I am the rear tire of a bicycle not trusted enough to be a front tire expected to go round and round in one narrow rut never going very far ignored except when I break down.

1
ThenI get lots of frightening angry attention
and lam put intoagarage sometimes for months
whereI forget my function andI become afraid
to functionand all functions seem
useless.Next time out I think I will be an
off-ramp from a freeway. Lynne Morris 9/8/80
Iamthe rear tire of a bicycle not trusted
enough to be a front tire expected to go
round and round in one narrow rut never going
very far ignored except when I break down.
2
Recovery from a Psychiatrists Point of View
Ronald J Diamond M.D. Medical Director, Mental
Health Center of Dane County Consultant,
Wisconsin Department of Community Mental
Health Department of Psychiatry, University of
Wisconsin
3
Autobiography in Five Short Chapters by Portia
Nelson

• Chapter One I walk down the street There is
  a deep hole in the sidewalk. I fall in. I
  am lost... I am helpless. It isnt my
  fault. It takes forever to find a way out.
• Chapter Two I walk down the same
  street. There is a deep hole in the
  sidewalk. I pretend I dont see it. I fall
  in again. I cant believe I am in this same
  place. But, it isnt my fault It still
  takes a long lime to get out.

4
Autobiography in Five Short Chapters (part II)

• Chapter Three I walk down the same
  street. There is a deep hole in the
  sidewalk I see it is there. I still fall
  in. Its a habit.., but. my eyes are
  open. I know where l am. It is my
  fault. I get out immediately.
• Chapter Four I walk down the same
  street. There Is a deep hole in the
  sidewalk. I walk around it.Chapter Five I
  walk down another street. Center for
  Community Change

5
Implications of a Recovery Approach

• What do we mean by getting better
• Decreased symptoms
• Decreased hospital recidivism
• Increased ability to function
• Economic self-sufficiency

6
Process of Recovery
The Person
The Illness
The Person
The Illness
7
Process of Recovery
Play
The Person
Friends
Work
The Illness
Family
8
Recovery

• Recovery is not the same as cure
• Recovery is having more to life than illness
• Recovery is a process, not a destination
• Recovery is both done and defined by the person

9
Consumer Survivor movement

• Political movement of marginalized people
• Focus on rights and civil liberties
• Expectation that the system should accommodate to
  needs of consumer/survivor
• Part of disability rights movement
• Ground uppremium on personal expertise

10
Recovery from AODA tradition

• Ongoing process
• Short term and long term goals
• Symptom management and relapse prevention

11
Psychiatric Rehabilitation Approach

• Pat Deegan 1988Recovery as part of the lived
  experience of overcoming disability
• Kathleen Crowley-Procovery
• Attaining a productive and fulfilling life
  regardless of the level of health assumed
  attainable

12
Recovery

• Rehabilitation is what professionals do
• Recovery is what consumers experience
• Clinicians focus on prognostic factors that
  predict improvement
• The persons own experience is in the center of
  recovery

13
What do we mean by recovery

• Clinical Recovery
• absence of symptoms
• Social Recovery
• work, friends, function
• Behavior does not cause distress to other
• Economic Recovery
• Personal Recovery
• Ron Coleman Recovery, an Alien Concept

14
Assumptions about Recovery

• Recovery is highly individualized
• Recovery can occur with recurrent symptoms
• Recovery is NOT linear
• Recovery from Stigma if mental illness is
  sometimes more difficult than recovering from
  illness itself
• Adapted from Anthony, Deegan and others

15
Phases of Grief Kubler-Ross
Not linear Not everyone goes through all
phases Trajectory and timing is different for
each person Understanding how a person is
experiencing grief can help us be more
effective Hope is critical

• Denial
• Anger
• Bargaining
• Depression
• Acceptance

Workshop by Mary Neubauer and Tom Harding 10/06
16
Myths about Schizophrenia

• Inevitable downhill course of illness
• Rehabilitation useful only after stabilization
• Medications needed forever
• People with MI can only work at low-level jobs
• Adapted from Deegan and Harding

17
Vermont Long Term Study 32 year follow up
Harding CM et al. Am J Psychiat 1987144 718-22
18
Models of Recovery
Internal Conditions
Recovery
External Conditions
Jacobson N, A Conceptual Model of Recovery
19
Models of Recovery
External Conditions
Recovery Oriented Services
Positive culture Of healing
Human Rights
Jacobson N, A Conceptual Model of Recovery
20
Positive Culture of Healing
Recovery Implementation Task Force Wisconsin
Bureau of Community Mental Health

• Maintain positive attitude towards consumers
• Emphasize what is working
• Reframe to focus on strengths
• Acknowledge and celebrate successes
• Work to earn trust of consumer
• Practitioner Competencies

21
Recovery oriented services

• Who get to set goals of treatment
• Who gets to make what decisions
• Who gets to read charts, or write in them
• Inclusion of clients into decisions about the
  services
• Symbols of exclusion

22
Wellness Deegan

• You live in a place you like and can call home
• You have something that you believe is meaningful
  to do during the day
• You have at least one someone to laugh with and
  pour your heart out to
• You find some joy in life and have fun now and
  again
• You see that you have choices
• You like yourself (mostly)
• You feel you are able to do most things you would
  like to do

23
Wellness (cont) Deegan

• You take a calculated risk now and again
• You recognize that there are some things about
  life that cannot be changed, at least in the
  short term
• You have found a place in the world and feel
  reasonably good about it
• When you feel bad, you are able to make yourself
  feel better and ask for help when you need it
• When others feel bad or need help, you give when
  asked

24
Phases of Mental Illness Experience

• Confusion
• Denial
• Loss of Control
• Anguish
• Grace
• Suffering
• Hope
• Joel Slack

25
Models of Recovery
Internal Conditions
Empowerment
Healing
Hope
Connection
Jacobson N, A Conceptual Model of Recovery
26
Connection

• Help people to find purpose and meaning in their
  lives
• Help people to fulfill valued roles and
  participate in life in the community

Recovery Implementation Task Force Wisconsin
Bureau of Community Mental Health
27
Healing

• Help consumer see themselves apart from illness
• Accepts individual emotions and disagreements as
  personal expression rather than pathology
• Recognize the individual view that people have
  about mental illness
• Help people identify and develop ways to cope
  with distress and problems

Recovery Implementation Task Force Wisconsin
Bureau of Community Mental Health
28
Empowerment

• Help individuals exercise personal autonomy and
  self-determination
• Invite and value consumer input and participation
• Minimize use of involuntary, coercive or
  intrusive actions

Recovery Implementation Task Force Wisconsin
Bureau of Community Mental Health
29
Dignity of risk and the Right to Failure

• Do not automatically assume that a clients poor
  choice is reflective of mental illness.
• Many of us make
• Poor choices
• Mistaken judgments
• Lack of insight
• Repeated mistakes
• Self-defeating choices
• Without being mentally ill
• Pat Deegan

30
Essential Elements of Recovery

• Relationships
• Taking Responsibility for Oneself
• Self-Advocacy
• Education
• Transformation of Suffering
• Hope
• Adapted from work of Nora Jacobson and
• Patricia Deegan

31
Spirituality Survey of 406 people with
schizophrenia, bipolar or major depression

• 92 used at least one religious coping strategy
• prayer, scripture reading, meditation, singing
  religious songs/hymns, meeting with spiritual
  leader
• 80 used a religious activity to cope with
  symptoms or difficulties
• 65 felt that religion was moderately helpful or
  the most important thing that kept them going
• 47 reported that religious coping was more
  important when symptoms were worse
• Tepper, Coleman and Roger 2000

32
Factors Identified By Consumers As Most Important
To Their Recovery

• The role of an active sense of self
• Determination to get better
• Understanding the illness
• Taking responsibilities
• Managing their illness
• Accepting the disorder
• Accepting the need for medication
• Optimistic attitude
• Self help
• Human Support (relationships)
• Friends who accepted them
• Supportive health professionals
• Friends who were affirming
• Spiritual beliefs

Tooth, Kalyansundaram and Glover Recovery from
Schizophrenia A consumer perspective 1998
33
Hope

• Attitude Change
• Recognition Acceptance of Disability
• Commitment to Change
• Focus on Strengths
• Look Forward
• Look for Small Changes
• Change Priorities
• Optimism

• Grace
• Spirituality
• Purpose
• Meaning
• Creativity

Jacobson N, A Conceptual Model of Recovery
34
The Importance of Hope

• I think one of the keys is remembering what your
  life was like before you got sick. Youve spent
  so long sick and you get into such a mind-set of
  hospital situations and being looked after and
  everybody feeling worry for you and so and so,
  then you get into that mind-set where you dont
  want to be well, you dont want to be normal. It
  seems acceptable to sit around and do nothing
  and go through life being treated like a
  schizophrenic. You start to believe that thats
  quite a good way of living, doing nothing.

Tooth, Kalyansundaram, Glover Recovery from
Schizophrenia A consumer perspective 1998
35
You and I

• By Laurie Curtis Adapted from a poem also
  entitled You and 1 by Elaine Popovicti
• I am a resident. You reside. I am placed. You
  move in.
• I am learning daily living skills. You hate
  housework. You use a cleaning service, a laundry
  service and have take-out pizza for dinner.
• I get monitored for tooth-brushing. You never
  floss.
• I have to be engaged in a meaningful activity
  everyday. You take mental health days, holidays
  and go on vacation.

36
You and I

• By Laurie Curtis Adapted from a poem also
  entitled You and 1 by Elaine Popovicti
• I am aggressive. You are assertive. I am
  aggressive. You are angry.
• I am depressed. You are sad. I am depressed. You
  grieve. I am depressed. You feel stressed and
  overwhelmed.
• I am manic. You are excited. I am manic. You feel
  passionate and energized. I am manic. You charge
  to the limit on your credit card.
• I am non-compliant. You dont like being told
  what to do.
• I am treatment resistant because I stop taking
  medication when I feel better. You never complete
  a 10 day course of antibiotics.
• I am in denial. You dont agree with how others
  define your experience.
• I am manipulative. You act strategically to get
  your needs met.

37
You and I

• By Laurie Curtis Adapted from a poem also
  entitled You and 1 by Elaine Popovicti
• My case manager, therapist, nurse, doctor,
  rehabilitation counselor, residential counselor
  and vocational counselor all set goals for me for
  next year. You havent decided what you want out
  of life.
• I am a consumer, a patient, a client, a survivor,
  a schizophrenic, a bipolar, a borderline. You are
  a whole person complete with your gifts.
  strengths, weaknesses and challenges in living.
• Someday I will be discharged...maybe. You will
  move onward and upward, perhaps even out of the
  mental health system. You see, I have problems
  called chronic people around me have given up
  hope. You are in a recovery process and get
  support to take it one day at a time.

38
Ive finally decided,With some inner will,
-That Im too busy,To be mentally ill,I take
my meds,And try to think,Sitting and
talking,With the shrink,I am so busy,I dont
have time,To think about it,All the time.Im
so busy,Be assured,I wont even noticed,If I
am cured. Dylan Abraham
TOO BUSY 2/99
39
Heinrichs and Zakzanis Neuropsychology
1998meta-analysis of 204 studies

• Drugs do not seem to help much