Thursday, July 22, 2010

recovery in psychiatry--part 3

What if a person has no goals?

People at the Collage social club and Ellis continuing day treatment center are being asked about their goals for recovery. It's one of the first questions and it's interwoven with asking them about their dreams, hopes and vision as they learn to get ready for the conversion of their programs to a new one called PROS, or personal recovery oriented services.

In it they'll be expected to work at these goals in individual and group settings with the help and support of others. The program isn't to get going till November. People have to enroll in one of the programs that Ellis Hospital will offer, probably at the continuing treatment site downtown, where classes, workshops, counseling sessions and social and recreational activities can be held.

Everybody is expected to have at least one goal and this ties them to enrollment in PROS. If you reach your goal you can drop out of the program or you can go on to achieve further goals, like education or developing skills you'd like to have, their mentors have told us at meetings.

But what if someone is unable to express any personal goals, has lost the spark to want to achieve something? It's another challenge, another way to look at recovery. You can't recover if you don't have any goals, can you?

There's a very good discussion of goals and how to draw someone out to learn to express them in an article in the July 16 Weekly Highlights on a new website called Recovery to Practice. A shorter version starts below. It's written by Larry Davidson, PhD, and Priscilla Ridgway, PhD, of Yale Department of Psychiatry. It rings true because we don't find our children or their friends in the system talking about goals. They've either given up or never were inspired to shoot for realistic goals. Why hasn't this been addressed before this?

(Davidson and Ridgway:) “This question is raised often by providers who are concerned that the people they work with have given up on whatever hopes, dreams, or aspirations they may have had earlier in life or who have been met with an initial blank stare or a shrug. The process of identifying and setting personal goals provides the foundation for recovery‐oriented practice, however. The question of whether or not people have such goals, therefore, is important.

“Restoring hope--Has this person perhaps become demoralized over time due to repetitive experiences of failures and losses that have been due to mental illness, stigma or discrimination, or a combination of both? Has the person lost hope as a result?

“It can be extremely difficult to have a mental illness, and extremely challenging to carry on one’s life in the face of it. It also may be hard to keep picking up the pieces time and time again when things fall apart, or to continue to believe that the future might be any better than a bleak or desperate present. The presence of a basic sense of hope is crucial to a person identifying any goals for the future. When hope has been lost, it can and must be restored as an essential basis for the person’s active engagement in recovery, and in the central role of identifying and pursuing personally meaningful goals.

“The restoration of hope can come about in a variety of ways, including through the activation of spirituality and faith, experiences of pleasure, and supportive and inspiring social relationships. When a person has lost hope and/or faith, it is crucial that other people continue to carry hope for that person until a time that he or she begins once again to believe that life can get better. Peer staff, who can provide tangible and credible evidence of the possibility of recovery, can be especially effective in instilling hope through their function as role models.

“Regaining interests--It is possible that through the combination of socialization and the lack of means to pursue their interests, people may lose any sense of what they might find interesting or enjoyable. In this case, helping the person to get back in touch with what interested him or her, or what he or she enjoyed, prior to becoming ill may be a useful place to begin the process of re‐igniting or” jump starting” his or her passion. There also is an array of tools, including interests and strengths assessments, that might help the person to recall those things that he or she had found pleasurable or meaningful in the past.

“Finally, there can be no substitute for actual life experience in re‐igniting, or eliciting for the first time, a person’s interest,” Davidson and Ridgway point out. “For some people, simply talking about participating in an activity is just as likely to raise anxiety and introduce doubts as it is to whet his or her appetite for involvement. Especially for people who have become accustomed to viewing life as if from a distance, as something that happens primarily to other people, it may require both encouraging and accompanying the person for him or her to feel comfortable trying new things."

The authors go on to discuss the possibility of co-occurring depression and achieving trust so the person is comfortable enough to share personal information. These and other useful insights are found on the website: (Roy Neville)

Recovery in psychiatry--part 2

Idealism and optimism at the heart of the recovery movement

The recovery movement in psychiatry is sweeping the day. The state commissioner of mental health calls for a transformation in services to grant mentally ill people a higher level of self-esteem, rights and independence. National policy making bodies like SAMHSA and the Center for Mental Health Services finally come on board with financing for recovery models. The consumer movement is elated off its rocking horse. The state, with little money of its own but a mandate to capture federal Medicaid money, swoops down on provider programs like the social club and continuing day treatment in Schenectady to force their conversion to PROS, which stands for personal recovery oriented services.

The idealists and dreamers are finding full expression in many areas of modern life--like health care, in psychology, how we spend money, in military planning. It's rubbed off in the mistakes they've made, in the false cheerfulness we see in the world around us. People want to buoy each other up when illness strikes a friend, saying things they don't believe, like “you'll get better soon.” They make foolish investments and buy houses without enough collateral to pay for them when the going gets tough. Businessmen, thinking the world has a rosy glow to it, have sunk us in wasteful practices with their easy deals and careless mortgage lending. They refused to face reality.

How do I know? From what I read, it's a matter of ideology. Americans are cheerful people, who think positively, but not often realistically when we have to be. We don't want to think the worst about anybody or anything. We're compulsively optimistic, it's ingrained in us by our culture to look on the bright side of everything. We can't do otherwise than tell sick people they'll get better soon, greet people we don't know with a smile, and try to make others feel better.

That's called positive thinking and where it goes wrong is in the excesses. Read Barbara Ehrenreich's book, “Bright Sided,” about the extravagant way our culture perceives happiness and a better life as an entitlement for all. She claims “the relentless promotion of positive thinking has undermined America.” She writes that in this idealistic age churches preach that you only have to want something to get it because God wants you to prosper. And when she went down with breast cancer recently, she was told she had to battle hard against it in order to join the hallowed body of survivors. A man suffering with prostate cancer was told it was God's will for him to get cancer whether he survived or not. For those not hopeful enough there is plenty of self-blame.

Some of this irrational exuberance naturally has come over to the recovery trends in mental health.

Remission, not recovery

Along the way, the people who promote the recovery movement in psychiatry have found a way to overcome the medical profession's negative thinking about mental patients. That feeling prevailed, according to the movement, as a staple view for some time, labeled the “clinicians illusion.” It was widely held that patients were doing poorly in between visits when they weren't seeing them. Instead, writes Larry Davidson, PhD, a Yale psychologist and lead author of the new website Recovery to Practice, “the evidence suggests that many people recover over time and that when people drop out of treatment,they often are doing better than we might have expected.”

In his Weekly Highlight column recently, Davidson tells how a workgroup of patients, caregivers and clinicians tackled this by introducing the concept of remission of symptoms. The work group decided that a sizable number of patients sustained periods of symptomatic relief and improved functioning, disrupted by episodes of recurrence or relapse. They called these “periods of remission.” Davidson says there is increasing recognition that such improvements are common.

Thus, the “clinician's illusion” has been turned upside down and given way to the concept of remission. If you're in remission you're part way to recovery. Remission means the worst symptoms have gone away and your functioning is better. But it's a long shot from being free of symptoms. There are still people out there with schizophrenia and bipolar who are on the streets and in shelters and in jail and prisons and repeatedly visit emergency rooms. They have periods of remission, too, but they're not moving ahead toward recovery.

Recovery would involve a more demanding and longer term phenomenon in which a person is relatively free of disease and has the ability to function in the community, Davidson writes. He believes that's possible for some people. He cites the Harding study in Vermont years ago as evidence that long- term hospitalized patients can “recover.” But these were older folks and they were moved to serene farm-like villages in the country. Would they have met a different fate in New York City?

I don't see full recovery for people with schizophrenia. I see them "in recovery" or "in remission". Of course, we want them to make it. I remember my friend at a NAMI national meeting years ago confessing that he and his wife felt they gained sensitivity and understanding in bringing up a mentally disabled child. “But I really do wish it was happening to someone else and not me,” he added. (Roy Neville)

Wednesday, July 21, 2010

Recovery in psychiatry--part 1

The new mantra of recovery

So much we read nowadays in psychiatry has to do with the recovery model, moving away from doctors recommending disease treatments to asking patients what they want from treatment and discussing ways to meet those goals. It's turning the field of psychiatry topsy turvy.

Patient advocacy groups have been pushing this for a long time. The recovery focused movement has won the day, points out an article in Psychiatric News last November. The President's Freedom Commission on Mental Health endorsed the recovery approach back in 2003 when it called for a “fundamental transformation of the nation's approach to mental health care.” And there have been a spate of articles, conferences, speeches and webinars since then, some from the highest perches in the land in favor of converting to the new religion of recovery oriented services.

Now SAMHSA, the Substance Abuse and Mental Health Services Administration, has begun issuing guidelines, moving the educational concept of recovery more to specific instructions for psychiatrists to integrate recovery models into their practices. This training is going on now and is causing professionals to rethink entirely how they provide care, right down to what types of questions they need to ask patients.

The idea is to focus less on a remission of symptoms and more on helping patients overcome the effects of mental illness on their lives, the new gurus explain. This includes difficulties they have with employment, housing, and a lack of hope about their future. The new movement has both adherents and critics. It is behind the thrust in NY State to impose PROS (personal recovery oriented services) on existing networks of community outpatient clinics, day treatment and social club programs here and elsewhere.

What do they mean by recovery?

There's a debate about what anybody means by recovery—is it measurable and lasting? What's the evidence for that? Larry Davidson is a PhD psychologist from Yale who writes for a new website called Recovery to Practice. He addresses these problems quite admirably. In a column June 11 he writes how we have held out hope for a 'magic bullet' to make the illness go away and restore everything to normalcy. But instead, “What we have learned over the past couple of decades is that the truth lies somewhere else. Mental illnesses are not necessarily permanent but even the most evidence-based of practices in mental health are limited in their effectiveness.”

He points out that recent studies have shown that “newer psychiatric medicines are not that much better than the older ones and their side effects are still onerous. It remains the case that only 70% of people with a serious mental illness will derive any relief from these medications and the benefits are limited to only one domain of symptoms—primarily the so-called positive symptoms of hallucinations and delusions—having little to no impact on the more disabling aspects of the disease.” And as noted elsewhere, “treatments do not cure schizophrenia or fully ameliorate symptoms and problems for the majority of affected individuals.”

So where does recovery come in? Davidson tells us: “Recovery, as it turns out, has more to do with what the person with the illness does to contain and minimize the intrusions of the illness than with what professionals do to treat it. One thing people with serious mental illnesses can do is to take the medications prescribed for their condition by mental health professionals. But this is only one thing that they can do among many others, and most likely is not the most effective thing they can do, at least for those people for whom the medications are very limited in efficacy.
“Recovery also has to do with all of those other things people can do, and may need to do in addition to taking prescribed medications. Recovery also has to do with how people go about leading their lives in the presence of, or despite, serious mental illness.

Davidson makes a surprising assessment. He writes: “The most robust evidence base for interventions targeting serious mental illnesses are not for the traditional treatments of medication or psychotherapies that were aimed at eliminating the illness. On the contrary, what mattered most “were those interventions that supported people in participating in the community activities of their choice, in occupying normal adult roles, while they continue to have a mental illness.

This suggests to him that “the most effective breakthroughs in practice for people with serious mental illnesses since the introduction of chlorpromazine in the 1950s have not been in the development of new and better medications but in development of assertive community treatment and the related psychiatric rehabilitation practices of supported housing and supported employment. What these advances have taught us,” he says, “ is that it may be less difficult for people to figure out how to live with a mental illness than to be rid of it altogether. While the mental health field has had limited success in treating the illness, many people have themselves found ways to live with it and some to eventually recovery from it fully.”

These are persuasive arguments for the recovery theorists. They leave out some points. They still talk in generalities. We see our adult children doing well for some time and then suddenly, without notice, falling back into the throes of their disease, perhaps hospitalized, losing a job, pulling out of activities they enjoyed. There isn't any easy explanation—is the medicine not working or has his body worn off its effects? We should expect something like this, it happens with other diseases. But it keeps us on edge over a lifetime that true recovery in schizophrenia or major depression doesn't happen. Nobody gets a free bill of health without a lifetime of checkups and staying on the right medicines. And, we think, symptoms are more manageable with the aid of a steady counselor, trusting friend, supportive family and a good place to live. Those seem to be essentials whether you buy into the new recovery models or not. (Roy Neville)