CHAPTER 4:
Concepts And Definitions

INTRODUCTION

The terms and concepts related to mental health, mental illness and addiction are not easy to define.  Different countries have adopted differing terminology and, within countries, professionals and lay groups, organizations and associations often utilize different conventions in defining and describing key concepts relevant to mental health, mental illness and addiction.  Consequently, one concept may be referred to by a variety of terms, while some terms will hold different meanings for different groups. Even within Canada, some terms have multiple meanings that are applied inconsistently, often creating confusion.

This chapter defines the various concepts used throughout the report related to mental health, mental illness and addiction.  It is divided into nine sections related to: mental health and mental illness (Section 4.1); major mental disorders (4.2); substance use and addiction (4.3); co-morbidity, concurrent disorders and dual diagnosis (4.4); suicidal behaviour (4.5); services and supports (4.6); chronic disease management (4.7); promotion, prevention and surveillance (4.8) and, individuals with mental illness/addiction and recovery (4.9).

4.1        MENTAL HEALTH AND MENTAL ILLNESS

Mental illness undermines mental health, but mental health is more than simply the absence of illness. It is a fundamental resource of all human beings and an essential component of all health.

[Tom Lips, Health Canada (11:7)]

Mental health is defined as the capacity to feel, think and act in ways that enhance one’s ability to enjoy life and deal with challenges.[184]  Expressed differently, mental health refers to various capacities including the ability to: understand oneself and one’s life; relate to other people and respond to one’s environment; experience pleasure and enjoyment; handle stress and withstand discomfort; evaluate challenges and problems; pursue goals and interests; and, explore choices and make decisions.

Good mental health is associated with positive self-esteem, happiness, interest in life, work satisfaction, mastery and sense of coherence.  It is well recognized that good mental health enables individuals to realize their full potential and contribute meaningfully to society.[185]

By contrast, mental health problems refer to diminished capacities – whether cognitive, emotional, attentional, interpersonal, motivational or behavioural – that interfere with a person’s enjoyment of life or adversely affect interactions with society and environment.  Feelings of low self-esteem, frequent frustration or irritability, burn out, feelings of stress, excessive worrying, are all examples of common mental health problems.[186]  Over the course of a lifetime, every individual will be likely, at some time, to experience mental health problems such as these.  Usually, they are normal, short-term reactions that occur in response to difficult situations (e.g., school pressures, work-related stress, marital conflict, grief, changes in living arrangements) which people cope with in a variety of ways, employing internal resilience, family and community support, etc.

Mental health problems that resolve quickly, do not recur and do not result in significant disability do not meet the criteria required for the diagnosis of a mental illness.  Mental disorders or illnesses generally refer to clinically significant patterns of behavioural or emotional function that are associated with some level of distress, suffering (even to the point of pain and death), or impairment in one or more functional areas (e.g., school, work, social and family interactions).[187]

There are many different forms of mental disorders.  They vary widely in terms of the course and pattern of illness, the type and severity of symptoms produced and the degree of disability experienced.  An individual may have only one or may have repeated episodes of illness separated by long periods of wellness.  While some mental disorders are episodic or cyclical in nature, others are more persistent with lengthy or frequently recurring episodes.  Individuals with persistent illnesses usually require long term treatment and support.

4.2       MAJOR MENTAL DISORDERS

In Canada, the classification of mental illnesses follows either the Diagnostic and Statistical Manual of Mental Disorders (DSM) published by the American Psychiatric Association, or the International Classification of Diseases (ICD), Mental Health Section, published by the World Health Organization.[188]  Each of the two classification systems lists more than 300 mental disorders that can be diagnosed; these are often grouped together on the basis of similarities in their symptoms or patterns of illness.

The complete list of mental disorder diagnoses is available in the DSM and ICD manuals.  Some of the major groupings of mental disorders include: mood disorders (depression and bipolar disorders), anxiety disorders (generalized anxiety disorder, phobias, panic disorder, obsessive-compulsive disorder and post-traumatic stress disorder), psychotic disorders (schizophrenia and schizoaffective disorder), eating disorders (anorexia nervosa and bulimia), personality disorders, pervasive developmental disorders (autism and Asperger’s disorder), attention deficit and disruptive behaviour disorders, and cognitive disorders (dementia and delirium from a variety of causes).[189]  Substance use disorder is also included within the classification of mental disorders.  In this report, substance use disorders are discussed in a separate section in order to highlight their importance and relationship to addiction.

Mood disorders include both major depressive and bipolar disorders.  Major depressive disorder (also referred to as unipolar depression) is characterized by one or more depressive episodes lasting at least two weeks.  The core symptom is a sustained depressed mood (different than normal feelings of sadness) and/or a marked decrease in pleasure from or interest in usual activities.  This is accompanied by four or more other symptoms characteristic of depression such as disturbance, fatigue or loss of energy, appetite and weight loss or gain, decreased ability to concentrate, think, and make decisions, and recurrent thoughts of death.  Females have higher rates of major depression than males by a ratio of 2:1.  Bipolar disorder, classically known as manic depressive illness, is a mental illness associated with dramatic mood swings ranging from mania to depression.  Mania, a condition recognized since antiquity, is characterized by at least a week of an altered mood state of euphoria, labiality or irritability.  Like depression, it is associated with a number of other related symptoms, often as the mirror image of depression, including a marked increase in energy, decreased need for sleep, elevated self-esteem, and a propensity for risky activities.  Bipolar disorder usually begins in early adulthood; the average age of onset is around 18-24 years, although it can sometimes start in childhood or as late as the 40s or 50s.  Men and women are equally affected.[190]

Anxiety disorders may take many forms.  They include: generalized anxiety disorder, specific phobias, panic disorder (with or without agoraphobia), obsessive-compulsive disorder and post-traumatic stress disorder.  Generalized anxiety disorder is defined by a protracted period (i.e., over 6 months) of anxiety and worry that is accompanied by other symptoms such as muscle tension, fatigue, poor concentration, insomnia, and irritability.  Phobias reflect marked fear of certain things (such as animals, insects, heights, elevators, etc.) or situations (social phobia); exposure to the object of the phobia, either imaginary, on video or in real life, invariably elicits intense anxiety which may include a panic attack.  Panic disorder is diagnosed when an individual has experienced a number of unexpected panic attacks – periods with sudden onset of intense fear or discomfort, often associated with palpitations, rapid breathing, and a sense of impending doom – coupled with worries about further attacks.  Obsessive-compulsive disorder involves either or both obsessions or compulsions which the individual recognizes as excessive or unreasonable.  Obsessions consist of persistent, intrusive, inappropriate thoughts, ideas, impulses or images that cause marked anxiety or distress.  Compulsions refer to repetitive behaviours (such as hand washing) or mental acts (such as counting) that sometimes occur in a ritualistic way or in response to an obsession.  Post-traumatic stress disorder involves re-experiencing a traumatic event through dreams and recollections, avoiding stimuli reminiscent of the event, emotional numbing, and a heightened level of arousal; it occurs following a traumatic event in which the person experienced or witnessed threatened or actual physical harm (such as rape, child abuse, war/battle, or natural disaster).  Overall, anxiety disorders affect men and women equally; they tend to begin  early in life (during childhood or adolescence) and often persist for many years.[191]

Schizophrenia is a mental illness that typically emerges in late adolescence and early adulthood.  Classically, it has often been a chronic, severe and disabling long term disorder.  In the last decade, systematic efforts at earlier detection and comprehensive biopsychosocial intervention offer hope for a different trajectory for this often long term illness.  Decades of genetic, brain imaging, and other lines of research support a biological model of schizophrenia, although its cause remains unknown.  It seriously affects a person’s thinking, causing hallucinations (such as hearing voices when there is no one there), delusions (fixed false beliefs such as the fear that strangers are following the ill person or wanting to hurt him/her), a loss of contact with reality and disrupted work and social interactions.  The disease often begins slowly; once it has taken hold, it usually manifests itself in cycles of remission and relapse.  Men and women are affected by schizophrenia with equal frequency.[192]

Eating disorders involve serious disturbance in eating behaviours.  While some cases of eating disorders will resolve themselves spontaneously or with treatment during adolescence, others may become chronic conditions.  Some long term follow-up studies reveal death rates of up to 18% in affected individuals.  The most common eating disorders include anorexia nervosa, bulimia nervosa and binge eating disorder.  Anorexia nervosa is characterized by low body weight (under 85% of expected weight), intense fear of weight gain even when markedly underweight, an inaccurate perception of body weight or shape, denial of thinness, and an intense emphasis on weight as a yardstick of self-evaluation.  Bulimia nervosa, by contrast, most commonly occur in individuals of normal body weight. It is characterized by recurrent episodes of gorging, followed by compensatory activities to eliminate the ingested calories (such as self-induced vomiting, abuse of laxatives or diuretics, intensive exercise, etc).  It shares, with anorexia nervosa, however, many of the core psychological preoccupations with weight and shape.  Binge eating disorder is a newly recognized condition featuring episodic uncontrolled consumption of food, without the compensatory activities of bulimia nervosa.  Eating disorders usually arise in adolescence and affect females disproportionately.[193]

Personality disorders include a number of disorders that vary considerably in their characteristics and patterns or behaviour.[194]  However, they all share the following characteristics: an enduring pattern of inner experience and behaviour that deviates from the expectations of society and behavioural patterns that are pervasive, inflexible and stable over time, creating distress or impairment.[195]  Some forms of personality disorder result in suffering that primarily affects the individual (e.g., avoidant personality disorder, characterized by feelings of extreme discomfort and intense self-criticism in social circumstances, leading to marked loneliness and isolation despite intense longings for social contact).  Other forms of personality disorder may not only cause distress to the individual, but also produce profound harm to others and incur substantial cost to society (e.g., antisocial personality disorder, a pervasive pattern of disregard for and violation of the rights of others that often includes repeated criminal activity, impulsive violent behaviour, deceitfulness and lack of remorse.)  The onset of personality disorders usually occurs in adolescence or early adulthood, but they can also first manifest themselves in mid-adulthood.  In contrast to the mental illnesses described previously, personality disorders are more intimately linked to the affected person’s individual temperament and character.[196]

Autism is a mental disorder which emerges in childhood and which, for some affected individuals, may be an incapacitating and life-long disability.  Generally, autistic individuals display the following: impaired ability to engage in social interaction; impaired communication skills; and specific behavioural patterns (e.g., preoccupation, resistance to change, adherence to non-functional routines and stereotyped and repetitive behaviours).  Developmental delay or abnormality in interaction, language and play is evident before 3 years of age in affected individuals.  Autism may be accompanied by other disabling conditions, such as seizures or significant cognitive (intellectual) delays.[197]  The symptoms and deficits associated with autism, however, may vary.  For example, some individuals with autism function at a relatively high level, with speech and intelligence intact, while others are developmentally delayed, do not speak, or have serious language difficulties.[198]  Autism tends to be three-to-four times more common in males than females.

Attention Deficit Disorder (ADD) and Attention Deficit Hyperactivity Disorder (ADHD) are terms used to describe patterns of behaviour that appear most often in school-aged children.  They adversely affect the learning process by reducing the child’s ability to pay attention.  Children with these disorders are inattentive, overly compulsive and, in the case of ADHD, hyperactive.  They have difficulty sitting still, attending to one thing for a long period of time, and may seem overactive.  ADD and ADHD are diagnosed 10 times more often in boys than in girls.[199]  The attention deficits associated with these disorders may persist throughout childhood and adolescence into adulthood, whereas the symptoms of hyperactivity and impulsivity tend to diminish with age.  Although many children with ADD and ADHD ultimately adjust, a higher proportion than in the population of unaffected individuals are more likely to drop out of school and fare more poorly in their careers later.  As they grow older, some teenagers who have had severe ADHD since middle childhood experience periods of anxiety or depression.  They may also be vulnerable to problems with substance abuse and antisocial behaviour.[200]

Alzheimer’s disease is an organic brain disorder that leads to the loss of mental and physical functions.  Together with a number of other illnesses including, for example, Parkinson’s disease and Huntington’s disease, it is classified as a degenerative disease of the central nervous system.  Alzheimer’s disease is the leading cause of dementia.  Several changes occur in the brain of the affected individuals, notably a progressive loss of neurons from the cerebral cortex and other areas.  Consequently, a person with Alzheimer’s disease has less brain tissue than a person who does not have the illness; the shrinkage continues over time, affecting how the brain functions.[201]  Memory loss is the most prominent early symptom of Alzheimer’s disease, often followed by a slow deterioration of cognitive functions and personality features and physical capacity.  Some individuals experience hallucinations, delusions, seizures and aggressive behaviour.  Alzheimer’s disease affects both men and women equally.[202]

Although not classified as mental disorders, Fetal Alcohol Syndrome and Fetal Alcohol Effects (FAS/FAE) are major birth defects leading to disturbance in brain function.  Damage to fetal brain development is caused by the effects of the mother’s drinking alcohol during pregnancy.  Infants with FAS/FAE display irritability, jitteriness, tremors, weak suck reflexes, problems with sleeping and eating, failure to thrive, delayed development, poor motor control and poor habituation.  In childhood, problems such as hyperactivity, attention problems, perceptual difficulties, cognitive deficits, language problems and poor motor coordination are common.  In adolescence and adulthood, the primary difficulties are memory impairment, problems with judgment and abstract reasoning and poor adaptive functioning.  Some common secondary disabilities, characteristic of adolescents and adults with FAS/FAE, include easy victimization, unfocused and distractable behaviour, difficulty handling money, problems in learning from experience, trouble understanding consequences and perceiving social cues, low frustration tolerance, inappropriate sexual behaviours, substance abuse and trouble with the law.[203]

4.3       SUBSTANCE USE AND ADDICTION

It is important to distinguish between substance use, abuse and dependence. Psychoactive substance use is very common. Abuse is less common and dependence affects only a minority of people who use psychoactive substances. The level of severity of consequences is higher for those with abuse and even higher for those with dependence.

[Dr. David Marsh, Centre for Addiction and Mental Health (16:44)]

According to Health Canada, substance use includes the use of any of a range of psychoactive substances – i.e., substances that have an effect on a person’s mental state – including alcohol, non-prescription and prescription drugs, illicit drugs, solvents and inhalants.  Patterns of use may range from abstinence, to occasional or regular use, to frequent heavy use, to full-blown substance abuse.[204]

Substance use disorders, which are considered to be mental disorders under both the DSM and the ICD, refers to a habitual pattern of alcohol or drug use that results in significant problems in work, relationships, physical health, financial well-being, and other aspects of a person’s life.  Substance use disorders encompass two sub-categories: substance abuse and substance dependence.[205]  Substance abuse refers to a maladaptive pattern of use despite the affected person’s knowledge of the negative consequences associated with such use.  Substance dependence is characterized by a loss of control, preoccupation with and continued use of substance(s) despite its negative consequences.[206]

Dependence can be physical, psychological, or both.  Physical dependence consists of tolerance (needing more of the substance for the same effect).  Psychological dependence is present when a person perceives an intense need to use the substance in order to function effectively or in particular situations.  The degrees of dependence range from mild to severe, the latter being characterized as addiction.[207]

Addiction implies uncontrollable use of one or more substances, associated with discomfort or distress when that use is discontinued or severely reduced.  Addiction may also describe certain other behavioural problems, such as compulsive or pathological gambling, which can be considered a process rather than a substance addiction.  Research to date suggests that pathological gambling may progress in stages similar to those in alcoholism.[208]

In this report, we often use the term “addiction” to refer to the broad field of substance abuse.  The addiction treatment system encompasses treatment, services and supports for those suffering from substance abuse and substance use disorders.

4.4       CO-MORBIDITY, CONCURRENT DISORDERS AND DUAL DIAGNOSIS

Co-morbidity simply denotes that two or more illnesses affect the same individual, whether two different mental disorders, two physical illnesses or a mental disorder and a physical illness.  In this report, the concept of co-morbidity refers to the occurrence of a mental illness together with a physical illness.  For example, epidemiological data show that 25% of arthritic patients have co-morbid depression or anxiety; there is a high level of co-morbidity between cancer, diabetes, respiratory problems, hypertension or migraine and some mental disorders.  The interactions of physical and mental illnesses are, however, very complex.[209]

The term concurrent disorders most commonly refers to individuals who suffer from a mental illness and a substance use disorder at the same point in time.  The relationships between mental illness and substance use are not straightforward.  One the one hand, mental health problems/illnesses may act as risk factors for increased substance use (e.g., increased anxiety may lead to increased reliance on alcohol) and, on the other, substance abuse may act as a risk factor for increasing mental health problems/illnesses (e.g., problematic alcohol use may be a risk factor for depression).  In other situations, a shared causal explanation may apply in which both disorders are promoted by a third factor such as genetic predisposition or family environment.  Research indicates, however, that, in some circumstances, mental illness and substance use disorder occur independent of each other.[210]

In this report, dual diagnosis refers to individuals who have a mental health problem or illness together with developmental disability (formerly referred to as “mental retardation”).  Because there are difficulties in diagnosing mental illness in a person with developmental disability, dual diagnosis is often unrecognized (undiagnosed) and untreated.  Affected individuals have complex and challenging needs and are certainly among the most vulnerable members of the Canadian population.  They are more likely to experience abuse (more particularly sexual abuse), neglect and exploitation than other Canadians.  They often “fall through the cracks.”[211]

4.5       SUICIDAL BEHAVIOUR

The term suicidal behaviour encompasses completed suicide (death by suicide), attempted suicide (including intentional self-inflicted harm) and suicidal ideation (thinking about suicide).  Suicidal behaviour is often the consequence of a number of factors that have interacted, including acute stressors and negative life events (e.g., bereavement, loss of employment, separation, illness), symptoms associated with an acute episode of mental illness or substance use disorder (e.g., psychosis, depression, intoxication), personality characteristics, social and/or economic circumstances.

While not itself a mental disorder, suicidal behaviour is highly correlated to mental illness and addiction.  Studies indicate that more than 90% of suicide victims have a diagnosable mental illness or substance use disorder.[212]  Suicide is the most common cause of death of individuals with schizophrenia.  Suicide also accounts for 15% to 25% of all deaths among individuals with severe mood disorders.[213]  Addiction often predisposes to suicidal behaviour by intensifying a depressive mood swing and by reducing self-control.[214]

 

 

4.6       SERVICES AND SUPPORTS

Traditionally, mental health care in the formal health care system has encompassed primary, secondary and tertiary care.  Primary mental health care, i.e., first-line services, traditionally included simple diagnostic procedures, basic treatment, and referral to more specialized services as needed.  A great deal of attention has been directed to enhance the capacity of primary mental health care given that it is now recognized that a large proportion of the population should receive services for mental health problems in this sector of the health care system.  Secondary care is more specialized care that provides more extensive and complicated procedures and treatment; it may be provided within hospitals, clinics or office-based practices, on an inpatient or outpatient basis.  Tertiary care is generally defined as specialized interventions delivered by highly trained professionals to individuals with problems that are particularly complex and difficult to treat in primary or secondary settings.  In the mental health system, tertiary care also refers to the long term care that has historically been provided in large psychiatric hospitals to individuals with persistent mental disorders.  Research and teaching activities are also undertaken within tertiary care institutions.

In this report, it is recognized that many and diverse services and supports are required by those who experience mental illnesses and substance use disorders and, as such, they are provided by numerous professional and non-professional service providers and organizations.  These services and supports extend beyond those provided in the traditional mental health care system.  A Canadian review of best practices suggests the need for the following core mental health and addiction services and supports[215]:

·        Case management refers to the constant ongoing support provided to individuals with mental illnesses/substance use disorders to help them obtain the services they need.  The case manager assesses needs, identifies skill deficits and refers the individual to providers of the appropriate services.  Case management is intended to help patients/clients to develop skills for daily living, enhance their community tenure and prevent hospitalization.  Assertive Community Treatment (ACT) is acknowledged to be the most appropriate model of case management to provide services to those with severe and persistent mental illnesses and concurrent disorders.  In the ACT model, case management is provided by a multidisciplinary team in the community where the individual lives rather than in an office-based practice or an institution.  The team involves psychiatrists, family physicians, social workers, nurses, occupational therapists, vocational specialists, etc., and is available to the patient/client 24 hour a day, 7 days a week.

·        A wide range of inpatient and outpatient services are needed, including: counselling; psychotherapy; individual and group therapy; partial hospitalization (day treatment programs); acute home treatment (as an alternative to acute hospitalization); specialty services in both the community and psychiatric units/facilities; forensic psychiatry; and shared care.  Shared mental health care[216] is of particular interest.  This refers to a broad spectrum of collaborative activities between primary health care providers and psychiatrists or other mental health care providers; some have a strong clinical focus, integrating mental health services into primary health care settings, while others offer creative educational programs to primary health care providers through collaboration among academic departments.

·        Community supports, including housing, vocational services, supported education and supported employment are important components of the spectrum of services required by individuals with mental disorders.  It has been demonstrated that the availability of such community supports can substantially improve outcomes.  It is recognized that individuals with mental illness have the capacity to work and that employment programs should be encouraged for even the most disabled of individuals.  Similarly, supported education programs enable individuals to return to school on a full-time basis.  Evidence also suggests that community residential programs can successfully substitute for long-term inpatient care.  Thus, a range of different housing alternatives (e.g. supervised group homes or other residential settings) should be provided.

·        Mental health crisis/emergency response provides a broad range of services to address the widely varying manifestations of acute mental health/substance use.  There are five essential components to the crisis response/emergency service: telephone crisis lines, mobile crisis outreach, walk-in crisis stabilization services, crisis residential (non-hospital) services, and hospital-based psychiatric emergency services.

·        Most importantly, there should be a strong focus on initiatives by individuals with mental illness and addiction and their families: The involvement of individuals who themselves have had mental illness/addiction problems in the planning, delivery, management, evaluation and reform of mental health services and supports has led to the development of a wide range of consumer/family initiatives that provide information, education, training, self-help, mutual aid and peer support.  More importantly, significant strides have been made in this domain with the recent development of consumer based businesses as a means to promote self fulfillment and a reduce dependence on social services.

In this report, the mental health system refers to the broad range of services and supports available to individuals with mental illness.  Similarly, the addiction system describes the entire range of services aimed at preventing or reducing/treating substance abuse, substance use disorders and problematic gambling.

4.7       CHRONIC DISEASE MANAGEMENT AND SELF-MANAGEMENT

Chronic disease management is a relatively new approach that has been shown to be very effective in the long term treatment of diseases.  The approach is based on the "Chronic Care Model" used by a United States national program called Improving Chronic Illness Care (ICIC) based in Seattle, Washington, at the MacColl Institute for Healthcare Innovation at the Group Health Cooperative of Puget Sound.[217]

Chronic disease management rests on evidence-based clinical guidelines and protocols and involves many health care professionals and administrators througout all sectors of the health care system that share a common vision and collaborating on several initiatives in parallel.  This approach contrasts with the model of treating a care episode as a single event – a visit to a health care provider.  In Canada and the United States, chronic disease management has been applied with great success to many chronic diseases, such as diabetes, arthritis and even asthma; it is now being contemplated for application to mental illness and addiction.  Chronic disease management emphasizes community based care and aims to foster independence and fulfillment.[218]

An important element of chronic disease management is the active participation of affected individuals themselves in the management of their illnesses on a day-to-day basis.  This participation of patients/clients is usually referred to as self-management.  The concept of self-management does not mean that individuals deal with their illnesses or disorders on their own.  It is a process that enables the individual to develop the knowledge, attitudes and skills necessary to manage his/her illness or disorder and to make improved use of existing health services and supports in order to access help when it is needed.[219]

4.8       PROMOTION, PREVENTION AND SURVEILLANCE

The goal of mental health promotion is to provide information to the public to raise and enhance awareness and understanding of mental health issues, reduce stigma and promote positive mental health.  Mental health promotion also includes education and training of human resources in the formal mental health/addiction system.

The concept of mental health literacy is often used in the context of mental health promotion.  Mental health literacy refers to the knowledge, beliefs and abilities that support the recognition, management or prevention of mental illnesses or substance use disorders.  A high public level of mental health literacy makes early recognition of and appropriate intervention in mental illnesses and substance use disorders more likely.  It is also effective in reducing stigma.[220]

Prevention is categorized as primary prevention when directed at averting a potential mental health/substance use problem; secondary prevention is directed at early detection and includes the appropriate intervention to prevent or delay onset or mitigate a mental health problem; tertiary prevention is directed at minimizing disability or avoiding relapse in a successfully treated, stable patient/client.

Surveillance usually refers to the ongoing systematic collection, analysis and interpretation of health-related data used to determine the occurrence of diseases, assess relevant needs and evaluate effectiveness of policies and programs.  Currently, Canada has no national surveillance system for tracking mental illnesses and substance use disorders.[221]

4.9       INDIVIDUALS WITH MENTAL ILLNESS/ADDICTION AND RECOVERY

As described at the outset of this chapter, no commonly accepted language and terminology exist to describe all concepts and issues in the field of mental illness and addiction.  There is little agreement in regard to the most respectful and appropriate terms to identify those individuals who themselves have experienced a mental illness or substance use disorder.  Some individuals have very strong feelings about the language used in view of the societal stigmatization and pejorative labelling that is far too commonly encountered by individuals with mental illness and addiction.

Traditionally, individuals with mental illness and addiction being cared for by physicians are called patients.  Other health professionals often refer to such individuals as clients or service users.  The individuals may describe themselves by a number of terms, commonly consumers and survivors.  Consumers usually refer to individuals with direct experience of significant mental health problems or mental illnesses who have used the resources available from the mental health system.  Some individuals have chosen to refer themselves as survivors, a term that they feel acknowledges their strength in coping with mental illness and/or addiction.  In this report, the Committee uses the terms individuals with mental illness and addiction or patient/client.

Individuals with mental illness and addiction often talk about recovery.  Recovery is not the same thing as being cured.  For many individuals, it is a way of living a satisfying, hopeful, and productive life even with limitations caused by the illness; for others, recovery means the reduction or complete remission of symptoms related to mental illness.

In the field of mental health, recovery is a personal process of overcoming the negative impact of mental illness despite its continued presence.  In the field of addiction, recovery describes an abstinence-based approach to substance use disorders, such as those practiced by Alcoholics Anonymous and Narcotics Anonymous.  The recovery concept presupposes that, with the appropriate treatment and supports in place, individuals with mental illness and addiction can take charge of their lives, create new goals and aspirations, and engage in society as productive citizens.[222]