Acceptance that one has a mental illness and is at increased risk of relapse is an important first step for relapse prevention. Acceptance is acknowledged to be an important step in developing effective illness management strategies and working effectively with mental health services and complying with medications and treatments (Van Meijel et al 2002a, Van Meijel et al 2002b). This can be a difficult process, however, and takes time (Nemec & Taylor 1990). Acceptance is unlikely to occur immediately after the first episode; at this time, most people want to return to their previous self and previous life and are very reluctant to accept that they may have ongoing problems with their mental health.

Looking at your life and how it's changed, the what ifs, how am I going to go back to my life, the grief is overwhelming. —Consumer
The process of acceptance is somewhat of a paradox: it requires acknowledging the illness as part of the self, but not seeing oneself as a sick person and defining the self solely within the boundaries of the illness (Deegan 1988). The process of acceptance is particularly complex for younger people as it may not be clear what a first episode of apparent mental illness means in terms of future mental health and child and adolescent services do not prioritise diagnostic labelling. Pathologising the self is not conducive to wellbeing at any stage of the lifespan, but particularly for young people. Self-help and peer group programs can be uniquely effective in helping people to come to terms with having a mental illness.

It's like, "Welcome to the club! You may not have chosen to be here, but this is where you are!". —Consumer
Acceptance of mental illness is not, therefore, a clear-cut issue. What is important is that people come to have a developmentally appropriate realisation that they may be at increased risk of future mental health problems so that they are able to put appropriate supports in place. However, there are additional barriers to acceptance of mental illness in the form of substantial stigma and its impact on self-worth. In the context of mental illness, acceptance needs to evolve over time and be appropriate to the current life-stage of the person concerned.

It means coming out of denial, accepting it in yourself and not hating yourself for it. Once you stop hating yourself you become more open to doing the things that will help. —Consumer
Often, it is only after further episodes or a particularly traumatic episode that many people acknowledge and are prepared to accept that they have mental illness. This can be a period of intense loss and grief—of self and of one's previous life—and it is important that other people involved recognise this process. The process of grieving differs for the person involved compared with their family and significant others. When the family accepts a diagnosis of mental illness, but the person concerned does not, this can create significant conflict and frustration between the consumer and their family. People need to have the support to go through the process of acceptance in their own way and in their own time. Some adults continue to deny the label of mental illness, despite repeated episodes, and it is possible that techniques like motivational interviewing (Miller & Rollnick 1991) may be useful in helping people to accept that they have a condition that needs particular management strategies.
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There is a displacement between when the carer starts grieving and when the consumer starts grieving. When someone first gets ill the carer starts grieving but the consumer is still going through a period of illness, so they don't start grieving until further down the track and then there's displacement between the grief of the consumer and the carer and that can cause problems and conflict because people want to move on at different paces. —Carer
Coming to terms with having a mental illness is a time when people need easy access to information that is developmentally and culturally appropriate. Self-help groups are a significant resource in terms of providing information and advice and fill in the many information gaps that remain after contact with mental health services. There are, however, some cautions regarding relying on peers as a source of help and advice, if they are not ready to be in a support role by being untrained or misinformed.

If you talk to some inpatients you might get the wrong idea because they might say the medication does something but it doesn't do that so you don't take that medication for that reason ... You need people who are well. —Consumer
Importantly, self-help groups can provide role models of people living well with mental illness. This is essential to give hope to people who have recently been diagnosed with mental illness and their families. Many people still fear that such a diagnosis means the end of a "real life", but contact with other consumers who are "living proof" of the prospect of building a new and meaningful life is an essential part of the recovery process and important to building confidence to prevent relapse, which can be triggered by isolation, hopelessness and despair. As shown in the following quote from the consultations, such role models can also help people to adjust more easily and hopefully to treatment plans during their early episodes:

If only we'd known from another consumer that it wasn't always going to be like that. Because we developed this hope by seeing other consumers being well. You get this diagnosis from the doctor, and it's like what you've seen in your family and then you read about it and you go "My god, there's no hope, there's just no hope". Then when you find out there's these other consumers, they're doing ok, they've got jobs, it's just like amazing, because you believe. It's no good a psychiatrist telling you, but if there's another consumer in front of you. —Consumer

For young people with episodes of psychosis, if they know there's someone they can talk to who has already been through it and they know that there's a way through it and that you do feel better, maybe not 100% but you do feel a bit better. If I had that when I first came here I know that I wouldn't have been so stubborn with the doctors. I would have eased myself up saying, "OK, we can try this", but because I didn't have that I think I was a bit more stubborn thinking, "I don't need help, I'm fine". —Consumer

More positive attitudes toward people with mental illness are fundamental to awareness and acceptance and thereby to effective relapse prevention. Positive attitudes are required at all levels: positive self-attitudes for people who have mental illness, positive attitudes of families and carers, and positive attitudes among service providers and the community in general. Stigma and discrimination are internalised by people with mental illness and this impacts negatively on their sense of self-worth and wellbeing.

With stigma we have our own stigma, you can't think lower of yourself than we do of ourselves. —Consumer
The attitudes of service providers, both clinical and non-clinical, are of major significance. The negative attitudes of service providers, particularly of clinical services, came through clearly in the Evaluation of the Second National Mental Health Plan and the MHCA report Out of Hospital, Out of Mind (Groom et al 2003). As a result, improving the attitudes of the mental health workforce is an identified outcome of the National Mental Health Plan 2003- 2008.

People who work in acute have quite negative attitudes. —Consumer
It is possible that differences in attitudes between clinical and psychosocial support services may be due to different points of contact with consumers. In the consultations, it was repeatedly suggested that the acute care workforce has more negative attitudes toward people with mental illness because they only see people when they are acutely ill; they don't see them when they are well. It is well documented that greater familiarity and exposure can improve attitudes toward people with mental illness (Kolodziej & Johnson 1996). For mental health care providers, seeing consumers during periods when they are well, rather than only when acutely unwell, may greatly improve attitudes through recognition that the people they work with are actually well much of the time and that there is considerable scope for recovery.
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Clinicians and providers of acute services only see people when they are having an acute episode. They don't see them when they are well. So, they only think of them as being in relapse or being discharged. They don't see the different levels of wellness. It's a pity they don't see them when they are well, to see the real person. These are the real people we see and work with. —Psychosocial rehabilitation provider
At the more macro level, there is ongoing need to reduce the societal stigma associated with mental illness. Some major initiatives have occurred in this area, with considerable effort targeting the media, and there appears to be progress in this regard (Steering Committee for the Evaluation of the Second National Mental Health Plan 2003). However, there is still much more to be done to eliminate the stigma of mental illness. Negative attitudes, stigma, and exclusion are powerful risk factors for relapse as they limit the opportunities for people with mental illness to be involved in the activities they need to stay well.