A Psychiatrist Looks at Recovery And Finds it Wanting

By Dr David Laing Dawson

There is something to be said for challenging our attitudes and shaking up our systems every decade or so, trying to improve them. Improve them, review them, discuss them, reorganize them, improve them. Even if it is really only putting old wine in new bottles. The new bottles can create a buzz, some excitement, add some energy, or, to use one of those terrible management phrases, achieve “stakeholder buy-in.”

But language is important, especially when we use unassailable words, feel good words to hide something quite different. The Pro-Life Movement. Who could object to that? Until you realize it is really an anti-choice movement, and that it ignores the reality of the suffering and deaths of millions of young women around the world.

And in all our systems, not least in Mental Health and Mental Illness treatment, we are fond of forming a myriad of committees and steering groups, planning groups, focus groups that create a language of their own, and formulate, vote on, and sanction such meaningless phrases as,

“Co-occurring issues and conditions are an expectation, not an exception.
The foundation of a recovery partnership is an empathic, hopeful, integrated, strength-based relationship.
All people with co-occurring conditions are not the same, we all have a responsibility to provide co-occurring capable services.
When co-occurring issues and conditions co-exist, each issue or condition is considered to be primary.
Recovery involves moving through stages of change and phases of recovery for each co-occurring condition.
Progress occurs through adequately supported, adequately rewarded skill-based learning for each co-occurring condition or issue. ”

–and then, on paper, design the most cumbersome and impossible organizational structure to carry out this mission, this formulation.

I get tired just thinking about it.

Usually such organizations and arrangements are wasteful but benign and fall by the wayside in a few years. But a few can be both wasteful and destructive.

Now the “recovery movement”, or “recovery model.” Who could object to the word “recovery”?

Until you look closely at it’s origins and implications.

It comes from addiction services, their philosophies and jargon. An alcoholic who no longer drinks is “an alcoholic in recovery”, or a “recovered alcoholic.” Similarly an addict. It is a useful term used in that context, I think, for it implies quite reasonably that if the alcoholic no longer drinks he is recovered, but still vulnerable. His recovery may end if he takes glass to mouth. And it also implies, quite clearly, that reaching that point of recovery and maintaining that point of recovery is primarily his own responsibility, an acknowledgement that ultimately he, the alcoholic, has the power within his own hands (with a little help from his friends) to choose to be and stay “recovered”.

But the “Recovery Model” as it crept over to mental illness, carried with it an anti-medical tone, a clear implication that we doctors and nurses did not pursue a goal of recovery for our patients. We were in the business, it implied, of maintaining illness, and thus maintaining our positions of power and our paychecks. A trifle insulting to say the least.

I, and all the people in our professions I know, are delighted when one of our patients really succeeds. Drops back to visit after graduating from High School, or University. Comes in to show me her brand new baby girl. Comes in and says, “I’m doing fine doc, just need my prescription renewed.” Sends me a card from his travels in Europe.

Well, I can get over the insult and their pejorative use of the term “medical model”.

It is those other implications of “the recovery model” that can be quite damaging. It does carry an implication, as with alcoholism, that the mentally ill person, this person suffering from schizophrenia, has within his own hands, his will power, the way he conducts his life, the means to “recover.” It implies that those who don’t recover are simply not trying hard enough. It implies that if you have to take a lot of drugs to stay well you are not trying hard enough. And, it must, by it’s own convictions, ignore, banish from view, those with very serious mental illness who can hope for some quiet, some peace, some contentment, some happiness, some dignity, a relationship, some activity that gives them a sense of value, but never full recovery.

We would all like our patients to recover, to become well, to be able to live full lives with minimal suffering. Fine. But the “Recovery Model” with its emphasis on hope and prayer and peer support and its mantra that everyone can “recover” (with hard work and a little help from his friends) provides a foundation of easy denial for our politicians, our civil service, and our managers.

Often, through history, one can find that the theories of the day, regarding the human condition, are really rationalizations, comforting explanations for the terrible realities of the day. The Recovery Movement is a theory, a formulation, a rationalization for this day. It allows us to believe all mentally ill could get well if they really wanted to, just as all alcoholics could stop drinking if they wanted to or had to (with a little help). It allows us to ignore the millions of mentally ill now living in our prisons and flop houses, on the street and under bridges.

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14 thoughts on “A Psychiatrist Looks at Recovery And Finds it Wanting

  1. Once more I find my self rejoicing at the sound of your words. I only wish you and Dr Ross could get your views elevated to that ‘top’ table where the decisions are made. You are both brave enough to speak the truth.

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    1. Thanks John – I posted this one on the mental health groups on linkedin and 5 of them moved it to jobs. No idea why. A small point and I’ve been called much worse but I’m not a doc 🙂

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  2. Thank you Dr. Dawson for this blog. All I can say is “Wow”. Wouldn’t it be great if more echoed these sentiments. I totally agree with John McFadyen’s comments.

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  3. This truly made me cry…recovery models are well intended but not realistic for serious mental illnesses….the reality is the complexity of the illness of schizophrenia itself! I can understand this thinking from lay people but not from the health professions who work with these suffering individuals all the time. It’s not a matter of trying harder or trying to see something a different way to have a wonderful outcome…their brain just doesn’t have the capacity to work that way…it does give our politicians the wrong message…we need to help these young people with subsidized housing and group housing with professional support while encouraging independence and dignity. We need to encourage businesses to hire our young people on a part time basis..with government kickback for the employer…we need realistic models to help our young people have a sense of purpose..that is what they need……mother of a son with schizophrenia and also a nurse.

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    1. Dr. D’s words also “hit home” for me Vivian and made me cry. And as a family caregiver/social worker, it is alarming to see all the public money spent on implementing “recovery orientated” practice, as if the motivations to assist the patient have not been there before.

      Families see the complexity of the illness from day to day 365 days a year perspective and understand the profound need for research to better understand these conditions. The apparent standard of seeing a client for brief sessions four times a year does not meet the patient’s profound and complex needs and causes difficulties and confusion for the patient and untold anguish for the families who try to support them.

      Again thank you Dr. D. for cutting through the distracting hypocritical rhetoric and making sense.

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    2. We also need the scientific research into chronic diseases of human brains to eradicate them our lives. Such a prevalence among our populations demands a massive approach to cure them. Let’s begin with the example of AIDS where we persistently sought and identified the root cause and are still working on a complete cure.

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  4. Hi David. I enjoyed this post an awful lot. I believe you are correct in almost all of your points. Absolutely the burden of becoming well has in some way been shifted back to the patient. Which is rediculous, the patient may manage his condition but the patient cannot treat his condition. And for clinicians to throw up their hands and say “Thank God. a model where all we have to do is a little supervision, ” joy, kalloo kallay!” Well it just does’nt do the job does it?
    There is a subsection of people with mental illness which need to be considered before trashing the recovery model.
    Complex PTSD , often caused by severe, persistant and long term developmental trauma is at best treatment resistant.
    I say resistant. This is because many clinicians get offended when you utter the forbidden words “untreatable”.
    I have such a condition. I am a contributor to several lived experience forums that are exclusive to survivors of child abuse and complex disorders. I can tell you that the several thousand people who i have shared time with on these forums have several things in common.
    We all have been accused of lying and attention seeking, we have all tried to find workable solutions to our issues. We are all immensely strong and resilient and finally we have discovered that no treatment exists yet for us to live normal healthy lives. And yes there is normal. It may be subjective but the concept of normaility is real and tangible.

    So Recovery for the likes of us cannot mean a life free from symptomolgy. It cannot mean having a sense of well being. It certainly doesn’t have any thing at all to do with any concept of stability. We manage, day to day. Hour to hour. This might strike you as melodramatic, but if I read you correctly I would hope not.
    In Australia less than fourteen per cent of aduly survivors of child abuse seek support services. The reason? Fear of being dismissed as has been the UNIVERSAL experience for us. They had until recently nothing to offer.

    This Recovery Model does offer one thing. A resource for those of of with complex MI to change hoplessness to wary hope. For me it provides an external focus. A focus on quality of life . Without which I am lost.
    Recovery for me, requires me to get meaningful employment. To work in peer support would give meaning to the experiences that lead me to develope this “treatment resistant” mental illness. Otherwise it makes no sense.

    I like the idea of the Recovery Model. It promises little. And if properly supported one may be able to find meaning and external focus. The external focus being the only option which allows us the function well.

    I too find the model wanting. But mainly it is not the conceptual which is the issue. It is those who interpret the model and either use it as a facilitation device to improve life quality or a stick to beat the failure with.
    I have been seeing a private psychiatrsit who specialises in trauma weekly for 12 years. We have only two more psychopharmaceutical options left. As for psychological therapies I have used them all, to no effect or affect. We have had second and third opinions from leaders in the field. The is always the same. We are doing the best we can with the little that we have.

    Where does that leave me? Knowing fully well that even if the drugs bring a measure of relief, experience informs both of us that it is most likely in the medium to long term to fail.
    A concept like recovery is my only usable hope.

    So no. Do not under any circumstances allow this model to take the place of best clinical practise, Do not stop trying to find effective treatments for those of us who need them most.
    Clinicians find a way to see your patients regularly for as long as needed.

    In the mean time the rest of us will try to find hope in a model that promises little but at least attempts to give us options for improved quality of life.

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  5. I appreciate the view expressed, but I would lay the problem at a different set of feet. I feel that the problem has a lot to do with seeing someone as “an alcoholic” or “a schizophrenic” or some other label, rather than as a person with a problem. Whether the sufferer makes tremendous progress in alleviating or even eliminating symptoms– or none– they are still a person with a problem, not the problem itself.

    Whether you call the process of dealing with the problem “treatment” or “recovery” or something else, the process is about a relationship between two people, or among several people in a treatment team. The provider wouldn’t know the person if the one with the problem didn’t want input from someone who (presumably) has expertise in treating the problem. It has to be a collaboration, with everyone involved taking responsibility– not just the provider, and not just the sufferer. This seems like common sense to me, but sometimes, I guess, common sense isn’t common.

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    1. Thanks for your comments and I agree language is important. I try hard to use the cumbersome phrases, “suffers from schizophrenia” or “those afflicted with serious mental illness” rather than “schizophrenic” or the “mentally ill”, including the verbs, “suffers from”, and “afflicted by” rather than “has” or “is”.
      Of course, the need to do this is itself a symptom of stigma. Nobody seems to have a problem saying, “I am diabetic.” Or “I am lactose intolerant.” Or “I am allergic”. Or even “I am bipolar”. And thousands of people today are attending “Alcoholics Anonymous” meetings, and not “Meetings for people who suffer from alcoholism.”
      Some of this is just our natural inclination toward short forms. I suspect that with any disease or problem that has a name to which one can easily add an “ic” an “ac” an “ict” or an “ile” at the end, we will do it.
      Arthritic, diabetic, quadraplegic, insomniac, addict, pedophile, manic, neurotic, psychotic, brainiac…
      But I have two issues here. The first is that it was not until we (hospitals, doctors, nurses, the public) were willing to openly, freely use the word CANCER, to label and describe this particular disease that it began to lose its stigma, and money and resources were poured into helping people who suffer from CANCER.
      So we need to say SCHIZOPHRENIA and not hide the word within that ridiculous phrase, “Mental health issues” or the rather benign word, “problem”.
      The second issue I have (the word “issue” used correctly in this instance) is with the idea that we should consider alcoholism and schizophrenia as not dissimilar problems. Alcoholism, like smoking, is an addictive behaviour that will eventually lead to poor health and disease. Schizophrenia is a disease.
      Although, I must admit, if we knew the specific cause of schizophrenia, and also found it to be a substance most people want, we could tax it, sell it in government stores and use the profits to support programs for people who suffer from schizophrenia.

      Liked by 1 person

      1. Just to clarify – the above comment was posted by Dr Dawson but because we share admin duties, it comes up under my name. I do agree with his comments

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      2. Marvin and David, you make an excellent point regarding the lanuage of labels and dignosis.
        I have polled many people who use lived experience forums on this very issue.
        i was not surprised to find that the vast majority of the 279 responses I recieved to the poll were such that they find all this cumbersome lanuage to be slightly ridiculous. And in it’s own way stygmatising, because the implication feels like have mere problems or challenges. This is complete and utter bollocks. We mentally ill refer to our selves as ,wait for it………. mentally ill. Not people with a mental illnesss, Not people with mental health issues. But simply by our separate dignoses. Schizophreniacs refer to themselves as such. while folk with bi polar say My name is Barry, I’ve got bi-polar or I’m bi-polar . Those of with complex illness just say my illness. We know what we mean and we don’t need the coddling of misdirection to be accepting of that. By saying that I’ve got a mental illness or I’m mentally ill you are saying you have a disease that have some terrible ramifications to our lives.. Which is the truth.
        We know how to separate ourselves form our illnesses. We know that being ill is merely a part of who we are. even the term lived experience is a joke to most of us. It trivialises the actual suffering we undergo. And we do suffer as any one with a chronic or debilitating illness suffers. So to say less than that by using more words to describe is to demean the amazing strength and resilience we must bring to bare daily to manage our lives and illnesses. And that precisely is what most of have to do. We must manage.
        Everyone talks about the lived experince perspective. Well that’s it. PsycheUnits have become mental health units. I’ve been admitted a few times and I can say unequivocably that the one thing that mental health units don’t keep in stock, is mental health. Otherwise we would be discharged as happy, healthy, normal people. You may be surprised to find we are not discharged happy, healthy or normal. Would we like it to be so? Yes , yes, a thousand times yes, but we’re are not naive.

        We have discussed this subject at great lengths on the forums. The general consensus is that these terms and this kind of lanuage is merely for those not mentally ill. Obviously it makes others feel more comfortable when faced with the challenge of thinking about mentally ill people. What use is that to us? It has no therapeutic value, it does’nt address the causes or symptomolgy of mental illness it is to many of us simply an example of busywork.
        Can we not leave the overblown and somewhat clunky lanuage to the sociologists? They appear at least to have some use for it.

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  6. Well said, Rick. Distressing to me, the psychiatry ward and the Psychiatric Hospital have become The Mental Health Unit, and the …. well, here we have a range of cumbersome titles like “St. Joseph’s Health Care West 5th Campus for Mental Health and Addictions” and “Centre for Addiction and Mental Health”. Euphemisms are a short step from denial. When we can comfortably say, “I have schizophrenia.” “This is a hospital or program for people with mental illness.” and “You have schizophrenia.” – then we can all relax and get down to the business of treating and helping one another.
    David

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  7. Thanks for your work in exposing the lame word abuse and staging in many sociology discussing. The aim should be to have concern for the reader, not to show your own knowledge of rare words peculiar to your profession..

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