Recovery of people with mental illness : philosophical and related perspectives

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This concept may be more impregnating for those who do not believe in a supra-entity. Camus 5 and Sartre 6 wrote about this quest for meaning, by emphasizing that human beings should accept responsibility for shaping their life-meaning rather than by discovering a meaning from God or Nature. There can be altruistic personal life meanings e. Yalom 3 describes secular activities that are likely to confer significance and purpose. Unsurprisingly, altruism, dedication to a cause and creativity are mentioned, but hedonism in the sense of aiming at living fully in the moment and self-actualization i.

Cosmic meaning concerns the spiritual dimension of our lives, i. Religions can provide some answers for those who believe in God, by providing comprehensive worldviews. What are the determinants of meaning? Authors such as Yalom 3 and Battista and Almond 7 discussed or studied the conditions under which an individual develops meaning in life. Spirituality, self-esteem and close relationships may help to gain meaning in life.

Debats et al. Beyond this necessary yet insufficient prerequisite, meaning would be correlated with phenomena further orientated towards life goals. In terms of behavioural sciences, values are considered as reinforcing factors, the benefits of which are often delayed 9. The capacity to establish values requires that humans are able to build psychological functions without the necessity of direct conditioning processes. Values are different from goals, which are achievable ends.

Unlike goals, values cannot be completed or achieved in an absolute sense. For example, getting a degree is an achievable end.

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Education might be a value that can continue — and be modified - for a lifetime. Values can be determined according to domains such as work, family, education… 10 or according to broader principles such as autonomy, power, altruism, and so on Therefore, the postulate is that values foster a feeling of meaning 3. Conversely, living in a society where human rights are neglected can affect individuals for whom this value of altruism is important. This principle may be applied to patients with severe mental disorders, and whose values decline due to the psychological and social effects of their disorder.

As mentioned above, one may infer that persons carrying the burden of a chronic psychiatric condition are challenged when searching for meaning. At the same time, Frankl 12 , a holocaust survivor, insisted that having a reason to live can help individuals make it through terrible ordeals, such as those he encountered in concentration camps.

Despite the likelihood that existential therapy or ACT provides important tools in the pursuit of recovery, this topic has rarely and sparsely been addressed in literature. We therefore made the assumption that it is possible to conduct experimental research on this issue, by testing a formerly-hypothesized model This model is embedded in the bio- psycho- social paradigm 14 and relies on the current principles of cognitive behavioural approaches This model postulates that various biological e. It follows that the fulfilment of values allows subjects to achieve a sense of meaning. Finally, the sense of meaning or lack thereof may retroactively bear an impact on some of the aforementioned bio-, psycho-, and social contexts of subjects, as discussed formerly by Debats 16 Fig.

In this research, we tested this model by hypothesizing that the psychological state of patients and some social parameters are related to values and secondarily to meaning in life. In turn, meaning is associated with various symptoms and social parameters. More specifically, according to our model, we went further in terms of causalities , by testing whether symptoms and social parameters influence values, which in turn influence meaning; retroactively, this specifically has an impact on symptoms and social parameters.

We studied subjects with long term — yet stabilized - psychiatric conditions. Indeed the issue of meaning is likely to be challenged when life involves persisting symptoms and relapses with important social consequences. The study of four different psychiatric populations aims at providing a picture of distinct alterations of meaning and values depending on specificities of these disorders.

They were randomly recruited from four psychiatric facilities: two public ambulatory facilities in Geneva, Switzerland, and two psychiatric units in Montpellier France. The third and fourth psychiatric facilities were a hospital unit admitting patients suffering from eating disorders and an outpatient clinic assessing BD in Montpellier. This is a second-line unit where patients are sent for EDs or suspicion of EDs for a multidisciplinary assessment, diagnostic confirmation, and organization of care both for outpatient and inpatient management.

To avoid a selection bias related to the characteristics of subjects, patient lists were screened by the research investigators to identify patients who were eligible for the research, without a priori. All participants received detailed information about the study and gave their written informed consent.

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None of the BD subjects had a score above the thresholds for mania or hypomania on both scales see Table 1. The importance of values was established with the Valued Living Questionnaire 9.

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The VLQ is a two part self-report questionnaire designed to identify the importance of 10 main domains in life family relationship, intimate relationship, parenting, social relationship, professional life, education, hobbies, spirituality, citizenship and physical well-being on a point Likert scale. The total score is a composite score, representing the degree to which patients live in accordance with the values they consider as important or not, with higher scores indicating higher importance and commitment. A composite variable was obtained by multiplying the importance of each person by the frequency of contacts per month.

Religiousness and spirituality were investigated through a self-report questionnaire developed by Mohr et al.

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We obtained this variable by summing the scores for subjective importance and the scores for frequency of spiritual practices. Linear regression with adjustment on age, gender and clinical groups was used to assess the association between VLQ total score and the following variables: BDI, BHS, self-esteem, number of relevant relationships, the frequency of contact with them, the importance of religion and spirituality in daily life and the frequency of practicing it.

At this stage, as we tested the association between 5 independent variables number of relevant relationships, the frequency of contact with them, the importance of religion and spirituality in daily life, the frequency of practicing it were considered as non-independent variables , and two different outcomes LRI and VLQ , a correction for multiple testing was required.

Variables significantly associated with VLQ total score were then used as independent variables in a multivariate linear regression model with adjustment on age, gender, and clinical category to assess their impact on values VLQ total score. This method was used to follow the rule established by Peduzzi et al.

The same models were used to assess the association between LRI total score and these clinical and demographic variables. Multivariate linear regression models 2 models: one for VLQ and one for LRI were used to reduce the number of tests performed and thus reduce the risk of type I errors. The variables that remained significant in the multivariate models either with LRI total score or VLQ total score were then used in a mediation analysis to test their effect on LRI total score through the mediating effect of VLQ total score.

Our study was thus enough powered to detect even small associations in the whole sample and associations of mild to moderate magnitude when considering the subsamples. The four samples significantly differed on almost all the clinical and demographic variables, the only exception being measures of hopelessness. LRI total score [ This association was significant in each of the clinical samples taken individually.

The mediation analyses were performed on variables significantly associated either with the VLQ total score or the LRI total score in multivariate models.

These models showed the same direction and the same magnitude of effect when considering each category of diagnosis individually. The present study focused on values as a mediator between various symptoms or social dimensions and meaning in life. Furthermore, we tried to assess whether, in turn , meaning in life impacts these parameters. These hypotheses, stemming largely from existential literature and clinical intuition, were confirmed by our analyses, for four different psychiatric conditions, all of them being characterized by a chronic course and a high level of severity.

LRI results, as indicators of meaning in life, were used in other populations and it is interesting to compare these results with those from our sample. This may reflect the fact that BPD patients have preserved a framework of meaning in life, but are unable to implement it in their life. BPD has recently been thought to be the result of deficient mentalizing capacities, i. This poor mentalizing process might impact the ability a subject has to fulfil life goals, despite the fact that these goals are clearly well defined in the mind of the subject.

Further research is clearly needed in this area in order to better understand the reasons why BPD subjects show deficits in the fulfilment of goals related to meaning in life. Values in the general population were measured with the VLQ by Wilson et al. This should reflect varying coping styles depending on diagnoses, PSY patients giving more importance to values, while having only limited opportunities to implement them in their life.

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To note, the results for the PSY group could reflect at least in part the possible influence of some alterations of cognitive function. This suggests that symptoms such as depression, hopelessness or psychotic symptoms alter values. The mediation analyses showed that the models tested were the most significant pathways. The loop involving values and meaning was found for multiple variables. It appears to be quite logical to find that this process involves depression, hopelessness and low self-esteem.

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Data confirms such an association. If some symptoms impact meaning, what is there to say about a possible reverse impact of meaning or rather meaninglessness on symptoms? Our data goes further by examining the influence of meaning on numerous characteristics or symptoms, in four different psychiatric disorders characterized by a chronic course. For patients suffering from psychosis, one may postulate that meaning can be altered, as argued by Berna et al.

These authors showed in their research that meaning-making was impaired for self-defining memories among patients with schizophrenia. Beyond this finding, we may postulate that this limitation for giving meaning retrospectively may also be present when trying to give meaning to present or future events. In research more specifically oriented towards the relation between meaning and clinical state, Debat et al. At that time, the authors admitted that it was not possible for them to conclude whether lack of meaning in life was the cause or the effect of psychological problems. More recently, Ju et al.

Among these healthy subjects, the authors showed that optimism was indeed associated with well-being, while meaning in life partially mediated this association. It was therefore suggested that optimistic attitudes help perceive meaning in life, which in turn contributes to better subjective well-being. In another study, carried out among a population of students, presence of meaning in life was associated with decreased suicidal ideation Also, as mentioned in discussion, cognitive function, particularly for the PSY group, may partially account for some higher scores on values and meaning.

Further research should assess the role of cognitive function on these variables. Patients in the different group were not free from comorbidities such as depressive or anxiety disorders for BPD for instance. Although these comobidities were assessed using the MINI or the DIGS, for power issues and in order to avoid ending up with small groups not allowing proper comparisons between them, we decided to stick to the main diagnosis for which the patient was referred to one of the facilities.

There are therefore some tautological aspects to our mediating analyses that may account for the significant findings. Furthermore, detailing items on the scales used for symptoms, values, and meaning shows that some of these items may be, to some extent, similar across constructs Beyond these limits, which may lead to consider our results as somewhat tautological, we should keep in mind that this type of research on cognitive processes involves delimitation of constructs which are a priori and to some extent arbitrarily delineated and inevitably overlapping.