mental health - "recovery"

Wither "recovery" today?
     The mental illness industry has once again glommed onto its treatment flavor of the month from those who are in the system. The clients argued during the 1990s that people can and do recover from prolonged bouts of psychic/spiritual/emotional disabling experiences (short version "mental illness") and, eventually, many service providers got the words but not the message.
     Some have partly gotten the message, going so far as to self-disclose during therapy sessions with "their" patients. But many just mouth the words without having any idea what they are talking about.
     As an academic or clinical concept, "Recovery" drew attention as far back as 1985 when researcher Courtney Harding and John Strauss conducted a long term follow-up study with people in Vermont [taking date gathered in the 1960s] to see what success they had (if any) at "recovering" from their travails.
     The findings of their work revealed that as many as 66% of the people once believed to be "forever ill" had gone on and left the mental health treatment system. A number of those interviewed said they recovered "in spite of" what the system proffered as care or services.

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Photo to the left ~ typical of housing provided from the late 1800's until the end of the 20th century

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     Now, more than 25 years later, the career bureaucrats have latched on to this and suddenly embrace the concept like a fuzzy toy, while further try to shoehorn the idea in with their own career objectives. Show "success" and maybe they will go on and get accolades at a national conference.
     But what they are still doing is riding the evident success of some who were once severely disabled without ever having done much more than fill out some grant applications from SAMHSA [that's the Substance Abuse & Mental Health Services Administration, an arm of the federal government].
     Alright, maybe that sound too cynical, but they are still slow on the uptake. And, by trying to make the process of recovery ~itself a very personal journey~ into some facet of the rehabilitation treatment model for mental health, they show how far they miss the point.
     What point is that, you ask? Point being that rather than create a new set of complex treatment plan curriculae and models and workshops to force non-comprehending staff to encourage or cajole "their clients" into following in hopes they get better (so as to allow the system to meet "measurable goals" and satisfy funding sources) how about providing people with:

• Affordable Housing
• Supportive, non-judgmental helpers
• An atmosphere of safety
• Chances to be treated as equals
• Combat the prejudices of a society that devalues people who don't appear to be "doing anything"
• Ask people what seems to work for them when in crisis ~and then make sure its available
• Make certain that basic needs of food, clothing, shelter, ability to get around are ensured
• LISTEN to people who suffer and/or experience disturbing discontinuities of thought
• Help provide people ways OUT OF the treatment system

     ...to name but a few things that could be accomplished ...or at least tried for.
     Finally, do things to help a person integrate back into the larger society at their pace and preference, rather than create a subordinate caste with "clubhouses," or programs and services that already duplicate what may exists out away from the mental health system funding and employment machine.
     Just wondering.

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IMAGE SOURCES: "Tell Me..." face: International Journal of Psychosocial Rehabilitation; [left side] South wing of Weeks Hall, Middletown CT - destroyed in a fire October 2010; [right side] Gate in the Callan Park Mental Asylum, Sydney, AU - Frangipani's Flickr Photostream

mental health - Recovery is not treatment

"Recovery" is not a "treatment modality". For at least three decades [longer, if you go back to Clifford Beers] advocates, ex-patients and dispassionate observers have repeatedly argued that people can and often do, "recover" from long lasting disabling, debilitating conditions and experiences.
     At the same time, the idea was scoffed and dismissed by high ranking administrators and clinicians, citing [still] the ghosts of Kraepelin and Beuler as the rationale for why such an idea was untenable. "People don't recover from 'mental illness.' Their lives are lost and so is any hope for them doing much better" the clinical careerists would steadfastly maintain.
     Little or no thought was given to asking patients in mental hospitals what might be their wishes, hopes, dreams, or aspirations to achieve.
     Bean-counting bureaucrats spoke of "bed spaces," "treatment modalities" and "managed care." They asked drug companies when "the next miracle drug cure" would get people out of institutions and back on the streets.
     The standard response to those who had different ideas about treatment, care or rehabilitation, was to ignore them, keep them from the decision making process and to demean and invalidate the critical voices that offered options.
     Now, times have changed. Budget constraint called for innovation and "outcomes." Major funding sources started telling them that "recovery is good"! Gradually, those same clinicians and bureaucrats who walk past patients without seeing them took up the call.
     However, while the language has been embraced, other obstacles remain. "Clients" get wheedled and cajoled to large group meetings and say the process is "patient driven." Abusive staff and practices continue unabated. Known wrongs that take place fail to get "substantiated" when only patients witness those wrongs.
     How can this be? That bureaucrat driving his new custom SUV to the workplace while the patient gets penalized by Title 19 with "spend-downs" on maybe less than $500 a month. Patient driven huh!
     Folks, you don't have a clue.
     Admittedly, the samples mentioned oversimplify the problems inherent in social injustice and lack regard for people with mental illnesses. Administrators, Nurse Educators and other who shape professional opinion are still no different than the society at large. But my point would be the same no matter what quick capsule glimpse got noted.
     Recovery is not a treatment modality! The reasons people can and do recover are many and multifarious. But they come as much [or more] from within.
     "Recovery" may or may not include taking medications. For John Nash [the subject of the film A Beautiful Mind] they by and large did NOT, no matter what the film said.
     "Recovery" may or may not include assistance from mental health programs. In the case of survivors in the Vermont Longitudinal Study in 1987, for a goodly number it was in spite of what services the "system" provided.
     Recovery is a process It involves learning to live with complex and inexplicable phenomena [that many may call delusional], of freedom from unrealistic pressures to "get over" that phenomena within discrete time frame, and of being considered, cared for and loved as a fellow human being by others. Simple as that.
     How much more difficult this is to achieve in a society and culture that does not value those souls who are not immediately responsive to time-motion-study lifestyles. So challenging to those who drive efficient bureaucrats to distraction with abstruse, and often unexplainable questions. In the long run, it may call for dramatic and complete changes in cultural attitudes and norms, not something so easy to implement when it isn't even discussed.
     So...if you, the fashionably dressed mental health careerist can grasp this, then next time you wish to speak to someone -anyone, even one of your professional colleagues- about "Recovery" for people with living dramatic, even severe, cognitive / perceptual dissonance, then do so only after you actually drop your important paperwork and pre-occupation with meetings and give someone the time, energy and effort to sit with and actually get to know some of those persons who walk past you daily, but of whom you only know by diagnosis. Incidentally, it's a whole lot cheaper than funding the psycho-pharmaceutical companies, but takes longer to see results.
     Now that would be a step toward recovery.

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SOME RESOURCES: Clifford Beers' A Mind That Found Itself, National Empowerment Center, MindFreedom, Mary Ellen Copeland's Self-help Strategies

mental health - Toronto "community" to replace old Asylum

 • A Canadian architect, Frank Lewinberg, and a psychiatrist, Paul Garfinkel, have teamed up and planned for a nice new neighborhood for "the mentally ill".
     They acknowledge the limits of their vision, writing that “the history of urban planning is littered with idealistic projects that withered in the harsh light of everyday living.”
     A recent article in Canadian Architect quotes Garfinkel:

"People need to be treated in a respectful, dignified, holistic manner that sometimes requires them to be confined in a hospital voluntarily or involuntarily. The more we normalize the hospital stay, in keeping with safety and security, the better it is for the person's recovery, and ultimate reintegration. Normalizing starts with an urban village, like the rest of the city, but it gets into the nature of public space, treatment space, what our hospital rooms look like. We want to make [the hospital] a more homelike setting, just as you would want in a normal community."

     Dr. Garfinkel claims to be especially critical of the "biological reductivism" fashionable in psychiatry for the last 30 years, a theory that lays great emphasis on medication--often, he believes, at the expense of the patient as a whole person, and at the expense of the settings of his treatment.

     I have worked with, and on behalf of, people with psychiatric disabilities for over 20 years. I remain skeptical about the plan. This isn't a plan for a new neighborhood, it is adding more office rental space while tossing a few bones to the clients and community.
     Not only because the rationale behind building the great Victorian-Era behemoths that housed "the Insane" was based on providing mad people with sylvan settings; but also due to the fact that the plans ~ as extensively described ~ show more effort going into office space for clinicians than to actual housing. That housing seems to be limited to three ""alternative milieu" dwellings: 72 motel-like rooms, with private washrooms and lockable doors, for patients who still need hospital care, but who have progressed beyond the acute stage of their illnesses."
  •  "Housing" people in "motel style" accommodations does little to restore a sense of normalcy to one's life, yet that seems to be the only client housing being given serious consideration in the multi-blocked endeavor.
     Moreover, if are planning a community, why is there only circumstantial mention of cultural amenities? Instead "...the exact nature and placement of the non-hospital uses have yet to be determined, a grocery store and health club, scientific institutes and laboratories, cafés and private residences have been mentioned."
     During the reconstruction phase, The Workman Theatre, a popular visual and performing arts gathering place, "...a space much loved by local residents and others throughout the city...," operated and managed by people with psychiatric disabilities, [and funded, in part by the Centre for Addiction and Mental Health, Canada's largest mental health and addiction teaching hospital and the agency that stands to benefit from reconstruction] will be demolished.
  •  To destroy the Workman Theatre without having prioritized a replacement structure ~ is patently absurd! It is a popular gathering place, run by clients and former clients of mental health services. Across the continent theatre groups run by ex-patients have shown themselves to helps bolster self-esteem, foster independence and self-determination. Toronto's Centre for Addiction and Mental Health (CAMH) partially funds the theatre group; it is a bafflement that CAMH management would even consider razing a structure so integral to helping mental health service clients in recovering.
  •  That single action alone speaks volumes about the arrogance of clinicians towards the clients the agency supposedly serves, and makes a lie of any claims that CAMH may make about "...advocating for public policies [and practices] that are responsive to the needs of people with addiction and mental health problems." Why eliminate the Workman Theatre, a truly integrated service, that actually provides supportive services that CAMH claims they want to offer?
     If Lewinberg and Garfinkel really wanted to help developing a community that helps "normalize" life for people with psychiatric diagnoses, and help folks integrate into the larger society, why then act like just a real estate developer hawking densely packed office buildings? How about affordable housing and street level spaces for small businesses. So much for an clinical commitment to the Recovery Model. And practically nothing to promoting "Community."

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IMAGE CREDIT: Rendering of one of the new buildings by Montgomery Sisam Architects

harm reduction - Restraint + Seclusion Training

For those of you new to this weblog, I work at a large psychiatric inpatient facility.

A couple of years ago the facility where I work established a goal to eliminate the use of mechanical restraint and seclusion.
     Although this effort was first met with opposition, and there were a significant number of direct service staff who fearfully argued that such an approach would result in more assaults and injuries, in fact, the opposite occurred. Statistics show that as restraint interventions became less frequent, the number of injuries and assaults went down. Another thing that was done [thanks, in part due to mandates from the Center for Medicare and Medicaid Services] was to dramatically limit the length of time that a person could legally be placed in mechanical restraints.
     Perhaps most important, the values that provided the foundation behind the move to eliminate mechanical restraints are based on the premise that people with long term "chronic mental illnesses" often can and do recover; if the treaters would but recognize this truth.
     As these values translate into organizational policy [and clinical practice], the state's Department of Mental Health's training manual on "Safe Recovery Orientated Environments", teaches the following:

Safe recovery orientated environments have several essential cultural characteristics. Our focus is on these three:
• Risks are continuously prevented and managed to provide the safest environment possible.
• Care is customized to the individual and is focused on fostering recovery – our focus today is on helping people self regulate dangerous behavior.
• All people are treated with respect and dignity. As such, the use of R/S imposed as a means of coercion, discipline, convenience, or retaliation by staff is not permissible. Instead, everyone works together to find paths to recovery.

“The best way for you to BE safe is to help your patients FEEL safe”.

     Translating these points into everyday clinical protocols is a dramatic remove from the conventional wisdom practiced at most psychiatric facilities. Instead, industry standards are more often based on the flawed teachings of Dr. Benjamin Rush, who, in 1813 published a treatise entitled Medical Inquiries and Observations Upon the Diseases of the Mind, indicating his recommended treatment for "the Mad."

...if all the means that have been mentioned should prove ineffectual to establish a government over deranged patients, recourse should be had to certain modes of coercion:
   1- confinement by means of a straight waistcoast or of a chair...
   2- privation of their customary pleasant food;
   3- pouring cold water under their coatsleeves, so that it may descend into the armpits and down the trunk of the body;
   4- the shower bath continued for 15 to 20 minutes.
   If all these modes of punishment should fail in their intended effects, it would be proper to resort to the fear of death. - By the proper application of these mild and terrifying modes of punishment chains will seldom, and the whip, never, be required to govern mad people." page 181 [the chair shown just to the right is what Rush had patented as his "tranquilizer chair"]

     Rush is widely regarded as "the father of modern psychiatry". His writings first codified his beliefs almost 200 years ago. His premise was that forced, brutal and coercive treatments were what worked best. Even now what continues to pass for inpatient psychiatric care goes back to that, and many still [who work with "the MAD"] do not seem to question Rush's opinions since the day he penned them.
     Although there is still a coercive tone to the place, in the past decade where I work has changed dramatically. Many staff, if they do not actually embrace these new values, recognize that they are expected to comply with their enactment. And there still remain some who yearn for the "good old days" when they could tie down people for days at a time without any oversight or official complaint. That still has to change ~ not just where I work, but throughout the "system". More sobering, the place where I work is just one of hundreds [thousands?] such facilities across the continent.
     While progress is slowly being made on eliminating mechanical restraints, there is still scant consideration regarding the widespread use of chemical restraints that are psychiatric medications.
     Virtually nothing is done about treatment-induced ailments such as: learned helplessness, clinically encouraged self-absorption or the disdain for self-determination. There are also the traumatizing effects of living with the impacts of cumulative institutionally induced emotional and psychological manipulation and abuse; of being constantly treated and regarded as a less-then-normal patient/person. All these have bearing on a person's ability to get to that state of "recovery".
     And I'm not even going to begin to address the total lack of clinical interest in seeking non-harmful interventions that are outside the mainstream, nor the aversion to spiritual quest paths as a means of healing one's self.
     Administrators - both in-state and elsewhere, boast we are among the best of the lot. They should not yet rest upon their laurels. And for the "patients" in the other places? We - and society - still has a long, long way to go before truly becoming coercion free.

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COMMENTARY SITES ON THE STATE OF THE MENTAL ILLNESS INDUSTRY: 1- Beyond Meds; 2- The Standard Review / Diversity Rules; 3- The Icarus Project
COMMENTARIES ON MIND/SOCIAL CONTROL: Are your thoughts your own? Turn off the TV Set!; Richard Gosden's Coercive psychiatry, human rights and public participation [first published in 1999, ever bit as relevant today.
IMAGE INFO: Dr. Benjamin Rush's "Tranquiliser Chair." Rush, ironically, was one of the signatories of the US Declaration of Independence; Pillhead found online some time ago; source unknown

mental illness systems

I work as a human rights advocate with and for people with psychiatric disabilities. I got started doing this after watching a friend get bounced back and forth between agencies and medications by workers (from line staff to psychiatrists and administrators) who had scant regard for human suffering. That was 27 years ago.
I can't say that much has changed.

Sure, the use of mechanical restraints has been reduced somewhat.
But it was the unnecessary deaths of poor souls held in them for unconscionable lengths of time - resulting in a highly publicized political outrage - that brought that change about, not any great change in public consciousness or caring. Human indifference about the sufferings of "...the mentally ill..." continues to remain a constant.

It is also sobering to witness how those who hold the purse-strings have adopted the words of the mantra first chanted by 1970s era ex-patient activists - that people with prolonged suffering can "recover". Yet the actions of the administrators have not evolved into either effective caring or coping options for those supposed to be the beneficiaries of clinical largesse. MH System administrators (and clinicians) still work hard to hinder their clients' from recovering.

Mind you, I'm not writing about CIA funded psych crimes like MK-Ultra or even the "extraordinary rendition" abuses conducted during the heyday of the Bush/Cheney era Iraq adventure. I'm thinking more of the little tortures, that eat away at one's soul, yet are encouraged and promulgated by folks making life-altering decisions about others yet who completely lack vision or understanding about the impacts of what they do. These little tortures are instead everything from lecturing people about obesity while prescribing drugs that cause rapid weight gain (such as Seroquel). Or denying people fresh air, or pushing clients into low paying careers (it is still the food - filth - filing and tending to flowers that are offered as "job possibilities") instead of trying to discern what people's talents are.

Finally (for now, at least) there is still no safe haven for people in crisis to go to. People still have to wait to when they are no longer able to make thoughtful self-admissions (ofttimes when many are actually willing to seek help) when at the most acute levels of psychic pain, to get into mental health facilities. They have to suffer indignities like social isolation, attempts at self-injury, or even arrest - before admitted in emergency to be shot up with drugs that numb one from reacting to adverse symptoms, but do little to make those symptoms go away.

I have no solution for correcting these societally tolerated wrongs, but I'm still not giving up. My friend still suffers from poorly designed treatment options - conceived mostly by people with no first-hand knowledge or experience what it is like to be on the receiving end; the very least I can do is make sure he isn't also horribly abused.

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LINKS TO FOLLOW: Organizations and people who promote social justice and fairness in metal health: Mind Freedom, Ecopsychology Community, Freedom Center,