Why Psychiatry needs Recovery

1
Why Psychiatry needs
Recovery
yale program for recovery and community health

• Larry Davidson, Ph.D., Director
• Program for Recovery and Community Health
• Yale University School of Medicine and
• Institution for Social and Policy Studies

2
Todays Agenda

• We usually focus on what psychiatry needs to do
  to promote recovery
• Today Id like to focus on what recovery can do
  for psychiatry

3
Is there cause for concern?

• Current backlash against pharmaceutical industry
  due to excesses in use, misleading marketing,
  poor quality control, etc. (additional assault of
  autonomy of the field parallel to introduction of
  managed care in 1980-90s)
• Identification of clinical psychiatry with
  medications to an almost exclusive degree,
  resulting in lower quality of work life and
  continued devaluing and distrust of the field by
  both medicine and the public

4
Appeal to evidence-based practices to gain
credibility, improve quality, etc., but

• What is the evidence base for psychiatry?
• or
• What would an evidence-based psychiatry look
  like?

5
What we know about treatment

• Only about 1/3 of individuals in need of
  psychiatric treatment for a serious mental
  illness receive any psychiatric care at all
• Only about 70 of those people (with a psychotic
  disorder) will respond at all to medications
• Less than 20, and as low as 5, of those being
  prescribed medications are receiving the most
  appropriate and effective care available (i.e.,
  evidence-based)

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for serious mental illnesses

• Medication effects are limited primarily to
  positive symptoms, which account the least for
  the impairments or disabilities associated with
  the condition
• Second generation anti-psychotic medications
  appear to be no more effective than their
  predecessors, and to have equally (if not more)
  serious, if different, side effects

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• About ¾ of people stop taking medications on
  their own in less than 18 months after episode
• About 80 of people will be rehospitalized within
  5 years following a first episode
• Cognitive behavioral psychotherapy reduces
  positive symptoms and gains are maintained after
  treatmentbut ecological validity is unknown

8
What we know about rehabilitation

• Cognitive remediation has small-to-moderate
  effects on neuropsychological performance,
  symptom severity, and cognitive functioning, but
  ecological validity is once again unknown
• Supported employment (IPS) has large effect size
  in increasing employment from under 20 to over
  50 of participants, but is received by less than
  1 of population
• Unfortunately, employment also tends to be
  part-time, job tenure averages lt 6 months, and
  monthly earnings average only 122/month or
  1,464/year
• ACT significantly increases housing stability and
  moderately improves symptoms and quality of life,
  but is received by very few peopleas are most
  evidence-based practices (less than 5 of
  population)

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If this were all we knew, there would be ample
cause for pessimism and concern

• However, we know even more

10
What we know about recovery

• Domains of functioning are only loosely linked
• There is a broad heterogeneity in outcome
• 45-65 of people with DSM-IV-TR psychosis
  experience significant improvement over time,
  many recovering fully
• Unfortunately, people also will lose on the
  average 25 years of life due to co-morbid medical
  conditions and poor quality care (i.e., the
  longer they live the better their chances at
  recovery)

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An Intriguing Discrepancy

• Few people (5) benefit from the few effective
  interventions we have, and the effects of these
  interventions are only small to moderate.
• Yet over half will experience partial to full
  recovery over time, with only 15-25 experiencing
  a deteriorating condition.
• How are we to understand this?

?
12
Guiding Questions

• How do people describe the roles of treatment
  and rehabilitation?
• First, how do they describe experiences of the
  illness and its effects on their lives?

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A Model of Serious Mental Illness
Davidson, L. (2003). Living outside mental
illness. NY New York University Press.
14
Cognitive Intrusions and Disruptions
Its like being sick. Its like being
nauseated or having a really bad headache and
youre trying to relate, but theres something
bothering you. Its a distraction, you know ...
Like if you have a headache or something, you can
relate, but theres always that pain, so youre
going to be thinking of that pain ... It was like
I was trying to relate and yet ... I was having
to struggle to make conversation or to
concentrate. My attention span was low and my
concentration was low. And I think thats a very
common problem with people who are mentally ill.
Their attention span and their concentration seem
to wax and wane and ... theyre not always
there... People take for granted that you just do
things. A person with mental illness, its
sometimes hard ... its like youre distracted,
you cant get involved because youre not sort of
all there.
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Ways of Making Sense Taming the Illness

• It took several years before I realized that
  this is something you have to work with, and
  really have a conscious relationship to, because
  in the beginning I guess I thought that this is
  sort of like breaking a leg. I thought it would
  take two or three years and then it would pass
  and it wasnt like that. It took some time for me
  to realize that.

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Another look What is our role?
Neo-Kraepelinian models of illness
Hope
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Stigma, discrimination messages of hopelessness
Chronic mental patient to Contributing (but
invisible) citizen

• Tinkerbell
• or
• Edwina

Contributing person with psychiatric
disability to Contributing citizen visible
role model
Hope, determination encouraging support
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Where Psychiatry is TodayThe Beggars by Pieter
BRUEGEL, the Elder (1568)
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Social-Political Analogy
Deus ex Machina
Customary view
Resources ()
Developing Country
Political Freedoms Participation
Life?
Economic Growth

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But

• Not enough money has led to . . .
• Not enough economic growth . . .
• Political freedoms delayed indefinitely (and thus
  denied)

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Sens Upside Down World
Reduce Unfreedoms
External Resources
Developing Country
Economic Growth
Increase Freedoms Participation

Internal Resources
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As Applied to Recovery
Deus ex Machina
Customary view
Treatment
Person with Mental Illness
Normality?

Life?
Reduce Symptoms
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But

• Not enough treatment has led to . . .
• (not enough compliance, etc.)
• Not yet normal enough
• Recovery delayed indefinitely
  (and thus denied)

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Turning Psychiatry Upside Down
Reduce Stigma Discrimination
Treatment Supports
Person with Mental Illness
Recovery (meaningful life in the community)
Increase Agency Participation

Persons own resources
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Lessons learned (and to be applied)

• What people can do and be is more important than
  what people can have
• One group of people cannot develop another group
  of people
• Countries do not have to be rich first before
  ensuring freedoms economic growth does not
  stimulate freedom, but freedom does stimulate
  economic growth
• Free choice really does have to be free With
  human beings there is an infinite variety in
  normality or healthWinnicott

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Fundamental Distinction and Division of Labor

• Recovery is what the person with the mental
  illness does to manage his or her condition and
  reclaim his or her life.
• Recovery-oriented care is what health care
  providers offer in support of the persons own
  efforts toward recovery and includes enhancing
  the persons access to opportunities to learn how
  to manage his or her condition and pursue his or
  her own hopes, dreams, and aspirations (i.e., a
  meaningful life in the community).

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Basic Recovery Tasks

• Making sense of the illness and learning how to
  live with it
• Maintaining/regaining hope and being determined
  to have a life

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Maintaining Hope and Determination

• the hope of knowing that everything that is,
  that I go through, would not continue the rest of
  my life, that there would be an end of it and
  just knowing that I knew that I could keep
  going.
• My desire to get better, maybe the good fortune
  to finally realize that health is a precious
  thing its a matter of will power, of believing
  in myself, pushing myself.

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Basic Recovery Tasks

• Making sense of the illness and learning how to
  live with it
• Maintaining/regaining hope and being determined
  to have a life
• Belonging and acceptance

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Belonging and Acceptance

• Im nobody till somebody loves me. Thats the
  way I look at it.
• When I was going through my psychotic changes
  she was always there for me. She never turned
  her back on me.
• I think riding the horse helped me ... It
  relaxed me. And, well, I guess it made me feel
  like the horse loved me. Spending time with the
  horse, it felt like unconditional love... you
  connect with the animal and with yourself and
  youre outdoors and it does something to you.
  Its hard to explain, but when you go home you
  think, Wow, another lesson! Wow, Im getting
  better!

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Basic Recovery Tasks

• Making sense of the illness and learning how to
  live with it
• Maintaining/regaining hope and being determined
  to have a life
• Belonging and acceptance
• Reciprocity and giving back

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Reciprocity and Giving Back

• It made me feel like I was being helpful and in
  situations like that I dont think so much about
  my illness. It kind of goes on the back burner
  because sometimes I just think about my illness
  and it seems like when Im helping somebody or
  somebody says something nice to me ... as soon as
  people say that, oh, you look good, things like
  that, it makes me feel better about myself.

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Basic Recovery Tasks

• Making sense of the illness and learning how to
  live with it
• Maintaining/regaining hope and being determined
  to have a life
• Belonging and acceptance
• Reciprocity and giving back
• Involvement in meaningful activities

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Involvement in Meaningful Activities

• I could choose to be a nobody, a nothing, and
  just say the hell with it, the hell with
  everything, Im not going to deal with
  anything. And there times when I feel like that.
  And yet, Im part of the world, Im a human
  being. And human beings usually kind of do things
  together to help each other out ... And I want
  to be part of that... If youre not part of the
  world, its pretty miserable, pretty lonely. So I
  think degree of involvement is important ...
  involvement in some kind of activity. Hopefully
  an activity which benefits somebody. That gives
  me the sense that I have something to offer ...
  thats all Im talking about.

35
Basic Recovery Tasks

• Making sense of the illness and learning how to
  live with it
• Maintaining/regaining hope and being determined
  to have a life
• Belonging and acceptance
• Reciprocity and giving back
• Involvement in meaningful activities
• Having successes and pleasure

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Successes and Pleasure

• I said to myself one day youve got a couple
  of extra bucks, so why dont you just try at
  least to do some-thing that maybe you normally
  wouldnt do. So I went and did something... I
  actually did something different and I enjoyed
  it! Then I found myself saying What can I do
  tomorrow? And one thing led to another... If
  you could bottle it, it would be the best
  anti-depressant I could take... Its enabled me
  to go out looking for a job so now I can get some
  extra money. Getting used to having money and
  learning ... the things I could do with that,
  enabled me to want to go out again, to go out and
  make more money, so I could spend more time with
  my friends.

37
Basic Recovery Tasks

• Making sense of the illness and learning how to
  live with it
• Maintaining/regaining hope and being determined
  to have a life
• Belonging and acceptance
• Reciprocity and giving back
• Involvement in meaningful activities
• Having successes and pleasure
• Reconstructing a life

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Reconstructing a life

• The whole story of my health was a very
  difficult experience because I had to really
  reconstruct myself as a person.
• Before I was in recovery I felt I couldnt do
  anything right. I constantly felt that I was
  stupid and dumb and everything my father told me
  But then I realize that Im not stupid and
  Im not dumb, that I actually know quite a bit,
  and that I have a lot of knowledge and that if it
  wasnt for the knowledge that I have a lot of
  people wouldnt have gotten, you know, a lot of
  things

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Basic Recovery Tasks

• Making sense of the illness and learning how to
  live with it
• Maintaining/regaining hope and being determined
  to have a life
• Belonging and acceptance
• Reciprocity and giving back
• Involvement in meaningful activities
• Having successes and pleasure
• Reconstructing a life
• Coming back normal

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Coming back normal

• There are problems but I think no matter what
  situation you get into theres going to be
  problems, no matter what. Youve got to learn to
  work through problems because if you dont you
  arent going to live thats a human being. In
  order to get from one place to another youve got
  to learn to get through the problems or around
  the problems in order to get to the next step.
• Recovery/being normal means having only
  ordinary worries

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Some Paths to Life Outside of Psychosis
Increased community involvement
Enhanced sense of agency and belonging
Cognitive intrusions and disruptions
Successes and pleasure
Sense of belonging and hope
Life before illness
Decline in functioning
Demoralization and despair
Ways of making sense of intrusions and disruptions
Inside
Outside
Increasing withdrawal and isolation
Diminished sense of agency and increased
vulnerability
Delusions and other idiosyncratic ways of making
sense
Experiences of failure, stigma, and rejection
not cure
Neo-Kraepelinian models of illness
Davidson, L. (2003). Living outside mental
illness. NY New York University Press.
42
So now what do we do?

• Offer evidence-based practices to those people
  who will be likely to benefit from them and
  assess their responsiveness.
• Offer them in a person-centered fashion in
  combination with clinical skill and within the
  context of a collaborative relationship.
• Appreciate the distinction between minimizing
  illness and maximizing health and the need to
  attend to both.

43
Different Forms of Recovery

• Recovery from refers to eradicating the symptoms
  and ameliorating the deficits caused by serious
  mental illnesses.
• Being in recovery refers to learning how to live
  a safe, dignified, full, and self-determined life
  in the face of the enduring disability which may,
  at times, be associated with serious mental
  illnesses.

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What if

• the processes and factors that contribute
  to long-term recovery have little to do with the
  processes and factors involved in learning how to
  live with the illness?
• our obsession with cure keeps us from
  helping people to live quality lives here and
  now, in between appointments, while waiting for
  the medications to work, etc.

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If I cant tell my clients what to do, then what
do I do?

• Most people figure out how to live with the
  illness. We could do a much better job supporting
  them in those efforts through
• offering information and education
• enhancing access to opportunities
• providing in vivo supports (as in supported
  employment)

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Does it matter?

• Mental illnesses are highly disabling, and, as
  recent reviews have emphasized, our science has
  not come even close to being able to cure or
  prevent them. Learning to live better in the face
  of mental illness doesnt alter that reality.
• -- Dickerson (2006)

Dickerson, F. (2006). Disquieting aspects of the
recovery paradigm. Psychiatric Services, 57647.
47

• From the perspective of the person with the
  disorder, Dickerson has it backward. It is
  especially when the illness is most severe, and
  because we do not yet have a cure, that people
  who have these disabling disorders have no choice
  but to live in the face of them. This is the
  reality that takes priority in recovery-oriented
  care.
• -- Davidson, OConnell Tondora (2006)

Davidson, L., OConnell, M.J., Tondora, J.
(2006). In reply. Psychiatric Services,
571510-1511.
48
Toward a Psychiatry of the Person (e.g., WPA)
rather than of the illness

• Someday, in the 21st century, after the human
  genome and the human brain have been mapped,
  someone may need to organize a reverse Marshall
  plan so that the Europeans can save American
  science by helping us figure out who really has
  schizophrenia or what schizophrenia really is.
• --Nancy Andreasen (1994)

Andreasen, N.C. (1994). Changing concepts of
schizophrenia and the ahistorical fallacy.
American Journal of Psychiatry, 1511405-1407.
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• Comments?
• Questions?