higher community integration. The difference occurs because the goals and expectations of the client are social inclusion, community integration, and increased quality of life from the beginning of treatment. Recovery is expected through meaningful community engagement and medications, counseling, and support for immediate return to productive roles within their communities.
This model stands in contrast with our society and system. At its worst, our system encourages clients to settle for living on a disability pension and accepting a life of poverty. Doing “well” means little more than “avoiding hospital.” The client is expected to be “psychosis/symptom free” before exploring a reclaimed role in society.
To change this pattern, we need to strike a balance, trying to find the “optimal challenge” to encourage a life worth living. Even though the Strathcona Mental Health Team in Vancouver is usually committed to the values of recovery and tries to instill hope, our environment, both within the health care system and in our communities, continues to significantly impede success. However, we are making progress.
In the Strathcona Psychosocial Rehab Program, we facilitate not only traditional life skills, leisure, and a wellness program. We also introduce clients to other clients who have regained power within our society. I define this power as having the freedom and opportunity to exercise choice based on their strengths, desires, and hopes for their future. At every opportunity, we highlight individual stories of success and encourage these stories to be spread. We try to influence social opinion beyond the person with the mental illness. If possible, we encourage clients to develop leadership skills and to perceive themselves as dynamic and useful citizens. We create a voice for the people targeted for mental health care service. We invest in the relationship by creating a partnership where our clients perceive us as human beings, problem solving together to overcome barriers. Some staff members have been hired specifically for positions requiring a personal, “lived” experience of mental illness. As time progresses, I hope to see more professional staff (Nurses, Occupational Therapists, Managers, etc.) who are chosen because of the wisdom that comes with their personal “lived” experience with or supporting a family member with mental health issues. Although the same message may have been stated many times, it often takes trust on a “peer” level for information to have a positive impact.
I have found that, in so many cases, the message is far less important than the messenger who gives it. The inherent power differential between a therapist and a client needs to be understood. The power of peer support, family involvement, and the concept of partnering to achieve a goal need to be acknowledged.
How do we lead a recovery-oriented system? We create leaders within our client and family population. We provide a space where we, as professionals, can step back and listen. Based on continuous feedback, we work with communities to create windows of opportunity for people with mental illness and their families. We look for the “just right challenge” to demonstrate that we expect recovery and we continue to support citizens in achieving valued roles in the community.
 McKnight, J. (1995) The Careless Society: Community and Its Counterfeits. NY: Basic Press, 1995.
 Anders, S. Psychiatr Rehabil J. Improving community-based care for the treatment of schizophrenia: Lessons from nativeAfrica. 2003 Vol 27 (1).