Severe Mental Illness and Recovery
Week 1
Chapter 1: Personal Recovery and Mental Illness: A Guide for Mental Health Professionals -
Overview of the Book (Slade, 2009)
Examines how MH services need to change if goal is to promote personal recovery
Clinical recovery: symptom reduction / return to normal functioning
Personal recovery: deeply personal, unique process of changing attitudes, values, feelings,
goals, skills, and / or roles
- A way of living a satisfying, hopeful, and contributing life even within the limitations
caused by the illness
- Recovery involves the development of new meaning and purpose in one’s life as one
grows beyond the catastrophic effects of mental illness
Problem identified:
People using mental health services exist on a spectrum:
- Some benefit and return to normal functioning - current services work for them (clinical
recovery = personal recovery)
- Some improve partly, but recovery involves more than treatment - current services are
insufficient
- Some are harmed - services reinforce illness identity and dependence, creating a virtual
institution
→ Current insufficient or toxic systems must change to promote personal recovery
Aims of the book:
1. Convince: show why focusing on personal recovery is necessary
- Epistemological rationale: mental illness is best understood from a constructivist view
prioritising individual experience
- Constructivism: understanding mental illness through meanings, experiences,
and values of individuals
- Ethical rationale: professional “best interests” have sometimes caused harm, support
should align with the person’s own goals
- Effectiveness rationale: treatment benefits (especially medication) are overstated, a
broader approach is needed
- Empowerment rationale: traditional focus has subordinated the individual’s interests to
others, recovery restores power to the person
- Policy rationale: many national systems already instruct services to focus on personal
recovery
2. Crystallise: clarify what personal recovery means
- Personal Recovery Framework
- There are different types of knowledge: blending of group-level and individual-level
evidence needed
- Optimal balance: individual perspective + expert-by-experience perspective +
training, knowledge and personal views (blend individual and scientific
knowledge)
1
, 3. Catalyse: provide a response to the MH professional who is convinced about the values,
has crystallised beliefs and knowledge about personal recovery, and wants to know
where in practice to start
New goals and values:
- Goal shift: from treating illness (clinical recovery) to promoting well-being (personal
recovery)
- Values shift: services should follow individuals’ aspirations, not professional imperative
- Professionals should listen to and act on what the person says
- Professionals should be tentative: applying professional knowledge competently but
humbly to support people in their recovery journey
- Recognise that treating illness and promoting well-being involve different processes
and timelines
- Short-term focus (symptom relief) can harm long-term recovery (dependence, no hope)
- Balance needed between managing illness and building a meaningful life
- Incorporate new knowledge: lived experience and positive psychology (focus on
pleasure, engagement, meaning, achievement)
Personal Recovery framework
4 key recovery processes: hope, identity, meaning, personal responsibility
- Professionals’ tasks should align with supporting these processes
Core shifts proposed
- Change of goal: from clinical to personal recovery
- Value-based shift: from professional authority to person-centred values
- Integrate positive psychology into practice
- Focus on recovery-supporting tasks rather than illness control
Language and terminology
Terms for people vary across a spectrum from internal “brain illness” (too simplistic) to external,
“psychiatric survivor” → book uses mental illness for clarity
- Uses consumer, patient, client, service user, peer interchangeably depending on context
- Professionals, MH professionals and clinicians
Slade’s stance: clinical academic and psychologist perspective
- Mental illness is real but cannot be reduced to simple biological explanations
(unhelpfully simplistic)
- Book aims to translate consumer perspectives into professional language
- Acknowledges biases
- Seeks to promote services centred on well-being, justice, and person’s own priorities
Promoting personal recovery means transforming MH services - shifting from illness treatment
to well-being support, from professional dominance to person-centred values, and integrating
lived experience and positive psychology into all aspects of care
2
,Chapter 2: Personal Recovery and Mental Illness: A Guide for Mental Health Professionals -
The Nature of Mental Illness (Slade, 2009)
What is Mental Illness?
Central focus: subjective experience
- Psychiatry relies mainly on patients’ self-reports rather than objective tests
- No biological test can detect mental illness independently of awareness or experience
Mental illness: disorders without a proven physical cause (functional illnesses)
- Understanding mental illness starts with personal experience, not biology
3 Broad models of understanding mental illness
- Clinical models: dominant in services, focus on illness and treatment
- Disability models: see mental illness as a form of social disability
- Diversity models: see experiences as part of human variation, not pathology
1. Clinical Models
Frameworks developed by mental health professionals to diagnose and treat mental disorders
- Emphasise expert authority, intervention, and treatment
- Focus on what’s wrong inside the person, not the environment
- 3 main models of mental disorder: biomedical, biopsychosocial and cognitive
Biomedical Model:
2 assumptions: (neither universally true to mental illness)
1. Illness is caused by biological dysfunction
2. Removing the disease restores health
Based on Jaspers’ phenomenology: verstehen over erjkaren - clinicians use empathy to
understand patients but fit experiences into pre-set diagnostic forms
- Focus on universal forms of psychopathology (hallucination type), not personal meaning
Aim: obtain an objective, “scientific” description of symptoms
Biomedical model: listening is used to elicit phenomena of psychopathology
Critics (Bracken & Thomas, Johnstone):
- Reduces rich, contextual experiences to de-personalised “symptoms”
- Removes meaning and personal responsibility
- Encourages dependence on external “cures”
- Consequence: personal meaning and context ignored (meaning is the first casualty of
the biomedical model) → impoverished and decontextualized version of meaning
Biopsychosocial Model: recognises interaction between biological, psychological and social
factors
Recognises that interpersonal, contextual and societal factors impact on the interpretation,
onset, course and outcome of mental illness
- Built on the stress-vulnerability model: vulnerability interacts with environment
- In theory, holistic - in practice, still bio-dominant
- Empirical studies show that biological explanations dominate clinical notes and teaching
3
, - Often functions as a “biomedical model in disguise”: social and environment factors have
an impact on physical process, physical malfunction is the underlying cause
- The structure of the mental state examination influences the results obtained
- Diagnosis remains central, social and psychological factors are seen as “triggers”
rather than core causes
Lucy Johnstone’s distinction:
- Weak version - everything interacts, but explains nothing
- Strong version - biology still treated as primary cause
- Reasons for bio-dominance: easier to research biological variables, maintains
professional power and medical status
Example: schizophrenia
- Many risk factors identified - genetic, developmental, psychological, social
- Evidence on genetics inconsistent and inconclusive
- Overemphasis on “brain disease” narrative due to cultural and professional bias
- True understanding requires a balanced biopsychosocial approach, not bio-primacy
Most funding goes to biomedical model
Strengths of bio models: systemized, lead to action (guidance), patients benefit from
treatments based on these models
Problems with biomedical and biopsychosocial clinical models:
Typical assumptions:
- Clinician acts in the patient’s “best interests,” defines the problem, and prescribes
treatment
- Patient’s role is to comply
- Focus on symptoms, deficits, and pathology
- Goal: symptom reduction and “return to normal”
4 major mismatches between model and reality
1. Mental illness is not only caused by disturbed homeostasis
- Diagnoses in psychiatry are understandings, not explanations - they differ in everyone
- Explanations: reveal essence, can be ranked, closest approximation available
- Physical illnesses (meningitis) have clear causes (explanation), mental illnesses depend
on context and meaning (understanding) - “diagnosis is prognosis” true for physical
- Using “diagnosis = truth” is misleading - it’s a communication tool, not a revelation
Generative vs successionist causation (Pawson & Tilley):
- Physical illness = secessionist (fixed cause → effect)
- Mental illness = generative (connection between causally connected events, depends
on context and meaning)
Mental illness cannot be explained outside social, cultural, and temporal context
- Human psychology is embodied, encultured and temporal (not essentially biological)
The invariant use of a biomedical or biopsychosocial model is sometimes helpful, sometimes
insufficient, and sometimes toxic
- Generative model is more helpful in understanding MI
- A mental illness diagnosis should not be treated as if it is an explanation
4
, Professionals should offer tentative interpretations, not authoritative pronouncements
- “Your experience can be understood as depression” rather than “You have depression”
The DSM’s purpose is to facilitate communication among MH professionals, it is not a revealed
truth
2. Diagnosis does not reflect natural categories
There cannot be stable, invariant, psychological diagnostic categories
Diagnostic systems (DSM) are socially constructed, not objective: impact social understand
of human experience
- The categories created for DSM reorient our thinking about important social matters and
affect our social institutions
Categories have changed over time (“homosexuality” once listed): DSM I had had 112 mental
disorders, DSM II had 182, DSM III had 265, DSM IV had 374
Diagnoses expand due to professional and commercial interests - “colonisation of the human
condition”
Diagnosis can help some by providing structure but can stigmatise or hinder recovery for others
3. Assessment creates stigma
Clinical assessment should cover 4 dimensions:
- Dimension 1: deficiencies and undermining characteristics of the person
- Dimension 2: strengths and assets of the person
- Dimension 3: lacks and destructive factors in the environment
- Dimension 4: resources and opportunities in the environment
Assessments focus on deficits (Dimension 1) and ignore strengths or environment
3 resulting problems of this focus:
- Deindividuation: diminished within-group differences and exaggerated between-group
differences (optimal distinctiveness theory)
- People reduced to labels (“schizophrenic”) → loss of uniqueness
- Belief that people with MI are fundamentally similar → but people with the same
MI are fundamentally different (diagnosis ignores this)
- Neglect of environment: context rarely assessed or valued, more focus on problems,
not resources (but biomedical interpretations are limited)
- Negative bias: diagnosis and neglect of environment foster stigma and hopelessness
- Strengths, resilience, and protective factors are rarely assessed or taught
- Results in confirmation bias → reinforces belief that patients have deficits and
problems
- Supports the belief that the clinician’s job is to treat the illness, not the person’s
job to recover their life
- Deficit-only focus reinforces dependency and “engulfing roles” (lifelong patient
identity)
- The DSM = “the book of insults”
4. Treatment does not cure
The need to treat = the cause of psychiatry
Treatment involving the clinician doing something to the patient is the norm
- Psychiatric care assumes treatment = recovery / cure, but this promise fails
- Leads to blame when people don’t improve (“non-compliant,” “lacks insight”)
5
Week 1
Chapter 1: Personal Recovery and Mental Illness: A Guide for Mental Health Professionals -
Overview of the Book (Slade, 2009)
Examines how MH services need to change if goal is to promote personal recovery
Clinical recovery: symptom reduction / return to normal functioning
Personal recovery: deeply personal, unique process of changing attitudes, values, feelings,
goals, skills, and / or roles
- A way of living a satisfying, hopeful, and contributing life even within the limitations
caused by the illness
- Recovery involves the development of new meaning and purpose in one’s life as one
grows beyond the catastrophic effects of mental illness
Problem identified:
People using mental health services exist on a spectrum:
- Some benefit and return to normal functioning - current services work for them (clinical
recovery = personal recovery)
- Some improve partly, but recovery involves more than treatment - current services are
insufficient
- Some are harmed - services reinforce illness identity and dependence, creating a virtual
institution
→ Current insufficient or toxic systems must change to promote personal recovery
Aims of the book:
1. Convince: show why focusing on personal recovery is necessary
- Epistemological rationale: mental illness is best understood from a constructivist view
prioritising individual experience
- Constructivism: understanding mental illness through meanings, experiences,
and values of individuals
- Ethical rationale: professional “best interests” have sometimes caused harm, support
should align with the person’s own goals
- Effectiveness rationale: treatment benefits (especially medication) are overstated, a
broader approach is needed
- Empowerment rationale: traditional focus has subordinated the individual’s interests to
others, recovery restores power to the person
- Policy rationale: many national systems already instruct services to focus on personal
recovery
2. Crystallise: clarify what personal recovery means
- Personal Recovery Framework
- There are different types of knowledge: blending of group-level and individual-level
evidence needed
- Optimal balance: individual perspective + expert-by-experience perspective +
training, knowledge and personal views (blend individual and scientific
knowledge)
1
, 3. Catalyse: provide a response to the MH professional who is convinced about the values,
has crystallised beliefs and knowledge about personal recovery, and wants to know
where in practice to start
New goals and values:
- Goal shift: from treating illness (clinical recovery) to promoting well-being (personal
recovery)
- Values shift: services should follow individuals’ aspirations, not professional imperative
- Professionals should listen to and act on what the person says
- Professionals should be tentative: applying professional knowledge competently but
humbly to support people in their recovery journey
- Recognise that treating illness and promoting well-being involve different processes
and timelines
- Short-term focus (symptom relief) can harm long-term recovery (dependence, no hope)
- Balance needed between managing illness and building a meaningful life
- Incorporate new knowledge: lived experience and positive psychology (focus on
pleasure, engagement, meaning, achievement)
Personal Recovery framework
4 key recovery processes: hope, identity, meaning, personal responsibility
- Professionals’ tasks should align with supporting these processes
Core shifts proposed
- Change of goal: from clinical to personal recovery
- Value-based shift: from professional authority to person-centred values
- Integrate positive psychology into practice
- Focus on recovery-supporting tasks rather than illness control
Language and terminology
Terms for people vary across a spectrum from internal “brain illness” (too simplistic) to external,
“psychiatric survivor” → book uses mental illness for clarity
- Uses consumer, patient, client, service user, peer interchangeably depending on context
- Professionals, MH professionals and clinicians
Slade’s stance: clinical academic and psychologist perspective
- Mental illness is real but cannot be reduced to simple biological explanations
(unhelpfully simplistic)
- Book aims to translate consumer perspectives into professional language
- Acknowledges biases
- Seeks to promote services centred on well-being, justice, and person’s own priorities
Promoting personal recovery means transforming MH services - shifting from illness treatment
to well-being support, from professional dominance to person-centred values, and integrating
lived experience and positive psychology into all aspects of care
2
,Chapter 2: Personal Recovery and Mental Illness: A Guide for Mental Health Professionals -
The Nature of Mental Illness (Slade, 2009)
What is Mental Illness?
Central focus: subjective experience
- Psychiatry relies mainly on patients’ self-reports rather than objective tests
- No biological test can detect mental illness independently of awareness or experience
Mental illness: disorders without a proven physical cause (functional illnesses)
- Understanding mental illness starts with personal experience, not biology
3 Broad models of understanding mental illness
- Clinical models: dominant in services, focus on illness and treatment
- Disability models: see mental illness as a form of social disability
- Diversity models: see experiences as part of human variation, not pathology
1. Clinical Models
Frameworks developed by mental health professionals to diagnose and treat mental disorders
- Emphasise expert authority, intervention, and treatment
- Focus on what’s wrong inside the person, not the environment
- 3 main models of mental disorder: biomedical, biopsychosocial and cognitive
Biomedical Model:
2 assumptions: (neither universally true to mental illness)
1. Illness is caused by biological dysfunction
2. Removing the disease restores health
Based on Jaspers’ phenomenology: verstehen over erjkaren - clinicians use empathy to
understand patients but fit experiences into pre-set diagnostic forms
- Focus on universal forms of psychopathology (hallucination type), not personal meaning
Aim: obtain an objective, “scientific” description of symptoms
Biomedical model: listening is used to elicit phenomena of psychopathology
Critics (Bracken & Thomas, Johnstone):
- Reduces rich, contextual experiences to de-personalised “symptoms”
- Removes meaning and personal responsibility
- Encourages dependence on external “cures”
- Consequence: personal meaning and context ignored (meaning is the first casualty of
the biomedical model) → impoverished and decontextualized version of meaning
Biopsychosocial Model: recognises interaction between biological, psychological and social
factors
Recognises that interpersonal, contextual and societal factors impact on the interpretation,
onset, course and outcome of mental illness
- Built on the stress-vulnerability model: vulnerability interacts with environment
- In theory, holistic - in practice, still bio-dominant
- Empirical studies show that biological explanations dominate clinical notes and teaching
3
, - Often functions as a “biomedical model in disguise”: social and environment factors have
an impact on physical process, physical malfunction is the underlying cause
- The structure of the mental state examination influences the results obtained
- Diagnosis remains central, social and psychological factors are seen as “triggers”
rather than core causes
Lucy Johnstone’s distinction:
- Weak version - everything interacts, but explains nothing
- Strong version - biology still treated as primary cause
- Reasons for bio-dominance: easier to research biological variables, maintains
professional power and medical status
Example: schizophrenia
- Many risk factors identified - genetic, developmental, psychological, social
- Evidence on genetics inconsistent and inconclusive
- Overemphasis on “brain disease” narrative due to cultural and professional bias
- True understanding requires a balanced biopsychosocial approach, not bio-primacy
Most funding goes to biomedical model
Strengths of bio models: systemized, lead to action (guidance), patients benefit from
treatments based on these models
Problems with biomedical and biopsychosocial clinical models:
Typical assumptions:
- Clinician acts in the patient’s “best interests,” defines the problem, and prescribes
treatment
- Patient’s role is to comply
- Focus on symptoms, deficits, and pathology
- Goal: symptom reduction and “return to normal”
4 major mismatches between model and reality
1. Mental illness is not only caused by disturbed homeostasis
- Diagnoses in psychiatry are understandings, not explanations - they differ in everyone
- Explanations: reveal essence, can be ranked, closest approximation available
- Physical illnesses (meningitis) have clear causes (explanation), mental illnesses depend
on context and meaning (understanding) - “diagnosis is prognosis” true for physical
- Using “diagnosis = truth” is misleading - it’s a communication tool, not a revelation
Generative vs successionist causation (Pawson & Tilley):
- Physical illness = secessionist (fixed cause → effect)
- Mental illness = generative (connection between causally connected events, depends
on context and meaning)
Mental illness cannot be explained outside social, cultural, and temporal context
- Human psychology is embodied, encultured and temporal (not essentially biological)
The invariant use of a biomedical or biopsychosocial model is sometimes helpful, sometimes
insufficient, and sometimes toxic
- Generative model is more helpful in understanding MI
- A mental illness diagnosis should not be treated as if it is an explanation
4
, Professionals should offer tentative interpretations, not authoritative pronouncements
- “Your experience can be understood as depression” rather than “You have depression”
The DSM’s purpose is to facilitate communication among MH professionals, it is not a revealed
truth
2. Diagnosis does not reflect natural categories
There cannot be stable, invariant, psychological diagnostic categories
Diagnostic systems (DSM) are socially constructed, not objective: impact social understand
of human experience
- The categories created for DSM reorient our thinking about important social matters and
affect our social institutions
Categories have changed over time (“homosexuality” once listed): DSM I had had 112 mental
disorders, DSM II had 182, DSM III had 265, DSM IV had 374
Diagnoses expand due to professional and commercial interests - “colonisation of the human
condition”
Diagnosis can help some by providing structure but can stigmatise or hinder recovery for others
3. Assessment creates stigma
Clinical assessment should cover 4 dimensions:
- Dimension 1: deficiencies and undermining characteristics of the person
- Dimension 2: strengths and assets of the person
- Dimension 3: lacks and destructive factors in the environment
- Dimension 4: resources and opportunities in the environment
Assessments focus on deficits (Dimension 1) and ignore strengths or environment
3 resulting problems of this focus:
- Deindividuation: diminished within-group differences and exaggerated between-group
differences (optimal distinctiveness theory)
- People reduced to labels (“schizophrenic”) → loss of uniqueness
- Belief that people with MI are fundamentally similar → but people with the same
MI are fundamentally different (diagnosis ignores this)
- Neglect of environment: context rarely assessed or valued, more focus on problems,
not resources (but biomedical interpretations are limited)
- Negative bias: diagnosis and neglect of environment foster stigma and hopelessness
- Strengths, resilience, and protective factors are rarely assessed or taught
- Results in confirmation bias → reinforces belief that patients have deficits and
problems
- Supports the belief that the clinician’s job is to treat the illness, not the person’s
job to recover their life
- Deficit-only focus reinforces dependency and “engulfing roles” (lifelong patient
identity)
- The DSM = “the book of insults”
4. Treatment does not cure
The need to treat = the cause of psychiatry
Treatment involving the clinician doing something to the patient is the norm
- Psychiatric care assumes treatment = recovery / cure, but this promise fails
- Leads to blame when people don’t improve (“non-compliant,” “lacks insight”)
5
