 |
An electronic circular of the Coalition's Center for Rehabilitation and Recovery
|
|
No. 94, June 2013
|
|
The Center for Rehabilitation and Recovery provides assistance to the New York City mental health provider community through expert trainings, focused technical assistance, evaluation, information dissemination and special projects. Recovery: From Diagnosis to Dialogue: An Interview with Daniel B. Fisher, MD, PhD United States Supreme Court Justice Potter Stewart once said he did not know how to define pornography, “but I know it when I see it.” Recovery is also hard to define, perhaps because people view it from different theoretical perspectives, with different beliefs about how to move towards it. In this issue, newsletter editor-in-chief Elizabeth Saenger, PhD, interviews Daniel B. Fisher, MD, PhD, Executive Director of the National Empowerment Center, to find out more about a philosophy of recovery Dr. Fisher has adapted from varied sources. Question: What do you mean by recovery in psychiatry or behavioral health? Dr. Fisher: I will tell you what recovery is not, to begin with. Recovery is not the same as remission, since remission is based on an illness model. If you think a mental health condition is an illness, just like diabetes, then you think, “Oh, you can never really cure it, the best you can do is reestablish a chemical balance.” That is pretty much the dominant belief right now, that the illness or deficit would probably be lifelong, and the medication just brings the chemicals somewhat back into equilibrium, but the person is still ill, just in remission. So recovery is not remission. Recovery is also not rehabilitation, because rehabilitation, too, is subtly based on a permanent impairment of some sort. The analogy some people use is a spinal cord injury. You rehabilitate, you adapt, you get in an environment that is adaptive, but the illness is still there. Question: So what is recovery? Dr. Fisher: Recovery is based on a different picture, a different conceptual framework, about what difficulty led to these problems. It is increasingly much more connected to trauma, than to some inherent, intrinsic deficit. So most of us in the consumer/survivor movement would say that recovery is not necessarily going back to where you were, but rather developing a stronger sense of self, perhaps from an inner core of health, that bad things have happened to us, or that we have differences, but that they are not illnesses, they are just differences. I like to use the analogy of left-handedness. We do not say, “I am being cured of being left-handed.” We say, instead, “This is part of who this person is.” The person, and others around the person, learn there are certain strengths to left-handedness. So recovery is really finding a way that you, and your deepest self, can express that self in an environment that is not only supportive, but recognizes you as a valued member, whose voice contributes to the existence of people in that community. You cannot have recovery alone. It needs to be in context with a community of people who say, “Yes, I value you.” At the National Empowerment Center, we note seven characteristics of a person who is recovering, and one of the more important ones is that neighbors would probably say, “Yes, you are doing your best. You are pursuing relationships and meaningful work, and you are not overwhelmed by emotions, but learning from them. You may or may not be taking medications. You no longer meet the criteria that society puts out for a certain diagnostic group, such as impairment, and you can fill the expected roles as a worker, student, parent, or neighbor." Question: How does this definition of recovery differ from SAMHSA's definition: “A process of change through which individuals improve their health and wellness, live a self-directed life, and strive to reach their full potential”? Dr. Fisher: They are similar. I think SAMHSA does not really emphasize that full recovery is possible. SAMHSA talks about reaching your full potential, and having a sense of home, and purpose, and having meaning in your life. Those are certainly vital. SAMHSA does not emphasize having a voice in your life, except in terms of self-direction. But having a voice is much more than self-direction. It is really having a recognizable place in the world. We also emphasize empowerment a bit more. Self-direction is different than empowerment. It is an aspect of empowerment, but it is narrower. We feel that full recovery means the person has achieved the autonomy, and the sense of agency, that most adults are expected to have, or are recognized as having. Question: What advice would you give to clinicians and to administrators to enable them to advance the recovery agenda for the people they serve? Dr. Fisher: In the last couple of years, I stumbled into dialogical relationships through Dr. David Bohm, who developed Bohm dialogues in the 80's. He was a physicist, and he said that new solutions, new enlightenment, emerges when people gather together with genuine dialogue. He builds somewhat on Martin Buber's “I and Thou” relationship, in contrast to most of the world, which is based on “I-it” relationships. Unfortunately, the mental health system is very much “I-it”. Recovery is understanding that shift from diagnosis to dialogue. So the first thing a clinician can do is not believe too deeply in the diagnostic category, but understand that the person is always much more than the diagnosis. I was told years ago that I was not just a person with schizophrenia, I was a “schizophrenic.” The labeling process is very dehumanizing. Dialogue is a way of rehumanizing the person. It is a way of reestablishing, through a relationship, a genuine relationship, an “I-thou” relationship, and validating the other person's existence as essential. Through dialogue you and the person share in each other's humanity. It is interesting because the Africans in South Africa, the Zulus, have a term for it, “Ubuntu.” The closest translation is probably “humanity.” The Zulus say that Ubuntu is the most important quality a person can have. If they are treated in any disrespectful fashion, they feel like it is diminishing their humanity, which changes in response to each relationship. So clinicians need to think, “How can I enhance somebody's humanity, and what are the elements of dialogue?” There is a treatment approach in Finland, “open dialogue,” that is very similar to Bohm dialogues. I just completed a two year course taught by Drs. Mary Olson and Jaakko Seikkula. I think recovery work gives open dialogue a framework, and validates it, since we have discovered independently in our recovery movement that having somebody believe in you is essential to recovery. In short, a nonjudgmental relationship is essential to recovery, and essential to dialogue. Question: What else is key in dialogue? Dr. Fisher: Another central element in dialogue is equality. Especially in the public system, where people are not paying with their own money, and do not necessarily have the freedom to come and go, professionals have more of a challenge to promote recovery than in the private system, because inequality tends to be greater. It is also necessary in dialogue for clinicians to be themselves. That does not mean telling every dark, deep secret about yourself, but being genuine. It is close to Carl Roger's concept of authenticity. He called this “congruence,” indicating your words and your emotions matched each other. So as a clinician, you are modeling the way a person might interact and live, and sharing a certain amount of your own emotions turns out to be very valuable for somebody wondering about whether life is worth living, or feeling a tenuous hold on reality. I believe the emotional dimension is a more essential feature of reality than the cognitive dimension. I think that is why when people are in their own reality, that is called psychosis, emotional relating is at a premium compared with the verbal cognitive level. When I was in psychosis in my youth, I thought of myself as a truth meter. I would only relate to people I felt were authentic in their emotional expression, and so I paid much more attention to the nonverbal communication than verbal. Recently, as a psychiatrist, I developed a training program called “emotional CPR” that really focuses on how to communicate on an emotional level with people who are not as focused on the verbal. Another element of that, which is also emphasized by the open dialogue people, is the here and now – the present moment, or, as they call it, the once-occurring moment. They value every moment as unique, and precious. Question: How did the dialogue movement develop? Dr. Fisher: The Russian philosopher, Mikhail Bakhtin, inspired the Finnish psychologists in the open dialogue movement. He influenced them to make statements that always have openings for further elaboration, and to pose their statements with curiosity and wonder. They might say to you, “Your bringing up the word ‘recovery’ leaves me wondering what you might be thinking about with the word ‘recovery.’ What idea did you have when you were asking about ‘recovery’? What was the idea behind that question?” They always try to look at the social context, the person in relation to the people around them. So they believe psychosis is in the space between people, and cannot solely exist in any individual, which is non-stigmatizing. This is in line with our understanding of recovery in this country, where we say that recovery occurs through relationships. That is why peers are so very valuable: they often are able to step into that space--the space of equality, the space of recognition--more readily than the clinician. Resources Visit the National Empowerment Center, one of SAMHSA’s Centers, for additional information, and free resources. The Center also has books, DVDs, and other material you can buy, including Open Dialogue: An Alternative, Finnish Approach to Healing Psychosis by David Mackler. You can see a trailer for this 74-minute documentary on YouTube. Two related documentaries by Mackler, Take These Broken Wings and Healing Homes: An Alternative, Swedish Model for Healing Psychosis are also for sale there, along with links to trailers. Recommended reading includes:
Interview condensed and edited for clarity and style. Snapshot: Recovery Through Relationships Susan Rogers In 1975, my family, fearing (with cause) that I was suicidal, brought an outreach team from a local hospital to my apartment. After a brief conversation, I was told that I could either enter the hospital “voluntarily” or “involuntarily.” Both options were terrifying, but I agreed to go “voluntarily,” and was taken to the locked psychiatric ward of the nearby general hospital. Hearing the key turn in the lock, I realized that I had lost all power over my own life. This was borne out by my next “choice”: I could either take Stelazine orally or be held down and shot up with it. My protests that I had no psychotic symptoms were to no avail, so I “chose” to take the drug. But even the lowest dose knocked me out and, because everyone was locked out of their rooms in the daytime, I lay down in the hospital corridor. Soon those with power over me recognized that I had been right and took me off the drug. But I had learned that I was the expert on my own life, and that staying strong was essential to my recovery. During the three weeks I spent on the ward, my roommates became my greatest source of comfort and healing. In the decades that followed, I have found peer support to be consistently helpful whenever I have struggled with mental health challenges. I am not surprised that it is now recognized as a vital component of recovery. Employment Tips for Individuals with Disabilities: What Your Clients Need to Hear Erin Sember-Chase Jobseekers and employees with disabilities often have skills, talents, and valuable experiences because of their disabilities. However, we know that the general public is not always aware of this. So, for some individuals with disabilities, the challenge is in knowing if, how, and when to share the disability part of their life. For some, having a disability has presented very real limitations. For others, even if the impairment has not been particularly challenging, other peoples’ reactions and attitudes toward the impairment may have been the real obstacle to their success. Either way, individuals may come to view their disability as a major concern, leading them to wonder, “when should I disclose my condition to the employer?” or “how can I get them to see beyond my disability?” Those of us who counsel individuals with disabilities have a chance to help our clients answer those questions for themselves, and to better understand how to use their lived disability experience in a way that enhances their job search and employment experience. Many of us are already familiar with employment services and aids for people with disabilities, such as disability online job posting boards, workforce development offices, government hiring authority programs, and the Coalition’s online resource guide, available at: http://www.coalitionny.org/the_center/workbook/, and soon to be updated. While these resources are helpful, they won’t necessarily address those deeper concerns. Thus, you can encourage them to consider the following: Is disclosure even necessary, and if so, when? It is up to each person if and when they choose to disclose, and this is particularly relevant when the disability is not visible. According to the employment provisions of the Americans with Disabilities Act, disclosing a disability is only necessary if an accommodation is needed. A person can ask for an accommodation during any phase of the employment process--including applying for the job, interviewing, or any time after being hired. Revealing the actual diagnosis is not necessary; only share that, due to a medical condition, something different is needed (for example, to fill out an online application instead of hard copy, hold the interview in an accessible location, or get a particular tool to facilitate performing the job duties). Coach the people you serve to disclose with confidence. They should be clear about what work-related activities are impacted by the condition, and what accommodations would be appropriate. As noted above, individuals with disabilities can disclose at any time, and are not required nor expected to disclose when hired, unless an accommodation is needed at that time. If no accommodation is ever needed, then it becomes a personal choice whether sharing that part of their identity in the workplace ever happens. What has been positive about having my disability? Instead of just thinking about what limitations or challenges one’s disability presents, shift the focus to what skills and experiences have been developed because of the disability. For example, it is not unusual for individuals with physical impairments to have developed problem solving skills and creative ways of thinking because they were forced to navigate the inaccessible environment or systems around them, in a different way. Individuals with sensory disabilities often develop attention to detail, concentration, and memory skills to counterbalance their lack of natural visual and auditory abilities. For many with both physical and mental health disabilities, living a life of dealing with medical situations and professionals, or needing to find, and try, a variety of resources, treatments, and medications has enabled them to develop savvy when managing difficult situations, researching solutions to problems, communicating needs, and interacting with multiple professionals and stakeholders. How can I relate my disability experience in a way that works for me and for the employer? Once a person with a disability has established their skills and experiences, including the ones that have been gained from having a disability, the quest to find a job that will dovetail with those skills can begin. The attitude and approach can shift from “I can’t do that job because of X part of my disability” to “I can do that job because of Y part of my disability.” Then these skills should be recognized and highlighted in cover letters and skills-based resumes, when appropriate. For example, people with a disability and limited employment experience can craft a resume that focuses more on the unique skills and abilities they could bring to the particular job they are applying for, rather than a resume that puts their minimal job experience at the forefront. When answering interview questions about handling certain situations, it may be advantageous, if the jobseeker is comfortable sharing, to give examples that illustrate how their lived disability experience enabled the person to successfully meet a similar challenge. (Question: “What is an area that you would like to improve on?” Possible Answer: “I know it’s not obvious, but sometimes I have trouble remembering things. So I have become very well versed in a variety of electronic organization tools that help keep important dates and information at the front of my mind.”) Drawing upon one’s experiences and expertise derived from having a disability shows confidence in one’s abilities and can help employers shift their own attention away from the disability and onto the unique skills and experiences that would be an asset and value to their workplace. Service providers, counselors, and advocates have the opportunity to help empower clients to own their disability in a way that works for them, rather than against. We can help them recognize the choices they have about if, and when, they share their disability identity, and to identify what they can gain from their disability, and capitalize on it, thereby increasing the potential for success in the working world. Erin Sember-Chase is Technical Assistance and Project Coordinator, Employment and Disability Institute, Industrial and Labor Relations School, Cornell University. New Biography of Sylvia Plath Rehabilitates the Martyr--Minus the Mania Carl Blumenthal While Betty Friedan's The Feminine Mystique has been much dissected in the media recently, due to the 50th anniversary of its publication, no notice has been paid to the same milestone for the printing of Sylvia Plath's The Bell Jar, which first appeared in a British edition, under the pseudonym Victoria Lucas, just one month before she killed herself on February 11, 1963. The conventional feminist wisdom is that Plath was a victim of her misogynist husband, the British poet Ted Hughes, who left her for another woman six months before her suicide. However, in a new biography, An American Isis: The Life and Art of Sylvia Plath (New York: St. Martin's Press, 2013), Carl Rollyson contends that Plath was the forerunner of today's modern woman who wants it all; she tried to free herself from the shackles of 1950's (white) suburban mores condemned by Friedan in her classic. Through close examination of previously overlooked journals and letters, in addition to crucial stories and poems, Rollyson concludes Plath was so intent on being a great daughter, writer, friend, lover, wife, and mother, she created a myth for herself as the primordial Egyptian goddess Isis, who was all things to all people. In a later incarnation, Isis put back together the pieces of her consort, Osiris, after his jealous brother chopped him up. Unfortunately, in the case of Hughes, the glue didn't stick. His sister Olwyn was notoriously envious of Plath, and collaborated with her brother, as executor of Plath's estate, in trying to block, usually successfully, any biographies they didn't authorize. Hence, Rollyson relied on other sources to achieve what is a sympathetic, yet balanced, chronicle of Sylvia Plath's brief, turbulent life. Nonetheless, in his zeal to present these new findings, Rollyson overlooks an important piece of the psychological puzzle that was Sylvia Plath. He readily admits that Plath was depressed many times, and often in psychiatric treatment. This was the case not just before she ended her life, but also before her only other suicide attempt, at age 20, on which the fictional Bell Jar is closely based. Although he repeatedly notes Plath's moodiness, and even angry outbursts, as inexplicable for someone always on the make to please a potential audience, he never uses the word "manic" to identify what is outsized about her personality even though irritability can be one symptom of mania. Writing not as a clinician, but as someone living with bipolar disorder, I recognize mania, at least in part, as the energy that fueled her ambition. In my opinion, Plath was cycling rapidly through elation and dejection during the last months of her life, when she wrote her best poems, yet was plagued by the doubts of a single mother of two. She was also a stranger in a strange land--an American in England, no matter how friendly she initially thought the place. I base this interpretation on my own humble experience as a writer, whose moods lurched like a subway train, before being thrown on the track to my worst depression in 2006. I wish I could claim the poems I wrote that year were the equivalent of those collected in her final work, the ground-breaking "Ariel," but I'm glad I didn't pay with my life to produce them. More typically for Plath, a letdown would follow a period of achievement, as the pressure for continued success overwhelmed her. For example, she was at the top of her form as a Smith College student, and Mademoiselle guest editor, but then plunged into an unexpected depression that sapped her creative energy, leading to her suicide attempt. It would take almost a decade for her to "exorcise" this experience by writing The Bell Jar, whose heroine Esther Greenwood has a mordant wit that Rollyson rightly identifies as one of Plath's chief literary mechanisms for "exercising" control, throughout her writing career, over her largely autobiographical material. Am I newly pathologizing Plath at a time when many people, who feel misdiagnosed, or even wrongly labeled as mentally ill, would like to bust out of the straightjacket of such interpretations? Find out in the next issue of RECOVERe-works. Carl Blumenthal is a peer advocate with Baltic Street AEH (Advocacy, Employment, and Housing), Inc., and a culture critic at the Brooklyn Daily Eagle. The Latest Research: The Effect of Mental Illness on Healthcare Treatment Elizabeth Saenger, PhD Mittal D, Sullivan G, Reaves C, et al. Does Serious Mental Illness Influence Treatment Decisions of Physicians and Nurse? American Psychiatric Association 166st Annual Meeting: Abstract NR12-12. Presented May 21, 2013. An increasing number of studies find that people with serious mental illness tend to die twenty to twenty-five years earlier than their counterparts. Some of this increased mortality appears to be associated with the weight gain and cardiovascular side effects of many psychotropic medications, but a recent meta-analyis showed that part of it seems to be due to the tendency of physicians and nurses to prescribe medications, such as beta blockers and statins, less frequently to people with psychiatric diagnoses, especially those with severe mental illness.[1] To find out whether provider treatment decisions were influenced by a patient’s psychiatric diagnosis, as opposed to other possible factors, Dinesh Mittal, MD, and his colleagues conducted a vignette study with providers. The patient in all vignettes had the same physical symptoms—except that in some vignettes, the patient had a diagnosis of schizophrenia, too. Mittal et al found that primary care physicians and nurses, as well physicians and nurses specializing in psychiatry, all viewed vignette patients with serious mental illness less favorably. These care providers also were less likely to refer such patients to weight reduction programs, or believe they would adhere to treatment instructions. These providers also considered the patients with schizophrenia to be lower functioning than their unlabeled counterparts, and less competent to make treatment decisions. These findings are consistent with an immense literature on disparities in healthcare, both medical and psychiatric, associated with demographic characteristics. While it is clear that these findings are consonant with prior research, it is not clear how to solve the problems they underscore. For example, it suggests, uncomfortably, that difficulties in forming a therapeutic alliance may be due to the provider. While this may be embarrassing, it may also be a blessing if we want to fix the situation, since the only people we can change are ourselves. Reference
Free Quality Guides for Clinicians on Substance Abuse Treatment SAMHSA (Substance Abuse and Mental Health Services Administration) and CSAT (Center for Substance Abuse Treatment) offer free Treatment Improvement Protocols (TIPs), which they bill as “best practice guidelines for the treatment of substance abuse.” These texts strive to present practical clinical information quickly, responsibly, and with citations to indicate the evidence base for recommendations. More than fifty titles are available, including separate guides for offering group therapy, family therapy, and brief interventions for substance abuse. Some handbooks address the specific needs of different populations, including men and women. Manuals also specialize in adolescents (both for screening and treatment), older adults, people with co-occurring disorders, and, most recently, homeless individuals. There is also a guide for supervisors, which the RECOVERe-works editor found helpful, and ones for administrators, primary care clinicians, and case managers. Other guides address specific issues, such as detoxification, combining treatment with vocational services, and enhancing motivation for change. See this page for many more selections. While print versions of many publications are out of stock, they can still be downloaded for free.
Heads-Up: Views and News on Recovery Mini-Site Coming Soon! The Center for Rehabilitation and Recovery will soon be devoting a portion of its site to stories, articles, resources, and more on recovery, from rehabilitation to empowerment. Do you have five tips for supporting a client in the use of self-help techniques? Do you have a telling anecdote about stereotypes about recovery? Would you like to share a new insight on empowerment? We also welcome suggestions about what you’d like to read, what works for you, and what your concerns are about recovery for clients, and the recovery movement. Please write to the editor-in-chief, Elizabeth Saenger, PhD, at [email protected].
We look forward to emailing you about our trainings at the end of the summer. There will be no trainings until then. Call for Your Free WORKbooks Today! The Center has updated its popular WORKbook, a practical guide to finding what you need in the world of employment, from services to opportunities. Prevocational counseling? Supported employment? Transitional employment? Job services? This handy guide will tell you what a service is, and how to locate it in the five boroughs. In addition, the WORKbook answers questions about how to get a paying job without losing benefits. For copies, please call Deborah Short at 212-742-1600 x 235.
|
|
The Coalition Home | Center for Rehabilitation and Recovery | Site Map
Tel: (212) 742-1600 Fax: (212) 742-2132