The
International Journal of Psychosocial Rehabilitation
A slab over my
head:
Recovery Insights from a Consumer’s Perspective
Dr Pam McGrath, B.Soc., MA, Ph D
Research Fellow
School of Nursing
Central Queensland University
Rockhampton Qld 4702
Tel: +61 7 3374 1792
Email: pam_mcgrath@bigpond.com
Ms Vivian Jarrett
Mental Health Educator
Training in Psychiatry
Citation:
.
& Jarrett, V. (2004). A slab over my
head: Recovery Insights from a
Consumer’s Perspective. International
Journal of Psychosocial Rehabilitation. 9, 1, 61-78
Abstract
It has only been in very recent times that the notion of
‘recovery’ from mental illness has begun to gain wide acceptance. The
1990s was labelled the ‘decade of recovery’ to signify a paradigm shift
from the notion of mental illness as a predictable deteriorative/
maintenance course to an understanding of the potential for recovery.
It is now considered possible for individuals to recover fully from
even the most severe forms of mental illness. Increasingly in the
literature it is emphasised that insights from the lived experience of
individuals who have recovered from mental illness should be central to
considerations of mental health care planning and reform. The case
study presented in this article is one response to the call within the
literature for consumer accounts to direct and guide the development of
a recovery oriented system. The findings emphasise respect for
individual strengths, along with self-advocacy, assertiveness, finding
the right support and having choice.
Keywords: Mental Health; Recovery; Rehabilitation.
Introduction
It has only been in very recent times that the notion of ‘recovery’
from mental illness has begun to gain wide acceptance (1,2,3). The
1990s was labelled the ‘decade of recovery’ (4) to signify a paradigm
shift from the notion of mental illness as a predictable deteriorative/
maintenance course to an understanding of the potential for recovery.
The work of researchers such as Harding and associates (5,6,7) led the
way to indicate that the factors other than the illness were
influencing progress, with the consequence that recovery was a
possibility. It is now considered possible for individuals to
recover fully from even the most severe forms of mental illness (8).
Drake and associates’ (9) survey of current treatments indicates that
interventions are now more patient-centred and emphasise autonomy and
recovery.
Historically, personal accounts from consumers have provided a strong
impetus to putting the notion of recovery on the mental health agenda
(1). The present metaphor is that of recovery as personal journey,
rather then the biomedical notion of ‘cure’ from ‘disease’ (10).
Increasingly in the literature it is emphasised that insights from the
lived experience of individuals who have recovered from mental illness
should be central to considerations of mental health care planning and
reform (11, 12, 13). In Australia it is now government policy to
include consumer participation in all levels of mental health service
provision (14).
However, the concern is that although the notion of consumer-led
recovery is on the mental health agenda there is little consensus about
the nature of this phenomenon (15, 16). This article is one response to
the call within the literature for consumer accounts to direct and
guide the development of a recovery oriented system (17). The
findings presented in the article are from a research project exploring
the process of recovery from mental illness through qualitative
interviews with consumers. The data from one of the interviews in
the study is so rich in information and insight that it is presented
here as a stand alone case history in order to do it justice.
The Research
This case history is part of a research project funded by a Central
Queensland University Merit Grant. The aim of the grant is to explore
through qualitative methodology the factors that contribute to recovery
from mental illness. This arm of the research involves interviews with
individuals who are chosen because they are articulate about their
recovery from mental illness. The participant interviewed for
this case study is a highly articulate consumer advocate who is
presently studying psychology at university level. As a consequence the
data from the interview is extensive and rich and requires the space of
a full article in order to be dealt with in sufficient depth to do the
findings justice.
Full ethical clearance has been obtained for the interview from the
university ethics committee. The interviewee was provided with a
written project description, informed verbally of her rights as a
research participant and signed a written consent form at the point of
agreeing to participate. The participant has had the opportunity to be
involved at all stages of the development of this article.
Demographic
The case study interview was conducted with a female person who was
diagnosed five years ago with type one rapid cycling bipolar disorder
during a severe depressive episode experienced after the birth of her
second child. The diagnosis was identified by the local general
practitioner, followed by a referral to a psychiatric consultation
eight weeks later, and confirmation of the diagnosis in 1999. The
evidence of recovery is provided in the findings section.
Methodology
The ten (n=10) participants for this arm of the study represent a
purposive sample of individuals who are chosen on three criteria:
first, they have an official DSM-IV psychiatric diagnosis for a mental
illness; second, they are able to demonstrate recovery from that
illness; and, third, they are articulate and sufficiently motivated to
express in words the experience of recovery. Participants are enrolled
through the snowballing techniques of networking within the mental
health consumer network. The intent behind such a purposive sample is
to provide an opportunity for articulate mental health consumers to
provide leadership in the way of providing insights on recovery for
those who are less able to express themselves.
Data was collected through a non-directive Rogerian interview that
proceeded at the interviewees pace, with constant checking by the
interviewer that the material dealt with remained within the comfort
zone of the participant. At times the interviewer would ask for
clarification of statements and would also make summaries of the
progress of ideas to affirm that the interviewer understood the ideas
expressed correctly. The interview lasted for approximately two hours.
It was audio-recorded and transcribed verbatim. The language
texts were then entered into the NUD*IST computer program and analysed
thematically. A phenomenological approach was taken to the
recording and analysis of the data. The aim of
phenomenology is to describe particular phenomena, or the appearance of
things, as lived experience (18). The process is inductive and
descriptive and seeks to record experiences from the viewpoint of the
individual who had them without imposing a specific theoretical or
conceptual framework on the study prior to collecting data (19). All of
the participant’s comments were coded into free nodes (free nodes is a
technical term for the categories created on the QSR NUD*IST N5 program
to store statements that relate to a similar topic), which were then
organized under thematic headings. There were thirty three (n=33) free
nodes created for the interview and, with the exception of the nodes on
spirituality and stigma, all of the findings are presented here.
Findings
The focus for the findings presented will be on the recovery coping
strategies. However, it is important to first explore the information
on the participant’s distressing childhood experiences in order to set
the context for understanding the recovery discussion.
Family Background
During the first seventeen years of her life at home the participant
had to deal with a controlling father who was often depressed and had
problem with gambling. He would isolate the family from other members
of the community and hold them under a realistic threat of death as he
possessed a gun and shooting licence. In later years the participant
came to understand that her mother felt frightened and powerless to
protect her children in the face of such threats. The following two
examples of distressing childhood experiences are provided as
background information to demonstrate the significant family-evoked
distress with which this interviewee had to deal.
• My father would put
a light in my eyes and make me stay up and do maths homework all night
long because that is what he would do when he was manic. And if I got
anything wrong the threat was to always be shot.
• There was one day when my mother dressed me up and
said ‘I want you to get in the car. Now your father has told me he
wants to drive both of you off a cliff and kill you because I’ve been
bad. So I want you to get in the car and if you think he is going to
kill you I want you to run away.’ And so we went … I have vivid
memories of the amount of the anxiety that I had .
Aspects of mental illness as functional response to distress
In the context of such a traumatic childhood, it is possible to view
many dimensions of the bipolar condition as functional coping
mechanisms for such a dysfunctional situation. As the following
texts demonstrate, the hyper-arousal and depression associated with
bipolar disorder can be seen as a response to the continuing fear
associated with a life-threatening situation.
• (You really did
have parents with very difficult problems) I might have had a
predisposition; maybe it might never have been triggered. But there is
that having to be hyper aroused (Yes, you were on alert for your own
life basically) … I had a skill to stay awake when I was stressed.
• So when our father was threatening our lives, being
depressed meant that I didn’t care if I died.
Personal isolation and lack of childhood spontaneity, also
characteristic of mental illness, can be seen as responses to the
family situation,
• To wanting to
isolate myself in the back corner of the house to actually use that to
cope.
• Also it reinforced that adult identity I needed to
have when I got home.
So successful were the participant’s coping strategies that it was not
until adulthood (27 years old) that the underlying condition (onset age
7) was manifest and diagnosed. During this time the participant did not
have access to counselling, psychiatry or medications.
• I had lived with it
for, I found out, two and a half decades. I was diagnosed at 27, I’d
been sick since for two decades because my onset was the age of seven.
Strategies for Recovery – Part 1:
Personal Strengths
The following discussion will outline the full range of coping
strategies that contributed to recovery, starting with those developed
during childhood.
A. Coping strategies – insights from childhood
The participant spoke of significant insights from childhood
experiences that informed her method of coping and later recovery. As
can be seen by the following statement, a mature concern for others and
a belief that suicide was inherently ‘wrong’ provided a defence against
taking her own life, in spite of suicidal feelings.
• I remember I was
ten when my next door neighbour gassed himself in a car in the garage.
I thought to myself ‘Gee, that would be a really good way to go’, and
then I thought to myself as I watched the whole process ‘No, I don’t
think I could ever do that to anyone’.
That experience combined with moral insight translated into a workable
modus operandi
• I think these are
the thoughts I had: that I would want to die and I think they are
wrong. And I don’t ever want to think like that again. So actually at
the age of ten I decided that I was never going to be suicidal again.
In such a frightening family situation, precocious maturity and the
ability to think quickly about complex situations are advantageous,
• She (mother) was
trying to get me to grow up to fend for myself. I suppose at the age of
four I was quick thinking on my feet and from that day I just thought
‘I have to grow up’.
The precocious maturity extends to assuming responsibility for the
fathering role for sibling and providing an anchor for the mother,
• My mother said I
was an emotional rock.
• I took up the fathering role of my younger brothers
and sisters….
Part of the ‘adult-like’ maturity included the ability to make
long-term plans and use delayed gratification as a means of enduring
hardship.
• I actually made a
long term plan to earn as much money as I could and at the age of 17 I
would move out with my mother and siblings. My mother didn’t have the
courage to do it by herself. And that is what happened, in the end we
ended up doing it. So by the age of nine I made that long term plan to
move.
B. Coping strategies – Self initiated
cognitive strategies
The participant spoke in considerable detail about the energy she
invested in developing effective cognitive strategies for recovery.
Such strategies depend on personal insight and a willingness to explore
cognitive solutions. An example of such a strategy and its
effectiveness in relation to depression is as follows,
• (The doctor) gave
me a depression questionnaire and I didn’t answer ‘yes’ to anything
because I realise now that I had already developed ways to cope with
not thinking that way. I was actually trying to stop myself feeling
depressed by thinking the other way. My strategy was to not think
suicidally as I wanted to live. That is why I didn’t rate on the
depression scale because I learned to deal with the depression quite
competently.
Another example is seen in her struggle with suicidal thoughts,
• I learned to
overcome suicide, that feeling of wanting to die. I probably learned a
sense of humour. I learned how sometimes my intelligence worked for me
or against me. To be a little creative.
C. Coping strategies – understanding of others
The sense of understanding also extended from self to other. The
participant indicated that insights into others emotional lives
assisted the recovery. Of particular importance for this participant
were insights into her father’s psychology,
• The abuse we
suffered as children was a result of him (father) having severe bipolar
disorder.
And also her mother’s inability to protect her,
• As a child maybe
what hurt me more is, ‘I don’t understand why my loving mother is doing
this?’ As I got older I realised how scared she was. Of him, because he
had a shooting licence… was able to kill her.
D. Coping strategy – Obtaining
information
Access to information from varied sources such as books and the
Internet, is an important factor informing the understanding of self
and other. Information from others coping with mental
illness is vital. Mention was also made of the importance of
books of hope, information on relationships and psychology.
• I do think the sharing of information between
consumers or advocates does help. It is not something any professional
would ever teach you.
• Psych degree… really loving it, really loving
studying it. There are concepts that are really helpful there are
others that are really useless.
One important coping strategy obtained from the Internet that was
discussed in detail was called the ‘Survival Techniques for the
Mentally Ill’. This included learning to cope with others reactions to
a psychiatric label.
E. Coping strategies – forgiveness
Forgiveness based on understanding and information was recorded as a
factor contributing to recovery.
• I felt forgiveness
for my father because I had never understood what was wrong with him.
Relief because I could forgive him more easily knowing there was
something I thought biologically wrong with him. That he wasn’t
necessarily a bad person.
F. Coping strategies – sense of humour
From an early age the participant discovered that humour was an
important strategy because it provided relief and good feelings, the
space to face difficult realities, and the opportunity to reframe
challenging realities in a safe way.
• I probably learned
a sense of humour. It was a safe way to talk about anything. My mind
was very quick at picking up things that make me feel good and don’t
have consequences. Humour is a way of looking at anything and
being real to the fact that it exists. And finding a way of thinking of
it differently.
G. Coping strategies – fitting the cultural stereotype
In a society with high expectations on the role of women, the ‘manic’
dimension can be an advantage in coping.
• I was super
efficient… I was generally super woman. . I totally fitted what other
people wanted me to be. … As a housewife and I was also a construction
manager.
H. Coping strategies – spirituality
The participant provided a rich discussion of the central role that
spirituality played in her recovery. Because of the limitation on
space available in an article, this wealth of information will be
published elsewhere. It will have to suffice here to indicate that
spiritual values, prayer and involvement in the church community were
important dimensions of the recovery process. As the participant
sums up,
• Everything deep
down is related to my spiritual beliefs
I.Coping strategies – finding ways of
connecting with others
With a background of isolation as a child one of the challenges in
recovery was to learn to connect with others. The freedom to express
emotions as they occurred played an important role in managing
stressful situations.
• I thought ‘well if
I can talk to my psychiatrist can I talk to other people?’ I could I
was experimenting. So then I’d come back to the psychiatrist and I’d
go, ‘Oh well I tried. I had a breakdown with the pastor at church. I
got myself a French accountant who can tolerate a lot of stress. I’m
getting a good support network going here.
Strategies for Recovery – Part2:
Dealing with the Mental Health System
The journey from diagnosis to recovery was recorded as a direct result
of the participant’s self-initiated struggles to work creatively and
assertively with the mental health system. As the following discussion
explains, the participant’s insight, intuition and drive were met by a
serendipitous connection with a psychiatrist prepared to listen, affirm
and take risks. It was that healing combination of consumer initiative
and compassionate professional response that assisted with the process
of recovery. This journey started with many unhelpful connections with
professionals.
From diagnosis to drugs
From the beginning of this account there is a tension between a mental
health system where the primary modus operandi involved compliance with
medication and a consumer with an intuitive sense that talk therapy
would be a more productive alternative. The system pressure was
expressed as,
• I wasn’t offered
any other options. Just told you to take (drug name). So one year past
I was on every type of medication. At the end of one year I was seeing
a psychiatrist every week with no therapy. A huge cost per hour too I
must say.
And the intuitive drive was described as,
• I’m not going to
kill myself, we already knew that. What is the risk in … and I wanted
therapy. And week after week I would say, ‘Can I please have therapy?’
I needed to recall what happened to me in my childhood.
The ambivalent compliance with
medication incorporated an optimistic hope that the drugs may provide a
solution,
• I wanted to fix
that so I prayed that his little pills would work
However, the ambivalent optimism was also accompanied by difficult drug
side effects from up to nine pills a day, for example,
• I was thirsty all
the time and I did not feel like myself.
• I think that this is really bad’. Like I’ve swollen
up. I can’t even walk on the soles of my feet, because I got spots and
everything. I’m like really sick. Physically really sick as well.
The intense medication resulted in anaphylactic shock and cessation of
all medication,
• I went into an
anaphylactic shock in the end. So I blew up. I went to the psychiatrist
and said, ‘Look at me’ and he said, ‘Oh, you had better go off
everything’ and then I was on the pill to control my hormones, I was on
so many things, I was even on thyroid tablets. I was on everything; I
had to go cold turkey off everything.
During the period of cessation of medication there was no appropriate
support other than a psychiatric appointment in two weeks.
• You are telling me
I have chronic bipolar disorder and you are going to take me off all of
this medication and return me to a family of two young children and a
husband with no one to help me. At that point I sacked him.
As seen by the following statement, the control by the system is
experienced as a repeat of the cycle of abuse,
• For me it was abuse
happening all over again. It was ‘I don’t have control’, I have someone
else controlling my life. I know what I am doing… I am not
going to kill myself…
Feeling better without drugs
The period without medication is recorded as positive, in spite of
physical problems, because of the return to self and the opportunity to
be in touch with present emotional pain and past memories considered
necessary to access for healing.
• I was on nothing. I
felt like myself again. Even though that might be bad, but it was
better than the worst (on drugs).
• For me my memory opened up. The pain and suffering
I was now in because now I was not medicated. …To me it was all of a
sudden my memory was coming back and that is where I needed to be.
Need to do therapy without drugs
The participant reported having a strong intuitive sense that talk
therapy without medication would be the most effective means to
recovery. The rationale being,
• I felt that the
trauma I suffered was so bad it was what was affecting my life more
than the bipolar disorder was. … It is like a band aid on a boil. The
boil just needed to be lanced. And that is so much more painful and
takes so much more skill. There is no easy way. I have had others who
have gone through this and I am aware that this is not just true for
me, it is also true for other people.
• I needed to do that without medication because that
is how my memory was most active, especially when I was in the current
emotional state.
Efforts to find a psychiatrist willing to engage in this process were
blocked by gaps in the system.
Gaps in the mental health system
The expectation was that a serious diagnosis of type one rapid cycling
bipolar disorder would provide direct access to help. This expectation
was thwarted for the participant by the fact that the private
psychiatrists contacted were not taking new patients and in the public
system she did not qualify for the criteria for the local mental health
service as she was not a suicide risk. The gaps in the system created
confusion and fear,
• I didn’t know how
this worked. Because I thought the diagnostic history was enough to get
me help. But I was afraid of getting locked up. Now I had fear of
getting locked up. I thought there was a danger of me getting locked up
trying to seek help. Now I had this fear I didn’t have before.
It was a combination of her self-advocacy and pure serendipity that she
eventually negotiated a self-referral to a sympathetic psychiatrist at
a public forum,
• I went to a public
forum and asked psychiatrist, ‘How does this work? Do I need to attempt
suicide in order to use your services?’ I said, ‘because I am really
sick I need help and I know there surely has got to be someone around
here who can help …I can’t afford private health insurance. Can you
tell me how I do this?’ And that was the point he took me on as a
private patient. (You created the referral yourself?) This is me
finding my own life buoy.
The creative therapeutic process
As the following description will outline, a significant part of the
recovery process eventuated through the therapeutic psychiatric
relationship. There were a number of factors that facilitated
this process and they included turning points that provided an
emotional openness to work on difficult issues, the courage of the
psychiatrist to engage in a degree of therapeutic risk, the creative
use of drugs, and nourishing elements in the counselling relationship.
Turning point
The participant spoke in detail of a number of factors that converged
in her life that made her open to, and insistent on engaging in talk
therapy. First amongst these was the grief she experienced from her
sister-in-law’s suicide,
• It was my sister in
law, probably committing suicide that actually probably got it all
going, because at the end of the day it triggered off so much other
stuff for me.
Second, her emotional devastation and the fact that she was no longer
on medication provided access to memories that energised the
therapeutic exploration,
• I was back in
emotional devastation of how I felt when I was a child. For me my
memory opened up. The pain and suffering I was now in because now I was
not medicated. The very extreme emotions were a memory trigger. I could
remember everything so to me it was like a good thing as well.
Thirdly, the trust she experienced in her relationship with her
psychiatrist gave her the confidence to begin the therapeutic process,
• The catalyst was
probably trust occurring in that (psychiatrist) relationship. …I
remember him (psychiatrist) consoling me over her death. And when he
supported me in that he gave me the insight to know that he could
support me retrieving the past.
Need to take risks
A theme underlying the discussion was the idea that the use of
medications not only have their problems from side effects, but they
also have another level of problem in that they stop the patient from
entering the therapeutic space needed to unpack childhood trauma and
move on. Consequently, to some degree the prescription of medication
operates on the principle of risk management, keeping the person locked
into the present status quo. The participant expressed appreciation for
the fact that the psychiatrist who helped her to recover countered this
by taking risks (albeit responsible and calculated risks).
• So having a
psychiatrist that was quite happy for you to take the increasing and
decreasing and your own prescribed amount of anti-psychotics because
you are experimenting with them. (He wasn’t your usual conservative
psychiatrist?) No.
The boundaries of the risk taking were discussed and agreement reached
as to the limits and strategies to ensure the risk taking was within
ethical boundaries of the profession.
• Psychiatrist would
make me aware of when he had an ethical problem in letting me go out of
his office. I found creative ways to talk about this that I could
reassure him that he would feel unobligated by his ethical
responsibilities.
The important outcome of the process is that the patient felt in
control of, and thus responsible for, her own healing process.
Experimenting with and without drugs
An important part of the therapeutic freedom that the participant
valued and attributed as part of her recovery process was experimenting
with medications. Not all experiences were positive as can be seen by
the reference to anti-depressants,
• I tried
anti-depressants. They did send me off the deep end so that was a bad
idea.
A positive example is her use of anti-psychotic drugs to understand,
for a brief time, the feeling of not being in a psychotic state. As the
participant explains, it is this feeling, not the drug, that is used
for the recovery process,
• I knew that if I
took an anti-psychotic it would have a chemical effect of reducing
those chemicals in my brain … I’d get a feeling of what it would
be like to not be in a psychosis if I took them. I’ve got to say that
to some degree it felt good but I did not like the side effects. … I
experimented with them.
The use of medication became a tool to self-learn about the effect of
chemicals in her system.
Effective therapy process
Once the talk therapy began, there were many factors within the
therapeutic alliance that fostered recovery. First and foremost is the
sense of trust creating a safe space,
• I started the
therapy process and three or four months into that; I suppose it
probably took me that long for the trusting to start occurring. But the
catalyst was probably the trust occurring in that relationship.
• (Previously) there is all this stuff I’m trying not
to remember because if I do I will fall apart. I’ve not really been in
a place where I felt safe where I can fall apart.
Second, is the importance of having control over the therapeutic space,
• I needed control
over my lifelines. Maybe I can put it that way.
Third is the emotional openness obtained without medication,
• I needed to do that
(therapy) without medication because that is how my memory was most
active.
Fourth, was the sense of having someone with a solid base in the
present from which to explore the past,
• The psychiatrist
gave me somebody who was in the present …he kept pulling me back to the
present. Sometimes I felt I could just get lost back there … rather
than ‘lets go deeper’, a lot of my therapy was, ‘you have dug too
deep’.
The process involved revisiting a frightening past with a message from
the present that there was no longer anything to fear,
• As a child a lot
happened under intense fear. Sometimes I needed to retrieve it right
out. Just not be afraid of it anymore. I need to circle that around in
my head, ‘There is nothing to fear’.
The medium for such exploration is simply talking in a safe space for
reflection and integration of fearful past memories,
• So if I can get
through this I can put the pieces back... I’ve had friends who have
gone through this and I’m aware that this (talk therapy) is not just
true for me. It is also true for other people (Just talking did help
you?) Yes.
An essential element of the process was to do this with someone, rather
than alone,
• I wanted someone to
be with me. I had always been alone. Alone, doing it myself.
One of the disadvantages of being innately independent had been others
would not see the need to offer support.
Recovery
The outcome of the above detailed process is that the participant moved
from being a consumer of the mental health system to a consumer
advocate involved in education of psychiatrists and other mental health
professionals and organisations at local and national level. The
indications that the participant is in recovery include A. a letter
from her psychiatrist affirming her successful coping abilities and
releasing her from therapy as she no longer needs psychiatric
follow-up; B. the fact that she remained symptom free and without
relapse since 2001; C. her success in undertaking a university degree;
D. her strong contribution to the welfare of others through her
important work as mental health consumer advocate (eg. National
depression initiative); E. her ability to develop an extensive support
and friendship network; and, F. psychiatric and educational evidence
that her children are demonstrating emotional adjustment and
educational success.
Recovery reinforces recovery
There are many benefits from recovery that help to affirm the
individuals sense of self worth and thus further reinforce the recovery
process. In this case there were two areas of life where this
positive process is demonstrated - as mother, and consumer advocate.
The central role of mothering
A
concern for the welfare of her children is the central force driving
and maintaining recovery.
• And having my
children. That is really important to me. And I probably didn’t
emphasise that enough.
The participant spoke of her pride in that fact that since her recovery
her children had progressed past early adjustment problems and were now
doing well.
•
Every parent
wants to know that they have done the right thing by their kids. I want
to emphasise that – that is one of my driving forces. All the fears of
what your parent did to you as a child - and my child was now becoming
depressed and sick at the age of seven like her mother. But now I had
the opportunity to do things right.
• (After discussing
prior problems with children) Both of my children are now ahead in all
aspects at school. And the parent teacher night is always wonderful.
Consumer advocate –seeing how far you
have come
The participant is a well respected consumer advocate who uses her
energy from recovery to make a difference to the lives of others. The
advocacy role provides further opportunity to reinforce her progress
and present strong position.
• I ended up an
interpreter between the professional and the consumer. A skill I am
really enjoying developing. It is wonderful to be able to value how far
you have come. You don’t realise that until you see somebody who is
just diagnosed. And all of a sudden you realise what a hole that they
are in and what information we have. And you remember how hard it was
and within a very short period of time you are able to show people how
to turn on the light.
The Mental Health Metaphor
The process of recovery within the mental health system as outlined in
this article is eloquently summed up by the participant’s metaphor of
the slab,
• I would often
describe the mental health system as a slab over my head. I would feel
that it was so solid and so concrete that at any point in time it could
fall and crush me to death. Then I saw my psychiatrist in the therapy
process as a chain that held this slab off my head and I would say,
‘please hold the slab don’t let it fall’ I know I am standing here but
I trust you to hold it because I need you to. I realised that he could
not do that forever for me. I knew the slab would eventually fall on me
and so I needed to do something with it. I’ve got to say that in doing
my psychology degree. I am above the slab. I have built a couple of
walls. From where I am now it is really good. The slab turned into the
ground floor for the next level.
Discussion
Recovery is now understood to be a ‘unique process’ (17, p. 160). This
case history of recovery provides a clear demonstration of the
importance of respecting the strengths within individuals with a mental
illness to drive their own recovery. As such, it echoes Deegan’s
(12) argument that people who experience a diagnosable psychiatric
illness are much more resilient than myths about mental illness would
suggest. As outlined in Figure 1, the person in this case study brought
a wealth of personal strengths combined with an assertive self-advocacy
to a mental health care system unresponsive to her needs. In doing so
she avoided the more usual process of engulfment in the role of passive
recipient of care, a treatment effect that contributes to chronicity
(1, 20). Through assertiveness and serendipity she manages to find a
therapeutic alliance within the system through which she explored her
intuitive ideas about what was needed for her recovery. It is the
combination of her personal strengths and a supportive psychiatric
relationship that allowed her to deal with difficult issues from the
past and refine present coping strategies. Kotake Smith’s research (21)
also affirms the importance for the consumer of finding the right
psychiatrist.
Figure 1. Flow Chart of Ideas
The essential
ingredients of the therapeutic process are that it came at a crucial
turning point in her life, and that the relationship was built on trust
and respect. Corring and Cook (22) argue that at the core of an
effective ‘client-centred’ approach to practice is the professional
view of the person with the mental illness as a valuable human being.
Another key central feature of the therapeutic relationship reported
here is that it gave priority for responsible risk taking over the need
to control. Taking responsibility for one’s recovery is
documented as a core component of recovery (1, 23, 24). As Deegan (25)
states part of that responsibility includes self-management of wellness
and medication, autonomy in one’s life choices, and the willingness to
take informed risks in order to grow. She argues,
Professionals must embrace the concept of the dignity of risk, and the
right to failure if they are to be supportive of us.’ (25, p. 97)
The literature on recovery is emphatic about the centrality of the
notion of choice (4,17). As Anthony (17, p. 160) outlines one of the
core assumptions about recovery is that it demands that a person has
choices, ‘The notion that one has options from which to choose is often
more important than the particular option one initially selects.’
The case study documents the pressure within the mental health system
to respond to consumers primarily through the prescription of
medication. The limits to medication both in terms of distressing
side effects and blocking therapeutic progress were noted along with
evidence of a medication free recovery. Elsewhere there are description
of the problematic use of medications, sometimes described as being
worse than the disease and blocking recovery (24, 26, 27, 28). The work
of Carpenter (29) points to the detrimental effect of the hegemony of
the biomedical model in mental health policy and service provision and
argues for a consumer-survivor recovery movement. Similarly Watson (30)
points to the lack of consistent evidence to support the use of
neuroleptic medications and their problematic side-effects. He
argues for a post-modern psychiatry that dispenses with the biomedical
model. McGruder (31) echoes these ideas with anthropological arguments
that demonstrate that the medical paradigm of disease strips away the
meaning of the illness experience. The findings concur with Deegan’s
(32) concerns about the spirit breaking practices that are documented
as a destructive potential of mental health professionals within the
system.
A full discussion of the findings on spirituality will be dealt with
elsewhere, so it will suffice here to note its importance. Although
spirituality is marginalised in the mental health literature (33),
there is evidence that this dimension is starting to be recognised as
central to recovery (21).
Of the several models of recovery in the literature, the one that is
the closest fit with the findings in this article is that of Jacobson’s
(34) four component processes: recognizing the problem, transforming
the self, reconciling the system, and reaching out to others. The
participant’s extensive signs of recovery, which include taking
effective control of her own life and finding the creative energy to
make a difference to the lives of others, is a testament to Spaniol’s
(35) argument that people do recover and go on to fulfilling and
contributing lives. The suggestion for the way forward coming from such
findings would echo the Australian work of Shanley and associates (36)
that identifies a new system of mental health called the Partnership in
Coping (PinC) system. The PinC system uses a positive, holistic
perspective that focuses on the strengths in clients.
Conclusions
The participant’s metaphorical description of the mental health care as
a concrete slab capable of killing her which is held up only by the
slender chain of a therapeutic psychiatric relationship is a sobering
reminder of the power within the system. Recovery for this participant
symbolises the removal of the fear of being crushed and progress from
the dependency on the slender chain that keeps the slab from falling.
The benefits of recovery bring further strengths: metaphorically
speaking the building of a room above the slab. It is the hope and
expectation that by sharing the metaphor of the slab and the insights
that go with it, that the information will go some way to strengthening
the chain of recovery for other consumers negotiating their own journey
of recovery through the mental health care system.
Acknowledgement: The authors would like to thank Mr Hamish Holewa for
his work as Project Officer and Mrs Elaine Phillips for her
transcription of the interview for the study.
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