Now I See a Person: A New Model for Breaking Free of Mental Health Labels

What happens when people seeking support are viewed as normal human beings who are going through difficult times? When we honestly care about others and genuinely invest the time to attempt to understand the hardships they face? When we embrace the idea that people can get over “mental illness” and invite others within a person’s community to join in the acknowledgment of a person’s strengths and capacity to heal?

Transformation.

Now I See a Person Institute (NISAPI) is a non-profit teaching and clinical institute devoted to helping people achieve a complete and sustainable recovery by pairing the normalcy of a horse ranch and the nurturance of horses with a philosophy of postmodern collaborative practice.  Here, people are seen as who they are as persons rather than their diagnoses, and we identify and nurture the inherent positive strengths and self-agency of each client and family member to facilitate their journey of healing.  All of our clients are “high risk” individuals who have lost hope after previous therapy, medication, or hospitalization and/or who have been considered unchangeable by previous mental health providers.

In this blog, I’d like to introduce our work: Who we are, what we do, and how, and share a success story that is representative of our highly effective model of care.

Origins

In 2002, after three decades as a professor, author, theorist, international educator, researcher, and supervisor in the field of marriage and family therapy, I moved to California from Texas to take a position on the faculty of Loma Linda University. Previously, I had always worked in a bubble of social constructionism. All of my colleagues were postmodern theorists, educators, and clinicians passionate about healing underserved populations without using “deficiency” models to describe people and how they suffer in terms of disorders. One colleague put it well when she described DSM diagnosis and treatment plans as “hate language.” For this is the language one would use to describe people they not only did not believe but also disliked. And when people are seen as merely the sum of their illness, symptoms, maladaptive behaviors, and triggers, they will remain imprisoned in these labels.

Sadly, what I found in my new home was an abyss of pathology and deficiency thinking in both academics and clinical practice. I remember talking with Lynn Hoffman, a keynote speaker at the annual American Association for Marriage and Family Therapy conference who, after surveying the agenda, asked me what was wrong with California. Here we were, at a national conference on therapy using the lens of relationships, not individual pathology. Unfortunately, every seminar at the conference pointed to something wrong in the individual and then proposed a theory and treatment plan that could make that individual as normal as possible so they could survive their diagnosis.

My heart sank, realizing I had moved to a foreign land where hate language abounded to describe human suffering. For me, marriage and family therapy still held the revolutionary potential of moving from focusing on individual pathology to focusing on relationships and the conversations within relationships that lead to trauma.

But then, in 2007, I received an email from a colleague that talked about doing therapy with horses. That gave me an idea, and at the urging of my international colleagues, I decided to open a postmodern institute where I could practice therapy, teach, do research, and supervise clinicians as I had previously done for decades in Texas. So, I brought all my current master’s level students and a handful of PhDs from the university to a horse ranch in Chatsworth, California, and we created the Now I See A Person Institute (NISAPI): Healing Underserved Populations Using Community Engagement: A Collaborative Recovery Model (CEACRM).

The name as well as the philosophy of our new nonprofit emerged from the experiences of one of my young students. She had told me during a practicum session, “I hate my client,” and I was surprised she felt safe enough to use those words. I recalled the words of collaborative therapy pioneers Harry Goolishian and Tom Anderson, who said, “When we do not like our clients, it has to do with us as a therapist, and not a client, we were holding prejudice to our clients….”

In the next practicum session, I asked the student how things were going with this client that she did not like. And she said, “The client I hated is now my most beloved.” I replied, “Let’s get this on tape.” For the next hour and a half, the class learned about this student’s journey. During her interview, she kept repeating that for the first time in 10 sessions, she had left the treatment plans, diagnosis, and progress notes outside the door and walked in with an open heart. And for the first time, she saw a “person” in front of her. She did not see the treatment plan, which was hers, not the client’s, and she could understand the pain and suffering that the client was going through.

It is amazing what happens when therapist and client both see each other as people. A collaborative relationship evolves wherein the client takes charge – sometimes for the first time in their treatment and their lives.

Who We Are, How It Works

To facilitate this collaborative relationship at NISAPI, we created an egalitarian environment where diagnosis is transcended, people are seen as honored guests, and everyone wears boots and jeans. The horse ranch setting provides normalcy and nurturance from the moment a client arrives—a respite from the problems of our world.

When coming onto the ranch, they meet and engage with the entire team of therapists—both human and equine. The horses—an original family plus additional rescues—are active co-therapists. Each client and therapist bonds to a particular horse, and all bond to the environment focused on listening, caring, and co-creating change tailored to the individual client. We call what we do Community Engagement: A Collaborative Recovery Model (CEACRM).

As in Open Dialogue, the clients are seen with members of their community—family members and/or mandated social workers and lawyers—rather than individually, and rich conversations emerge among all parties. We view clients and their families as the experts in their lives and believe they have the strength and answers within themselves; it is merely our role to listen intently and honor their stories. Through this collaboration, real hope and sustainable change emerge. And, as the clients begin to see themselves as people and not a diagnosis, so do others.

All sessions take place in front of the horses, who are family pets or former “athletes.” Horses are relational animals who naturally live in herds and everyone that comes to the ranch is part of that herd.  This provides a backdrop where conversations are actions of everyday life, where some themes are more urgent than others but where all discourse represents human-to-human interaction rather than therapist-to-client interaction. Too, horses have the natural gift of experiencing people as they are within the present moment. Through the eyes of a horse, there is no prejudice, no judgment, no psychological jargon. They exude love; it is that simple!

One can imagine how much easier it is to talk about traumatic events such as sexual abuse, or seeing a parent murdered, while petting and hugging your favorite horse.

We have also seen how people connect to the horses and then connect to themselves and others, becoming hopeful about new possibilities. For example, one woman who had been in violent relationships and had lost hope gained feelings of power and confidence when she became able to walk Jack (the biggest horse) into his stable. We’ve seen a parent and child’s relationship soften after viewing love expressed between Theresa (a mother horse) and Oliver (her foal).

We feel our journey with our clients results in becoming what we like to call “Extraordinarily Normal.” The narratives of pain and suffering they begin with are transformed into conversations honoring their innate strengths, resiliency, hope for the future, and other themes that are Extraordinarily Normal.  These themes include new ways to live daily life: building relationships, celebrating when days go well and problem-solving when they do not.

A Closer Look

When a client is referred to NISAPI, our first task is to make them comfortable. This means making no distinctions between the client and anyone else; they are simply a person who has suffered trauma and resultant symptoms. That is why when someone calls for an appointment, we spend from 30 minutes to an hour on the phone with them as part of beginning the therapeutic relationship. In this way, the therapist can learn about the client and, in turn, the client can learn about the therapist. The client is invited to bring whomever they wish to be in conversation with them to the first in-person meeting. For couples, this is usually a partner; for individuals or children, it is a parent or family member.

As mentioned, our goal when they set foot on the ranch is to welcome them and create a bond of trust. There is no standard way to do this. Harry Goolishian used to say that if we know what not to do, then the actions we can take are infinite. So, when we first meet clients, we do not talk about the deficiency of the client or family members.  Instead of leading them by asking a list of questions, we let them initiate conversations with a therapist while meeting each horse. (Three of our horses smile for treats, and our older horses beg for petting and attention—a great ice-breaker!)  Typically, these “starter dough” conversations are about horses, nature, or natural subjects. We find out at the clients’ own pace what is important for us to know about them.

In these dialogues, we tend to stay away from what we call “psycho-babble.” We do this intentionally to separate ourselves from other types of therapists.  Of course, we talk about the clients’ pain, but we try not to use clinical words such as depression, anxiety, triggers, coping skillsets, or anything you learned to get your degree. We are, foremost, people who care.

As family members, therapists, and horses start to talk and listen (yes, the horses too!) we may sometimes separate for a bit to learn of what everyone wants to happen and begin to come up with ideas of how this can occur. Often, this may happen in one of our outdoor “offices,” which are simple tables and chairs in the sun or under a tree. Here, everyone’s voice is heard and valued as we engage in conversations from multiple perspectives on how the trauma and suffering occurred, past attempts to resolve them, safety factors to consider, how to survive the pain today, and how to build hope for tomorrow.

From this posture and team effort, individualized blueprints evolve. Everyone decides together how often they should meet and when. Because the time limit required to help the client varies based on the needs of the individuals and their families or other collaborators, sessions may be scheduled for several hours a day, every day, depending on the crisis. During this intensive process, we are all engaging in conversations in which we share ideas as co-equals; together, we become a chorus of caring.

At the end of each session, every client exits with a sense of hope, and this hope leads to extra therapeutic change between sessions. Here, the client and family have time to ponder and build personal plans for change instead of what a powerful therapist who “knows best” or has a magic bag of tricks tells them to do.

Research Findings

The data we’ve collected about NISAPI shows that what we do is highly effective. We have been conducting qualitative research for 10 years now, and it reflects that up to 98% of our clients transform and lose their deficiency labels as well as find joy in Extraordinary Normalness. Themes that resonate when we interview clients for this research include:

• They and family members do not feel like they are having therapy
• They feel safe to talk about trauma and pain
• They do not feel judged for who they are or what they do

These results have born out even under COVID, where we have used telehealth instead of in-person meetings (which we’ll resume as soon as possible).

Case Study

Here is a before-and-after case study about a recent client.

The client, whom we’ll call Megan, was referred to us after she was shoved out of residential care without informing her parents, just shy of her 18^th birthday. This occurred after a significant suicide attempt after her therapist had left the room, and at a time she could not feel love for herself or her parents and was intent on ending her life.  Megan and her family had endured over a decade of psychiatric interventions, therapies, hospitalizations, and residential care programs which, according to them, not only did not help but created more suffering and trauma, robbing all of them of positive relationships and self-identities.

The treatment plan: Open and collaborative dialogues. We consider each time we meet with the client and/or their family members or support community to be a new opportunity for change, so as I mentioned, there is no treatment plan other than to talk with the client about what is important to them each time we meet.

In an interview, we asked Megan and her family about what life was like before their time with NISAPI and the changes that had occurred for them during their time with us. Below are their responses in their own words. In Megan’s case, we decided to meet twice a week, but spoke every day or whenever we were needed. This could be many times a day. Megan initially was suffering and did not want to live. At first, if I asked Megan and her family what their main initial goals were, for Megan it would be to survive the day and for her parents, to find her alive each day.

Eventually, the goals became not just surviving but thriving: being able to attend college, socialize with peers, have a boyfriend, and develop ambitions for the future like any other young adult—all of which she achieved. In turn, her parents’ goals evolved to being able to see their daughter not as someone with a mental illness but as a person with strengths and aspirations, with the potential to build whatever kind of life she wants for herself. The horses were instrumental in being able to soften the serious nature of Megan’s and her family’s suffering. They provided normalcy at a time when nothing was normal. They were also a conduit for nurturing Megan and her family and allowing all of us to speak together.

Before:

They summed up their experience this way: “Previous therapists and psychiatrists did not treat us as human beings and would sum us up in a few minutes to coerce us to do what they thought we should do without even knowing us, and this led us down a rabbit hole to nowhere.”

• Feeling lonely, unhappy, distraught
• Cycles of hospitalizations, being told by professionals “Send her there, throw her there, that’s the place to be for her.”
• Disconnected family
• Living on fear
• Being told “You are bipolar, you are this or that.”
• I couldn’t be free enough to speak.
• Defending my whole existence
• Shoving an attitude or thought process [onto me] that you have to adhere by
• Not only do they label the one who they think has an illness, they label [the parents] in conjunction with them.
• Every time we [the parents] went the [child protective services] would blame us.
• We were the neglect [i.e., the parents were held responsible for the daughter’s suicide attempts].
• If the client is not strong enough to push back, you get swallowed.

After:

Themes that arose during the interview about their experiences with NISAPI included finding the freedom to speak, being embraced by a spirit of welcoming at the ranch, viewing one another through a lens of shared humanity, generosity of time, guiding rather than telling, freedom from being “pinned to a wall” of deficiency, and collaborative care through community engagement.

• Less suicidal thoughts, less being depressed, less medications, less stressed, being able to go to college
• The biggest thing was Dr. Swim wasn’t looking at me like some crazy person.
• You allowed me to be me and not feel I had to be someone other than myself.
• Helping me to be more me, not being this “depressed” person and being labeled with all of these things
• Being with more positive energy, not coming around in therapy being sad all the time sitting there not wanting to go
• More happy
• Being able to express [myself] as just a person
• Doing the things I’m able to do now that I wasn’t able to do before
• Breaking the cycle of hospitalizations, not relying on the hospital
• Helped our family be more connected rather than being disconnected
• [Mom speaking about daughter] I can laugh now because I know she knows her limits and she knows she’s OK.

We wish to share these stories in qualitative research to support the idea that all people can heal when people are seen and treated as people, as for us it is a social justice mandate.

To learn more about our work, including workshops and training programs, visit our website here.

Resources

Colleen’s Healing Journey

YouTube page 

*David Abramovitch, JD, MA; Megan Kadler, BA, MC; Momo Takeda, PhD candidate; and Emma Wilson, MSW contributed to writing this article.