This was peer reviewed article was written for Community Mental Health Journal
By Ken Braiterman, MA
ABSTRACT: Recovery is possible for everyone with mental illness; complete recovery for many. Mental health professionals can play an essential role, and many do. But they can also stand in the way of recovery, usually with the best of intentions. Helping people make themselves well, and move beyond their learned role as mental patient and helpless victim, requires a different therapeutic approach than the old notion of maintaining people who will be sick and dependent forever. As recovery stories accumulate, it is becoming increasingly clear how professionals can help, or hurt.
For several years now, I’ve been talking to mental health professionals about how they can help their clients recover. Everyone I talk to sincerely wants to help their clients recover, and most do good recovery-based things every day.
A therapist gave me the insight that started my recovery, and another therapist pointed me in the direction that kicked my recovery into irreversible high gear.
But I’ve also had therapists who tried to prevent my recovery, actually stood in the way or set me back – always with the best intentions. Nearly everyone in the mental health system for a long time has been held back in recovery by at least one clinician with good intentions.
Guiding a client through genuine recovery is a lot more fun and satisfying FOR THE CLINICIAN than lifelong maintenance of a disabled, disempowered victim who never gets any better.
Many clinicians still don’t believe that recovery is a realistic option for their clients, except maybe the very high functioning ones who were never very sick to begin with. They think recovery is just the latest therapeutic buzzword. But it has become politically incorrect for them to say that, so they pay lip service or convince themselves that they’ve been doing it all along and don’t need to change.
The people we serve need more progress on recovery-based therapy than lip service. Today’s mental health centers (CMHCs) were designed — and treatment professionals trained — to maintain de-institutionalized people who would never get much better. These people needed medicine, therapy, job preparation groups, community supports, and money management (not money management training) to stay out of the hospital, in poverty housing or group homes, and maybe obtain a dead-end, low stress part-time job. That was considered success. It required a small, community-based, all-powerful, all-knowing institution to replace the big centralized institution.
Recovery is a paradigm shift as significant as de-institutionalization was 30 years ago. Clients expect to get well, and expect their treatment teams to help them get well. Our mental health institutions and professionals must change to serve this new generation of clients, or become part of the client’s problem, not the solution, and I’ve never met a mental health professional who wanted to be part of their client’s problem.
If recovery is unrealistic, account for me. I was desperately sick and not high functioning, except that I was articulate – a mixed blessing that caused many professionals to underestimate how sick I was. I have bipolar disorder, combined form, rapid cycling, with psychotic overtones. Without medication, I can go from extreme agitation and irritability, to being unable to get out of bed, and back to acute hypomania in two hours, ten complete cycles in a day. I’ve had suicidal impulses all my life and suicidal sieges that sometimes lasted for days. I’ve had full-blown mania, and long periods of dangerous isolation.
I was immobilized by accumulated anger and shame. I was homeless twice and lost two careers (this is my third), my savings, two marriages, my friends, my community, my religion, and (temporarily) my family. I was emotionally abused in my first marriage and first job. I drove a cab on the streets of New York City for two years after I lost that first career. I still hear voices and have post-traumatic flashbacks.
I’ve completely recovered. I write, advocate and lecture. I work on mental health policy and planning at the highest levels of state government, and consult with some of the top psychiatric researchers in the country. I change people’s lives in my recovery workshops. I’ve been in a stable relationship for five years, stopped smoking, lost 80 pounds, even gotten active in church after 30 years of post-traumatic reactions every time I stepped inside one. Most important, I’ve become a person I respect, a person other people respect, and a person I like.
A therapist started that recovery. She had the nerve to tell me something I didn’t want to hear right when I was ready to hear a new idea because my life was at an unsatisfactory dead end. The idea was to stop the blame game and take responsibility for my choices. Even when things just happen to you, she said, how you react is your choice. The horrible things that happened are not your fault, but your life is your choice and you are in control of your choices and responsible for them.
Re-examining my life in terms of choices I made, instead of horrible things mental illness and rotten people did to me, caused 50 years of anger and shame to melt away. I could understand why I made those choices, forgive myself, let go of the pain and move on. Until that moment, I stuffed all that pain inside, and it came out at times I couldn’t control, in ways that damaged me.
A client might dismiss or resist a message like that for years before he gets it. I did. Don’t give up on anyone.
A few weeks later, another therapist got me acquainted with peer support. Suddenly, I was surrounded by new friends who could truthfully say, “I’ve been there. I know how you feel. I’ve chosen to recover.” That was the end of my isolation.
Then the therapist got me into a Mary Ellen Copeland wellness and recovery (WRAP) workshop. Her five prerequisites for recovery include hope (a firm belief that recovery is possible), taking responsibility for your choices, and peer support. The other two are education about your illness and learning to advocate for your needs. I’ve been teaching those workshops for five years.
Those are two examples of recovery-based therapy that changed my life.
Many therapists discourage their clients from going to peer support. It makes the client harder to manage. He starts asking too many questions about his treatment and making demands. Those are signs of independence and growth that should make a caregiver happy. But the system has plenty of caregivers who only care about having an easy day with easy clients. If a client makes those demands in impolite or inappropriate ways, it’s the clinician’s job to teach appropriate ways, not stifle the demands or intimidate, invalidate and control the client.
For many years, we said you couldn’t define recovery because each individual has his own recovery goal, and recovery is different for everyone. That’s still true, but as more and more personal recovery stories accumulate, we find there are many generalities we can make.
Recovery is different from being stable on medication or having a job. I was stable on medication, winning journalism awards, for 15 years, but my life consisted of going to work, doing the work, and getting ready to go back to work. I was isolated and full of anger and shame. Personal relationships were impossible and professional relationships were uneven. I thought I was well because I was working. When I got sick again and couldn’t do the job, I lost my identity, my reason for living, and my self-esteem. I had to reinvent myself completely. That was having a job, not recovery.
Recovery is having a balanced life with choices, autonomy, and connections in the community, a sense of self-worth based on who you are not what you do.
Recovery is possible for everyone. You can’t recover unless you think you can, and the therapist can’t help recovery unless he believes it is a realistic goal for this client. The therapist can communicate that hope to the client, but often communicates just the opposite without realizing it, but always with the best of intentions.
We’ve all seen hopeless-looking clients hanging around the mental health centers, smoking, inarticulate, and barely awake. Sometimes they’re over-medicated. Sometimes they’re reacting to a learned belief (often from their treatment teams) that they are helpless and hopeless, not responsible for their lives and unable to change. Sometimes they’ve gotten COMFORTABLE in the role of mental patient and helpless victim.
THESE PEOPLE CAN RECOVER TOO! They can increase their level of hope, improve their self-esteem, learn that they have choices and how to develop choices, improve their connections with the community, learn new ways of enjoying leisure, develop new and better supportive relationships, move beyond their self-definition as hopeless and helpless patients and victims. The therapist can help.
Medication is often necessary, but can become part of the problem. Often, these apparently hopeless people are over-medicated by doctors who do not practice collaborative medicine. They give the client as much medicine as he can stand instead of as little as he needs to manage symptoms effectively and live a good life. It’s a very rare doctor who talks to a client about coping skills or symptom management as part of the medication process.
Clients need to know about what they’re taking: what it’s for, what side effects to watch for, how to know it’s working, and when to complain to the doctor that it’s not working, or that side-effects have become intolerable. Some doctors still want patients to take what they’re given and ask no questions. Others dismiss complaints about side effects that are dangerous or destructive to the quality of life. One of my peer support clients thinks he’ll be hospitalized as non-compliant if he questions the doctor about medication. How can that doctor make decisions if the client is afraid to speak?
Our system too often gives people as much medicine as they can stand after their first crisis, and keeps them on it for life. The medicine rots their teeth, damages their liver, and causes sexual dysfunction and catastrophic weight gain. One of my doctors wouldn’t admit that my loss of interest in sex was a side effect of my medicine because he was afraid I’d stop taking it. My poor wife, feeling unloved and rejected, dragged me to marriage counselors, sex therapists, even urologists, then divorced me. Coping skills can reduce the need for medicine, even if they can’t replace it. Very few doctors talk to clients about that.
I had one doctor I’ll always be grateful to. I got depressed once, and time and coping skills didn’t help. I went to him, expecting to take more of something or be given something different. Instead, he cut my Depakote in half and that broke the depression. Another time I asked him to take me off Zyprexa because being 100 pounds overweight was much more dangerous to my health than some voices I could handle with coping skills. He agreed. I’ve lost 80 pounds and am now able to exercise every day. Again, less medicine was the key to recovery.
It’s the therapist’s job to teach clients about medication and coping skills. Doctors don’t take the time.
The relationship between recovery and a job is often a tense, uneven one. Jobs provide money, a sense of self-worth and usefulness, social contact, and a satisfactory answer to the dreaded question “What are you doing now?”
(Being asked that 20 times at a family wedding can make people symptomatic. They feel threatened, put on the spot, and judged when asked that question. Therapists can help the client develop an answer that’s true, based on what the client actually does, not how he makes money.)
But jobs are part of recovery ONLY IF they are congruent with who the client is, consistent with his recovery goal, or a necessary, conscious interim step toward the recovery goal. For a person with two years of college, bagging groceries is not part of recovery. Two more years of college might be. Bagging groceries might be a way of paying for the car the client needs to go back to college. One problem here is that many states give CMHCs incentives for placing people in competitive employment – any job – but not for sending them to school. And our American ethic says that any kind of work is morally and spiritually superior to no work. But clients are often told to aspire only to dead-end, part-time work that will not threaten their benefits.
Twice, in two different states, two years apart, two sets of clinicians decided my illness was refusing to let go of the grandiose notion that I was a writer, not a cab driver. My “cure” was a job driving a cab. That’s what I was doing when they found me, so that’s who I was. Their job was to make me accept who I really was and forget who I thought I was. They never grasped that driving a cab was an isolation strategy, part of the illness, not the cure. In a cab, I could have 40 mood swings a day and no one would be with me long enough to know. I could be psychotic as long as I was quiet about it. When Hollywood made a movie about the deadly effects of psychosis and isolation, they named it “Taxi Driver.”
Seven years of published writing and editing made no difference to these experts. One held my writing folder at arm’s length from his nose with two fingers like soiled underwear and said, “What do you want me to do with this?” Invalidating a client that way is form of emotional abuse.
I said, “If driving a cab is such a good thing, why don’t you do it? I was a writer before I got sick, and I’ll be a writer when I get well.” They said I was lazy, arrogant, looking for a free ride. I was nothing special like I thought I was. According to a standardized test they made me take when I was a distracted basket case, I wasn’t even particularly bright. That writing idea was crazy, impossible, and keeping me sick.
NEVER invalidate a client’s dream, no matter how sick the client seems or how unrealistic the dream appears. You don’t know what’s in that client’s heart. And you can use that dream in positive ways. You can ask the client if he’s more likely to achieve his dream with medication or without. Or you can use that dream to set more realistic, intermediate recovery goals, like getting a car, getting out of an abusive relationship, finding a better place to live, going back to school.
.Recovery is not a straight line. It’s more like two steps forward, one step back, and three steps sideways. It can be very distressing to compare where you are now to where you were a month ago. You might see no progress, or even negative progress. You have to compare where you are now to where you were six months or a year ago. Clients who feel stuck — suffering through those three steps sideways when they just can’t get anything going – often can’t remember six months ago. But the therapist can, and must remind the client that it was not always like this, and it will get better. The client is not really stuck; he just feels that way. These periods are part of recovery and the only answer sometimes is patience and hope.
A setback is also part of the process, not a failure by the client or the clinician. In fact, the clinician has the most important role to play in turning a setback into a learning opportunity, first by letting the client know this is not a failure but part of getting well.
If the setback is a bad outcome from a risk the client chose to take, the therapist’s job is to help the client regroup and get ready to take another risk. Risk is the only way to grow, and the client has a right to fail. But too many clinicians discourage risk because they’re afraid of a setback, and clients buy into this fear. This is one of the most destructive mistakes professionals make, always with the best of intentions.
If the setback is a significant return of symptoms or a crisis, it’s possible for a client, with help, to look back and see what triggered the symptoms, and what early warning signs there were that the symptoms were starting to come back.
Early warning signs can be increased smoking, appetite change, too much or too little sleep, increased anxiety. For Mary Ellen Copeland, an early warning sign is crossing the street without looking both ways. For me, it’s feeling overwhelmed by something I have to do, forgetting or losing things, or trying to multi-task too much.
A sudden humiliation, invalidation or burst of anger can be a trigger. So can a birthday, holiday or other anniversary, or a post-traumatic flashback, loss of a night’s sleep. Each individual should have a personal list of triggers and early warning signs, and a list of things to do when they pop up. This list might include breathing and meditation, an extra appointment with the therapist, phone calls to supporters, exercise, writing in a journal.
The earlier one picks up on the triggers and early warning signs, and responds in a pro-active way, the less severe the symptoms will be. Often you can keep the symptoms from returning at all.
Symptoms, behavior and “recovery assets” are more important than diagnosis. It seems the first thing every clinician wants to know is the diagnosis, even before they meet the client. Insurance companies won’t pay without a diagnosis they can recognize. And sometimes, a formal diagnosis helps a client by telling him that he has a real illness with a treatment, and is not a bad person or losing his mind.
But those labels can be damaging as well. They determine how a patient will be medicated and what self-fulfilling notion professionals will have of that client’s capacity to recover. The label can become a filter that enables the clinician to see what he expects and miss other important things. And the label can stay on that chart for years, through a series of clinicians, without ever being seriously questioned or challenged. It can also change every time a new clinician takes over the case.
If I had mentioned hearing voices to the first clinician who interviewed me – a resident with three months’ experience – he would have written down “schizophrenic.” He would have given me Thorazine and told my parents I would slowly get worse. Instead, he told them I was manic-depressive, and they knew manic depression often responded to medication. So they treated me like I was going to get well. My life would have been totally different – non-existent really – if I’d been labeled schizophrenic.
The best first interview I ever had was with a clinician who started talking about my “recovery assets” even before he mentioned what was wrong with me. My recovery assets included a reliable car, enough money, and a safe, affordable place to live. Also, I was intelligent with good insight into the illness, which made me a good candidate for cognitive interventions. Everybody has recovery assets, and they’re more important long-term than whatever “deficit” brought the client into treatment. Sometimes, the client doesn’t even know what they are. How can a clinician and a client collaborate on mobilizing these assets if neither one knows what they are because no one ever asked? Social workers use the term “strength-based therapy.” It means the same thing.
Avoid unsolicited advice. I remember another first interview with a case manager who informed me, after he’d known me five minutes, that “everyone” with mental illness has a problem with time management, and it makes their symptoms worse. I explained that I worked successfully at a daily newspaper for years, often with five deadlines a day. I had other problems, but I was an expert on time management. “Ever watch television?” he asked. “Sometimes,” I said. “See what I mean,” he replied.
Then he gave me a form and told me to write down everything I did in the coming week, with the time I started and the time I stopped. I did it all week, thinking I might learn something. I brought it back and said I found it insulting. He said I shouldn’t have done it. “You should take what you need and leave the rest,” he said. That’s good, I said to myself. He gives me bad advice, then calls me stupid for taking it. I never listened to another word he said – except once when he gave me advice about Social Security that kicked off a three-month audit and almost cost me my benefits.
To help clients recover, clinicians must finally revisit their all-powerful, all-knowing, “I’m OK and you’re sick” posture. When I say it that way, it’s obvious, but when clinicians say it, they use the word “boundaries.”
The traditional notion of boundaries must be re-examined. A recovery-based relationship has definite boundaries, but is more mutual, more equal, more “we’re in this struggle together.” I don’t have all the answers. I don’t necessarily know what’s best for you. I can help you form the questions and clarify what’s really important to you. I can help you analyze problems and create alternatives for yourself. I can help you discover coping skills. I can help you tease apart your anger and shame, and find ways to overcome your isolation. I can help you break your big goals down into smaller, measurable, time-related, achievable goals. I can help you get up when you fall. I succeed when you succeed and I suffer with you when you slip back. I believe in you and am committed to you.
For clinicians accustomed to the old, rigid boundaries, this might turn out to be the hardest change. But it’s the one that makes all the other changes possible.