I was recently asked to write an article for SAMHSA’s Recovery to Practice newsletter. This is a slightly edited version of that post.
Let me be clear: I was never anti-recovery. I will admit, however, that when the recovery movement first came to my attention in the 1990s, I was not drawn in. Whenever I attended a presentation on the topic, rather than being able to listen openly to the speaker, I felt defensive. At the time, I was working in a state that was pushing hard to close its state psychiatric hospital. While the mantra was of recovery, it seemed to be promoted by fiat. Since people were expected to recover, therefore, we did not need a state hospital.
A consequence of this assumption was the expectation that my colleagues and I would know how to help those who were referred to us live safely within our community. Simply saying that recovery is possible did not magically transform the lives and minds of individuals who were clearly struggling. For a long time, therefore, I viewed the recovery movement as merely a slogan rather than a helpful or instructive practice.
Fast forward to today. As I meet recovery movement leaders, I find myself listening to what they have to say in a new way. I have learned many things, but perhaps the key lesson is that the power differential inherent in the “doctor–patient” relationship distorts my connection with the person in my office. Furthermore, the opportunities to listen to people who have experienced being “psychiatric patients” are invaluable. Their stories of recovery have prompted me to examine the myriad ways in which I—in my earnest attempt to be helpful—may be undermining the person’s autonomy and sense of agency.
The most compelling experience that crystalized the power of a recovery approach comes from my own clinic. Several years ago, after Hurricane Irene shuttered Vermont State Hospital, a long-standing debate over the hospital’s fate was suddenly moot. Clinics like mine were asked to develop programs that might prevent people from requiring hospitalization. Our crisis program tended to see people a single time and then refer on – to outpatient treatment, hospital, etc. I wondered if some of these individuals could be helped if we extended this crisis intervention from one of evaluation and referral to include more extended support. We created a team, START – Stabilization and Recovery Team -modeled to some extent on Open Dialogue, which was pioneered in Tornio, Finland. Members of the team respond to a person in crisis; they work in teams, see people in their homes or in the community, and follow them through the crisis.
At the time we were creating START, there was a suggestion from Vermont’s Department of Mental Health to integrate people with lived experience into our community crisis services so we decided to hire mostly peers to work at START*. This was a leap for us. We wondered if we could find people to fill these roles, if they would know what to do, if they could tolerate the stress. The team has evolved over the four years it has been in existence and we have all learned and grown through this process. Recently, a person with lived experience became the director of the program. The team receives referrals from many clinicians who work for our agency but anyone in our county can refer to them. They typically work with people for several weeks. The most critical aspect of their work is that they share their own stories openly. Most have been trained in Intentional Peer Support. So while the Open Dialogue model informed the structural design of the team, IPS is a foundational element of the work they do. I work with them and I bring my own perspective and dialogic orientation to our meetings where we also try to involve the individual’s social network.
The peers have taught me so much. I understand that as professionals we often – intentionally or not – are in the position of being the experts who are going to fix the problem. This brings a sense of hierarchy into the relationship and, if we are not careful, will result in us not fully appreciating the person’s strengths and abilities. This kind of relationship can diminish a person’s sense of agency – the notion that he or she has the ability to see the problem through. With humility, I realize that even on my best days, a peer can offer something that I cannot. These simple words, “I have been there and made it through,” are potent indeed. START is incredibly responsive to staff and clients; they rarely turn down referrals. Satisfaction with the program is high. For these reasons, they are incredibly popular among both clients and staff
Beyond that, I have witnessed the transformation of the team members. START itself has been a recovery force for the team. A number of peers have entered the work force after living for years on disability insurance — first as substitutes, and then as regular staff members. Some have gone on to full-time employment or return to school. Our clients look up to the team as role models and the team has influence within the clinic as well. Practitioners who did not think peers could be effective are now among our most ardent supporters.
It has been humbling, instructive, and inspiring to work as a member of this remarkable team and to be part of our collective journey of discovery and recovery.
*A friend and colleague has recently challenged the use of the word “peer.” While I accept and understand her objections, I am using this term here to mean both someone who has lived through a so-called mental health crisis and is willing to share that experience.
Mad in America hosts blogs by a diverse group of writers. These posts are designed to serve as a public forum for a discussion—broadly speaking—of psychiatry and its treatments. The opinions expressed are the writers’ own.
I’m glad alternatives to today’s biopsychiatric system – the defame, ignore, disbelieve, declare a person’s whole life a “credible fictional story,” and massively drug as many as possible, esspecially to cover up child abuse and/or easily recognized iatrogenesis, system – are starting to exist. And I do hope the medical community will some day learn that the adverse effects of the antidepressants are not “bipolar.” And that adding an antipsychotic to an antidepressant is likely to make a person “psychotic,” via anticholinergic toxidrome, which is also not “bipolar.” Do you think the psychiatric industry will ever change today’s unwise “bipolar” drug cocktail recommendations? Truly, we do need alternatives to today’s ungodly disrespectful DSM stigmatization and iatrogenic illness creation system. Thanks for working on such, Sandy.
Thanks, Sandy. Some of what you say about including peers in the system seems to be in line what Dr. Jim Van Os has been saying about reforms in the constitution of the mental health system. There seems to be a way forward, a more inclusive and democratic one, beyond the present crisis, based in a new view of mental health stressing empowerment and the open meeting of challenges. It’s interesting that Dr. Van Os opined at one point that this might in some ways be easier in the United States: the idea that we are agents in charge of our own health, seeking help as we choose. I don’t feel comfortable with the economics of this yet, and how it all can get twisted, but idea that experts can take care of us, and we just have to accept their health, though socially justifiable, doesn’t work so well in the sphere of personal fulfillment and the pride of agency. And I don’t think this is so much necessarily antipsychiatry, as a new approach, weaving a stronger network more inclusive of those coming through an experience of more extreme aspects of the journey.
Thanks for the comment. It is always good to know I am thinking along the lines of Jim Van Os!
I do not think it is anti-psychiatry at all. I agree with you -it IS more democratic. There can be instances where the support person may help to give voice to an individual’s questioning of the expert opinion. but that is not anti-psychiatry, that is thoughtful clinical care.
I guess I am anti-recovery because
– Just because medical authorities chose to diagnose and coerce me, doesn’t mean I have to recover or change or improve myself in any way
– Fundamentally, how I want to live has little in common with what authority considers healthy
etc, but I appreciate what you’re saying here.
And I appreciate what you are saying! Even “recovery” is defined more in my terms. I think this is what my friend was pointing out with the term “peer.”
there was a suggestion from Vermont’s Department of Mental Health to integrate people with lived experience into our community crisis services so we decided to hired mostly peers to work at START
And thus begins the slippery slope.
Care to elaborate (and I see another editing error here but I doubt that is what you are referencing)?
I’m not challenging your personal commitment or sincerity in any of my posts past or present, but commenting mainly on the social/political milieu in which you practice.
In this case I was making an aside to those who have already come to the conclusion that human suffering is not a medical issue, that portraying it as such is a disempowering form of mystification, and that these fundamental contradictions should be examined, not smoothed over by making the psychiatric approach more palatable on a practical level. Though this may not always be the case, the use of “peers” to keep newbies to psychiatry toeing the line, taking their drugs, etc. has apparently been a recurrent phenomenon. That’s what I was alluding to. (Though since you mention it I also think the term itself is sort of icky and condescending.)
Thanks, Oldhead. I did not take it personally, I was genuinely curious. I think this is an evolution (or I am just late to the party) in rejecting the recovery construct when it is placed within the medical framework. But having supports in place that are helpful to facilitate personal growth is important.
Not exactly sure what you mean as those are pretty general statements with which it is hard to disagree. I’m sure that on an individual level, given the parameters within which you are currently expected to operate, you do as well as you can.
I would not be as dismissive of notions such as “recovery” were it not for the implication that the recovery is from a disease (or “disorder”). That’s the semantic level. There is just as serious a problem in that psychiatry as a profession is being pressured to look at the very idea of “recovery,” no matter what you call it, as being a naïve anachronism in the face of modern pharmacology, and to view the false diseases they have created and promulgated as requiring lifelong purchases of psychiatric drugs.
I just edited that comment to try to clarify what I was trying to say.
I think, if I am not off base here, that the implicit question in Oldhead’s comments is whether “recovery” is construed to mean whatever the client thinks it means, and if they are supported in pursuing their goals and preferences in whatever way makes sense to them, or if “recovery” means following the treatment plan you have been given and staying “on your meds” and not causing unnecessary trouble for the authorities. “Peers” have often been coopted into the role of helping explain to clients/patients/victims of the system why the system is right and why they should follow the doctors’ orders even if they don’t want to. In other words, are the clients TRULY empowered and are the “peers” TRULY empowered to do what makes the most sense from the client’s viewpoint? Or are the “peers” simply agents of the medicalized system helping enforce social norms and ensure compliance with directions from the authorities in charge?
Steve captures the gist of what I was getting at.
Even “wellness” in the sense of “I was mentally ill but now I’m well” is a mystification on some level no matter how “well” the person feels.
The defining of “wellness” in terms of one’s becoming a “productive member of society” is flawed as well if what they are producing for “society” doesn’t also contribute to their personal fulfillment.
As for the term “peer,” it seems to scream hierarchy — anyone understand what I mean?
I do understand what you’re saying. “Peer” implies a lower status – you’re not a REAL professional like the doctors or the psychologists or therapists. It’s condescending from the word “GO.”
Great article. Even though sometimes I disagree with your ideas, I always enjoy reading your articles as they are interesting, sometimes provocative (in a good way), and get me to think… so I always click to read them when I see them on MIA.
In this particular article I don’t disagree with anything. It sounds like an awesome program Vermont has with the peers, and I would wish that it could be repeated in many other states. People (“peers”) who have been through very difficult experiences and gotten well are a very, very powerful motivator and hope-inducer in people currently suffering or hopeless. Kudos to your group for finding ways to use them to increasingly good effect.
I will say that I agree with some others who want to reject the term “recovery”… as recovery is arguably a word of the disease model. It is a slippery slope… It implies that someone was well or normal, then became unwell, then needs to get back to normality or wellness. The problem is that for many severely disturbed people (often labeled borderline or psychotic), they have never been well or “normal” in the first place… their relationships and sense of self has been severely impaired since childhood. Thus recovery does not make sense for these people… recover to what? A past “good” state (that never existed)? They have to grow, mature, trust, become a person for the first time.
Problem is I am not sure what word could replace recovery. Perhaps people are too varied and there cannot be one single term. Personal growth, maturation, self-actualization, gaining of agency, living the life you want, would be terms I’d suggest for consideration.
Sorry Sandra… you see, I can’t go a whole article without finding something to disagree with, hehe 🙂
We do not disagree about this. If you figure out better language for this, let me know!
I think the “recovery” term originates from the physical illness model idea of a physical body that has been in a normally functioning homeostatic state, then becomes ill or dysregulated due to some pathogen or physical trauma, and then needs “curing” or “fixing”.
Emotional development is different, more nuanced and complicated, and proceeds along a continuum that requires much more input from other people compared to physical development… which mainly requires good nutrition, some exercise, and shelter/physical homeostasis. Going through the symbiotic and separation individuation phases as a child and young adult is quite different than simply growing up as a physical body, and restarting emotional growth (after developmental arrests due to trauma or lack of emotional support) after interruptions in normative emotional development should not be mislabeled as “recovery”… it’s a simplistic word that does not do justice to what people work on as they grow emotionally.
I would nominate the terms self-actualization or adaptive psychological development as replacements for “recovery”.
I think recovery in this context arose as a response to a conceptualization of schizophrenia that defined it in Kraepelinian terms as a chronic deteriorating condition. Courtenay Harding and others did studies suggesting otherwise. These researchers aligned with the many people with lived experience who were told they would be symptomatic for the rest of their lives but had a different experience. Meanwhile, psychiatry in the 80s and 90s moved in a direction of conceptualizing a growing group if disorders as chronic – and often requiring long-term medications.
This debate and rift in my profession is ongoing. I would not want to lose sight of this and it will be the topic of a future post when I have the time.
I see. Yes, your description makes sense, thanks.
I would say all of these psychiatric conceptualizations of chronicity/recovery fundamentally misunderstand the nature of human emotional development, both when it proceeds well into relative wellbeing/maturity, and when it gets developmentally diverted into primitive states using splitting/fusion/denial (i.e. psychotic states). Psychotic states are not physical illnesses but rather complicated individualized reactions to some mismatch, deprivation or trauma related to how the individual experiences their environment. The defenses used include especially fusion (nondifferentiation) and splitting, which operate as defenses against overwhelming feelings of despair, terror, and rage, as written about ably by authors like Volkan, Searles, and Boyer.
Psychiatrists’ distortions about there being a brain disease called schizophrenia has not changed this reality one bit: psychotic people filling mental hospitals today are still experiencing terror/rage/despair, and still using the defenses of splitting and fusion to defend against those feelings, just like they were before psychiatrists invented the fiction of schizophrenia the brain disease.
Thanks on all counts, BPD!
Please check the link for START. The link takes you to an executive summary for the Sobriety Treatment and Recovery Teams of Cuyahoga County, which is definitely a Vermont county and not the link you intended.
That should be “definitely NOT a Vermont county”
It should have been corrected. Thanks.
I would nominate the terms self-actualization or adaptive psychological development as replacements for “recovery”.
BPD, I do agree we need some new descriptive terms. Jung used the word “Individuation” to describe his own return from what Joseph Campbell called “The Hero’s Journey.” These words better convey what has to be done, but they suffer from being a bit unwieldy and flowery. I think “rebirth” describes the process too. It has the added advantage of being a sort of medical model that gives the doctor a place, provided s/he is aware that psychological birth pangs don’t necessarily signify psychological cancer. Anyway, many thanks for pointing out “self-actualization or adaptive psychological development” as the end result that Mother Nature originally intended. I think you’re absolutely correct. The real problem is to convince our psychiatrists and psychologists to be obstetricians instead of abortionists.
OK I’ll ignore that last line but
It has the added advantage of being a sort of medical model that gives the doctor a place
I would call that a disqualifying disadvantage.
Unless you’re trying to impress psychologists I don’t know why you need a word anyway, but “self-actualization” is more comparable to enlightenment than to just getting back to where you left off. Relatively few people in Maslow’s view reach self-actualization, I seem to recall.
Oldhead, I’m puzzled as to why you want to ignore “The real problem is to convince our psychiatrists and psychologists to be obstetricians instead of abortionists.” Would you mind telling me why?
I might add that I recognize the difficulty of convincing them; at present the psychiatric/psychological abortionists are the majority, and they are well paid for carrying out their unpleasant duties. Which may shed some light on why so many of their “patients” are now turning to internet support groups such as the Spiritual Emergency Network and Shades of Awakening and therapies such as Open Dialogue and the like. When I was going through my own “rebirth” or “self-actualization” or whatever we agree to call it, I was grateful for the help of medication for a couple of months, even though I stopped going to the psychiatrist for fear of being locked up for “anosognosia,” or the crime of disagreeing with a psychiatrist. What I desperately needed was a doctor with the wisdom to know that not all swollen bellies are physical illness, and not all suffering and fear is “mental illness.”
You don’t need a doctor to tell you that you’re not suffering from “mental illness”; a competent linguist could tell you the same thing.
I think there is a shortage of abortionists due to right wing terrorism so whatever you meant by that analogy falls short with me.
People don’t need to convince psychiatrists and psychologists of anything, just stay away from them if you aren’t satisfied.
“People don’t need to convince psychiatrists and psychologists of anything, just stay away from them if you aren’t satisfied.”
Tried that. I was under no care from any psychiatric services when my wife decided that as a result of a disagreement I needed to speak to a psychologist. I refused, and she attended an appointments with said psychologist. The plan?
-Spike his drink with benzos to drop him and deprive of liberty
-Plant a knife in his pants to obtain a referral from police to Mental Health Emergency Response Team when they jumped me in my bed.
-Lie to make me look paranoid when it was known I was being threatened by meth using home invaders.
In my instance the police didn’t find the knife and therefore had no reason to refer. Didn’t matter though the Community Nurse was prepared to work with my wife to ensure the evidence of the drugging was concealed, falsify evidence to justify his kidnapping by police, and then see that the Senior Medical Officer at the hospital was not informed of the drugging and thought there was something wrong with me that required an injection of more benzos, olanzapine, and quetiapine.
I thought at the time that I had been lucky when someone noticed and I was released by a Consultant Psychiatrist as there was nothing wrong with me. Until of course I found out how desperate people can become when they may be caught for such serious criminal offenses.
Did you know that a Clinical Director of a hospital can authorise the provision of fraudulent documents to lawyers? Take the ones out that demonstrate the drugging and the person appears both both paranoid and delusional? And if you have police retrieve those documents…… we can now ‘treat’ the person for this delusional state.
The Mental Health Act is being used to conceal criminality in my State, and it would appear that after 4 years of attempting to have something done about this with the documented proof of the crimes, that it is also being enabled by said authorities.