Defining Recovery

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Yesterday, Dr. Daniel Fisher emailed and asked my thoughts with regard to “recovery”. Even before I walked away from prescription-pad-only psychiatric work, others asked me about this. Other treatment providers, designated patients and family members asked what I thought they could expect to happen next and what they should do to make things better. I told them that chemical interventions are not the only, or even the essential, tool for recovery. Adherents to mainstream pharmaceutical beliefs expressed distress over my lack of faith in tablets and capsules.

What recovery means is a central issue.

I’m happy to have been asked for my thoughts. I love opportunities to explore ideas. If recovery is what we want, we should know what it is. If we don’t know what direction to point our boats, how will we know which way to paddle? And there’s a lot of paddling to do. Thankfully, there are many of us to do this work, each in our own way.

Listen for the message inside this story: Yesterday I went body boarding in the ocean with my family. These waves were the best of the winter. They weren’t the biggest, but there was a lot of power in those low sleek waves. This winter there have been a lot of storms. The surf has been brown, thick with debris and crashing high. The power in those enormous waves dissipated itself by bashing every direction at once. They knocked us off our feet and didn’t go anywhere. The clean lines of yesterday’s smaller and more consolidated waves carried us fast and far.

It would be convenient to define and validate measurable, countable and researchable features of recovery, things we could study to obtain “proof” that alternative paths to reach this condition are scientifically valid. Those that control the purse strings demand words like “evidence based”. We could eventually enter the playing field of mainstream medicine with our research protocols and data, our charts and double-blinds. We could make them listen and believe, fight research with research. When in Rome, do as the Romans do.

But those designated as patients in our society are people, warm soft humans that come in an endless variety of selves that are built from differing gifts and life experiences. When asked how I define recovery, I must begin by saying that I know every single person on this planet is recovering from something. And they are doing it in their own unique ways.

Another story: There was once a woman whose baby was taken unexpectedly from her by death. In the depth of her enormous pain, she called out to her God to restore her beloved child to life. God answered like this: “If you can find one person who has not suffered such a loss, I will do as you ask.” So the woman walked from village to village with her dead child wrapped close in her arms. She questioned every person she met. But she could find no one without such a loss. Every person she asked told her of their own griefs. At last, she returned home and gave up her child to God.

All of us are recovering from something. All of us.

I’m not so good at research definitions and statistics. There are others who are. I failed my long-ago attempt to make it in the world of professional medical academics. I researched the use of group therapy in recovery from addictions. Back then, I didn’t realize that the money, and therefore academic success, was in the pills. When I wrote my discussion of the processes and effects of group therapy, I talked about the people and their improved happiness. I explored the lovely things that happen when a group of people sit together in a circle and talk and listen. People discover that they are more alike than different. They discover that, despite the infinite variety of life experiences and despite their differences, they share an essential commonality of human spirit. They all want to feel happier and suffer less. My article got published only after all this had been cut out. Just the facts, ma’am. My grant request to study more about powerful therapeutic group relationships was denied. I was shown the exit ramp from academics.

I don’t believe there is an endpoint for recovery. There’s no one-size-fits-most set of criteria which mean you’ve reached your full human potential. I am at heart a follower of processes rather than a goal collector, a “feeler” rather than a counter of beans. Recovery is a verb to me, not a noun. It’s a process, not a goal.

The belief that there’s a quantifiable and universal state called “recovery” sets a culturally defined finish line for those designated as patients. Being graded and judged by the life standards of others, gives me chills. My life works well for me. Others may judge it broken when compared to the current American paradigm. There are those who need help obtaining their basic needs of life: food, shelter, safety and loving relationships. There are those who can help. Where you swim in this pond varies over time.

I like this new label, “lived experiences”. This designation of those with lived experiences creates a special belonging group for those that have lived through personal encounters with the psychiatric system. The intention is for people who have similar experiences to be in a group and share unique understanding and support with one another. Listening and sharing, understanding and support are good things.

I also like the inclusive sound of these words. All of us carry our lived experiences with us. We all continue to grow and change, make new relationships with our perceptions and have changing recollections of our lived experiences. This path of growth and change is the essential meaning of the recovery process to me.

It’s easier for scientists to measure and calculate endpoints and outcomes. It’s more complicated to study the process of personal transformation. Recovery is a meandering path made of starts and stops, backs and forths and arounds and throughs. There are times that the next leap forward is preceeded by slipping back.

Here is my measure of the recovery process this morning:

Are you happier now and suffering less than you were before?

Thanks for enquiring, Dr. Fisher. I wouldn’t have written this without you. This will take all our fine minds, together.

Thanks to everyone for inquiring, reading, thinking and writing.

All the best.

Alice Keys MD

 

 

34 COMMENTS

  1. At the risk of being contrary I would just like to posit an alternative perspective.

    While I agree recovery is a process it is also a subsidiary concept . What is most important is having a meaningful life and having a meaningful life is also the most important part of recovery.

    While I agree from a personal perspective the recovery process can go on endlessly this perspective also hides risks. The first risk is that it makes recovery an impossible goal. One can never say one is truly fully recovered in that case. Exactly the position people labeled with schizophrenia have always found themselves in. The second risk is that by having “fuzzy” definitions of recovery, that service providers take the chance to define it themselves, usually what happens is they just re-badge what they are currently doing as recovery oriented.

    Ron Unger is very good on this topic.
    “I believe that recovery remains a useful concept, but also that it will only give us leverage to change the system if we give it a clear and powerful definition, and resist efforts to water down that definition.”

    http://recoveryfromschizophrenia.org/recovery-why-is-it-being-redefined-to-mean-doing-better-but-still-mentally-ill/

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    • Dear Poet,
      Thanks for taking the time to read and respond to my essay here. I am delighted to have the opportunity to think about what you write. Every interaction gives me a chance to explore ideas further.

      You say this so much this better than I:

      “What is most important is having a meaningful life and having a meaningful life is also the most important part of recovery.”

      I agree with you completely.

      I also agree that mental health agencies are very good at “re-badgeing” (re-branding?) whatever they do as being in line with whatever the current word is. Examples: if “case-management” is what’s paid for then “case-management” is what we do. Exactly what is done when one does “case-management” changes over time.”Med-management” now means a brief ‘howdy’, lots of typing and prescription refills. What is being “managed” here?

      What kind of “recovery” is being facilitated when the primary “treatment” is a prescription? In my experience “recovery” inside financially strapped “mental health providers” currently means “stable on meds” which means “may be transferred to the primary care doc care for ongoing refills”.

      When I think about humans and recovery, I don’t think about recovery in terms of having “leverage” over what mental health providers do. I think about each person being in charge of moving their life forward in a way that makes sense to them.

      I suppose this all means that I’m not the best person to help formulate a “clear and powerful definition” of the “goal” of “recovery”.

      Thanks again for letting me have a chance to write more here.

      All the best.
      Alice

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  2. I love your post, Alice. I love your way of writing and your thinking. I am relatively new to this site, and this makes me want to read more!

    That said, I see things in a different way. 🙂

    I don’t like to use the word recovery in terms of health. Some people don’t have the option to retain a prior state of health and/or well-being. Perhaps one day they will, but people living with chronic pain, HIV/AIDS and any number of other things, often can’t (at least yet!) return to a prior state of health. And some people have nowhere to go back to, with trauma, pain and trouble having presented early in life.

    So, unless recovery means something different than our current definition, it doesn’t work universally. And if it does mean something different? Then what does it mean? I keep hearing about recovery and the recovery model and recovery programs. But what constitutes recovery? And what is the recovery model? In some cases the use of the word is actually a reflection of shifts taking place and things moving in a more humane direction. But in some cases it is a matter of simply adopting new language while doing the same old thing.

    I think that recovery means different things to different people, and sometimes even to the same person, over time. I think that each person should decide what recovery means to them, and when they have achieved it. And while I understand your thinking, I think the idea that recovery is a lifelong process is an overwhelming and exhausting one. Additionally I think that if we are to create real, lasting, systems change, we need to be able to identify and include in every single contract, specific healing outcomes that are required, and then not stop there, but actually hold the system accountable. We need to require (and contract for) services that recognize, support and sustain healing.

    The system, very sadly is all too often driven by money, when it comes to the big picture. If we attach to the funds paid out, healing outcomes expected and then we actually require fidelity, quality and accountability, I think we can actually create change.

    Kathleen

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    • Kathleen,
      Thanks for reading and commenting. I appreciate your kind and encouraging words about my writing. I love to write. And welcome to MIA. I enjoy the variety of perspectives and expertise in both the regular contributors and the commentary.

      I see your point about not liking the use of the term “recovery” in medical areas like chronic pain and HIV/AIDS. Recovery implies a return to some prior self. Even injuries we think of as being healed and recovered like broken bones may still cause pain from time to time later and need to have some additional care. I suppose there may be similar issues with the word “heal”. How does one “heal” from chronic pain? By definition you have it for long term.

      I’m sorry if a life-long process of recovery sounds “exhausting and overwhelming” to you. I can see how you would feel this way. I think you’re not alone in this response. But to me, having a lifetime of opportunities to change and grow gives me chances to continue to make myself over. From time-to-time I re-evaluate and re-frame old experiences and perceptions and find more peaceful ways to live with (or around) them. Thinking I have to be “done” or “not done”, healed or not healed, recovered or not recovered makes me feel like I’m waiting to be graded. And I always hated that.

      I’m familiar with the process of “being in recovery” of friends of mine that go to 12-step meetings. (Please. Any expert in the 12-step recovery process can speak up here and correct me.) Being “in recovery” sounds like a life-long process. One friend has over 25 years “in the program” and still considers herself to be “in recovery”. It doesn’t sound like she has to work at the same level of intensity on the same things now that she did once. “In recovery” seems an evolutionary process. I’ve never heard her talk about “being recovered” in a ‘done with it’ sort of way. I also hear her talk with great enthusiasm and hope about her process.

      Specific outcome measures are currently required in every mental health agency that accepts state funding. A lot of time is spent making an individual treatment plan or contract with each person. Every interaction that is paid for must be linked back to agreed upon, measurable and countable improvements. At this time, every agency is held financially accountable to the paper trail that documents that this is happening. I have seen agencies have to pay back a lot of money because of deficits in the documentation trail. This is why they type so much.

      Thanks for reading, thinking and writing.
      Alice

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  3. Alice,

    A lovely post – compassionate and accepting of how complex we and the world are. Paris Williams, in his book Rethinking Madness, formulates a definition of “recovery” that is compassionate, honors our humanity, and at the same time provides standards that can be used in research. At the same time I don’t think he would argue for a minute that those who don’t “meet” his standard of recovery are in any way “less than” or “sick” – just living and addressing their concerns in a different way.

    For me, “recovery” is not very useful. I assume each of us is inherently intelligent, loving, strong, courageous and possessed of energy and enthusiasm. Whatever, in our own minds, stands in the way of feeling, thinking and acting in ways consistent with that picture, is what we will be working on. As we change, progress or get pushed back, there are always new goals we can choose to work on, if we want to.

    For myself, the goal is to have a meaningful life. That can take many forms and is a far more profound and worthwhile goal than simply being “free from psychopathology.” Abraham Lincoln spent years being “depressed,” yet he apparently also got much satisfaction from life, worked tirelessly and made a difference to his fellow humans. Churchill took his country through WWII, yet he drank like a fish. I admire people like Martin Luther King, Eleanor Roosevelt and others who cared deeply about people. It is a disservice to anyone you propose to “help” not to have the attitude that they can have dreams, work for them and fulfill them.

    “Mental health” and “mental illness” are constructs imposed by others, for their own purposes, on us. Living like a real human is a far higher calling, and is a goal that is worthy of how good people actually are.

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    • Peter,
      Thank you for your support of my writing. I’m happy to hear that you enjoyed reading my essay.

      Your reply is eloquent. I see that “recovery” may not be useful to you personally as a concept. You sound like someone who is internally directed in your living. Perhaps recovery could be seen as a process in which a person becomes more internally directed, if they want. I suppose that a person choosing to relinquish internal control could be making an internally directed choice as well.

      In the olden days, when I was still able to do “talk therapy” with people as a psychiatrist, exploration of personal internal choices was an important part of this work. Even not making choices for oneself are kinds of choices. Being aware of how we give away our personal power and choices to others every day is a starting place. Examples: Saying “You make me mad” hands over control of your feelings to the object of your anger. Borrowing money gives away your power to choose how you spend your time and money in the future.

      Perhaps the focus of “helping” could begin with asking whether a person wants help and what sort of help they’d like. Even the most confused appearing adult is still an adult. The next step would be to listen well. I have asked many people presenting to psychiatric emergency care what they want. I hear things like safe housing, a job, to stay out of jail, food, to feel better, medical care, help sorting out a troubling issue. There are a lot of requests for pills but there are a lot of requests for help with basic needs.

      I agree that “mental health” and “mental illness” are cultural constructs. Today these constructs focus on behaviors that are unacceptable to the surrounding community, like sleeping in doorways and talking aloud to one-self in public. I suppose there may be other ways to manage these socially unacceptable behaviors than our culture’s current two-pronged management approach: drugs and/or incarceration.

      Having said that, I should add that I think there is a place for psychiatric drugs still. I have seen people, through the use of psychiatric drugs, regain their ability to be internally self-directed that they had lost while experiencing extreme states.

      Thanks for entering the discussion with me. I think of more to say when I meet others here.
      All the best.
      Alice

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      • Alice,

        As to, ” … I think there is a place for psychiatric drugs still,” – you sound like one of the few who can be trusted with that statement. 99.9% of psychiatrists cannot; they will likely agree that the drugs are “overprescribed” or “misused.” But the devil is in the details, and when it comes to specific cases, they almost always decide drugs are needed.

        It’s all about informed consent, and a setting in which considered decisions are possible. I like Open Dialogue’s practice of discussing drugs at 2 or 3 meetings with the client and her/his support network before any prescription is written, and generally a short course of benzos takes the place of neuroleptics.

        Open Dialogue values the meaning behind the content of delusions and hallucinations (and the client’s freedom to express what they experience), as important contributions to the process in which the client and his/her social network develop new understandings about their relationships and the client’s problems. Open Dialogue wants clients alert and feeling things so they can express what’s going on with them and respond to others. Therefore, they have less incentive to drug clients just to knock down psychosis as a precondition to any progress. This allows them to truly give drugs sparingly.

        American psychiatrists don’t have the chance to work within an Open Dialogue setting, in which the treatment team meets with client and support system 10 to 12 times in the first two weeks. The ability to really interact with clients makes the “need” for drugs a lot less. But it is something to aspire to. The greater the chance for psychosocial contact, the less the temptation for drugs, and the less clients feel drugs are their only credible route to relief.

        I recommend Dialogical Meetings in Social Networks, by Keikkula and Arnkil, in addition to Paris Williams’ book on all this. Thanks for your valuable contributions.

        Pete

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        • Pete,
          It’s nice to hear back from you.

          My thoughts on this that you wrote:

          “… when it comes to specific cases, they almost always decide drugs are needed.”

          This is true. People that work in psychiatric clinics are “afraid” not to prescribe drugs and more drugs. One cause is something the APA puts out, standards of practice or practice guidelines. I’ve forgotten what it’s called. There are also “community standards of practice” that require a kind of consensus prescribing habit. There are also clinic “standards of care” written by medical directors. There’s not much latitude for thoughtful work. Anyone who doesn’t toe these lines will be left out alone on the legal chopping block if anything goes wrong.

          They are afraid to reduce drugs, even complicated pharmacologic soups that no one could possibly know the effects of. There is a pervasive fear that people will become dangerous with drugs are reduced. I recently suggested at a job interview that I would be inclined to reduce and simplify med combinations if I worked there. “You can do what you want,” I was told. “But we don’t want anyone getting hit.”

          Open dialog:

          You’re right. Psychiatrists have not been allowed to even see patients before the decision has already been made that there is a “need for medication”. Open dialog sounds like a great process. Where is this happening?

          Thanks for your thoughtful input here.
          Alice

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          • Alice, Open Dialogue is in northern Finland. It is described in the book I cited, but a shorter, more technical piece that describes its excellent 5 year outcomes is: Five Years’ Experiences of First-Episode Non-Afffective Psychosis in Open Dialogue Approach, in Psychotherapy Research, 16 (2): 214 – 228. At 5 years, over 80% of patients were without psychosis and working, in school or actively seeking employment. I recommend the book, though – it is hard reading but if you stick with it, you get an eye-opening, phenomenological paradigm not based on diagnosis (and with very limited drugs) – that works. It is what the phrase “paradigm shift” was coined for. Thanks for your contributions – Pete

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          • Pete,
            I’ve heard of this program in Northern Finland. I’d forgotten it was called “open dialog”. When I read what you wrote earlier, I had a flash of optimism that there was something akin to this in the U.S. I had a spontaneous hopeful vision that there was one here. Rather like the two Soteria-style programs and the Second story peer support respite in Santa Cruz. I guess not then.

            In my private practice I found that people with episodes of psychosis do quite well on low dose and no medicine. This required a strong supportive treatment relationship, an individualized approach and flexibility of how we worked together over time. This meant keeping in touch very frequently at times. Sometimes it meant a house call. One universal goal was to avoid the hospital. We made plans on what that would take.

            I would like nothing better than to see an “open dialog” style approach here. When I brought the idea of this treatment approach up for discussion at work, I was told I had to be realistic, that these kinds of treatments only work when people have more resources (money and social supports). I was told the best we can do is stick with the medicines since this is what we have available.

            The people I’ve known that work in mental health are good people who are there because they want to help. There’s not a lot of room for movement to change things inside any company. A company has a life of its own. Bean counters have to sharp to keep a company alive. That knife cuts out a lot of choices.

            Any idea of the cost to run this? I know this treatment is effective. But people always want to know the cost, how much bang for your buck you’ll get and where the “resources” will come from.

            The bean-counter way of program development here is very short sighted. It thinks in quarters and fiscal calenders, terms in office and annual block grants. It doesn’t calculate the cost of human suffering, early death and long term financial costs of secondary medical illnesses from the drugs.

            I think 80% working, in school and looking for work sounds like a lot fewer people trapped in lifetime of disability and expensive drugs.

            Thanks a lot for clarifying this for me.

            Alice

            But what do I know.

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  4. Thanks Alice! I love the word recovery because it gives me hope that one day my son will be better. When we brought him to the hospital three years ago, the psychiatrist in the emergency told us he had a chemical imbalance in his brain and he would be fine when they medicated him. The next day they asked him to fill out medical disability forms. They told us that he would never be able to finish university or work because of this “disease” that they had diagnosed after seeing him for 15 minutes. When he got worse in the hospital they said he needed more drugs. That was three years ago. He is now off all meds and has been at the same job for over a year. It was Whitaker’s book that convinced me to let him find his own recovery while everyone around me was telling me to have him committed and force him to take his meds. Many thanks to Robert Whitaker and the people on this website for supporting me while my son “recovers”.

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  5. What a great post Alice! Sometimes it’s easy for me to think that “recovery” has an end point.. what I’ve come to for myself is a statement that doesn’t use the R word: “As far as I’ve come, I will always have that far to go again!”

    It helps me recognize my growth as well as realize it’s ongoing and lets me frame different experiences through a variety of lenses. I can see how and where I’ve grown and developed new skills and ways of being and I can see where I may wish to “tweak” something. It’s more developmental and learning based than anything else.

    Thanks again for your clarity!

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    • epower,

      Sorry to be slow responding. Your post slipped past me in the line-up.

      The “R” word. Reading this makes me smile this morning.

      Thanks for reading my post and for your support of my writing. I always hope to strike a chord with readers. I’m glad to hear that your personal growth is progressing. Re-framing has always been an important part of my own process of becoming as well.

      Thanks for your comment. Keep reading and writing.
      Alice

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  6. Alice,

    I don’t use the term recovery because the institution where I work coopted the word. They put the word “recovery” in their new mission statement but continue to do the same old things they way that they’ve always done. For the staff where I work, “being in recovery” is taking the drugs as you were assigned and commanded to do.

    I don’t use the word for myself because of what you mentioned; “recovery implies a return to come prior self.” I’m a different person now from the one who went into the system. I’m a stronger person and a more understanding person than I was before. I don’t want to return to a prior self. I do see all of this, whatever we eventaully call it, as a “process.” I used to teach my students something that I called the Principle of Being. I told them to always refer to themselves with words ending in ing since humans are capable of being in process, of changing, of discovering new things. Life is a rushing, surging river rather than a stagnant pond. I like Pat Deegan’s definition of recovery. “The task is not to become normal. The task is to take up your journey of recovery and become who you are called to be.”

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    • Stephen,
      Thanks for weighing in on this important topic. The word “recovery” is in frequent use in the places I’ve worked in recent years. Yes. By recovery they mean being cooperative with taking drugs as prescribed, keeping appointments and behaving agreeably.

      I doubt it’s possible to return to a prior self however much one may wish to do this. People grow and change. This is a natural process. Life is a “river rather than a stagnant pond”, as you said.

      I like the sense of a “journey of recover”y to become who we are “called to be”. This feels like each of us has an important purpose we may not yet be aware of. This is very forward looking and process oriented.

      Well-thought and well-written.

      Thanks.
      Alice

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  7. Great post Alice.

    It certainly seems we are all now suggesting that “recovery” needs to be re-defined in quality of life terms, rather than quantified in commercial terms. A human being as an organic creature, rather than a cog in the machinery of an economic system?

    “If you can hold down a full-time job, your recovered,” a psychiatrist once told me, confessing that his job was basically to get me back to work as the measurable component of a normal life. Yet what does real recovery look like, from the inside-out?

    From my own journey and need to understand psychosis from the inside-out;

    “Bipolar Cycles & An Ongoing Process of Recovery?

    October 27th 2012: 9am, and I’ve arrived back in Sydney, fourteen hours after a very emotional farewell to my Thai partner of the past two and half years, and an abrupt end to my South East Asia sojourn.
    As I waited inline at immigration the anxious butter-fly’s in my stomach rose to higher flight, in respect for an increasingly imminent, family greeting.

    “Stay grounded, resist replaying the scenes from the same arrival two years ago,” I told myself. Considering how my oldest son James was waiting for me again, after agreeing to bail his father out of a self-imposed “fix,” and fly me back to Australia. “No money, no home, no resources of a material kind, how could my children, not see me as having hit rock bottom?” I wondered, and would I get the chance to explain? Life is paradoxical, I thought, as I walked into the arrivals area carrying 15 less kilo’s of luggage than I’d taken to Thailand almost three years before. Materially lighter, stripped of all possessions save for my precious laptop, six books and 20 kilo’s of clothes. Objectively speaking, should I deny, my life appears to be going backwards? “Your a sad looser!” I probably would have told myself a decade ago, yet I feel more comfortable in my own skin than at any previous time in my life, ready, willing and able, to face the undoubted challenges to come.

    I couldn’t help a scenario running through my head though, as I pictured a coffee table family reunion, and some of the words we might, but probably won’t, say to each other. “When you stop defending yourself against life, it tends to bring you the experiences you need to have,” I pictured myself saying.

    ‘Hi Dad,’ James said, as he came up behind me, instantly relieving my concern that no one was here to greet me. Cordial greetings ensued, as I sat with James and Mathew, my two oldest sons, and talked about life in general, the catch-up family gossip, sport and the ever inflationary cost of living. “Five hundred dollars a week! For a one bedroom apartment!” I exclaimed, after Matthew filled me in on his new location, and I reminisced about life in Thailand were you could live comfortably for more than a month, with five hundred Aussie dollars. We talked real normal, in our usual social ritual of family “triangulation,” the anxiety of an awkward situation relieved by speaking of neutral topics, unrelated to an obviously difficult, and emotional situation.

    ‘So what do you want to do?’ James asked.
    ‘Head for the homeless shelters,’ I replied, adding that a search online had suggested it wise to get there as early as possible, to ensure a bed for the night. I needed to keep the tone positive, remembering the pain of his email comment, “its impossible for you to stay with any member of the family.” Impossible?

    So here I am, back in Australia and on face value alone, I would seem to be following a classic manic-depressive journey towards my demise? How could these circumstances possibly be described as a recovery in progress, I’m sure your thinking? How could this situation be described as life bringing me an experience I need to have? It sounds stupid and makes no objective sense, pure wishful thinking, even a delusional fantasy perhaps?

    What does Recovery Look Like?

    One of the most popular phrases in mental health is, “everyone’s experience is different,” and hopefully an explanation of my own “different” journey towards recovery, may help to enlighten the reader, on just how this seemingly desperate situation, is an experience I need to have. As I’ve written many times here on this blog, birth trauma seems to be the root cause of my bipolar type 1 disorder, with fearful avoidance, a life-long behavioral pattern. Two weeks after my return to Australia, I write this post in the very midst of my life-long fear, “the social group.” And on face value alone, its a pretty scary group with which I now reside. Here, I can’t avoid, can’t rationalize any movement towards isolating myself, here I come face to face with implicit body memories of my father’s violence, on a daily basis. Not that anyone is violent towards me, yet deep within there is an unconscious sense of threat, this group of men tweak’s my nervous system.

    ‘So how do you feel at the moment, in terms of mania or depression?’ The psychiatrist asked me, towards the end of my first assessment session, six days after my arrival.

    ‘There are no signs of mania, although there are depressive feelings and some suicidal ideation, but nothing I haven’t dealt with before,’ I responded, after already giving details of the self-regulation routine I’d developed in Thailand, after educating myself in Stephen Porges “The Polyvagal Theory” and coming to understand his term “neuroception,” on a felt level of sensations within my body.

    ‘You certainly seem to be managing an emotionally stressful situation pretty well at the moment, and I’m happy to let you self-manage considering your long experience and the fact that help is so readily at hand here,’ he advised me as we arranged a weekly appointment, during my stay at the Talbot.

    ‘Looking on the glass half full side of life, I’m certainly handling this crisis better than I would have done ten years ago, when I would have been well and truly under the blankets and drowning in depression by now,’ I offered as a reflection on perspective.”

    http://www.bipolarbatesy.blogspot.com.au/2012/11/bipolar-cycles-ongoing-process-of.html

    How should we define recovery, in an age when our economic systems of normality are failing? What does quality of life look like? Is life really definable by the quantity of objects one acquires?

    As Uncle Mosses once told us “don’t worship false idols,” yet we still believe that “objects” are more precious than a heart-felt smile and the vitality affects of love and affection?

    In the metaphors of the movie Avatar, is “unobtainium” really about material objects, or the human spirit and the Cosmos within?

    What does recovery look like, on the inside?

    Best wishes for 2013 Alice.

    David Bates.

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    • David,
      Thanks for adding your point of view on “recovery” and pointing out how it ties in with materialism.

      In America, most things are defined in commercial terms, how much money you have or appear to have. This drives the debt monster that’s enslaves so many people. Everyone is caught up buying their image and polishing it.

      When I meet people they want to know what I “do”. By this, they always mean “who do I work for” and how much income do I have. When I talk to people about writing I’m asked if I’ve sold anything. As a landscape painter (in a past life), people only wanted to know if I’d sold anything. Folks look at my twenty year old car and make value judgements about my worth as a human. One person took took me aside and laughed at my old car. He suggested I buy a “doctor car”.

      Thanks for sharing your personal experiences with recovery and with the system. The psychiatric system is definitely part of the larger culture. I’ve written a couple of recent pieces that explore materialism and industrial culture in my newly-up WordPress blog.

      http://alicekeysmd.wordpress.com/2012/12/24/the-biggest-gift-is-a-small-christmas/

      http://alicekeysmd.wordpress.com/2013/01/01/grapes-of-wrath-oped-submission/

      Thanks for your support of my writing.
      Alice

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  8. Alice,

    I think we have run out of space for replies, so here is my guess about cost of Open Dialogue: First, it appears to work with people who don’t have much resource. As I understand it, the region in Northern Finland is not economically well off – a small city with a fair amount of poverty. Second, although they might cost a lot locally, and up front – they assign teams (e.g., psychiatrist, psychologist, nurse, social worker) to stick with each client until they are better, in or out of the hospital and for five years or more, if necessary. And they meat 10 – 12 times in the first two weeks of crisis, and thereafter as needed; so that costs too.

    BUT the overall savings should be enormous. They rarely use drugs, and when they do, it is not long term maintenance, so that’s a lot saved. And they rarely hospitalize – another huge savings. On top of that, the program is so user-friendly that instead of avoiding the “system” for years, families and clients contact the program on average within 3 months of onset of psychosis – which makes a huge difference in recovery time. In fact, where Open Dialogue was started (per the 2008 book) has gotten its catchment area so well served with early intervention (even before full psychosis) that they report new instances of psychosis have dropped dramatically, and the book claims they simply do not hospitalize anyone any more.

    If even close to true, these dynamics would save tons of money – few drugs, next to no hospitalizations and quick voluntary intervention without the “screening” scams advocated in the US. But: the US system is designed to spend money, not save it. PhARMA and organized psychiatry aren’t going to be put out of the drug business; hospitals won’t forego reimbursement for hospitalization. So local programs will have a hard sell getting bigger budgets, and PhARMA and the hospitals won’t stand for the lost income. The problem is political, not substantive. The best bet is for someone somewhere to duplicate Finland’s success and then embarrass the establishment into doing something.

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    • Peter,

      So when do we start? I’m not an administrator or a grant writer. But I’m a psychiatrist. Me or not, it seems we’d need one of those.

      This would be a good time to promote treatment approaches that save money. Government third-party payers are stretched thin. When I watched about the new Soteria House start-up (MIA video), it sounded like there was a market for more humane treatments that could save money.

      Just thoughts. But everything human that is or ever will be started with thoughts.

      Keep thinking.
      All the best.
      Alice

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      • Alice,

        Some people are headed in that direction. Sandra Steingard, M.D., who blogs on Mad in America, went to Finland last summer for a course in Open Dialogue, and she will follow up with more training. She is on the board of the Foundation for Excellence in Mental Health Care, which funds an effort to propagate the Open Dialogue model in the U.S. I recommend reading her posts on the experience, and maybe contacting her. The primary creator of Open Dialogue, Jaakko Seikkula, is also involved in this grant.

        This Foundation is a group of very accomplished people, including Gina Nikkel, the president and CEO, her husband Bob (former Oregon State commissioner of mental health), David Healy and Courtenay Harding. I think the Foundation was formed in response to Anatomy of an Epidemic, but I don’t know if Robert Whitaker has a formal connection with it. You might want to contact the Foundation, which seems based in both North Carolina and in Wilsonville, Oregon (the Nikkels live in Oregon).

        I find Open Dialogue very exciting, but am not prepared to get directly involved now. I just finished 15 years as a social worker, supervisor and director in treatment foster care, and am in the process of writing things about “mental health” that I couldn’t publish while representing my agency. I want to use Open Dialogue as an example of how things should work. I probably won’t be through with this project for another year and a half.

        Your writing is a fine contribution to MIA pushing things in the right direction. I look forward to reading more from you.

        Pete

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        • Pete,
          I know Bob Nikkel. He and I worked together in the olden days of community mental health on a multidisciplinary treatment team. Great guy. I knew that he and his wife brought Bob to speak in Oregon through their foundation. It was through Bob Nikkel pointing me at Bob Whitaker that I began writing here.

          I feel much more comfortable writing here since I no longer have an employer. I don’t have to fret about losing a job if I don’t have one.

          Each of us can find ways to make our unique contributions to the cause. I love to write. I get to talk to so many people this way.

          Thanks for the leads.
          Alice

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      • The gentleman is being intentionally cryptic, and that’s abusive, according to the Pia Mellody school of recovery. Today’s social media often limits one into cryptic “one-offs” (especially Facebook with its “friends” inter-linking), i.e., “non-communicative” (tina Minkowitz 1/5/2013 on this website)…. except these boxes allow for more words…. “are you happier now and suffering less” merely goes against what I was “promised” by a student in training: “I can’t promise you you will feel better, but I can promise you that you will feel more.” That scared the socks off me, but, it was true. I have seen more and more how I was split. See the infamous “I am Adam Lanza’s Mother” in anarchistsoccermom blogspot for a comment about 1800’s psychotherapy. It’s not fashionable, but it matches my “lived experience”. Happiness and lack of suffering are society’s version of “pills”. Goodspeed to you, my dear. ~R

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        • rcymbala,
          Thanks for reading and posting here. I appreciate your support of my writing.

          I’m not certain what gentleman you refer to as being intentionally cryptic. Sorry. I’ve missed soemthing. Too cryptic for me to follow.:-)

          Cryptic “one-offs” that pass for relationships on social media aren’t very deep when it comes to interpersonal relating. You’re right. It’s VERY limiting. I still prefer face to face and shaking hands and knowing who people are. I like to hear a person’s voice and see who I’m talking to. But I reckeon I’m from the stone-age. 🙂 These days, I have to get by with typing little faces with computer marks so people know I’m smiling or making a joke.

          I hope that feelng “more” was what worked for you. Some people need help with emotional regulation and toning feelings down. There’s so much variety in the way people are made.

          I’m not so sure complete lack of suffering is possible in life. It seems that most people hope to suffer less. This makes sense to me.

          All the best,
          Alice

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  9. Dear Alice and respondents,

    Highley appreciate all the experiences and perspectives shared on RECOVERY. For approx. one year I have been a reader – living both in Germany and England. It takes a little courage to join in – not being a native Engish speaker. Peer support for healing and realizing oneself is what my prior mission is – thus related to recovery, exchange and growth. Am happy to listen, read and participate – here or at National Empowerment Center.

    Very kind wishes for you in 2013,
    Ute

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    • Ute,
      Thank you for reading my essay and for your kind words. I’m happy to know that what I write and what others write is useful to you.

      Welcome to MIA. Your English is lovely.

      Best wishes.
      Alice

      Ute,
      Vielen Dank für das lesen meiner Essay und für Ihre freundlichen Worte. Ich bin glücklich zu wissen, dass das, was ich schreibe und was andere schreiben, ist nützlich für Sie.

      Willkommen bei MIA. Ihr Englisch ist sehr schön.

      Die besten Wünsche.
      Alice

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  10. I don’t remember where I read it, but one peer run respite house can save a state up to $1 million a year supposedly. I wouldn’t bet my life on that figure but I’m pretty sure that’s what I read. If that’s true then we need to get cracking. The only problem in my state is finding the peers! People who would most likely make good peer workers drop out of sight once they leave the hospitals and never want to see the places again. They just disappear into thin air. I really don’t blame them, but it really makes things difficult.

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    • Stephen,
      I think you put adds in the paper and hire them like any job opening. The Second Story program in Santa Cruz was well staffed with peers. There’s a special peer training program. Some of the folks who used the respite come back as volunteers as well. What a happy place. This is a good place to look for how these can be set up. The woman who made this happen, Yana Jacobs writes here. She’s very capable. I bet she’d be a great consultant, should someone else be interested in how to make another peer respite happen.

      Are there other peer support respites out there already?
      Thanks for continuing this discussion.
      Alice

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  11. Alice,
    I am surprised that no one has mentioned that one can learn Open Dialogue at the Mill River Institute for Dialogic Practice in Haydenville, Massachusetts. Mary Olson (US), Jaakko Seikkula (Finland), and Markku Sutela (Finland) are the faculty. It has arrived in the US!
    Karina

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  12. Also, I think of recovery as recovering from being DIAGNOSED, not recovering from an illness, disease, condition, or symptoms. I think of life-long personal growth that I think everyone is enmeshed in, consciously or not. I think about searching out the meaning in life, satisfaction with the whole process, contributing to the world, connecting with people, and maybe some happiness, but all in all, experiencing the life one chooses.

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