Exploring the Experiences of Personal Recovery among Mental Health Consumers and Their Caregivers Receiving Strength-Based Family Interventions

Introduction

Mental illness could cause profound and long-term impacts on persons with the illness (hereinafter called the consumer) and their family caregivers. Consumers might suffer from damage in terms of functioning, a disability to role performance, and disadvantages in social participation [1]. Family caregivers shoulder the responsibility of helping consumers take medication, daily living activities, financial assistance, etc., which may create a sense of objective burden. Additionally, they may experience subjective burdens, including social stigma, family strain, consumer dependency, and guilt [2–4]. Family caregivers need to cope with the consumer’s behavior and their own reactions. They have expressed multiple needs, including knowing what the appropriate expectations are, learning how to motivate consumers, understanding the consumers’ disorder, learning coping skills, and having social support for themselves [2]. It seems inevitable that mental health professionals need to work with caregivers and provide support for them to perform their duties. The World Health Organization [5] calls for effective collaboration between formal and informal care providers. Furthermore, the global trend of mental health services suggests involving consumers and families fully in orienting mental health systems towards recovery [6,7].

Ever since the 1990s, recovery has been the guiding vision of mental health services [1]. Recovery has been defined by the President’s New Freedom Commission on Mental Health as “the process by which people are able to live, work, learn, and participate fully in their communities [6]. For some individuals, recovery is the ability to live a fulfilling and productive life despite a disability. For others, recovery implies the reduction or complete remission of symptoms”. In this definition, the first view refers to personal recovery with a focus on process, and the second refers to clinical or functional recovery with a focus on outcome [7–9]. Despite the diversity in the definition of recovery, Tse et al. [10] maintained that they are actually complementary to each other. Law et al. [11] studied how consumers defined recovery and found that the concepts of rebuilding their lives, their self-image, and hope were essential in defining recovery. Thus, from a consumer perspective, recovery usually refers to personal recovery.

Family plays an important role in a consumer’s journey toward recovery. Reupert et al. [12] reviewed 31 studies from 1980 to 2013 and found that family caregivers provide hope, encouragement, opportunities, emotional support, and instrumental support for the consumer. On the other hand, family caregivers may also bring a negative impact on the consumer. The intensive interactions between consumers and family caregivers might create conflicts. Some family caregivers may not be adaptable enough or even be overprotective, which could hinder a consumer’s autonomy over the course of their recovery. Family conflict may affect a consumer’s family dynamic and their recovery [13]. Lim et al. [14] found that more positive family relationships could predict consumer recovery for 6-month period after controlling for initial functional capacity. Reupert et al. [12] suggested in their findings that consumers and family caregivers maintain a balance between being apart and being connected so that the autonomy of each could be sustained with reciprocity and cohesion enhanced. Family caregivers and consumers could build a partnership and collaborative relationship instead of a division between caregiver and caretaker [15].

As for the models of family intervention, over the past six decades, multiple approaches have coexisted [16]. Those models vary in terms of their view of the family, treatment goals, professional roles, familial roles, and the focus of an assessment. Since the late 20th, there has been a pronounced paradigm shift in professional practice with families, from a model of pathology to one of competence. Professionals’ view of families has shifted from seeing families as pathogenic or dysfunctional to viewing families as basically or potentially competent, from emphasizing weakness, liabilities, and illness to one of strengths, resources, and wellness. The role of professionals has been changed from one of the practitioners who provide psychotherapy to one of enabling agents who facilitate families to reach their goals. The family’s role has shifted from a client to a collaborator. The focus of assessment has changed from clinical typologies to competencies and competence deficits [4]. As Wise [17] claimed that the service approach has been redirected towards a “growth-development model”; i.e., it intensifies the strengths and resources of a family. Moreover, the recovery movement emphasizes that a consumer assumes greater responsibility for directing their own path to improvement, and with the comprehensive consumer- and family-centered services as integral components of psychiatric services [7]. Glynn et al. [7] argued that “the last 35 years have witnessed a proliferation of psychoeducational family interventions for schizophrenia that have been associated with reductions in relapse and readmission… Nevertheless, most of the validated family interventions would benefit from further refinement to be totally consistent with recovery values. Modifications in language, content, and outcomes of concern are necessary to reflect fully a recovery orientation” (pp. 451–452).

Recently, recovery-oriented family interventions have been advocated and developed, such as the family-inclusive approaches towards reablement [18] and mindfulness interventions for family caregivers [19]. Tew et al. [18] found that the key to success in reablement (focusing on capability, personal agency, and quality of life) rested upon the family relationship issues being resolved and family caregivers could encourage the establishment of connections with the community while using the family as a safe base. Mindfulness interventions could help caregivers realize the importance of themselves, develop new perspectives on their circumstances, and have decreased self-judgment [19]. Martin et al. [20] also pointed out that meaningful family inclusion rests on a partnership approach that values the input of families and consumers.

For the caregiver to be a full partner in the services, a caregiver’s own recovery has gained attention as well. Dixon et al. [21] called for professional attention to caregivers’ own needs. For example, they need to resolve their own emotional burdens, preserve the integrity of their own lives, and fulfill their hopes and dreams. Wyder et al. [15] proposed the central elements of a caregiver’s own recovery: establishing connections with others, maintaining hope and aspiration for themselves, redefining their