There are many definitions of “recovery.” Clinical recovery is usually defined as symptom remission, return to work or education, distant contact with mental health services, and a sustained social support network (Liberman and Kopelowicz, 2002). Because clinicians tend to see much more of the disabled than of the recovered, a “clinician’s illusion” (Cohen and Cohen, 1984) arises – the illusion that recovery is rare. However, studies of long-term clinical recovery from schizophrenia published from the 1970s onwards revealed that clinical recovery is more common than previously understood, typically above 50% after 20 years.
In contrast to clinical recovery, the term “personal recovery” is often chosen to describe something with broader implications than dispelling clinicians’ illusions. Contributions to the recovery movement come from civil rights movements, the Consumer/Survivor/Ex-patient Movement, and consumerism (Davidson, 2008). From these perspectives, patients or clients are often disempowered. Their voices and preferences may have been unheard, unasked for, or overridden by health professionals carrying greater power in society and clinical relationships. In this paradigm, care is criticized as focusing unduly on symptom resolution or objective functional improvement. In relation to the things that matter to the patient or client, such a focus may miss the point. Symptom resolution, for instance, may be achieved at the cost of side effects such as drowsiness, weight gain, or sexual dysfunction, which may affect a client’s ability to participate in work or sustain critically important relationships. Patients or clients do not necessarily feel involved in decision-making or determining what is a priority in treatment. The kinds of interventions or service provisions that make a difference to an individual’s considered goals and aspirations may be quite different from what is commonly offered. Assisting the recovery process involves respect for clients and their autonomy.
From the USA, Anthony (1993, p. 13) provided an influential formulation of recovery as:
a deeply personal, unique process of changing one’s attitudes, values, feelings, goals, skills and roles. It is a way of living a satisfying, hopeful and contributing life even with 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.
Patricia Deegan (1996, pp. 96–7) brought a deeply personal, lived-experience perspective to understanding recovery, characterizing recovery as an approach to living life:
Recovery is a process, a way of life, an attitude, and a way of approaching the day’s challenges. It is not a perfectly linear process. At times our course is erratic and we falter, slide back, regroup and start again… The need is to meet the challenge of the disability and re-establish a new and valued sense of integrity and purpose within and beyond the limits of disability; the aspiration is to live, work and love in a community in which one makes a significant contribution.
Systematic analysis of international literature (Leamy et al., 2011) grouped issues for recovery-oriented practice under the categories of connectedness, hope, identity, meaning and purpose, and empowerment, using the acronym “CHIME.” The following material draws on this conceptual structure. In what follows, when we refer to recovery in the sense of personal recovery, the term will be capitalized: “Recovery”.
In addition to contributing the CHIME framework and emphasizing relationships that promote recovery, this influential British group have advocated the adoption of the following three key practices for clinical or other care settings (Slade et al., 2011).
Working practice 1: understanding values and treatment preferences
Care planning should be based on the person’s values and treatment preferences. Active intervention involves talking with individuals about their values and treatment preferences, and recording these values and treatment preferences in the clinical information system.
Working practice 2: assessing strengths
Care planning should be focused on amplifying a person’s strengths and ability to access community supports. To achieve this, individuals identify their strengths with staff, using the strengths-assessment worksheet, and these strengths are recorded on the clinical information system.
Working practice 3: supporting goal-striving
Care planning is oriented to personally valued goals and staff support active goal-striving. This involves identifying an individual’s valued goals, recording personally valued goals on the clinical information system, and supporting individuals in striving to reach their goals.
Moving towards a Recovery orientation involves a shift towards domains of practice more commonly and traditionally regarded as “nonclinical”. For many people embracing the Recovery journey, practical issues such as having a decent place to live and establishing a safe and secure base from which to take their Recovery journey forward may be their first priority. Fossey et al. (2012) suggest that access to educational and occupational opportunities in a range of supported or enabled environments are critical elements of a Recovery-focused system. From this perspective, a Recovery-oriented support system of interconnected service elements is needed. A Recovery-oriented service system requires good relationships between the service elements, all working with a common stance of respect and support of the wishes and the autonomy of the consumer (patient or client).
While Recovery is commonly suggested as best practice (Leamy et al., 2011), the role and functioning of parents with mental health problems have rarely been considered within a Recovery paradigm. In the USA, Nicholson (2010, p. 39) noted that “the links between parenting and mental illness recovery have only recently been suggested.” The addition of parenting support into routine service delivery in adult mental health services has the potential to greatly enhance Recovery-focused practice for those adults who are parents. To explore further the role that parenting and child-rearing responsibilities might play in Recovery, we examined several Recovery review articles (e.g., Bonney and Stickley, 2008; Leamy et al., 2011; Tew et al., 2011).
Across this literature, reference was commonly made to “people accessing mental health services,” “person,” “individual,” and “people with lived experience,” but it rarely (if ever) employed terms such as “children,” “parent,” or “parenting and recovery.” Terms commonly appearing were “carers” and “family,” and these were predominantly employed in relation to community participation, social inclusion, personal connectedness, and identity. Reference to family was usually described in terms of the family and the well parent providing care and support to the person (generally their child) living with a mental health condition. Parents living with mental illnesses and caring for others were rarely acknowledged.
The recovery literature was examined in relation to the CHIME framework for relevance to parenting and child rearing. This review is neither systematic nor exhaustive but attempts to demonstrate how each of the CHIME characteristics may apply, both positively and negatively, to parents and their Recovery journey.
Connectedness (see Leamy et al., 2011) has three core components: delivery or provision of services through forms of peer support, support from other members of the person’s community, and significant close relationships. Lee et al. (2001) defined connectedness as “an attribute of the self that reflects cognitions of enduring interpersonal closeness with the social world in toto” (p. 310). Others (e.g., Davidson, 2008) relate connectedness to the substantial literature of Recovery and social inclusion, where connections with others may include family members, professionals, community members, peers, and even animals (Davidson, 2008).
In a review of twenty-three qualitative studies of mothers with severe mental health problems, Dolman and colleagues (2013) found that connectedness was important for recovery in thirteen of the identified studies. Some studies highlighted low connectedness (termed “isolation”) whereas others highlighted good/strong connectedness for mothers with a supportive partner or other family member (Dolman et al., 2013). Stigma was related to connectedness for mothers in terms of feeling rejected or avoided, and being isolated as a result of their illness (Dolman et al., 2013).
Parenting connectedness and Recovery relate first and foremost to connections with parents’ children. Reports from those living with severe mental illnesses indicate that bonding with their children is a source of support during difficult times (Ackerson, 2003; Reupert and Maybery, 2009). Additionally, the parenting role may provide opportunities for meaningful interactions and activities with others in the community (Nicholson, 2010), such as with schools and teachers, other parents, and sports coaches. In a recent study of goal setting with parents with mental health problems, Maybery et al. (2015) found that 20% of parents’ goals were in relation to connectedness with others, including connections in and outside the family context.
Parenting connectedness provides opportunities for sharing milestones with children and adults through family events (such as birthdays), meeting other parents (school events) or other adults (children’s sports), and extended family relationships (grandparents). Family relationships and the links the family has to others can be important to individuals’ reintegration into home and community life following an acute episode of illness or hospitalization (Bradshaw et al., 2007). Connections developed as a result of parenting experiences (e.g., with school personnel), and the potential for a close bond between a parent and child may promote Recovery. While connections clearly aid Recovery, Campbell et al. (2012) showed that a high proportion of people with serious mental illness who are parents with dependent children are separated or single, suggesting that intimate relationships or connections may be limited for such parents. In addition, connections may be breached when the parent is ill and unable to actively parent, thereby jeopardizing relationships with children, or jeopardizing relationships with other adults, as a result of being isolated and stigmatized. These circumstances potentially affect the parent’s Recovery.
Hope and optimism about the future refer to one’s belief about the potential for good things to happen, including Recovery. Such events reflect or inspire motivation to change, are fueled by hope-inspiring relationships and positive thinking, and contribute to having dreams and aspirations. Hope-inspiring relationships may be critically important (Leamy et al., 2011). Hope is intimately associated with Recovery and involves confidence and expectation of a better future and a desire for personal conversion or transformation, including a desire for greater user involvement and collaboration with mental health services (Pitt et al., 2007).
Parenting is a role that affirms one’s belief in the future in the most simple, yet profound, ways. Nicholson (2010) found that children often give parents living with mental illnesses the strength and will to “keep going,” thereby promoting hope and fostering optimism. Similarly, Reupert and Maybery (2009) described the pride men felt in their role as father, the sense of meaning and purpose that came from fatherhood, and how being a parent motivated them to make positive changes in their lives for themselves and for their children. Children often serve as a vehicle of hope, representing the possibility of a better future if parents’ goals are attained, and supporting parents’ successful functioning in other role domains. For example, a father or mother may sustain employment, to provide adequately for their children on a day-to-day basis and to promote the likelihood that they will have a better future (Nicholson, 2014).
Parents often talk about wanting to “be better” and “do better” on behalf of their children. They may be motivated to seek help or to take better care of themselves to promote their children’s well-being or to avoid making the same mistakes their own parents made (Nicholson et al., 1998). The hope for the future conveyed by having children underlies the notion that positive changes are possible.
Identity refers to defining oneself in various roles (being a parent, an employee, and so on), and involves a process of building, refining, and repairing a positive sense of self, and overcoming self-stigma for those individuals who perceive themselves to have failed in some way (Leamy et al., 2011). For parents with mental illnesses, the defining characteristic of identity is feeling good about oneself as a parent who has a mental health concern. Davies and Allen (2007, p. 374) suggest that “women who are mothers and also users of mental health services face particular challenges of identity management because of the inherent tension between the societal ideals around the “good mother” and social norms associated with mental illness.” Mental illness, particularly when there are periods of hospitalization, can severely impair people’s confidence in their ability to be “good” parents. Further stressing the importance of the parent identity, Vallido and colleagues (2010, p. 1435) found that “Women disrupted in their mothering by illness view themselves as a mother first and a patient second.” Similarly, Dolman et al. (2013) found that mothers with a mental illness have two identities; one as a mother and a parallel identity as a person with a mental illness.
Notwithstanding the importance of the parent identity, many parents have found themselves unsupported by healthcare professionals and their parenting role or identity not acknowledged (Vallido et al., 2010). Others may view them as bad parents because of their illness (Dolman et al., 2013). Parents want healthcare professionals to acknowledge their identity as mothers along with the challenges they may experience in parenting, and to provide them with appropriate support. In particular, they want professionals to help them in “reconciling illness with mothering, and [obtaining] information and guidance on supporting their children” (Vallido et al., 2010, p. 1444). The parenting identity can also change for parents with a mental illness when they are ill and their children assume a caring role (Dolman et al., 2013), or when other family members step in to look after children and manage daily routines. This potentially fluid nature of caring and the parenting role needs to be discussed with all family members, including children.