Hope and Recovery

Pat Deegan reflects on her own experience an shares about the need for hope in recovery:

He said, I should retire from life and avoid stress. I have come to call my psychiatrist’s pronouncement a “prognosis of doom”. He was condemning me to a life of handicaptivity wherein I was expected to take high dose neuroleptics, avoid stress, retire from life and I was not even 18 years old! My psychiatrist did not understand that boredom is stressful! A life devoid of meaning and purpose is stressful! A vegetative life is stressful. A life in handicaptivity, lived out within the confines of the human services landscape, where the only people who spend time with you, are people who are paid to be with you – that is stressful! Living on disability checks from the government is stressful.

When I was diagnosed I needed hopeful messages and role models. I needed to hear that there were pathways into a better future for me. I needed to connect with others who had been diagnosed with schizophrenia and who had recovered lives of meaning and purpose. I needed to find others who had completed college and who had jobs and who got married and had families, and had an apartment and a car.

Why is hope important to recovery? Because hope is the root of life’s energy. In order to recover, I had to turn away from the wish that psychiatrists could fix me. I had to turn away from the myth that psychiatric treatments could cure me. Instead, I had to mobilize all of the energy I had. I had to become an active partner in my recovery. I had to learn to work collaboratively with my treatment team and to draw strength from the wisdom of my peers. I had to begin striving for my goals, not when I was “all better”, but from day one. I had to believe that there was a life for me beyond the confines of the mental health system. That is hope. Hope is the tenacious pursuit of pathways to a better life, despite the odds. Without hope, there is no recovery.

Amen. Please go and read the whole post at her blog and spend some time poking around her posts.

hope is a function of struggle

From On Being, some insight on hope and how people can foster it or inhibit its development:

Ms. Brown: You know, one of the most interesting things I’ve found in doing this work is, you know, something the wholehearted share in common is this real profound sense of hopefulness. And as I got into the literature on hope, very specifically C.R. Snyder’s work from the University of Kansas at Lawrence, that hope is a function of struggle.

Ms. Tippett: Right. I think that’s one of the most stunning sentences that I saw in your writing.

Ms. Brown: Yeah, and that hope is not an emotion, but hope is

...Hope...
…Hope… (Photo credit: ĐāżŦ {mostly absent})

a cognitive, behavioral process that we learn when we experience adversity, when we have relationships that are trustworthy, when people have faith in our ability to get out of a jam.

Ms. Tippett: Right, which is different from this pattern of having faith in us which means telling us everything we do is wonderful and shielding us from pain as long as they can.

Ms. Brown: Right. And, you know, I’m literally — I don’t even know how to talk about it. It really just floors me that, when I go out and I do a lot of talks for big corporations, you know, Fortune 100 companies, how many people tell me — like the HR folks who I end up — luckily, I love them and I get to talk to them a lot, who will tell me how often parents call to go over the performance evaluation of their children or to find out why they didn’t get a raise or a promotion.

Ms. Tippett: Really?

Ms. Brown: Yeah, oh, yeah.

Ms. Tippett: I mean, I just took my daughter to college and we got this lecture, the parents and the families who were there, from like the Dean of Students and it was so clear that they were dealing with that same thing, right? I mean, they basically said I need you to understand that we’re going to take great care of your gem and also that my relationship is to them and not to you. We got this lecture, which was clearly based on parents still trying to control. You know, again, it’s like, boy, we know this, don’t we, this desire that you have to create a beautiful world and life and experience for these people you love?

Ms. Brown: But you know what? I think we lose sight of the beauty. The most beautiful things I look back on in my life are coming out from underneath things I didn’t know I could get out from underneath. You know, the moments I look back in my life and think, God, those are the moments that made me, were moments of struggle.

Ms. Tippett: Or I look back at things I did where, if my parents or I had understood how crazy it was, like if it had been me, I would have tried to intervene and rescue?

Ms. Brown: Oh, for sure.

Ms. Tippett: And you’re right. Those are the moments you become who you are.

Ms. Brown: You know, and I’ve seen how this research has really changed, you know, like I’ll give you just a very specific example. My daughter decides, you know, that she wants to try out for something that she’s really new at. You know, a sport or something that she’s just taken up.

And I think before, maybe even three years ago, before this research, not only before I wrote it up, before I started trying to practice it and live it, I think I would have been the parent who said, you know, either let’s get you in 34 camps before you try out so you’ve mastered it, or I don’t think you should try out for that because there are girls who’ve been playing this sport as long as you’ve been playing soccer …

Ms. Tippett: And you want to shield her from disappointment.

Ms. Brown: Right. And I want to take away that moment that I had. You know, it wasn’t the moment. When I think back and I talk to parents a lot about this, it wasn’t the hard moments that we don’t want to expose them to. It was the isolation and shame we felt around those moments because a lot of us didn’t have people to process them with.

Like I think when I went out for something and didn’t make it, I don’t think my parents were ashamed of me, but I think they were ashamed for me. I don’t think they knew how to talk about that. I don’t think we had a conversation. I know we didn’t have a conversation that I can have with my daughter today where I say, you know what, I’m so proud of you not only for trying, but for letting the people around you who you care about, you let us know how much you wanted it, and it doesn’t get braver than that.

Ms. Tippett: Right. Right. Well, I mean, here’s this other sentence that’s a corollary to the sentence hope is a function of struggle. You say you look at a baby, your newborn baby is hard-wired for struggle. It’s built in us that that is how we are going to shape, that that’s what we’re going to encounter, that’s how we’re going to shape ourselves. That’s actually a really hard thing to take in, you know, as a parent, especially thinking about those moments early on when you first meet this being that is going to have dominance over your life.

Ms. Brown: Yeah, because I think we look and think I can make this right. I can do for her or him what wasn’t done for me. I can protect them from the things that hurt me. I think we are so much more hard-wired for who we are than what people, especially parents, want to believe. And I don’t think our job as parents is to make everything right and perfect and beautiful and true. I think our job is, during struggle, to look at our kids and say, yeah, this is hard and this is tough and you’re hurt.

Ms. Tippett: And you’re not alone, you’re not alone.

Ms. Brown: But you’re not alone.

Ms. Tippett: I’m not going to fix it, but you’re not alone.

Ms. Brown: Right, you’re not alone and I want to make sure you understand that this doesn’t change the fact that you’re worthy of love and belonging.

Related posts

The golden age

Keith Humphreys argues we’re entering a golden age0524-Golden-Age-Runway-show for mental health care:

For most of U.S. history, employers did not provide adequate mental health benefits in the insurance packages they assembled for employees. This wasn’t a controversial policy: most labor unions were quite happy to trade “mental for dental” when they negotiated fringe benefits. But over time, more and more families who were being destroyed by a loved one’s schizophrenia or alcoholism or manic depression went through a second round of suffering when they discovered that their employer-based insurance wouldn’t pay for care.

These families made common cause with other advocates to mount a 12-year push for equal treatment, which culminated in the 2008 Wellstone-Domenici Mental Health Parity and Addiction Act. As a result of this law, the more than 100 million Americans who receive insurance through large employers are now guaranteed that their mental health-related benefits will be comparable to those for the treatment of other disorders.

Also in 2008, a major effort to reform Medicare passed, one that critically included a little-noticed mental health provision that just came into full effect this year. Since its creation, Medicare had covered 80% of all outpatient care except for mental health and addiction treatment, only 50% of which was covered. This extremely high co-payment effectively prevented many Medicare recipients from receiving mental health care. Today, however, the 50 million senior citizens and disabled persons who rely on Medicare enjoy the same level of coverage for outpatient psychiatric care as they do for all other types of medical treatment.

The 2010 Affordable Care Act is even more transformative. The law allows a parent to keep their children on family health insurance until the age of 26, thereby fully covering the age range in which almost all serious mental illnesses and addictions begin. Furthermore, the law defines insurance coverage for mental illness and addiction care as “essential health benefits.” As a result, both the Medicaid expansion and the private plans sold on health exchanges all cover care for psychiatric disorders at the same level as other diseases. The Department of Health and Human Services estimates that over 60 million Americans will receive improved mental health insurance coverage because of the provisions of the ACA.

Hope, empowerment, capability, connection and purpose

Hopeworks Community recently listed his core beliefs related to his recovery from mental illness:

The idea was simple. There are a few core beliefs about recovery that make a difference. To the extent you are able to live them your recovery will be positively impacted.

My list of core beliefs was simple:

Life can get better.
I can help make it better.
I can learn the things I need to do to make it better.
I have support. People care about me and what I am doing.
What I do matters. It has meaning and purpose.

Or HOPE….EMPOWERMENT…CAPABILITY….CONNECTION…PURPOSE…

This rings very true for addiction recovery as well. Any practitioner or program that ignores these dimensions is inadequate. Some people will need no assistance with this kind of recovery–if we reduce their symptoms they can take care of all of this on their own without mutual aid or extended professional help. (I’m thinking of people with major depression or a problem drinker.) Others will more severe and chronic mental illness or substance use disorder will need lifelong professional and/or peer support. (Here, I’m thinking of an addict or chronic, debilitating mental illness.)

There’s a lot of pushback on this for addiction. Just this weekend, Anne Fletcher tweeted a dismissive reaction to a Bill White post about developing geographic communities of recovery.

Would she have the same reaction to a post about building communities of recovery for people with chronic and severe mental illness? Would she tweet a response that implies it’s overkill and these people (Who, together, are re-engaging in full family, occupational and community life.) need discover that there’s more to life and they need to get out of some growth-limiting bubble?

There’s been a whole new wave of these kinds of reactions recently. To me, they suggest a couple of beliefs:

  • The failure to acknowledge the different needs of people who have less severe or time-limited problems with alcohol and other drugs versus those with severe, chronic and debilitating addictions. Their reactions often focus on the experiences of the former, framing substance use disorders as a lifestyle choice.
  • The perception that recovery advocates (12 step recovery in particular) can’t tell the difference between these two groups and are bent on evangelizing every problem user into their one and only path to recovery while obstructing access to any treatment or recovery support that isn’t perfectly compatible.
  • That this perceived pattern of behavior undermines the legitimacy of mutual aid groups and the empirical evidence for the their effectiveness and their mechanisms of change.

Hopeworks Community closed with a thought that sums up recovery as a way of life.

But I know recovery is never a thing to have, but a way of doing.

Interesting that there is so much resistance to lifestyle change as an approach to managing addiction while there’s no dispute that lifestyle change is critical to successful management of other chronic illnesses and that peer support is important for successfully initiating and sustaining lifestyle change.

I don’t hear any of these reactions regarding people who join a gym, spend an hour there 5 days a week, start eating healthier, integrate being physically healthy into their identity and develop new social networks around these changes, like, say, a tennis league or a biking group. Why is that? We don’t hear that push back, and we’re not even talking about people who were occupationally, socially, emotionally and familially impaired. And, if some faction of these people exhibited evangelical zeal and insisted this was the only way to be healthy and that everyone needed to do this, would we be so dismissive of scholarly work describing the development of some communities organized around this kind of wellness for really sick people?

Am I going to hang onto these symptoms?

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Sherwin Nuland’s experience with depression led to the observation that some of his beliefs were bound up with his symptoms. [emphasis mine]

And they were indeed a symptom of a long-term obsessional neurosis. And if I was going to get out of this depression, I was going to have to give that all up. And I did. Interestingly, you know, people think well, you know, we’ll take pills, we’ll take electroshock therapy, we’ll get psychotherapy, and we will gradually get better and they forget that you reach a point in an emotional illness, on the upswing, when you’re starting to get better, when you have to make a decision because you’re now strong enough to make it. The decision is, ‘Am I going to hang on to these symptoms?’ Because the symptoms become very meaningful to you, you depend on them, you’re comfortable with them. They represent things to you.

This rings very true for both mental illness and addiction recovery.

Closing down?

closing_downFindings from a study of adverse interpersonal effects from antidepressants were recently published online. The adverse interpersonal effects we reported by more than half of the subjects, though more than half of the subjects were on them for 3 years.

The gated, full article described a cluster of reported side-effects that it described as “closing down”. Note the last sentence. [emphasis mine]

Our findings, from the largest sample to date, suggest that it may be important to follow up results from smaller, qualitative studies, with large-scale surveys. All four of the emotional or interpersonal effects identified in previous qualitative studies (Gibson et al., 2014Goldberg and Moncrieff, 2011 and MIND, 2012) were reported to be very common: Feeling Emotionally Numb (60%), Feeling Not Like Myself (52%), Reduction In Positive Feelings (42%), Caring Less About Others (39%). Between 16% and 35% experienced these four effects as either ‘moderate’ or ‘severe’. Furthermore, all four effects were strongly associated with the belief that suicidality was experienced ‘as a result’ of the ADs, as was Agitation. This is consistent with a study that found suicidality associated with the adverse effects ‘emotional blunting’ and ‘emotional instability’ (Goldberg and Moncrieff, 2011).

Younger people were more likely to experience Feeling Emotionally Numb and Feeling Not Like Myself, and men were more likely to experience Reduction In Positive Feelings and Caring Less About Others.

This diminished capacity to experience feelings, positive or negative, and to care about other people, might be characterized as a sort of ‘closing down’, a withdrawal from the emotional and interpersonal world. This might be considered an exacerbation of the problems for which ADs are prescribed in the first place. These effects may also reduce the probability of using other pathways to recovery.

The continued use of the drugs makes one wonder if some of these adverse effects, like numbing, aren’t also experienced as a benefit.

Recovery vs. Treatment

Hopeworks Community’s blog speaks from the perspective of a mental health care patient advocate. He draws some important distinctions between recovery and treatment:

Is treatment a necessary or a sufficient condition for recovery??  The answer is clearly on both counts no.  Mental health professionals have stolen the notion of recovery and defined it as the result of some type of professional service.  It has left recovery as an emaciated thing with little power or ability to meet the needs of people in severe distress.  One friend said it succently, “I feeel like I am in the old Wendy’s commercials.   I am still looking for the beef.”

Recovery is the result of succcessful living.  Successful living is always a matter of degree.  Recovery is when the gains in life begin to make a difference in the way you experience and live life.  Recovery is life getting better and that “getting better” giving you increased ability to make life to come better and better.  It is about restoration and transformation.  It is about life anew.  It does not mean things are all sunny and sweet.  It does not mean life is not hard, although it should mean everything is not hard.  It does not change life as much as it changes your capability to deal with life.

Some of the things that make life more successful include (but are not limited to) experiences that help to be more aware and open to the world around you, experiences that help you to learn how to anticipate and and see where things are going and help you to develop tools and skills to deal more successfully with those events, anything that increases your strength and capabilitities in life, anything that helps you to connect with other people and them to connect with you, that what gives you confirmation that life has meaning and purpose, anything that empowers you to make decisions about your life and accept responsibility for those decisions,  anything that helps you to think before you act, and anything that helps you to understand and accept that some things are beyond your control and no matter how bad it feels in any moment that is not all there is and life can and does get better.  And all that probably is just scratching the surface.  Recovery is a difference that makes a difference.

Treatment only matters when it is part of successful living.  For too many people, too often it is not.  No matter how much it helps it is not the same thing as successful living.  It is only a tool and like all tools it only matters how well it works.  By itself it is never enough.  And any program that tries to get their clients to identify their success in life with their participation in that program has done an injury that far outweighs any good they may have done.

Recovery is when you know it can get better, that you can make it better, that people support you in the making it better, that sometimes messing it up is part of it getting better and you can learn from mistakes, and that it is well worth the effort and that you are committed to making these truths guide and inform you in your pursuit of a better life.

via Recovery and successful living | Hopeworks Community.

“looking past these behaviors”

Lowering_The_Bar_Cover_2010.09.22This article got me thinking about the bigotry of low expectations and the importance of continuing to assert that every addict should be offered treatment services that provide a path to full recovery, not just symptom or harm reduction.

If it’s not suicide or drug overdoses doing the killing in psychiatric patients after all, how does that change the way we see severe mental illness? For one thing, it jerks this sort of disease back into the world of everyday misery. Society is excellent at sealing off the deep end, so to speak. Because this kind of illness is behavioral and has to do with the very ways in which we experience the world, it becomes easy to put the brakes on empathy. The study suggests that psychiatric patients are mostly dying in normal ways, albeit in hyperdrive: living life fast but miserable.

Hartz et al’s study also suggests that anti-smoking and other public health campaigns have effectively bounced off the mentally ill, perhaps in part because doctors are looking past these behaviors. “Some studies have shown that although we psychiatrists know that smoking, drinking, and substance use are major problems among the mentally ill, we often don’t ask our patients about those things,” Hartz says. “We can do better.”

via How Mental Illness Kills | Motherboard.

For Depression Treatment, Meditation Might Rival Medication – Forbes

Mindfulness-Doug Neill

A new study finds mindfulness meditation to be an effective treatment for depression:

On the list of ways in which meditation appears to benefit the brain, depression treatment may be the latest to gain scientific backing. A new review study, out yesterday in the Journal of the American Medical Association (JAMA) Internal Medicine, finds that mindfulness meditation may rival antidepressants in easing the symptoms of depression. The review is noteworthy for this reason: Its authors combed thousands of earlier studies on meditation, arriving at a small number of randomized clinical trials (the gold standard in science) for use in the analysis. Mindfulness meditation may not cure all, the research found, but when it comes to the treatment of depression, anxiety, and pain, the practice may be just as effective as medication.

How effective?

In the current study, the effect size for meditation on depression was found to be moderate, at 0.3.

. . .

But the results are more impressive when you keep in mind that the average effect size of antidepressant medication, the go-to method in the country, is also 0.3. So when it comes to treating depression, which has a notoriously low treatment success rate, the effect size for meditation in the current study is actually pretty impressive.

What’s the evidence for other problems?

There was no evidence for an effect of meditation on other measures, like attention, positive mood, substance use, eating habits, sleep and weight. Mantra meditation didn’t seem to carry the same effect as mindfulness meditation, but it may be in part because there were too few studies in the former to draw real conclusions.

via For Depression Treatment, Meditation Might Rival Medication – Forbes.