What is… Recovery?

In this series, I dig a little deeper into the meaning of psychological terms.

This week’s term: Recovery

The word recovery can have various connotations depending on the context.  It began to gain popularity in the context of mental health in the late 1980s and early 1990s, when it was used by the ex-patient/psychiatric survivor movement.  Its usage has become common in mental health services, and various mental health-related government agencies claim to have some degree of recovery orientation.

According to the Mental Health Commission of Canada (MHCC), “‘Recovery’ does not necessarily mean ‘cure’; rather, it focuses on people recovering a meaningful life in their community while striving to achieve their full potential.”  Recovery is unique for each individual, and draws upon strengths.  In the recovery process individuals with mental illness are empowered and enabled to live a meaningful life.  Principles that support recovery include hope, empowerment, self-determination, and responsibility.

The MHCC developed a set of guidelines for recovery-oriented mental health services.  These were built around several key dimensions, including:

  • Creating a culture and language of hope.
  • Recognizing that recovery is personal and unique, and requires consideration of the whole person.  There is a focus on strengths, autonomy, and self-determination.
  • Recognizing that recovery occurs in the context of one’s life, which is impacted by such factors as social supports, social determinants of health, and stigma.
  • Taking into account the diverse needs of all groups within Canada including Indigenous peoples, LGBT individuals and racialized communities.

The MHCC explains that recovery-oriented approaches break down power imbalances between those with mental illness and treatment providers, and recognize the experiences, insights, and expertise of people living with mental illness.

The Mental Health Foundation, a non-profit organization in the U.K., describes the recovery process, which:

  • provides a holistic view of mental illness that focuses on the person, not just their symptoms
  • believes recovery from severe mental illness is possible
  • is a journey rather than a destination
  • does not necessarily mean getting back to where you were before
  • happens in ‘fits and starts’ and, like life, has many ups and downs
  • calls for optimism and commitment from all concerned
  • is profoundly influenced by people’s expectations and attitudes
  • requires a well organised system of support from family, friends or professionals
  • requires services to embrace new and innovative ways of working.

The Mental Health Foundation also identifies a number of factors that support recovery, including good relationships, financial security, satisfying work (it was not specified whether this was volunteer as well as paid), personal growth, the “right living environment” (although it doesn’t specify what this is), and developing resilience.

The U.S. government site MentalHealth.gov identifies four dimensions of recovery: health, home, purpose, and community.  The Substance Abuse and Mental Health Services Administration (SAMHSA) identifies ten guiding principles of recovery: respect, hope, person-driven, many pathways, holistic, peer support, relational, culture, addresses trauma, and strengths/responsibilities.  Hop back across the Atlantic, and the Scottish Recovery Network uses the CHIME acronym to describe common themes of recovery: Connectedness, Hope and optimism, Identity, Meaning, Empowerment, and Connectedness.

Clearly multiple agencies in multiple countries are talking the talk, but does it actually mean anything?  Does the real meaning of recovery get buried under these dimensions and principles and acronyms?  And do the voices of those of us with mental illness get drowned out by the voices of those who want to tell us what recovery is?

I work in a concurrent disorders (mental health and addictions) program, and recovery is built right into the name.  Yet I see precious little recovery in the implementation, and often considerable paternalism.  The program leaders might know the language of recovery, but their decisions don’t show any real understanding.  I think in many ways it’s even worse to be recovery-oriented in name only rather than not claiming a recovery orientation in the first place, because it contributes to misunderstanding of what recovery actually is.  It becomes something that is hijacked by professionals and taken away from those of us living with these illnesses.

In some ways I’d prefer to set aside definitions of recovery entirely and say it’s whatever the individual living with the illness believes it is for them.  I used to think that my own recovery would involve being symptom-free, but I’m not sure that’s realistic, so now I’m looking to be able to engage in meaningful activities that give me a sense of purpose.

What does recovery mean for you?  What do you think of what the various organizations are saying about it?

 

This post was inspired in part by a recent post by Katie at Stumbling Mind.

Sources:

You can find the rest of the What Is series here.

How trauma-informed practice can improve mental health care

So, what is it to be trauma-informed?  Trauma-informed practice recognizes the intersectionality of trauma, mental health, and substance abuse, and involves an awareness that anyone may have experienced trauma, whether they have disclosed it or not.  Trauma-informed practice aims to create environments that prevent re-traumatization and promote a sense of safety.  The individual client’s safety, choice, and control is prioritized throughout services, and an approach of collaboration, learning, and building trust is used.  There should be a non-hierarchical and supportive organizational culture, and there is a focus on strengths and building resiliency, and hope that recovery is possible.

One area where being trauma-informed has the potential to make a huge difference is when it comes to seclusion and restraints.  The use of seclusion and restraints can lead to significant psychological or physical harm, and can be a major source of traumatization or re-traumatization.  The British Columbia Centre of Excellence for Women’s Health identified several strategies for a trauma-informed approach to seclusion and restraints:

  • staff training in de-escalation
  • have comfort rooms with low sensory stimulation
  • promote the development of crisis plans or advance directives to identify triggers and preferred interventions
  • assess for and address any unmet needs that may be influencing behaviour
  • debriefing following any use of seclusion or restraint to identify why it happened and what was learned.

When I was doing my masters degree one of my classmates was working in a psychiatric intensive care unit where they had instituted changes in their approach to seclusion and restraints in order to provide trauma-informed care.  My classmate had nothing but good things to say about this, and the unit had achieved very significant reductions in trauma and restraint utilization.

My most memorable occasion of being in seclusion was when I had taken myself into hospital, with the support of my community psychiatrist, and said that I was feeling suicidal and needed ECT.  They decided to commit me under the Mental Health Act and put me in seclusion, even though I had gone in voluntarily.  When I was informed I would be locked in seclusion I asked to be sedated, because I didn’t want to be trapped with nothing but my thoughts.  The nurse said there was nothing ordered.  I asked if it would make a difference if I told her that I’d throw my tiny tube of hand cream at her.  She disappeared, I heard a “code white” (aka violent patient aka me) being called over the PA system, and she returned a few minutes later with a bunch of security guards to give me the injection I’d asked for in the first place.  How very therapeutic.

Sometimes in the field of mental health care certain approaches or practices will become buzzwords, and many organizations will jump on board.  I think this has happened, at least to some extent, with trauma-informed practice, and it’s generally seen as something desirable.  Where the problem lies, though, is that there’s a difference between claiming to be trauma-informed and actually being trauma-informed.  I’m sure that the mental health and addictions program I work for would claim to be trauma-informed, just like they claim to be recovery-oriented.  But in practice, it’s just lip service, although I highly doubt the people running the place would see it that way.

I think all mental health care organizations should be trauma-informed, but it’s essential that it look trauma-informed from the client perspective, not just the staff or management’s perspective.  While individual care providers for the most part try (with varying degrees of success) to be empathetic, it’s difficult for some clinicians, and particularly for organizations, to have any real understanding of what the client perspective looks like.

Would you consider the mental health services that you’ve accessed to be trauma-informed?

 

Sources: British Columbia Centre of Excellence for Women’s Health Trauma-Informed Practice Guide and Trauma-Informed Approaches to Seclusion and Restraint Reduction

Profiles in tremendousness: The uncommon sense edition

The Daily Show Profiles in Tremendousness screenshot

In the Profiles in Tremendousness series, I borrow an idea from the Daily Show with Trevor Noah to celebrate the best of the worst in mental health care.  In this edition, I’ll take a look at some of the weird shit that’s gone on in places where I’ve worked, proving yet again that common sense really isn’t very common.

I used to work for a short-term crisis intervention outreach team.  Because we were rarely in the office, each day the main office phone line was forwarded to one of the team clinicians’ cell phone.  Then the powers that be decided they were going to transition this program into part of a new psychiatric urgent care centre they were starting up.  Because the secretary would be answering phone calls that came into the urgent care centre, they wanted her to get practice on the phones ahead of time.  So they decided to have her answer the phones for the crisis intervention team, even though 90% of the time there would be no clinical staff around for her to transfer the calls to.  I brought up how potentially dangerous this was; what if a client called experiencing suicidal ideation?  This was pretty realistic given that we were, after all, a crisis intervention team.  Was the secretary supposed to talk the client through it?   My email to the team was met with a derisive response from management that dismissed my concerns (and me in general, for that matter) as entirely unreasonable.  So I guess it was supposed to be up to the secretary to help out people in crisis…  Why not, right?!?

So, confidentiality.  It matters.  But at place I’ve worked, there is a pervasive lack of understanding of where and when confidentiality applies.  They are mad for initials, to the point of utter insanity.  In emails and in client charts, staff are regularly referred to by their initials; no one ever stops to think that not only do staff not require confidentiality, but quite the opposite; staff are responsible for the care they provide and if things ever went sideways it would be crucial that the staff involved be identifiable.  Also, staff will use a client’s initials when documenting in that same client’s chart.  I asked some coworkers about this once, because it’s completely ridiculous; the client’s name is firmly, permanently attached to their own medical record, and it’s asinine to think there’s a “confidentiality” issue using the client’s name in their own chart.  All these coworkers could come up with was that they’d been told it was necessary in case the medical record was ever subpoenaed.  Great, so the management who should really know better are spreading idiocy en masse.

Now, I could rant at length about this photo, but instead I’m just going to let it talk for itself.

IMG_0474

Interestingly enough, this is a “recovery program”, although apparently management thinks I’m just too darn recovery-oriented.  I told management that I believe clients are the experts in what they are experiencing…  Gasp!  Well, that’s just not acceptable!  After all, we’re the nurses who know best, and who are they?! …  I believe in empowering clients….  Gasp!  No, they need us to tell them what to do!  …  If a client asks for a prn medication, including a benzo, and I think it’s appropriate because they’re experiencing distress, then Im going to give it…  Gasp!  No, we don’t give benzos here! …  But the client has a doctor’s order for it …  Gasp!  But you still shouldn’t give it!  Benzos are bad!

The non-recovery recovery approach leaves me frequently shaking my head.. Clients are regularly discharged to places they don’t want to go, including cities they don’t want to live in, because “the team” decides that’s what’s most appropriate.  There are arbitrary rules galore, and if a client isn’t falling into line, they meet with “the team”, which from what I can gather is like the bloody Spanish Inquisition: a roomful of “the team” stacked up against a defenceless client.

If I sound bitter, it’s probably because I am.  This kind of insanity is everywhere, but it really runs rampant at one of the places I work now.  Unfortunately a change of job isn’t feasible right now for a number of reasons, so all I can do is soldier on.  And maybe try to find a little humour in it wherever I can.

Profiles in tremendousness 2: The coworker edition

profiles_tremendousness2

 

Not long ago I posted Profiles in Tremendousness round 1, which borrowed an idea from the Daily Show to identify some of the non-rockstars I’ve encountered in my own experiences of mental health care.  In round 2, I’m going to touch on some of the anti-superstars I’ve encountered in my work as a mental health nurse.

Let’s start with one of the biggest non-rockstars of all.  I’ll call him Kevin.  Kevin had a very high opinion of himself and of his ability to get to the root of what was going on with a client.  He firmly believed that bipolar II was not a legitimate diagnosis, and instead was just another name for borderline personality disorder.  He never came right out and said it, but it was pretty clear that he thought any female diagnosed with a mood disorder actually had borderline personality disorder.  He would tell these women that they needed to do some reading about DBT.  They did so, and of course ended up reading about borderline personality in the process.  If I was the next clinician to see these women, they would tell me how confused and distressed they were, because BPD didn’t sound at all like what they were experiencing (which it wasn’t).  I’d try to shift focus onto how DBT has useful skills for anyone with mood regulation difficulties (which is true, but not why Kevin was recommending it), and bite me tongue to keep myself from telling them that Kevin was an idiot.  One of his go-to’s for evaluating whether someone was seriously ill or not was the “bus stop test”, i.e. if you were standing at a bus stop next to them would you be able to tell they’re mentally ill.  Cue disgusted eye roll now.  And if he was unhappy with a client’s behaviour, he would “read them the riot act”, whatever that meant.

While a lot of mental health nurses are very knowledgeable about psychiatric medications, some are frighteningly clueless or prejudiced.  Kevin referred to clozapine as “poison”, while Janet was firmly anti-medication across the board.  Karen made medication recommendations to clients despite having astonishingly little knowledge about those same medications.

Brent was a big fan of CBT.  Which would have been great if he actually knew what CBT involved.  He believed that CBT involved distracting yourself from your thoughts.  End of story.  And this one-trick pony would be trotted out for almost every client.  His other standard recommendation was that clients read Eckhart Tolle’s The Power of Now.  I won’t deny that there’s some good stuff in there, but there’s also some stuff that’s a little out there.  Brent actually agreed with me on that, but didn’t bother tacking this bit of information on when he made the recommendation to clients.

Some nurses are overly keen on pushing the prn medications.  A couple of nurses that I used to work night shift with firmly believed that if a client was up during the night, they should be medicated back to bed, and if the client wouldn’t accept the prn orally, they’d call security and do it by injection!!!!  There was one time I was coming on for a night shift, and the evening nurse told me that she’d given a client a prn during the evening because he was quite psychotic, and she wanted me to wake him up to give him another prn in an hour or so.  I just kept my mouth shut and ignored her.

Then there was Sandra, who thought clients asking for prn meds were just being med-seeking.  She would never give prn benzos (even when the client had an order for them) regardless of how distressed or psychotic they happened to be.  She had no use for clients with personality disorders, and thought they were just being manipulative.  She thought that the only way to handle these clients was with her idea firm boundaries, which translated to being flat-out rude.  Clients would tell me that they just didn’t bother going to Sandra about anything because they knew they’d just be shot down.

These anti-superstars have thankfully been the exception rather than the rule.  Most of the mental health professionals I’ve worked with have been quite competent, and some have been truly exceptional.  But keep an eye out for the Kevins and the Sandras of this world – and when you see them, run as far and as fast as you can in the other direction.

BPD: Are the helpers actually hurting?

artistic rendering of faces dialoguing

People with borderline personality disorder (BPD) face a lot of challenges.  Unhelpful treatment providers shouldn’t be one of them, but I suspect this is the case more often than it should be.

One of my jobs is at a mental health and addictions transitional program.  While some of the staff are licensed mental health professionals, most are not.  For many  of the support workers, their only formal training is a one-semester community mental health worker certificate program.  Some of these support workers do a great job, but their lack of training limits the range of skills and knowledge they have to draw upon.

There are a number of clients with BPD in this program, and I think it would be safe to say that all of these individuals have a considerable trauma history.  This may be a gross over-generalization, but in my experience that pose the greatest challenge to service providers, and I would like to see more service providers take ownership of that rather than shifting blame to the clients.  I’ve been lucky enough to have worked with clinicians who were highly experienced in working with clients with BPD and providing dialectical behavioral therapy (DBT).  It was so powerful to see them in action and the impact this had on clients, and I learned a great deal from them.

What I see more often in support providers who don’t have that level of knowledge, skills, and experience is a rigid approach to clients with BPD that involves a focus on limit-setting, challenging (i.e. invalidating) clients’ beliefs/emotions/experiences, and establishing a clear hierarchy and power differential.  In my mind this comes from misinterpretations arising from limited understanding of some of the principles of working with clients with BPD.  And my observation has been that this approach doesn’t work.  Time and time again I have seen it develop into a combative relationship with the client, but I can’t think of a single time when I’ve known a care provider to take responsibility and acknowledge that by using this type of approach they have contributed to the problem rather than the solution.  It’s always the client that gets blamed, and this ends up becoming a self-fulfilling prophecy by reinforcing stigmatized ideas.  If you treat someone like a bratty child, then it’s likely they will react like a child; I’m not sure why this is so hard to grasp.

This came to mind recently because of some interactions I had with a client with BPD.  She had approached me and expressed irritation with certain things.  It quickly became clear that she was feeling invalidated, and the irritation had nothing to do with me.  As we talked, I took advantage of every opportunity I could find to provide any sort of validation, and it was clearly effective.  Yet this is a client I always hear other staff talk about as being difficult, and often when I hear them talk about their approach with her I think wow, no wonder you find her difficult.

It reminded me of a former client of the program, another female with BPD.  Staff often described her as game-y, and trying to negotiate around things like which meds she would and wouldn’t take.  All of the other nurses took a paternalistic, you-must-do-as-I-say approach, and they found her difficult to deal with, and she often refused at least some of her meds.  I approached everything I did with her as a collaboration, and explained my rationale for anything I was recommending.  She felt empowered, and ended up going along with my recommendations; by giving her the power of choice, I got meds into her 100% of the time.

It fundamentally bothers me that there are care providers out there who are making things worse for clients with BPD, and instead of taking professional responsibility they are blaming the clients.  That’s just not cool.  Unfortunately, the rigid limit-setting types generally don’t seem to be very open to suggestions that another way could work better.  In my current workplace culture, any attempts to rock the boat are considered totally unacceptable, and I feel powerless to bring about change.  I seem to be viewed as the nurse who is “too easy” on clients with BPD, and it really saddens me that there are people who think they need to be “hard” on that same group of clients.

I’ll put it out to my blogging buddies with BPD – have you encountered the rigid limit-setting type of care provider, and what has that been like for you?

 

Image credit: geralt on Pixabay

Book review: No One Cares About Crazy People

No One Cares About Crazy People by Ron Powers book cover

I first heard of this amazing book in a post by A Journey With You, and immediately after finishing the post I put a hold on the book at my local library, eager to get started on it.  No One Cares About Crazy People is Pulitzer Prize-winning and New York Times bestselling author Ron Powers’ exploration of his two sons’ journeys with schizophrenia combined with a sweeping social history of mental health care and attitudes towards those with mental illness.  He skillfully interweaves these separate threads, drawing the reader along from the early days of Bedlam to the tragic loss of one of his sons.  The toll that mental illness has exacted on the Powers family and the obstacles that arose in accessing care for sons Dean and Kevin are heartbreaking, while the historical picture painted is both eye-opening and profoundly disturbing.

Bedlam has made its way into the modern English lexicon, but its origins were in England in 1247, and it was officially designated as a mental institution in 1666.  Powers starkly captures the abuses that occurred at Bedlam and other institutions like it, including overcrowding, poor hygienic conditions, use of shackles for prolonged periods, and physical and sexual assaults.  Such practices were slow to change, and as the book points out, even now the mentally ill are often mistreated, particularly in correctional institutions.  Powers deftly ties these elements together, giving the reader a strong sense of the connectedness between past and present.

Powers touches on social Darwinism and eugenics, which were practiced far more widely than is generally known.  It’s unsurprising that forced sterilizations of the mentally ill were carried out in Nazi Germany, but Powers informs us that in the United States an estimated 60,000 forced sterilizations of the mentally ill were performed in the 20th century.  Between 2006 and 2010, 148 female sterilizations were carried out in the state of California, and this practice was not made illegal until 2014, a jaw-dropping reminder that, as the book title suggests, those with mental illness are treated as somehow “less than”.

Powers covers a broad range of 20th century influences on mental health care in the United States, including the anti-psychiatry movement, “treatment” strategies such as lobotomies, and misguided  beliefs that antipsychotic drugs such as chlorpromazine could “cure” schizophrenia.  John F. Kennedy’s Community Mental Health Act began a wave of deinstitutionalization, which led to a ballooning of the homeless population and large numbers of mentally ill ending up in the criminal justice system.  Powers points out that in many ways this approach criminalized mental illness, and the effects remain widespread to this day.

As any questioning parent might, Powers tries to identify factors that could potentially have contributed to his sons developing schizophrenia.  Both Kevin and Dean were highly artistic and passionate about music, raising the as yet unsolved question of whether mental illness is linked to traits like artistic creativity or scientific genius.  In his teens, Dean was socially vilified after a female passenger was seriously injured when the car he was driving crashed.  He was falsely accused of drunk driving and made into a sort of social pariah, and Powers suspects that the stress related to this incident likely contributed to the development of his son’s mental illness.

Powers raises the contentious issue of involuntary treatment.  The precedent for modern legislation in the United States can be found in the era of former president Ronald Reagan; deinstitutionalization was a key aim and decision-making was placed in the hands of the courts rather than medical professionals.  This can mean significant delays in accessing much needed treatment.  Powers argues strongly that involuntary treatment should be more readily available before a mentally ill person reaches a crisis stage where they present a risk to self or others, as by this point it may be too late.  He addresses anosognosia, a common symptom of schizophrenia experienced by both of his sons, that impairs one’s ability to recognize the nature of their illness and the need for treatment.  This caused significant negative consequences in the Powers family, which Powers points out to strengthen his argument.

The powerlessness that can go along with loving a mentally ill person is heart-wrenchingly captured in Powers’ account of his son’s illness journeys.  Kevin was initially diagnosed with bipolar disorder before the full extent of his psychotic symptoms unfolded, leading to a delay in getting him started on antipsychotic medication.  Before his suicide, he had been seeing his treatment team regularly, and was still passionate about his music and future-oriented.  Not once did he speak openly to anyone of suicide, leaving those who loved him powerless to intervene.

Powers openly challenges the social stigma and lack of understanding regarding mental illness. He likens the mental health condition of schizophrenia to the physical health condition of cancer: “a predator without peer and impervious to cure”.  He identifies numerous ways in which those with mental illness can contribute to their communities, and emphasizes the importance of having the right types of supports that can make that happen.

The book concludes with a call to action: “The mentally ill people in our lives, as they strive to build healthy, well-supported, and rewarding lives for themselves, can show us all how to reconnect with the most primal of human urges, the urge to be of use, disentangling from social striving, consumer obsession, cynicism, boredom, and isolation, and honoring it among the true sources of human happiness.  To put it another way: the mentally ill in our society are awaiting their chance to heal us, if we can only manage to escape our own anosognosia and admit that we need their help.”

There are many voices that can contribute to the dialogue around mental illness.  It is essential to hear the voices of those with lived experience of mental illness, and those voices can’t be replaced by the voices of love ones or professionals.  However, embracing all of these voices can allow us to construct a more coherent social narrative regarding mental illness.  This book makes a strong contribution to that narrative by improving awareness and challenging stigmatizing beliefs, and it will also resonate deeply with those whose lives have been touched in some way with mental illness.

 

You can find my other book reviews here.

My first book, Psych Meds Made Simple: How & Why They Do What They Do, is available on Amazon as an ebook or paperback.