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A Wellness Model of Recovery-Remission

Firmly establishing wellness models in mental health requires nothing less than a reformation of language, power structure, definition, and perspective throughout the mental healthcare community and beyond. Wellness must become the central focus of mental health because the disease model has provided grossly insufficient results. Rather than obsessing on disease and deficits, wellness models focus on the character strengths and virtues that generate motivation and persistence/perseverance towards recovery-remission. Implementing an institution/doctor-client knowledge exchange will help address the DSM’s falling reliability statistics and difficulty identifying etiological risk factors. Psychological science is there, but it needs positive implementation through program integration, positive evaluation, transparency, and information management. Understanding and communication must supersede etiology and misdiagnosis. This paper does not endorse a total dissolution of medical model approaches, but a review of their efficacy and the psychological effectiveness of their pathographic dominance is prioritized.

1.0. Introduction

In 2004, the World Health Organization (WHO, 2004) began promoting the advantages of a wellness perspective, declaring health, “a state of complete physical, mental and social well-being and not merely the absence of disease or infirmity” (Slade, 2010, p. 1). The World Psychiatric Association aligned with the wellness perspective, submitting that “the promotion of well-being is among the goals of the mental health system” (Schrank et al., 2014, p. 98).

A comprehensive wellness model has become a central focus of international policy (Slade, 2010). As clinical psychologist Kinderman (2014) writes, “we need wholesale and radical change, not only in how we understand mental health problems, but also in how we design and commission mental health services” (p. 1). This radical change should not deestablish traditional approaches. However, a full review of their efficacy and repudiation of the one-size-fits-all stance within the mental health community is warranted. Fundamentals like language, perspective, and diagnosis demand drastic adjustments.

Decades of pathographic focus in psychological research and studies, negative diagnostic attributions, stereotyping and stigma, public and institution resistance, the doctor-client power relationship, and the physiological aversion to change factor in the resistance to the wellness paradigm.

2.0. Language and Perspective

Language generates and supports perspective, and linguists agree that the relationship between language and power is mutual (Ng & Deng, 2017). Language influences thought and action. The State Self-Esteem Scale (SSES) (McFarland & Ross, 1982)offers 12 words used to measure explicit (conscious) self-esteem; the negative five are inadequate, incompetent, stupid, worthless, and shameful. Judging by public opinion, media representation, and mental health stereotype and stigma, these words frame the prevailing impression of a person with a mental illness. (DeMare, 2016; Pinfold et al., 2005; Pryor et al., 2009). Terms like incapacity, deceit, unempathetic, manipulative, and irresponsible describe DSM-5 criteria for personality disorders. The argument is not that these descriptions are invalid; they are overwhelmingly negative and perceptually hostile. The conclusions of the Hulme et al. (2012) study examining the impact of positive and negative self-imagery seem apparent. “Activation of a negative self-representation should be associated with a more negative self-view than activation of a more positive self-representation” (p. 16).

Institutions, psychiatrists, psychologists, and other mental health experts maintain a dominant relationship with clients by subscribing to the linguistic power domination of a faulty, pathographic, diagnostic manual. “Language reveals power, reflects power, maintains existing dominance, unites and divides . . . and creates influence.” (Ng & Deng, 2017, p. 15). Not unlike positive psychology, which recognized that strength and virtue could not function as a holism without their negative collaborators, transitioning from the disease model to wellness models requires constructing a positive and encouraging language, not to replace, but to balance current mental health language. The changes sought will help create a greater group and positive social identity of the mentally ill. 

It is time for mental health institutions, practitioners, and researchers to accept they do not know more than their clients; they know different things that can generate a functional outcome in combination with client knowledge and awareness. In the words of a clinical psychologist, understanding must take precedence over etiology. 

We must move away from the disease model, which assumes that emotional distress is merely symptomatic of biological illness, and instead embrace a model of mental health and well-being that recognizes our essential and shared humanity. Our mental health is largely dependent on our understanding of the world and our thoughts about ourselves, other people, the future and the world. (Kinderman, 2014, p. 3)

A recent article in Scientific American speculates that “mental illnesses are so common that almost everyone will develop at least one diagnosable mental disorder at some point in their life” (Reuben & Schaefer, 2017). Changing negative and hostile language to embrace a positive dialogue of encouragement and appreciation will open the floodgates to new perspectives. Realizing that mental illness is not uncommon, but a natural part of human development will help generate social accommodation. Recognizing that mental health disorders are illnesses like any other and that clients are not accountable for their condition will go far in revisioning public opinion that the mentally ill are weak and their disorder a reflection of behavior. Emphasizing the character strengths and virtues of the disordered will modify the public perspective of the unpredictable and dangerous mental person unable to fend for itself. Realizing its proximity and mutual susceptibility will impact the intrinsic fear and disgust of mental illness, and the desire to distance and ostracize. Accepting its social pervasiveness will alleviate the prejudice, ignorance, and discrimination attached to mental illness (Khesht-Masjedi et al., 2017; Pescosolido, 2013; Pinfold et al., 2005; Wood & Irons, 2017).

A more favorable reception of mental illness would positively affect a client’s self-beliefs and image, leading to more disclosure, recovery-remission, and discussion. The self-denigrating aspects of shame would dissipate; mental health stigma would become less threatening. The concentration on character strengths and virtues, propagated by humanism, PP2.0, and other wellness-focused alliances, would encourage client accountability and foster self-reliance, leading to a confident and energized social identity.

Transitioning from the disease model’s pathographic language to the optimistic and encouraging language of wellness models is the responsibility of everyone in the mental health community―its institutions, associations, practitioners, researchers, media, and clients.

3.0. Redefining ‘Mental Illness’

One only needs the American Psychological Association’s (APA, 2020) definition of neurosis to comprehend the mental health community’s pathographic focus. The 90-word overview contains the following words: distressing, irrational, obsessive, compulsive, dissociative, depressive, exaggerated, unconscious, conflicts, anxiety, disorders. The 3rd  Diagnostic and Statistical Manual of Mental Disorders (DSM-3) abandoned the word ‘neurosis’ in 1980, but it remains the go-to term in the mental health community. Its etymology is the Greek neuron ‘nerve’ and the modern Latin osis ‘abnormal condition.’ Coined by a Scottish physician in 1776, neurosis was then defined as functional derangement arising from disorders of the nervous system. 

U.S. government agencies define mental illness as a “diagnosable mental, behavioral, or emotional disorder of sufficient duration to meet diagnostic criteria” that can “result in functional impairment which substantially interferes with or limits one or more major life activities” (Salzer et al., 2018, p. 3; SAMSHA, 2017). This ‘defective’ emphasis has been the overriding psychiatric perspective for over a century. By the 1952 publication of DSM-1, the focus had drifted from pathology (the science of the causes and effects of diseases) to pathography (the delineation of a person’s psychological disorders, categorizing them to facilitate diagnosis). ‘Pathos’ is the Greek word for ‘suffering’ and the root of pathetic, and ‘graphy’ is its biographic rendering. Pathography is the history of an individual’s suffering, aka, a morbid biography. Pathography focuses “on a deficit, disease model of human behaviour,” whereas the wellness model focuses“ on positive aspects of human functioning” (Mayer & May, 2019, p. 159).

Realistically, most terms for mental illness cannot be eliminated from the culture. Unfortunately, the negative perspectives and implications of the term and its derivatives promulgate perceptions of incompetence, ineptitude, and undesirability. It is the dominant source of stigma, shame, and self-denigration.

4.0. Pathographic Consequences.

Studies and research portray the mental healthcare community drowning in pessimism (Henderson et al., 2014; Khesht-Masjedi et al., 2017; Pryor et al., 2009). “There is evidence to indicate the problem may be endemic in the medical health community” (Gray, 2002, p. 3), and universally systematic (Knaak et al., 2017).

Many disordered persons avoid treatment, reject diagnosis, or refuse to disclose their condition (Stangl et al., 2019). The term stigma-avoidance defines those who fear, justifiably, that public disclosure would stigmatize and discredit them. Statistics from the National Bureau of Economic Research “find that survey respondents under-report mental health conditions 36% of the time when asked about diagnosis” (Bharadwaj et al., 2017, p. 3).  

Statistics evidence a significantly low percentage of the disordered in recovery-remission. A recent study by Salzer et al. (2018) reveals that only one-third of disordered persons were in recovery-remission in 2017. Less than 6% of those with social anxiety disorder even attempt recovery in the first year of diagnosis (Shelton, 2018). Recovery-remission is the general term for those who have been in remission for more than a year. Individual who commits and surmount the hurdles to recovery-remission are in the minority. 

4.1. Mental Health Stigma

Society and culture shame people who disclose a disorder; 90% of those who do disclose are socially stigmatized, putting their livelihoods, relationships, housing, and quality of life in jeopardy (Huggett et al., 2018; Pinfold et al., 2005; Sowislo et al., 2016; Wood & Irons, 2017). Mental health stigma is the hostile expression of the abject undesirability of the disordered. Stigmatization is deliberate, proactive, and distinguishable by pathographic overtones intended to brand and isolate disordered persons (Pryor et al., 2009). Stigma is generated by prejudice, ignorance, and discrimination, (Khesht-Masjedi et al., 2017; Pescosolido, 2013; Pinfold et al., 2005; Wood & Irons, 2017), expressed by its three categories:

  • Tribal stigma devalues.
  • Moral character stigma implies amorality and weakness.
  • Abominations of the body stigma refers to physical deformity or disease (Pryor et al., 2009).

Mental health stigma can elicit unfathomable shame and currently contributes to a $16.3 trillion worldwide economic output loss (Trautmann et al., 2016)

4.2. Public Opinion 

Although recognition, attributions, and service use may reflect prejudice associated with mental illness, the heart of stigma lies in social acceptance” (Pescosolido, 2013, p.8). The image of the dangerous, unpredictable mentally ill person is widely endorsed by the public (Corrigan & Watson, 2002; Pinfold et al., 2005). Stuart and Arboleda-Flórez (2012) looked at two surveys (1990/2006) on public perceptions of schizophrenia, major depression, and alcohol. 54% to 60% of respondents believed persons with schizophrenia were violent, 33% thought depression elicited the most violence, and 66% believed alcohol dependency posed the most risk. “Between 80-100 percent of respondents . . . favoured involuntary hospitalization for that disorder when they thought that violence was an issue” (p. 7). 

4.3. Client Self-Image

Perceptions of moral weakness and aberrant behavior, and the imputation of undesirability generated by history, public opinion, and stigma negatively impact a disordered person’s self-beliefs and image. A 2008 review of literature found that 25% to 50% of family members “attempt to hide their relationship to avoid bringing shame to the family” (Stuart and Arboleta-Flórez, 2012, p. 6). Perceptions of incompetence and inability are reinforced by the institution/doctor-patient power relationship which values DSM etiology over the client. “The difficulties of living with psychiatric distress are magnified by the experience of rejection” (Gray,  2002, p. 1). 

4.4. Media Misrepresentation 

From Psycho to today’s horror franchises, disordered persons are stereotyped as “overly hysterical, unpredictable, and dangerous” schizophrenics (DeMare, 2016, p. 2). A 2011 comparative study revealed that nearly half of U.S. stories on mental illness mention or allude to violence (Pescosolido, 2013). Analysis of film, television, and tabloid headlines identify the three common misconceptions of mental illness: “people with mental illness are homicidal maniacs who need to be feared; they have childlike perceptions of the world that should be marveled; or they are rebellious, free spirits” (Corrigan, 2006, p. 50). Media coverage promotes images that negatively impact the disordered person’s self-beliefs and image.

4.5. Misdiagnoses

DSM diagnostic criteria change dramatically from one edition to the next, while the American Psychiatric Association supports its credibility. Lynam and Vachon (2012) cite therapists’ concern that criteria are “added, removed, and rewritten, without evidence that the new approach is better than the prior one” (p. 483).

The Social Anxiety Institute (Richards, 2014) reports, among patients with generalized anxiety, an estimated 8.2% had the condition, but just 0.5% were correctly diagnosed. A recent Canadian study by Chapdelaine et al. (2018) reported, of 289 participants in 67 clinics meeting DSM-4 criteria for social anxiety disorder, 76.4% were improperly diagnosed. In comparing required symptoms for a diagnosis of narcissistic personality disorder, Lynam and Vachon (2012) point out that DSM-4 listed eight; DSM-5, two. Revisions, substitutions, and contradictions between DSM’s are never universally accepted. Researchers cite “substantial discrepancies and variation in definition, epidemiology, assessment, and treatment” (Nagata et al., 2015, p. 724).

Adding to misdiagnosis is the prevalence of disorder comorbidity, which is especially concerning if the first diagnosis is inaccurate. The Anxiety and Depression Association of America (ADAA, 2019) reports many disorders closely related to social anxiety, including major depression, panic disorder, alcohol abuse, PTSD (Koyuncu et al., 2019; Lyliard, 2001), avoidant personality disorder, generalized anxiety disorder, substance abuse, eating disorders (Cuncic, 2018; Koyuncu et al., 2019), schizophrenia (Cuncic, 2018; Vrbova et al., 2017), ADHD, and agoraphobia (Koyuncu et al., 2019).

Anxiety and depression are commonly comorbid. “Some estimates show that 60% of those with anxiety will also have symptoms of depression, and the numbers are similar for those with depression also experiencing anxiety” (Salcedo, 2018, p. 1). Traits and characteristics within each of the three clusters of personality disorders are uncomfortably similar. Dependent personality has characteristics and symptoms mirroring social anxiety, and avoidant and histrionic personality disorders (DPD, 2007). The lack of definitive diagnostic structure can only lead to “worse treatment outcomes” (Koyuncu et al., 2019, p. 2).

Thomas Insel (2013), director of the National Institute of Mental Health, has been “re-orienting its research away from DSM categories” (p. 2), declaring that traditional psychiatric diagnoses have outlived their usefulness (Kinderman, 2014).  NIMH is attempting to transform diagnosis based on the emerging research data, and not on the current symptom-based categories. “Patients with mental disorders deserve better” (Insel, 2013, p. 2). However, this paper balks at throwing out the baby with the bathwater, positing that the current diagnostic system could be utilized as a part of a more thorough analysis focusing on the character strengths that generate motivation and persistence/perseverance towards recovery-remission. 

Etiology and diagnosis drive the disease model. Which disorder do people find most repulsive, and which poses the most threat? What behaviors contribute to the disorder? How progressive is the disorder, and how effective are treatments (Corrigan, 2006)? It is essential to recognize how these attributions affect public perception, treatment options, and client self-belief and image. Imagine being treated for the wrong disorder. Not only does it defeat the purpose of treatment, but it is also potentially dangerous. Firsthand, the client knows how the disorder impacts their emotional wellbeing and quality of life far better than the clinician, whose relationship is one of power rather than communication. A client armed with the knowledge of traits, characteristics, and symptomatology and their impact would have a far better probability of appropriate diagnosis and treatment. If not, the damage could be extensive.

5.0. A Wellness Model: A Dual Approach

A program of recovery cannot be entertained if the problem is misunderstood or misdiagnosed. The over-commitment to diagnosis and under-commitment to communication suggests a lack of motivation or aptitude for mental health practitioners to develop individual-based solutions. As has been statistically determined, the DSM’s disease focus can impede even the most knowledgeable and caring clinician from correctly diagnosing a disorder. The rampant misdiagnoses are as much the institution/doctor-client power relationship’s fault as it is the substantial discrepancies and variations of psychological disorders. This lacuna of accurate evaluation indicates that a dual approach of recovery for mental illness must include better methods to accurately determine both problem and solution. 

5.1. Evaluating the Problem

Programs must be developed to compensate for the mental health community’s disease mentality by shoring up the lacuna of individual characteristics and traits that emanate from personal awareness, introspection, history, beliefs, and statuses. While this paper disagrees with Kinderman’s (2014) assertion that the origins of distress are primarily social, it finds agreement that services might be best based on an individual’s current social condition.  Many established evaluative tests can be utilized, not as a determinant of faults and weaknesses, but of strengths and potentials. People and human psychology must be central to the wellness paradigm. The psychological science is there, but it needs to be implemented through program integration, knowledge exchange, positive evaluation, transparency, and information management. Empathy and communication must supersede etiology and diagnosis.

5.2. Solutions

Personal recovery is an individual process. Just as there is no one right way to do or experience recovery, so also what helps us at one time in our life may not help us at another (Perkins & Repper, 2003). The insularity of one-size-fits-all approaches are inadequate to address the complexity of the individual.

Let us use the example of cognitive-behavioral therapy. Almost 90 percent of the approaches to recovery involves cognitive-behavioral treatments. However, they are far less effective as a singular approach than in concert with others. Critical studies downplay CBT’s effectiveness (David et al., 2018;Kashdan et al., 2011), arguing it fares no better than non-CBT programs. Recent studies claim its effectiveness has deteriorated since its introduction (Johnsen & Friborg, 2015), concluding it is no more successful than mindfulness-based therapy for depression and anxiety (Lyford, 2017).

Despite these criticisms, the program of thought and behavior modification pioneered by Beck in the 1960s is still useful in modifying the irrational thoughts and behaviors that sustain a disorder when used in concert with other approaches.

The wellness model’s chief propagator has been positive psychology, which originated with Maslow’s (1943) seminal text on humanism and was legitimated by Seligman as American Psychological Association president in 1998. The study and research of the character strengths that generate the motivation and persistence/perseverance of a mentally ill individual in recovery-remission are of enormous benefit to psychology and individual mental health.

Positive psychology has its critics, too; it is still in its formative stage. Positive psychology focuses on virtues and strengths that help individuals transform and flourish (Mayer & May, 2019). Until recently, the focus on optimal functioning’s positive aspects ignored the individual’s holism by neglecting their negative aspects. The emergence of PP2.0 rectified the lacuna. Positive psychology now emphasizes the positive while managing and processing the negative to increase wellbeing. Although positive psychology works best in conjunction with other programs, its mental health interventions have proved successful in mitigating the symptoms of depression, anxiety, and other disorders. “Growing research suggests that a positive psychological outlook not only improves ‘life outcomes” but enhances health directly” (Easterbrook, 2001, p. 23). In their study of positive psychology interventions, Schotanus-Dijkstra et al. (2018) found PPIs showed “significant improvements in mental wellbeing (from non-flourishing to flourishing mental health) while also decreasing both anxiety and depressive symptom severity” (p. 7). Echoing that, Sin and Lyubomirsky’s (2009) meta-analysis of 51 studies with 4,266 individuals, found PPIs “significantly enhance wellbeing . . . and decrease depressive symptoms (p. 467).

There are a plethora of approaches to recovery. Textbook author, Farreras (2020) cites 400 different schools of psychotherapy. “Negligible differences have been found among all these approaches; however, their efficacy in treating mental illness is due to factors shared among all of the approaches” (p. 6).  Recovery programs must be fluid. Addressing the complexity of the individual personality demands integrating multiple traditional and non-traditional approaches, developed through client trust, cultural assimilation, and therapeutic innovation. Any analysis must consider environment, hermeneutics, history, and autobiography in conjunction with the individual’s wants, needs, and aspirations. Absent that, the holistic individual is undervalued. A working platform showing encouraging results for social anxiety disorder is an integration of positive psychology’s optimum human functioning with CBT’s behavior modification, neuroscience’s network restructuring, and other personalized supported and non-traditional approaches (Mullen, 2018).

The overriding reality is that if the problem cannot be correctly evaluated, there is little chance of creating a workable treatment. Replacing or repairing defects is fruitless without knowing what those defects are and their functions. Before a football team faces its opponent, they watch hours of film, review stats, and practice. The logical thing to do before a written driving test is to examine the manual. If an actor wishes to give an excellent performance, it is prudent to learn the character’s lines before getting on stage. For disordered persons to recover, they need to recognize the opposition. The disorder is the enemy; it is unhealthy. A client-in-denial is the worst enemy. These forces will prevail until and unless the client recognizes, accepts, and confronts them. 

Recovery-remission is a psychological construct. The self-revelation the disordered are not responsible for their disorder sets the foundation for recovery. The awareness they are the primary agents of change begins the construct, but negative reinforcement provides tools and materials that reflect the builder’s perceptions of incompetence and inability. The focus of wellness models and, by extension, positive psychology, and other optimistic approaches, is on virtues and strengths “not only to endure and survive, but also to flourish” (Mayer & May, 2019, p. 160), which might be a mantra for the recovery-remission community. Schrank et al. (2014) describe recovery as people “(re-) engaging in their life on the basis of their own goals and strengths, and finding meaning and purpose through constructing and reclaiming a valued identity and valued social roles” (p. 98). This paper suggests that effective and enduring recovery grounds itself not only on the client’s awareness of the opposition, and implementation of their character strengths and virtues but on their contribution to society, which is a natural extension of recovery-remission.

6.0. Summarization

Establishing wellness models in mental health requires nothing less than a reformation of language, power structure, diagnoses, and perspective throughout the mental healthcare community. 

Mental health experts must abandon erratically assigning disorders to single components of the human makeup. A disorder is a correctable inability to function in a reasonable, healthy mannerfacilitated by the mind, body, spirit, and emotions working simultaneously and collaboratively.

Addressing decades of pathographic focus in psychological research and studies is challenging. The transition is faced a surplus of negativity including diagnostic attributions, stereotyping and stigma, public and mental health industry resistance, linguist power domination, and the client’s self-beliefs and image.

Statistics show that a faulty and pathographic diagnosis system is reflected in the limited recovery-remission claims from mental illness. One-size-fits-all programs like cognitive-behavioral therapy, widely endorsed by the American Psychiatric Association, are insufficient by their exclusion. Recovery programs must be fluid, integrating multiple traditional and non-traditional approaches developed through client trust, cultural assimilation, and therapeutic innovation. Any analysis must consider environment, hermeneutics, history, and autobiography in conjunction with the client’s wants, beliefs, and aspirations. Otherwise, the holistic individual is not valued, and the treatment inadequate.

This paper does not endorse a total dissolution of medical model approaches, but a review of their efficacy and the psychological effectiveness of their pathographic dominance must be prioritized. This journey from a deficit and disease mentality to optimism and wellness is not a revolution but a timely and critical reformation.

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