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:
McGrath, P. & 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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