A short answer to your question is yes "recovery" is more than possible. However the term 'recovery' is somewhat problematic. The term recovery suggests a return to a former state of health. Whereas my experience as a survivor of mental health services and now as a psychotherapist who works within the psychiatric system within a psychiatric hospital is that people who move through and beyond their states of acute distress achieve new states of awareness, functioning and being based on profound growth.

I am fortunate to have worked with many people who have achieved freedom away from psychiatric services and consider themselves as experiencing 'breakthrough' from their former state of 'breakdown'.

I would also add that while there are helpful aspects of treatment that people receive while in hospital, generally people recover despite of their medical psychiatric model.

I would be happy to collaborate in greater detail.

Your question seems to suggest that stigma against mental health patients is still alive in the UK. Correct? If so, I suspect that the media may be the culprit in the promotion of the "dangerousness" of mental health. As such, a paradigm shift may be needed for both the public and mental health care providers to accept the possibility of recovery. I personally think that recovery is not only possible, but is actually happening. Some recovery may be gradual; others full.

Recovery is definately possible. I certainly agree that stigma is a disticnt barrier. The media is the biggest social influencer in shapng individual and collective ideas about mental health. Anti-stigma campaigns have focused to removing stigma but showed little or no change in atittudes. The RETHINK campaign had a vested interest - payment by results. Could the meda infleunce the philosphgy of recoveery ina national camapaign? Perhaps based around the work of Marius Rom?

Is payment by results, targets and audits a facilitator or barrier to recoery?

Is it a case that service providers say recovery on the tin and you get custard! There is a quagmire of policy reform anbd rand re-disorgansiation. Is policy a barrier or faclitator? Is policy a facilitator? Steve, how did people achieve a life beyond services? This is a part of my cosnidrations. For me, arguably, we have moved the walls of the aslyum to the community - institutionalisation in the community. For some this is deinstutionalisation, transintutionalisation and the advent of mini-asylums. How do people move beyond the invidible walls from a position of powerlessness to being empowered? In a sense, how do they continue 'in-recovery' outside services?

Regards

Andy

You may be interested in our papers: Yes it is possible but there are a lot of prejudices to conquer.

Hi Beatrice. Thank You.

Discharge, even defining discharge, is a complex issue of which stigma is a influential factor. If we consider Recovery and the impact of stigma the results of the studies seem show that the out of sight out of mind and not in my back yard are still an issue.

It seems that the results are positive and there has been a shift in attitudes in Sweden. Have Sweden engaged in public campaigns to inform the public about mental illness? In the UK we have the Time to Change Campaign that has resulted in a small positive change in attitudes. Although, the campaign has received criticism. It seems that Prejudice and Stigma are still live and well. Unconscious Bias or Prejudice are very influential. The studies you shared seem to support that attitudes have changed over time. They also seem to reflect the early work on stigma by Bruce Link, Patrick Corrigan and others especially the themes highlighted ‘Intention to Interact, Open-minded and Pro-Integration , Fearful and Avoidant , Community Mental Health Ideology’. These themes/factors are interesting. Are they taken from a Recovery Orientation? Are the campaigns co-produced?

The impact of stigma is a distinct issue and may have a direct or indirect impact. For example, the influence of the media and public perception of violence. It's interesting that the dynamics of stigma vary across age, gender and, even, marital status. Its seems the earlier works by Link, Corrigan etc, remain evident. For example, Corrgan and Penn (1999) (a) attempts to suppress stereotypes through protest can result in a rebound effect; (b) education programs may be limited because many stereotypes are resilient to change; and (c) contact is enhanced by a variety of factors, including equal status, cooperative interaction, and institutional support.

What do and others people think?

Do we think that discharge is a word without a definition?

It seems that it has not been defined and is simply a word or byproduct steeped in psychiatry's history - de-institutionalisation and wholesale discharge of patients from the asylums. Where are we with trans-institutionalisation, the move to mini-asylums, and for some simply re-framing the asylums walls in a community setting?

Discharge also seems to be under professional ownership but is often just a term we voice. Are we scared to discuss discharge because of psychiatry's history. Is professional defensiveness a issue?

Best Wishes

Andy

Does anyone know of any studies that consider discharge from Secondary Mental Health Services CMHTs such as Recovery or Social Inclusion Teams, CRHTs, EIP? Or, any research related to stakeholder perspectives such as service users, professionals including GP's, Psychiatrists or community workers?

It seems that discharge from Secondary Mental Health Teams such as Recovery and Social Inclusion is not studied. There is some evidence that discharge is part of a process of discharge from inpatients units but once admitted or referred into a SMHS service users are in the new asylums/community asylums not just residential institutions [supported living in care homes].

The clock towers may have disappeared, the old asylums gone but the sway of socio-political discourse including stigma - not in my back yard or on my door step, the running of services by services, the lack of integration - working in silo's, and, a hijacking recovery as service defined recovery, clinical recovery and recovery from challenges the idea that the asylums no longer exist.

The picture appears to be discharge from hospital involves referral to SMHS's and other options are not viable. This leads to increased caseloads for SMHS's, increased pressure on services, individual's abandoned - left out in the cold - whilst services seek to fulfill audits, targets and service viability to prove effectiveness. The over reliance on the medical model - medication first, risk minimisation, the professional knows best and service first - means the asylum walls, the ticking clock still exist.

Let me know what you think.

It appears that discharge has a historical context which has taken psychiatry per se down a cul de sac. Psychiatry is currently paying the price of history but are we in danger of repeating the past? Asylums had a place at a particular time. In the 1800's people were regularly discharged with many not returning. However, with the advent of mental illness as incurable the asylums expanded and discharge rates dropped dramatically. Contemporaneously, Recovery has started to gain traction but only, and wrongly, as defined by the medical model. For example, clinical recovery, service defined recovery. In the 1900's the asylums promoted engagement, inclusion albeit in a dichotomy with a largely dehumanising, societal exclusion and reliance on medication. Work programs in the asylum seem to shift from a recovery emphasis to financial incentives. It is arguable that the advent of the incurable, medication and money set the path around discharge. Today we still have an over reliance on medication underpinned by incurable, payment by results and austere times underpinned by being in work pays. It appears that the emphasis and nature of the asylums still exist today. Holding on to the mistakes of the past seems to be a factor in discharge from services - for example, having no service involvement - is not possible?

1) I think you would be wise (or helpful) to define your terms first.

Can you tell those to whom you pose this question: what do YOU mean by "Discharge"? Resolved, vanished, remission, not active, not requiring treatment? Or are you asking if certain diagnoses are lifetime? Are you asking the advisability of NOT maintaining a tag of a certain psych diagnosis knowledge lifelong, of a lifetime risk? This is an extremely broad question and I apologize if i have missed a follow up clarification. It is also helpful to state your goal of inquiry such as "I hope to learn if people benefit from reporting their past psych diagnoses." or , I don't know... "Do lifetime mental diagnoses accumulate and require XYZ?"

In regards to what "Discharge" might mean and why this itself feels vague:

A) IF you are asking Might a discharge be considered as a diagnosis? And can some diagnoses become less valid or inactive to the point they no longer need care? Or even to the point these are not vital? Yes, a diagnosis might recede, relent, or be seen as no longer active, as one might see in achieving remission for some conditions. That sticky phrase intrudes however: it depends. One might have been addicted to smoking for instance but--once a non smoker for ten years would you still call the person a smoker? How vigorously would you trail that person, obstenobly to cocoon them against nicotine and maybe other risk? Suppose they might be triggered in a bar? And so on. What then for a Vietnam Vet who used heroin in Vietnam but none for 45 years? Still a nicotine or drug addict or in remission or, well, what??

B) Are you asking if discharges are premature or shortsighted? C) Or maybe--how the heck do we come to know the rate of relapse in various conditions, it is so complex! MDD (Major Depressive Disorder) is highly recurrent but teasing out age of first event, gender, trigger, setting, to arrive that those overall statistics of: 50% of those recovering from a 1st episode can be expected to have 1 or more episodes in their lifetime. Those w/ 2 episodes have a higher odds-- 80% chance of recurrence.

B 1) Do those with mood disorders, once feeling well, have the right or freedom to keep themselves discharged or undisclosed? is THAT your question? In which case you may wish to learn if the terrible struggles of :

C) Diagnostic Overshadowing and the harm that befalls those who walk around with psych diagnoses tattooed on their chart. Are you concerned no one is discharged and carries these terms? or that no one should be discharged?

This is not meant to be critical. When you ask a question it is delightful to discover you are pushed along by others' puzzlement. This in turn encourages you to delve deeper into exactly where you want to go, what has caught your attention. Each of these answers has grabbed hold of possible perceptions of what you may be asking but the secret will next rest with you. It may feel intimidating to have your query yanked apart so aggressively unless you have been at this a while. No ill is meant to you but simply a team effort to work with you, to think aloud. It will be interesting to see where and how you chose and define your question as you move along. Thank you for giving us all something to ponder, even if we each wandered in and out with different questions of our own! -Marybeth Lambe MD FAAFP

Hi Marybeth

Thank you for your contribution. Nothing wrong with some passion and your questions simply highlight the complexity of the issues around discharge. There is much puzzlement not academically but when you ask “is discharge is possible?” the response is puzzled, befuddled and complex. However, I have tried to answer some of the issues and questions you raise. Hopefully, they help explain the puzzlement? And, may provide readers with other issues to ponder.

Discharge is simply defined as “end of service”. Discharge has long been a contentious issue in psychiatry but is rarely explored. From a historical perspective, the asylums in the 1800’s – or at least to the mid 1800’s – were focused to Recovery. They divided mental health into a disease of the brain and a disease of the mind. Asylums of the era were focused to rehabilitation of the mind. Individuals were discharged when they were rehabilitated and in recovery. When defined as rehabilitated they were simply discharged back into the community.

The advent of the term ‘incurable’ led us to the era of the Victorian asylums and an exponential increase in populations from 10 000 to 100 000. The mass deinstitutionalisation in the 1950’s and decades to follow was subservient to the state with financial drivers to pejorative reason for the advent of community care. Closing the asylums, the walls of the asylum and water towers were said to be a thing of the past. However, we can argue they still exist in the history community care. Over the past 150 years discharge has become the sole requisite and ownership of the state.

It is extremely vague and little has been explored around discharge, what discharge means and what discharge may look like. It is the ubiquitous and quixotic issue of contemporary mental health care. There is little or no evidence about discharge from secondary mental health services. Some evidence from early intervention in psychosis suggest that discharge is possible but may be reflecting the culture around discharge in the early 1800’s of the rehabilitated disease of the mind. And, may be in danger of ‘end of service’ resulting in discharge to the community.

Today we recognise carers as a fundamental aspect of social capita, social recovery or support network. The 1960’s saw research that blamed carers, namely mothers, for readmission and saw the advent of residential care which became the mini-asylums and saw the issue of trans-institutionalisation identified in the 1980’s and 1990’s. Over a century of incurable, once a patient always a patient and once in services you aren’t leaving, discharge became impossible. Service users were simply subservient, broken and discounted from living a life beyond the asylum walls or in today’s services secondary mental health care.

In this respect, your question "Do lifetime mental diagnoses accumulate and require XYZ?" is very relevant. We are still in an era of diagnosis first and diagnosis as a driver to service provision, e.g. payment by results or mental health clustering. In a sense, putting round pegs into square wholes in order prove service viability.

From my perspective discharge should never be a diagnosis but there are classifications such as personality disorder in the 2000’s that were a “discharge diagnosis” and more recently this has become mental and behavioural disorder. In my opening I was clear that Recovery is not discharge nor discharge recovery. Remission is an important issue. Previous research suggests that remission rates have previously been dismissed or ignored resulting in individuals not being discharged. Your example, of a smoker is a poor example. However, we should be supporting people beyond services and enabling discharge. The end of service definition drives anxiety for all including service users, carers and family, and professionals. In the latter, this perpetuates defensive ways of working and a narrative around “you must remain in services, you won’t survive without us”. From my perspective the medical model still drives service provision. Services are focused to medication first as a first line treatment option.

There are numerous factors at play, but if services embody recovery it may make discharge possible?

Discharge can be premature and short sighted. Discharge is under the ownership of the state. Services decide when someone is discharged and often at the behest of a psychiatrist stating “you have recovered”. I agree there can be an episodic nature for some mental health difficulties and service input may be necessary. However, mental health ebbs and flows. Does this mean that someone has to be in services? Does this mean that you cannot be continuing recovery outside of services? Services are chasing viability and effectiveness. Discharge may be set to become a way of reducing demands on services and set to return to either ds charging people to the community or enduring or serious mental health difficulties such as Schizophrenia becoming the abandoned illness. The two factors are a part of my question.

You are correct. People should have the right to be and remain discharged from services and absolutely have a right to not disclose a disability such as mental health. Stigma appears to be a factor in discharge. The issues are broad sweeping. For example, in the UK we have mental health awareness week and have previously had the Rethink national campaign. Both welcome, but the emphasis is on treatment. It’s time for a national conversation about mental and recovery.

Best Wishes

Andy