Per aspera ad astra – Through hardship to the stars: The role of psychiatry on the long and stony road towards recovery
“Recovery” is one of those tricky words in mental health. It carries a generally positive connotation to some, but not all, and means different things to different people. Some equate recovery with being “cured,” returning to a former state of wellness, or as synonymous with no longer needing psychiatric medications. Others conceptualize recovery as the development of self-acceptance, meaning and purpose in the face of adversity. In this opinion piece, I examine my own use of the term recovery, using in particular an idea from the Austrian psychiatrist, Victor Frankl. In 1946, following his experience as a Holocaust survivor, having observed that some people emerged from the ordeal of Nazi Germany with astounding resilience despite life-threatening and inhuman conditions in the concentration camps, he advanced the powerful notion that the attitude one has towards a situation is as important as the “objective” facts of the situation (1).
“Per aspera ad astra – through hardship to the stars…”
In medicine and psychiatry, we plan treatment around principles such as “achieving remission” and “improving functioning and quality of life.” One of the goals of psychiatric treatment is to have few or no psychiatric symptoms (i.e., symptomatic remission), which then creates a foundation that supports an individual’s innate capacity to study, work, and be a friend, parent, or partner (i.e., functional remission). In combination, symptomatic and functional remission allows for an enriched and fulfilling life (i.e., good quality of life). Symptomatic remission, functional remission, and quality of life are concrete outcomes that can be defined and tracked over time. One of the strengths of this approach (which I would call an enlightened or recovery-informed medical model) is that it provides clear recommendations about which treatment to use (e.g., medications, specific psychotherapy) in order to help a person move from being distressed, preoccupied, and feeling badly about themselves, to a state of being less bothered by symptoms and more invested in the roles and activities that they value in life.
While people frequently “recover” from acute and serious medical illnesses, medical providers and patients themselves are unlikely to use the term “recovery” for chronic conditions in which symptoms persist to some degree with a clear and direct impact on functioning. It is often the case, however, that we see people doing psychologically well despite extreme objective adversity. As a result, I prefer “being in recovery” over “recovered” as it emphasizes the journey and process, not the endpoint. In a broader sense, people could then be considered in recovery if they: 1) have “good enough” symptom control, 2) take an active role in managing their own condition (with the help of a physician and medicine if needed), 3) have a good quality of life and, perhaps most importantly, 4) have a positive attitude about living with an illness, enjoying the life they have, despite hardships from illness. I had already introduced Frankl’s idea about the importance of the attitude towards the situation in the beginning. Acceptance and Commitment Therapy are examples of a psychotherapy that is grounded in some of Frankl’s insights.
I consider many of the individuals for whom I am a care provider to be in recovery, despite their struggle with serious mental health conditions such as schizophrenia. Despite some ongoing symptoms and in the context of taking medications, they live a good life as they define it, and have carved out valued roles as members of their families and society. For most, it was a long, winding and stony road, – per aspera ad astra as the Latin saying goes (through hardship to the stars).
The role of medications in recovery deserves specific mention. I suggest considering medication not as an end in and of itself, but rather as a tool to first achieve symptomatic and then functional remission. With this accomplished, a person is in a much better position to make subsequent gains in cultivating hope and achieving life goals (e.g., finishing school, maintaining or obtaining work), all of which serve to contribute to a positive attitude towards the self and one’s recovery.
“Per aspera ad astra – through hardship to the stars…”
In a recent article in Psychiatric Services, the well-known advocate for patient empowerment, Pat Deegan eloquently described her struggles with determining the role of medications in support of her recovery (2). She describes coming to terms with understanding the value of medicines for her recovery, including at least periods of acceptance around the need for and use of psychiatric medications. She also highlights the importance of identifying personal motivation to find the most effective and best tolerated regimen and sets the expectation for a process of trial and error that takes time and is not linear.
In my view, the role of a psychiatrist in recovery is ultimately centered around supporting psychological recovery by outlining treatment options and offering treatment tools like medications – while also accompanying patients on their path towards making sense of their psychiatric condition. Psychiatrists can be seen as allies in this struggle towards acceptance of illness and adopting a helpful attitude towards living with an illness. How to live a good life despite a difficult illness and how to come to some form of acceptance of the condition and necessary treatment is something patients themselves must define and seek. Good care providers, friends, peers, and the community play a key role in this deeply personal journey.
Oliver Freudenreich, MD, FACLP
Co-Director, MGH Schizophrenia Clinical and Research Program
- Frankl V. Man’s Search for Meaning. Beacon Press, 2006. (Originally published in German in 1946).
- Deegan PE. The journey to use medications optimally to support recovery. Psychiatric Services (in press).