The Value of a Theory of Etiology
Our text in this course is primarily theoretical, exploring how certain philosophers, thinkers, and practitioners and their theories have shaped the concept of "Recovery." Some of them felt is was necessary to remove people from their everyday lives in order for them to get better, others thought "agency" and advocacy were key, etc.
Theory matters. How we think about "mental illness" and particularly, what causes it, greatly influences what choices are made available for people with mental illness. The fact that I phrased the last sentence this way indicates that people with mental illness "should be provided" with choices, by "normal people." Later we will discuss whether you can provide someone with rights and choices, or if they already HAVE THEM.
In the 1800s there were many prevailing theories of etiology. Benjamin Rush thought mental illness was the result of circulatory disorders...so he created the "spinning" treatment. The text will discuss that other folks theorized that mental illness came about from "problems in living."
What are the prevailing etiological theories in psychiatry today? What do these theories lead us to DO to (and with) people with mental illness?
Answer these questions, and respond in detail to at least 2 of your classmates' answers.
Theory matters. How we think about "mental illness" and particularly, what causes it, greatly influences what choices are made available for people with mental illness. The fact that I phrased the last sentence this way indicates that people with mental illness "should be provided" with choices, by "normal people." Later we will discuss whether you can provide someone with rights and choices, or if they already HAVE THEM.
In the 1800s there were many prevailing theories of etiology. Benjamin Rush thought mental illness was the result of circulatory disorders...so he created the "spinning" treatment. The text will discuss that other folks theorized that mental illness came about from "problems in living."
What are the prevailing etiological theories in psychiatry today? What do these theories lead us to DO to (and with) people with mental illness?
Answer these questions, and respond in detail to at least 2 of your classmates' answers.
As someone who works in the rehabilitation world, the idea of mental health as a stagnant (life-long) condition is something I've been exposed to a lot over the years. The rehabilitation view focuses on trying to "stabilize" people with mental illnesses, so that they can function competently in society and continue to live their life in spite of their diagnosis. Mental illness is treated as a constant that the rehab counselors can work-around. The mental health condition is often not viewed as changeable, or something that can ebb and flow, etc. After reading the National Empowerment Center's article, I couldn't agree more with the empowerment view. This theory recognizes the fluidity of diagnoses (changes in mental health), and considers mental illness the result of "severe emotional distress" coupled with a lack of support/resources/coping skills. It also emphasizes the fact that the individual is not maintaining their social role. I think this point is important to note. I often think about diagnoses like the anti-social disorder and how they reflect our society's ideals. In the U.S., we tend to idealize out-going, charismatic personalities. Are there times when undesirable personality traits are quickly diagnosed as a mental health disorder? In any case, the empowerment view works to assist individuals with mental health illnesses to gain greater control over their lives. This theory also posits that with the right supports, resources, and coping skills--some individuals with mental illness can recover and heal. In my work, I've seen several individuals who suffer from low self-esteem and anxiety. With the support of our counseling services and resources, suddenly their confidence soars.
ReplyDeleteHeather, you make some interesting points. I think you hit an important idea when talking about diagnostic criteria and social norms. The DSM changes over the years and looking back it seems they had some bizarre ideas of what is considered a mental disorder in the past e.g. homosexuality, etc. I think this might be what Patricia Deegan was talking about in her speech when she discussed the concept of not trying to 'mainstream' people with mental illness, but instead widening the mainstream to allow for people with differences to fit into it. That being said, I think you might have the wrong idea of what Anti-social Personality Disorder is - it is not a shy person, but one who shows no regard for other's feelings or well-being. But, I get what your point was. Social norms do seem to carry a lot of weight when it comes to how we treat patients. The DSM really is just a bunch of agreed upon terms describing deviant behaviors and traits. It is a bit arbitrary and definitions do change, and yet it does determine a lot. A diagnosis often guides treatment guidelines, which medications are prescribed, etc.
DeleteThe history of Bedlam and the past diagnoses like hysteria further highlight this idea of how mental illness and social norms have been blurred and abused in the past. "Females were typically locked up in madhouses for a range of conditions that today would not be considered to show signs of insanity. They would often suffer from postnatal depression, alcoholism or senile dementia and social transgressions such as infidelity - and still get sent away" (Hawken, 2017).
DeleteJessica,
DeleteI found the history of Bedlam to be facinating. Mental illness can be viewed as a social construction. Many of the conditions that resulted in placement in Bedlam would not hit the radar screen of a book like the DSM-5. Yet those conditions that were considered suitable for institutionlization on the timeline on the Bedlam website were very much products of the times. As we look at current diagnosis criteria, they too in many ways reflect the times in which we are living and are a reflection of the society and culture in which we live.
Nancy
Hi Jessica,
DeleteGreat points! In terms of the anti-social disorder comment, I think you are right. Instead I should have said something more specific to introverts. Often times, I feel like introverts can too be treated like "there is something wrong with you," based on our societies' expectations of out-going social behavior.
Heather,
DeleteQuiet by Susan Cain is a really great book about how the prevailing U.S. culture really stigmatizes introverted behavior. I completely agree with you.
Cheers,
Bronte
I would add that the empowerment view also assists with aiding individuals with mental health issues to gain greater control over their treatment as well as their lives. People can take a more active role in their recovery by focusing on what works best for them as an individual and considering their circumstances. The article on Empowerment Vision states: "...treatment is part of self-managed care. The goal of treatment here is assisting people in gaining greater control of their lives and assisting them in regaining valued roles in society." In terms of using medication or not, the article talks about individuals utilizing medication "on an as-needed basis, after having learned to self-monitor." Once again, allowing the individual to have some control over the treatment they choose that works best for them. - Lisa Sweet
DeleteLisa, I'm glad you brought that point up article from the Empowerment Center. I thought much of that article seemed outrageous, outdated and many broad statements and generalizations were made with no citations or supporting evidence. The idea of taking medication only when needed to me seems like or horrible idea and I would hope no provider told that to their patients. While I understand there are many conditions that this may apply to after initial stabilization for instance periodic depression, it most certainly should not be a general rule, and it should especially not be the case for people with serious mental illness. Decisions to go off medications should not be taken lightly. Staying on medications is important to prevent recurrent episodes of mania or psychosis. Each additional episode causes further damage to the brain which further impairs baseline functioning and that functioning in many cases does not return. That is why the take medication for the rest of your life idea is passed around - as a preventative measure. And if one does choose to go off medications they should still be followed by providers regularly to keep assessing if need to go back on. Not everyone has a severe and persistent illness though, some people have one time episodes of psychosis for instance or other variations. So while the "medication for the rest of your life" concept applies to some, it’s not the case for everyone. Providers may be overly cautious in this regard, or perhaps the understanding that there are many different presentations of these illnesses is a new development. But I do feel that there is not sufficient coaching and education about a patient's illness and prognosis in our current healthcare model. The limited time with patients due to insurance constraints is a major contributor to that, I believe. If we took a more broad view of the etiology of mental illness and how many factors were important to recovery our care model might be different. The Empowerment Article also talked about work/volunteering/having a purpose/social interactions as important components. That is a great point. Many people think just taking a pill will cure them, but it really needs to be a multi-faceted interdisciplinary approach. However, patients can choose to stop doing those aspects of recovery as well.
DeleteHi Bronte,
DeleteI will definitely check out the book, "Quiet." It sounds very interesting!
Heather -
DeleteI really like the point you make about ‘stabilizing’ people and treating them ‘in spite of’ their mental illness. I do not agree with the concept of ‘in spite of’ or with the idea that mental illness is a linear concept. It is not like a light switch, on or off. It is more of a river rapids ride with one oar. It is moving, but sometimes uncontrollable. It’s direction and course ever moving. No two people follow the same path or have the same experienced journey.
In the Deegan video, I was drawn to her comments of how clinicians need to know the humanistic side of people and their experiences. That (in my interpretation) knowledge gives us the tools we need and wisdom helps us know how and when to use them on an individual basis
That was me--Heather Allen. I'm not sure what it isn't showing my e-mail address! :)
ReplyDeleteI totally agree that society plays a huge role in mental illness; I also believe that it has long been the "forgotten factor" in mental illness. In our individualistic, pull-yourself-up-by-your-bootstraps society, I believe that we have long focused on the psychological/biological elements of mental illness and viewed the individual as weak. When we bring the sociological component in, it becomes clear that individuals are not the only ones who shoulder the "blame" for their illness; it is as much, if not more, a societal issue.
DeleteGreat discussion. I so agree that society plays a role in how persons with mental health diagnoses are viewed. If the person gets a label, then it's harder for the person to be seen as a whole person with strengths, weaknesses, - without strong supports, they sometimes can be only view through the disability lens. With a more consumer focused and/or biopsychosocial lens - it can provide a wider lens for both the person and their community and treatment team.
DeleteLisa, I totally agree with you about the blame being put on the individual due to the "pull yourself up by your bootstraps" mentality about mental health. I also agree it is a larger issue that society is contributing to. For instance, historically in times of economic difficulty suicide rates are higher. Additionally, I often wonder if the demands of society (college, career, children, etc.) being so high have caused the increase need for stimulant medications. It is very clear that mental illnesses come in trends, influenced by medication advertising, etc., as well. This is a terrifying notion when we think of the consequences, so I wonder what is being done to regulate this type of power.
DeleteSue - or anyone - can you explain to me further this idea of someone who is mentally ill being labeled and then being treated differently because of their label? The article talked about how this individuals are ostracized and viewed as though they can never work again, etc. Can anyone share experiences or highlight what exactly is meant by this? I'm really drawing a blank. The article says: “No wonder there is such a high rate of unemployment (85-90%) among those labeled with mental illness. The label defines the person as being incapable of work. No wonder so many people labeled with mental illness lose their children; the label itself defines the person as being an incompetent parent.” Those statements are atrociously inaccurate. But I also am apparently oblivious to these generalizations. Do you all see this in your line of work? Do you agree these are true? Does my lack of awareness of this struggle highlight a need for further education about the current inequalities or is it a sign that much has already changed due to the recovery movement that we have already won the first battle of as Davidson, Rakfeldt, and Strauss say in Chapter 1 ?
Jess, This is my best explanation -- the mentally ill are a marginalized population; hence, they are often "forgotten." Their needs/wants/desires often don't count in a society that values the able-bodied and able-minded. Consequently, they are not as readily employable or their rights as parents are not valued or enforced. As a matter of fact, the label that they have been assigned is often used against them in their fight to retain or regain custody of their children. In a society where social class matters so much, who will speak for people who do not have the dollars to hire the best representation. Who will advocate for them in meaningful terms? I totally agree that this marginalization occurs often; whenever any group is on the periphery of society, they are too often undervalued and underrepresented.
DeleteHi - Beautifully said Lisa.... Although everyone's situation is different, I agree with Lisa's statement about the mentally ill being considered as marginalized, often into sound-bites and generalizations. Particularly for those who has suffered from mental illness for a long time, there is a humbleness, a wonder if they can indeed find employment, participate in group settings, see themselves as unique and valuable....
Delete@Lisa - education and being a life-long learner is always valuable - the best experience is at the 1-1 street-level - to hear the stories, just listen. You may be the first person who has listened to them all day....
This is also another factor that comes into play here. I work with some people who are disabled and receive SSDI because of their disability. Some are able to work; however, if they work too much, the benefits they receive (housing assistance, food stamps, and other government assistance) will be impacted. The people I work with who receive SSDI and are able to work are afraid to work because if the assistance they receive is reduced they will not be able to pay their bills, or eat. It's a tough decision for them to make and so far, I have not worked with anyone who is willing to work more and receive fewer benefits. It's perpetuates the vicious cycle of poverty for the disabled. Lisa Sweet
DeleteLisa, that is a good point. They had a change a few years ago where a person's savings had to be less than a certain amount or they would no longer receive benefits. I think that may have only applied to Maine, but I'm not sure. There are frequent cases of people losing MaineCare benefits and then no longer being able to afford services as well. But there is a lot of "free care" or reduced rate for many services too. I think because our health care delivery system is so confusing patients often don't know how to access services. That is something a case manager could potentially help with. But my understanding is you must receive disability benefits in order to get a case manager, is that true? The Empowerment article mentioned adjusting disability determinations to be regular assessments of overall functioning to determine if services are still needed, this would be intended at encouraging people to return to work, but my understanding is they already regularly reassess need for services, is that not true? People lose their benefits all the time. But Lisa, I agree, the system as it is does not encourage people to return to work.
DeleteWhat a great discussion going on here. So many areas you are covering!
DeleteIn reference to your comments about disability benefits (SSI and SSDI), you can absolutely work full-time and still receive benefits; your benefits are impacted, but you ultimately have more income in the end between your paycheck and benefits, not to mention PASS plans and other programs that allow individuals to put aside money for education. Thinking about the different models and perspectives, I found it interesting that my study guide for the CRC indicated the independent living model is very different from the CRC rehab counseling model; according to this guide, the former focuses on how to change the way that society treats individuals with functional limitations, while the CRC model focuses on the way the person with a limitation functions (Mometrix Media, 2018); interesting clarification. At the same time, our CRC Ethics highlight the importance of understanding the historical and social prejudices around diagnosis, and to work to both become more aware of and address these biases (Code of Professional Ethics for Rehabilitation Counselors, 2017). My point is that we are making progress in understanding how our society can either advocate and support individuals in recovery (in how they are empowered to define it), or impede this movement forward.
From Davidson, Rakfeldt, and Strauss (2010), I was most struck by the information that individuals with serious mental illness died about 25 years younger than their peers. Understanding that there are multiple factors involved, it is important to take a deeper look at what we are missing in our approach and availability of services for this to occur in our communities.
Sorry, trying to cover lots of topics myself!:)
The current etiologies for mental illness are a combination of biological, psychological, and social/environmental factors. There are a few theories of what causes the onset of mental illness such as the kindling theory. But overall the dominant theory is the medical view. This perspective has led to the excessive use of psychiatric medications, sometimes against a patient’s will. Additionally, the focus on the biological etiology has led to important services like talk therapy, occupational therapy, vocational services, etc.,etc. to be less prioritized, dismissed entirely, reimbursed for at a lesser rate by insurance companies, etc.
ReplyDeletePatricia Deegan describes her doctor comparing schizophrenia to a medical illness like diabetes in that you will need to take medications for the rest of your life to manage your illness. This is common analogy because of how mental illness is often viewed as chronic and pervasive. Is it the best practice? Patricia describes this as “crushing” her hopes and dreams and argues that more emphasis on hope and resilience and sense of purpose would be better. I hear her concern, and it is true and important, but the fact is likely true that she does have to be diligent to take care of her mental health symptoms for the rest of her life.
Daniel Fisher’s perspective that instilling hope is far more therapeutic than traditional services which “take away hope” and function in a “fear-based system” of coercion, is a bit extreme as well. While I understand that learning news of a diagnosis delivered in a negative light like this is a traumatic experience, I do feel that that is the nature of hearing bad news about any diagnosis with a poor prognosis and the patient will struggle to accept the news. There needs to be a process of grieving to accept this newfound version of one’s self. The hope and resilience and new sense of purpose will come in time as the individual continues on their recovery journey. And yes, of course, the way the information is presented to an individual should be done gently and it should be individualized for that person’s particular needs. But the severity of the illness and the possibility of a worst-case scenario prognosis does need to be discussed, not in a threatening or coercive act to ensure medication compliance, but because an individual must understand the consequences of their choices when deciding whether or not to accept treatments.
That being said, I do agree with Patricia & Daniel that many psych providers may take an old fashioned black and white view about patient’s prognoses. I also feel that misdiagnosis happens far too often which can lead to all sorts of problems.
While current etiologies for mental illness are often listed as a combination of nature and nurture, I think we need to consider the impact of our current system and how bills get paid. We also need to consider the training and medical model of treating psychiatric disorders. In many of our current text books there is a combination of using medication and counseling as well as new emerging approaches that have yet to be considered to be EBP. I like the Dr. Deegan thinking that goes beyond the diagnosis and standard treatment and recognizes that this is a person and not just a diagnosis. The importance of connecting on a human level is so important.
DeleteAs a wife of a 100% service-connected disabled Vietnam Veteran who was long ago diagnosed with PTSD and more recently diagnosed with renal cancer, I find the biggest challenge is how providers view Wayne. They see his problem in terms of clear cell carcinoma and not as a person with both physical and mental health needs. I do see that Patricia and Daniel are correct in terms of how psych providers view patient's prognosis in terms of their understanding of a prognosis with little hope.
Nancy
HOPE, according to Dr. Deegan and Dr. Fisher, is a critical component of recovery. Dr. Deegan goes so far as to say that "hope ad biological life are inextricably intertwined." She further explicates that if a person believes that they are the "master of their destiny" life can be prolonged. It is imperative that we, as burgeoning counselors, instill this sense of hope and "captain of the ship" mentality in our clients. We should never lose sight of the fact that they are the experts in their own care; we are simply the facilitators.
Deletethis is Nancy
DeleteHope is a critical ingredient in both physical and mental health recovery. I think the ideas of valuing patient involvement in treatment plannng is so important. There is also the concept of learned helplessness that sometimes gets in the way of recovery. If all decisions are made by others and the person does not have voice and choice then it is much harder to engage the person in carrying out a plan in which they have no investment.
Nancy
Your point is well taken, Nancy. Why should clients care about a plan that involves decisions made by others -- a plan in which they have no "investment."
DeleteInstilling hope is important. But it's definitely not taught in med school / NP school. To bring this back to the question at hand about how does how we view mental illness effect what we do to and how we treat mental illness, I see a lot of forced medications and treatment refusal in my line of work.The goal is treatment concordance, meaning the patient and provider work together towards mutual goals as opposed to compliance or adherence. I think this change in perspective is part of the recovery movement efforts. However, getting a patient to buy in to a treatment plan can be very difficult. And getting them to continue to follow that plan is also difficult. (That is true of both medical and mental health patients.)
DeleteI think that forced treatments are important. I think the recovery movement and patient's rights advocacy faces real struggle in how to approach the severely ill when it comes to forcing treatment. Often a person’s goals are not in line with a provider’s recommendations. Those folks have the right to dismiss treatment recommendations. People have that right. I do get the impression referrals for alternative treatments are not prioritized, but honestly, I’m doubtful that they would be received any better than medications. For many of these patients, a lack of insight about their illness (a common symptom of their illness) inhibits their ability to accept treatment. According to SAMHSA and USPRA, individuals have the right to make their own decisions about their treatment. This is one of my real struggles because although they can refuse help, it doesn’t mean they don’t need it. In my experience professionally and through the NAMI organization, any families are very frustrated that an individual has to become dangerous before treatment can be forced. Perhaps a different etiological perspective might help in that various other interventions might be offered before hospitalization/psychiatric medications, but I imagine when it gets to this point it’s too late for those options and/or they have already been refused or found to be unsuccessful.
Forced medication does happen. But it’s a lot more humane than lobotomies, vomiting, blood letting, etc. of the past. Patricia talks about “Angry Indignation” and how you take a patient’s dignity away when you force treatment. I agree with her “you can’t medicate the anger away.” But there is not much else you can do with it either. I don’t love being assaulted by my patients, but it sure does happen. Should we send them to jail every time they hit us? Would using physical restraints alone be more humane? I don’t think so. But after the readings about Bedlam, I do wonder why we did away with the straight jacket. I don’t know of any other options though. Because hope is certainly not going to stop them from hitting me. Hope takes time. These patients that I’m talking about in my experience are generally the severely mentally ill who are in and out of long term hospitalizations at state facilities. These are the folks that other interventions like talk therapy, group therapy, etc., are not going to have any effect on now, or perhaps ever.
*many families, not any
DeleteYour posts bring the idea of supported decision making to mind. There have been several pilots in VT that look at options other than absolute guardianship. I believe that several of the individuals may have cognitive challenges; I also worked with a young man with severe mental health challenges as well as cognitive disabilities. If one were to look at the different barriers that he faced, there would some concerns about him solely determining all aspects of care. However, this has been a very effective model for him to get the services that he needs while also empowering him to manage his own care and support his goals. Here is a link to the website: http://ddsd.vermont.gov/supported-decision-making
DeleteI would say that if we think its inhumane to restrain and force a person to take Lipitor than its probably inhumane to restrain and force a person to take lithium. Violence should be met with highly trained professionals who are capable of subduing an individual quickly and gently. I believe that a complete staff would contain individuals who can calmly restrain a client. I also would not leave human or animal in permanent full-body restraints even for a short period of time. The feeling of being tied down is terror inducing and either produces intense hopelessness or intense fear. I feel like neither one of those is suitable states for someone with severe mental illness.
DeleteRestraints are used for as short amount of time as possible. But they are used. Especially in ERs.
DeleteAs for forced medications, this too is a common occurrence. One that is gaining more and more popularity in recent years with court ordered treatments, meaning patients must follow prescribed medications or face returning to court/returning to hospitalization. This may be a hot topic for you all as it touches on patient's rights which has been discussed a bit.
Wow, there is so many good points in this thread. You mention in your original post the importance of being diligent with ones care, in this case mental health and taking medications. I feel diligence needs to be used in any case when it comes to ones health, whether physical or mental. It's really more of a self-awareness and making informed decisions, it's choosing how you want to live your life! The other thing mentioned in this thread was the importance on instilling hope, which is such a big thing that as you said isn't typically the mindset in the medical field, but i feel that's why it's important for someone to have various supports in place to assist them and ensure they maintain the hope.
DeleteThe etiology and treatment of mental illness- Nancy Ackley
ReplyDeleteThe two questions we are asked to address this week of causes and treatments go hand in hand with our current medical model of diagnosis and treatment using medications .While the exact causes of most mental illnesses is not known, current research supports the idea that many conditions are the result of a combination of environmental, psychological, genetic, and biological factors. If we consider some of the ideas of Eric Kandel from Columbia University, he focuses on biology. if all mental processes are brain processes then all disorders of mental functionng are considered biological diseases. To many experts, mental illnesses are no different than physical illnesses such as heart disease or diabetes. All diseases either physical or mental have a behavioral component. So if we look at the patient with heart disease, diet, exercise etc. play a role in his / her disease. As a result of this kind of thinking, there is a high use of medication to treat both physical and mental illness. Because there is a behavioral component, psychosocial approaches such as counseling, self-help groups etc. are also used. The limitations of this approach is that it doesn't work very well and we need new ways of offering choice and voice to persons with mental illness.
Nancy
Hi Nancy,
DeleteI really like the points you make in your post. I recently read a book called, "How Not to Die" by Michael Gregor. It touched upon some of the elements you mentioned here. Such as taking a medication versus focusing on diet and lifestyle changes that could reverse some diseases both mental and physical. It was interesting (and sad) to realize pharmaceutical companies who want to earn money, continue to sell drugs that may or may not be effective. Often times, there are cost-saving alternatives that are actually proven more effective than the drugs our doctors are prescribing us.
Nancy Ackley
DeleteHeather,
I think it is important to have choice and voice in terms of treatment for both physical and mental health issues. I see both plusses and huge minuses in our current sytem that treats mental and physical health in much the same. That said I know that much work has been done to create parity in terms of insurance payment for mental health treatment. Underlying the system is the issue of stigma which still is there and in some ways blames the person who has mental illness but not the person with physical illness except in cases of drug/alcohol related conditions. The blame the person who has mental illness or the person's family is an idea that hopefully is no longer there. Yet it is in a microaggression way. As we consider the ideas presented in Bedlam of viewing those who were institutionalized as a sport is no longer permitted. Yet the attitudes as outlined by Patricia Deegan have not changed as much as they need to .One of my first jobs as a college work study student was at Bangor Mental Healh Institute in Patient Education. Some residents had lived there 30 years or more and their families had no contact and they had no place else to go. There was no talk of recovery.
Nancy
What is recovery? Deegan frames it in terms that mental health providers need to hear. She puts forth what recovery is not...it is not becoming normal or becoming mainstreamed. Essentially, it is being accepted for who you are and allowed the opportunity for hope and controlling your destiny -- isn't this what we all want? Why should folks with mental illness be any different? As providers, we would be wise (see Deegan's definition of knowledge and wisdom) to remember that recovery is a journey that may or may not be linear, but it should occur at the individual's pace and on the individual's terms.
Delete"What is recovery" is a good question! The Empowerment article went over different versions of what recovery is. Comparing Rehabilitation (recovery of function while having a disability) and this Recovery Empowerment. What did you all think of this difference? Perhaps it is my medical training (though nurse's are known to have a more holistic training than medical school) but probably it's from working in inpatient psychiatry and seeing patients at their worst, but I still feel that recovery of function despite disability is my definition. I don't think someone is ever "cured." While there are periods (perhaps even decades) without any symptoms, I still think someone with mental illness has to be vigilant to prevent future episodes. They certainly can and should utilize the services mentioned in the article like peer supports, resources, coping skills, etc. But some people simply don't want those things, or simply are not capable of utilizing them at that time. In an ideal world, that would be great.. But, you cannot make someone take offered help and services.
DeleteThe article also discusses how returning to work should be part of a full recovery. And that's great. But not everyone is able to do that. Work is stressful. We all know from the stress diathesis model of mental illness, too much stress with not enough coping ability leads to illness. Some people may never regain full function. Giving them hope that they can may be a disservice to them. I think part of recovery needs to be understanding one's new functioning level and accepting that (grieving the loss) and then learning to function successfully at your new level with supports.
Correct. Setting someone up for failure is never a good idea; however, as we read in Chapter 2 of our text, work was identified as an important factor in recovery going back to the work of Pinel in the early 19-th century. Consequently, it is important to, as you point out Jess, to understand a client's level of functioning and interests and help them obtain work that is both meaningful and fruitful.
DeleteYea, I thought it was interesting that they point out in chapter one that recovery from serious mental illness is easier to do in non-industrial, non-capitalist countries. A theory for this being that "capitalist economies insist more stringently on people 'fitting in' or adjusting to the requirements of the labor force." I would say the civil rights movement for people with disabilities has come a long way and this is already changing to a degree.
DeleteI also don't believe that someone can all of a sudden be cured, they will probably always have symptoms. But helping them live a life as normal for them as it can be with, medication and supports, is helping them. I also agree with you that you cannot make someone get the help and supports they need, they have to be willing to do so, and they have to want to recover. I have seen in my line of case management set someone up with all the supports imaginable and then they just did not utilize most of the services. It made me wonder if they really wanted to recover or if they were just out to see if they could get supports if they wanted to. This is sad, because there are others out there who would utilize supports and can't get any.
DeleteBeatrice, thank you for sharing that story. It is hard to watch that sort of thing as a provider. I imagine we've all seen it. I don't think any of us knows what to do about it. Perhaps instilling hope, perhaps continuing to offer support and be turned down over and over... but more often I see people just continue to struggle until they reach a point of crisis. But the way things are now with more patients rights than we've had before historically, that patient has the right to refuse. It's a real dilemma for the provider. And for the families.
DeleteBeatrice,
DeleteI too have seen what you describe. It is difficult to watch somone who struggles with recovery and does not access what is available to them. Yet it is important not to give up and they may get to the place when they can. I know my husband's brother had difficulty with a substance use disorder. He passed away nearly 3 years ago at age 57 and was never able to for more than a few months to use what was available to him through the VA.
Nancy
I've also struggled with the definition of recovery. One of the first textbooks I read on recovery-oriented principles was very biased by the dominate, western, white male cultural perspective. Constantly reiterated throughout the text was the idea that recovery meant that people could achieve the same milestones as everyone else, i.e. graduate high school, go to college, meet spouse, have children, buy house. Not only are these life milestones very culturally specific, but many people today don't want to adhere to such a strict life timeline. I come from strange folk. Generation, upon generation of dairy farming women who were unmarried and without kids until the day they died. My normal does not involve that timeline and I don't think the professional definition of recovery should adhere to this idea.
DeleteThis comment has been removed by the author.
ReplyDeleteThis is Bronte.
ReplyDeleteMy understanding is that most of the prevailing modern theories on mental illness etiology are derived from gene-environment interaction theories. I have found that many articles discussing etiological theory often cite studies on twins. Twin studies have generally pointed to a combination of molecular genetic and environmental factors that create a kind multi-factorial effect on onset and symptomatology of mental illness. The word I've seen used for this etiological phenomenon is "poly-causation". This modern etiological theory for mental illness has both positive and negative consequences for people with severe mental illness (SMI). I believe that the positive consequence of this medically rooted theory is that it has provided the foundation for the civil rights movement for people with SMI. Although popular U.S. culture still perpetuates and cultivates many of the damaging and horrific stereotypes long associated with SMI (eg. people with SMI are lazy, stubborn, violent, unpredictable and that parents are to blame for all of that), positive attitudes and language on mental health and mental health care currently prevails in clinical, communal, and government settings. While the cultural gears of change may change slowly, you can see evidence of this fundamental change in attitude and perceptions just about everywhere you care to look.
The negative consequences for people with SMI is the unfortunate focus on the illness aspect that comes with the clinical perspective that accompanies an etiological theory based on a premise of molecular genetics. Clinicians view their clients and patients as "incurably ill" leading to over-medication and a sense of hopelessness in people diagnosed with a lifelong "illness".
I found Pat Deegan's comments on widening our stream of normality to be both heartening and disheartening. Her speech in Rotterdam (I believe?) was over ten years ago and I don't believe we're any closer to widening our stream of acceptance of what is "normal". In fact, I feel like we may be actively closing in the banks. I think that if we broaden our view of normal, if we seek to view people with SMI as just on different parts of the spectrum of behavior instead of completely off the spectrum, we will find the key to integrating people with SMI based on a model of humanity not illness.
This is Nancy.
DeleteBronte,
I liked the widening the stream analogy. I think she is correct in that while this is not an easy thing to do, it will make a difference in the lived experience of persons with SMI and their families. I also think we need to look at our current political and social climate in terms of the impact on efforts to widen the stream. As we look at both our own state and the passage of LD 925 after it was vetoed by the Governor and the veto was overridden by our representatives, there is movement in the widening the stream. The movement is slow, but it is movement. In an election year we can all make our thoughts on widening the stream clear to candidates and newly elected officials.
Nancy
Hi Bronte,
DeleteI also found Deegan's comments on widening our concept of "normal" as both a positive and a negative. It's a positive because more acceptance of individuals with mental illnesses would be wonderful, and hopefully there will be a day where this is a reality. However, I also see her comments as a negative because, as you said, not much has changed since she delivered this speech. I think part of the reason society is so slow to change their views on individuals with mental illnesses is because they lack education on this population, with their only knowledge coming from the news, social media, Hollywood, etc., where the messages are usually negative and cast individuals with mental illnesses in a negative light. I'm not sure what the next step is to change this other than more education, and even then I know it will be a difficult process.
The prevailing etiologies of mental illness are: biological, psychological, and environmental. The biological etiology includes potential chemical imbalances in the brain, infections, and heredity. Psychological causes include trauma, loss, and neglect, while environmental causes include a dysfunctional or substance-abusing family which results in poor social supports or particularly stringent social or cultural expectations.
ReplyDeleteThese prevailing theories often result in psychopharmacological, group therapy, and/or psychological treatments, such as CBT. Moreover, emerging therapies, such as creative therapies or hypnotherapy can be implemented.
This is Nancy
DeleteLisa,
I think the phrase on the prompt of theory matters is important when we consider these prevailing etiologies of mental illness. The prevailing theories limit the treatment options. If new theories were developed ,it might expand the current options.
Nancy
Hi Lisa,
DeleteI'm glad you bring up the topic of emerging therapies to help treat mental illnesses. I don't think we give these therapies enough credit, which is a shame. Creative therapies are a wonderful way to support people with mental illness, as it gives them a chance to use their minds in a different way, and work towards recovery in a more fun atmosphere. I know several people who have worked with people with mental illnesses doing creative therapies, and they said that their clients love it. It helps them relax in a way they may not be used to, and they're able to create while doing it. I think working towards developing new theories and developing more treatment options is something we should be focusing on.
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ReplyDeleteWhen listening to Patricia Deegan's speech, I am reminded how unhelpful our society has been over the years in supporting individuals with mental health challenges. The stigma perpetuated by the traditional medical model of the doctor as expert and the patient expected to blindly obey naturally creates a power differential. The doctor is looking for a cure because there is something "broken" and needs to be fixed; this then presents the patient without human characteristics and therefore the individual does not require respect, genuineness, and empathy--those very qualities that make such a difference in engaging with individuals. Further, the genetic theory around mental illness also suggests that someone is born a certain way and there is nothing to be done, other than maybe medication to "treat the symptoms".
ReplyDeleteIn my professional and training experiences, no one ever painted a positive picture for individuals with schizophrenia or bipolar disorder. The language that I heard being shared was, "you are sick and you will be sick for the rest of your life". Also, professionals communicated the idea that all they could hope for in life was to just exist and "manage" their symptoms. I recall my first professional job (on an acute psych unit) meeting a man who was absolutely brilliant-- I still remember his name and it was 20+ years ago. He was so kind and had so many positive qualities, yet all the staff could say about him was how sad it was he had schizophrenia and he would never achieve anything in his life. While working at this same site, I encountered a young man who had been a star athlete and was early in his college career when he had his first psychotic break. The team had determined that all of his plans would need to change and his family would be taking care of him for the rest of his life. As I sit and write this post, I wonder what happened to them and the impact of this prognosis. The concept of learned helplessness by Seligman that Patricia Deegan references is so appropriate, because why would one believe that there were opportunities and goals to strive for with doctors telling you that you will never recover?
The mere existence of courses like "Recovery-Oriented Origins" create hope that recovery is possible, despite some of the prevailing traditional perspectives. Instillation of hope (Yalom's term) is such an important part of being a human service or health care professional. Many articles that I have read keep going back to the point that clients report the pivotal factor in engaging in treatment and reaching their goals was someone believing in them-- holding hope when they had none. This is so important to learn in our studies, right along with counseling theories, research and evaluation, and biopsychosocial aspects of disability. Thanks for reading.
Hi Tara-
DeleteI agree with your thoughts about how those individuals with more severe psychiatric diagnoses are never painted in a positive light. Once a label sticks, the person is told, treated and convinced that they are the diagnosis. How can a person plan for a future if they and their loved ones are convinced that the person with a diagnosis is stuck almost at a point in time forever with that label. If the person has strong advocates - families, friends, counselors, communities who believe in them, then the individual may believe they are worthy of a life of opportunity, hope, employment and joy.
Tara, your post resonates both challenges and hope for those who have a mental health condition. In the traditional way as you explain the doctor does look at the clients symptomology and with his best deductive reasoning and from the doctor has learned from previous patients will attempt to find a cure for his/her patient. Today through evidence based practices clients' can participate in patient to physician decision making participation or processes. Patient participation in decision making has been a proven game changer for many. Through participating in decision making the client can address if the medication prescribed to them is effective for them or not. The client can also state to the doctor to lower the dosage or increase the dosage to accommodate their needs in accordance to their level of diagnosis. The doctor will of course will subjectively take in what their patient is telling them and make changes accordingly or make no changes to see if other changes can be manifested on a later date, The EBP patient to physician decision making process eliminates the guessing game and places the patient in the drivers seat in being able to tell their doctor what they are going through and what is not working for them. Today's methods of medicine with the EBP process are very different from the days patients were locked up in an asylum and forced to take medications they did not have a say on. The evidence based practice has in many cases given back a clients live that they once lost and will be around for the many more years to come. You are absolutely correct the world of mental health is not described as a pretty picture. Methods of care and being receptive to clients who have a mental condition has improved and I foresee many more positive improvements will be made in the future.
DeleteGary:
DeleteThank you for your thoughtful comments. I do think there are changes being made from the traditional medical or functional approach, as I see more and more medical practitioners utilizing motivational interviewing techniques. I remember the days when I would walk into the doctor and they would tell me what was wrong with me and what I needed to change. No consideration of what I needed or how I might feel about it; I am not minimizing the expertise in any way of the doctors, as this is why we visit in the first place. I prefer the concept of someone "coming alongside" (MI skill) and asking open-ended questions to understand my perspective as they provide insights. It is these moments I recall from visiting the doctor's office in the past when I felt disrespected, ignored, and dismissed that remind me every day how much my language can impact a client.
I can just imagine why the stories of Dr. Deegan would make you reflect on your past experiences with mental health, because they are all very sad stories and situations. The good things is that you have chosen a field where you believe that you can help others like those mentioned, and that is encouraging. The more people learn about mental health and understand it, the better off others with mental health will be, as we encourage them to recover. Good Post !
DeleteSome of Patricia Deegan's references were so powerful -
ReplyDelete"I am speaking here of the heart that can break, the heart that grows weary, the hardened heart, the heartless one....and the one who has lost his heart. "(Deegan, 1995, p. 1)
"We have failed to teach them to reverence the human being who exists prior to and in spirte of the diagnosis we have placed on them (p. 92).
This so reminds me of so many of the VR consumers I have worked with over the years that describe their interests, their former employment life in the past tense....It's as though so many others have convinced and compartmentalized their lives as before the disability and then post-disability. By the time I see them, they describe themselves in those terms - they describe the sports they used to play, the jobs they held, etc. I think the medical model of psychiatry is still around, likely more in the acute hospitalization stages.
I've been heartened recently to meet some individuals who have come through trauma, diagnoses and convictions, who with lots of support and counseling, have such inspirational philosophical understandings of themselves, their journey, their heartbreaks, etc - and now are ready to come back to the workforce, and more importantly to view themselves as people not only with a past but also of allowing themselves to be at peace with themselves in the present and planning for a future once again.
I believe that, there are many solid models of psychiatry, treatments, etc. Practically, it appears that those individuals who have family and community supports, as well as maintaining treatment connections with medical, psychological, counseling, or naturalistic means for healing, appear to have the most effective outcomes.
"Each person's journey of recovery is unique (Deegan, 1995, p. 97).
Deegan, P. Recovery as a Journey of the Heart. 1995
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DeleteThe above entry is from me - Sue Zamecnik - just figuring out how to use this site.
DeleteDeegan is a powerful ally for one of the most vulnerable populations. Her insight and lived experience are truly powerful.
DeleteHi Lisa - I agree ! As I read Deegan's statements, they resonated so strongly with me. I work every day with vulnerable consumers, listening to their stories. She is so eloquent and spot on.
DeleteWhen listening to Patricia Deegan's story and her wanting to change the way providers see mental illness I could relate to her statement of moving beyond the diagnosis. I can't tell you how many times I needed to know what diagnosis is, before I got to know the individual. Voc Rehab has 90 days to determine eligibility to meet the federal requirements, that means we need documentation of the disability on file. This policy enables providers to focus what is wrong right out of the gate, before we can focus on the strengths.
ReplyDeleteToday's systems don't allow for one to come in and out of services as the mental illness may ebb and flow. And if they do, it is not set up so that is doesn't feel as thou it comes with a cost to the consumer. People often fear that they if they move off a service, it is going to be to very consuming to try to get that service back again.
I do believe in recovery, because I've seen it happen. I use this language when I'm working with individuals. My question to them is what would recovery look like for you? I've had a few map it out for me and it was amazing to watch them take the steps they spoke about. They also developed a social network that was in place should they ever need supports or ask for help in the future. Patricia Deegan is right we need to move away from the diagnosis and learn with the person. As Patricia stated society needs to expand so everyone can be a part of it!
Cindy Seguin
Cynthia, I also enjoyed watching Dr. Deegram's video. She stressed that many with mental illness do not receive the care that they need also that many mental disorders get overlooked or misdiagnosed. I like how she got personal and stated that her advocates never gave up on her. Keeping up with a patient and catching positive changes as they occur is key in getting clients to adapt to their newly acquired coping skills. If Dr. Deegan did not receive the quality care she received with the advocates she had who believed in her she may have digressed and not be where she is at today, Dr. Deegan has a lot to be thankful for as we all do. One thing that Dr. Deegan did was not remain stagnate she believed in the care she was receiving and she tuned in to what her care providers had to say. One day it clicked and she finally realized that through the proper medication management she could function as a normal person. Sometimes it takes a physician to client participation to find that right balance of care in taking away, or adding or lessening dosage of a medication to find that proper balance to function in life. Through it all Dr. Deegan was able to get out of the weeds and get back into mainstream and dedicate her life in helping others. Diagnosed with a mental illness since her teenage years, Dr. Deegan did not submit or yield to her mental illness diagnosis, she did something about it. She wasn't afraid to trust others with her life but she also was not shy from telling doctors what is and what is not working for her. Today Dr. Deegan is a role model and advocate in assisting those with mental illness. Dr, Deegan made a choice in her life to think out of the box and make changes to her life per guidance of her doctors and advocates today she is thriving independently and assist others with their mental conditions
DeleteCynthia,
DeleteI too found Dr. Deegan's ideas to be helpful in terms of the messages she shares based on her own experience. I found that she suggests that preparation programs are based on a diagnosis and treatment perspective. Yet it is important to remember that we are treating a person not just a disorder. We need to look beyond the knowledge and seek wisdom that sees the person as a person first and not just a disorder.
Nancy
Hi Cynthia,
DeleteThe system we currently have in place is not the best when it comes to supporting individuals with mental illnesses. While I agree that having a diagnosis is helpful for a variety of reasons, the sense of urgency we face when giving someone a diagnosis is neither helpful to us or the individual seeking out treatment. We should be able to be given adequate time to get to know the client, their background, and the background of their symptoms before we give them a clinical diagnosis that will stick with them for the rest of their lives.
I agree with you both, but there is one aspect that we need to keep in mind and I don't believe Dr. Deegan spoke about. What happens to the individual that doesn't believe in their treatment or agree with the way they have been treated? This is where a VR counselor or individual therapist may be helpful. I'm not saying we take the place of anyone or program, but we may be able to help them put the puzzle together.
DeleteI don't think that everyone can benefit from community programs, their individual program may look very different and I think that can be ok. I've seen several people that have not agreed with the way they were treated by an specific agency nor have they agreed with the medications they have been prescribed. Sometimes the side effects of the meds outweigh the benefits, therefore, we may need to look at alternative remedies for a person to move forward or be frank about the changes we see when there is a medication change. Some of the most successful people I've seen have developed their own coping skills and support systems.
Cindy - I agree with ‘systems’ keeping individuals at a disadvantage. It would be some much easier if (in VR, for example) counselors had the time to get to know the individual and their wants and needs, and perhaps assess them outside of knowing what others have decided is their mental health diagnosis. I have heard case presentations thru our various classes where a prior diagnosis did not seem to fit the individual as they presented to us as their current service providers. Were they misdiagnosed? Have they recovered from that condition, and now perhaps have other, separate issues going on?
DeleteLike the old saying “there's no ‘I’ in TEAMWORK” (referring to the individual as the ‘I’), I add that there’s often no ‘I’ in SYSTEMS, either.
What are the prevailing etiological theories in psychiatry today? What do these theories lead us to DO to (and with) people with mental illness?
ReplyDeleteAs I began pursuing my academic goal for vocational rehabilitation counseling I could not help to reflect on people who I saw throughout the past years in airports, subways, malls and parks. In some shape or form we are all curious of one another, meaning we all study the habits of our human counterparts. The reason why most of us are pursuing careers as counselors or social workers is because we like to study all forms of human characteristics and traits good and bad and we have a passion to assist people with disabilities to find themselves and through accommodations help them find a job so that they can build their confidence in growing in a position and gain independent living. Everyone has hopes, dreams and aspirations, a person with a disability may not feel that their hopes and dreams are attainable. Throughout the past years through serving in the active service and after retiring from active service, I have seen many troubled souls here stateside and abroad. I have witnessed many citizens throughout the world shouting by themselves, talking to themselves as of carrying a conversation with someone else and hallucinating. In this past year I have learned that mental illness is behavioral instability that creates distress and functional impairment. Having a mental illness may be like having an oversized hour sand glass and watching that sand glass drop its endless sand not knowing what the next hour will bring. For a person with a mental disability watching an hourglass pour its sand is like putting one’s life on hold. For many who have a mental disability or a persistent disability it is like going through life in slow motion or putting one’s life on hold. Some of the etiological prevailing theories in psychiatry today is that stigma no longer exists. As I have learned from my previous classes stigma does exist today but in a lower form than it did in prior years. By the way the current trend is going, it may be a fair statement to say that stigma will always be part of our society it is a part of mental illness that our text (L,Davidson; J,Rakfeldt; J, Strauss; The Roots Of The Recovery Movement In Psychiatry, 2010) describes the fact that discrimination and stigma continues to be a part of our lives throughout our nation. Another etiological theory in psychiatry today that a person with a mental disability cannot be fully rehabilitated to maintain gainful employment and live an independent life. As we witnessed Dr. Patricia Deegan’s story everyone with a mental disability has a fighting chance to change their mental disability capacity some much more profound than others. What I grasped from Dr. Deegan’s video is when she stated that her mental health advocates never gave up her on her. That shows that consistency is key and being persistent in showing the person with a mental disability that through medication management and proper coping skills they do have an opportunity to live a normal life and recover to gain independent living.
What these theories lead us to do as advocates, counselors and social workers is to assist our clients with professionalism and to deliver proper and moral treatment, so that our clients will overcome their levels of mental illness. Our text (L,Davidson; J,Rakfeldt; J, Strauss; The Roots Of The Recovery Movement In Psychiatry, 2010) states that as advocates, counselors or social workers we are to remain hopeful and stay the course with our clients and stimulate our clients thought process to stimulate growth and new experiences so that our client can gain or regain their confidence in life.
Ref:
L,Davidson; J,Rakfeldt; J, Strauss; The Roots Of The Recovery Movement In Psychiatry, 2010.
Dr. Patricia Deegan’s video.
SAHMSA Summary of Recovery Principles.
USPRA Core Principles.
Rehab or Recovery Article.
Hey Gary, I think you make a really important point here because it highlights what I see as the biggest flaw in our current health care delivery model. You talk about how providers needs to "stay the course" with clients and I think that is very true. However, since our system is so fragmented, providers change as a patient moves from inpatient to outpatient care and from one clinic to another. Additionally, if a patient decides to stop showing up to appointments, they may get a call or two to reschedule or a letter in the mail warning them about being dropped as a client perhaps, but I'm not sure what beyond that continues to stay with the client. Then they go without services until a crisis occurs and they start the process again. If our clinicians were reimbursed for services based on overall health outcomes instead of fee for service, perhaps there would be more incentive for follow up treatment. Even in more advanced level care like ACT, Access, Case management this cycle continues to happen. Davidson, Rakfeldt, and Strauss point out the need to move from an acute care to a disease, or recovery, management model (pg. 4). If patients had more supports it might be different, but the current supports offered are inadequate.
DeleteJess, fantastic of you highlight very important factors. In my previous classes we did cover how fragmented our our health care system is. I also remember going over on how primary care physicians and psychologist of the same patient do no communicate with each other. This breakdown of communication can make a difference in delay of proper treatment, prescribing medication or misdiagnosing a client. It is such an injustice to the client if they are misdiagnosed because the client's real condition that is missed may worsen which can lead to client frustration. I am elated to hear that most of the evidence based practices such as physician to client practices have been working. A client can discuss with their physician how certain medications are working or not working and the patient and physician can discuss what should be the best outcome for the patient with the patient's input. I like that fact that you bring the metric in today's health care system is a little dated and you are right if the health care providers are properly compensated for the health care services provided in lieu of fee services better customer service can be provided. What we see in the midst of our fragmented health care systems are changes but thus the changes that have been administered does not make a positive impact on overall health care for the client. Your post is enlightening and makes you think of what upcoming changes in our health care system may change.
DeleteGary,
DeleteAs the text stated (L,Davidson; J,Rakfeldt; J, Strauss; The Roots Of The Recovery Movement In Psychiatry, 2010) states that as advocates, counselors or social workers we are to remain hopeful and stay the course with our clients and stimulate our clients thought process to stimulate growth and new experiences so that our client can gain or regain their confidence in life.
I'm now wondering if maybe systems are beginning to change, because they know the way business has been done, it's not working. I always have to keep in mind ultimately, we are all in a business, we get paid for the services we provide, so usually has to be a measured outcome to the agency to receive payment. But back to my initial thought, VR is now looking at serving individuals for long term goals, to help them on a career pathway. A career pathway can be from bagging at a grocery store to moving into the next level at that same place of employment. We will not be looking at a 90 closure like we have in the past. If my head is in the right place this can mean that someone with MI would be able to take the supported steps necessary to move towards their goals. This as been the case with supported employment programs, but not everyone wants to be involved with those programs as their is a high level of stigma attached to those programs and they offer a greater deal of support. This may take lots of creative thinking to make this work for some people.
Cindy wonderful of you to chime in. From the VR perspective it is a challenge to find the balance between keeping a case open with a client and when to close it. Closing a case depicts a huge move forward for both the client and the VR counselor. The agencies that do well with supported employment are the International Clubhouses across our nation. The High Hopes Clubhouse of Waterville, Capitol Clubhouse of Augusta and the Looking Ahead Clubhouse of Lewiston all do a great job in managing their clients with supported employment. All clubhouses work in tandem with the State VR. I met one of your colleagues Diane at the Capitol Clubhouse the previous semester. It was fantastic to see her at work assisting the clients at the Capitol Clubhouse with such enthusiasm. I agree with you the American Disability Act of 1974 was supposed to abolish stigma, but we still see stigma at work to this day. A lot of barriers have been lowered, but there is still much work to do in showing employers the value of person who has a mental condition is still able to work and make independent decision just as one of their valued employees can.
DeleteYour post is enlightening to read, thank you for your post.
Gary & Cindy - the vocational supports for clients is invaluable. The clubhouses and centers like Amistad in Portland are wonderful resources. Someone told me vocational supports are only available to Mainecare consumers. Is that true? Do you know? If so, these types of limitations certainly are a barrier for individuals who want to access care. This is another example of how our system is designed to manage acute episodes but not well designed (yet) for preventative and supportive measures to keep people out of acute care.
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DeleteJess according to each of the club house directors Amy Kirkpatrick of Capitol of Augusta and Lisa from New Hopes Club House in Waterville, in order for a person with mental conditions to take part of supported employment or any services within the clubhouses international the person has to have been diagnosed with a mental condition and have Maine care. If the person does have a diagnoses but no Maine care, the clubhouse will provide funding from the state for a short period. I do think that short period is for the person with a mental condition is a waiting period for the application process to apply for Maine care to see whether or not they get approved for Maine care.
DeleteThank you so much for the follow up, Gary! That is so helpful to know.
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ReplyDeleteMy name is Liz Colby. I am not sure this post will recognize my name, so I am including it here. My comments here may take a slightly ‘less than popular’ stance on the principles and practices of what causes mental illness and how ‘it’ should be treated.
ReplyDeleteFrom my short-lived experience working and studying in the field of counseling, I have learned (been told) that we, as clinicians, need to “meet people where they are at” and to “treat the whole person and not just their labels”, be they of mental illness or specific diagnosis(es), etc. I whole-heartedly agree with the later statement, but question the other in its practical application.
I think “meeting someone where they are at” is a concept that has become a “campaign slogan” more than a practical application of working with someone to help them understand the nature of their illness, and how to live with it, not inspite of it. To me, the concept of living in spite of something would be like convincing someone with a bad eye (for example) that they should cut it out and learn to live with the damage left behind from the excisinon. That they should be reminded on a constant basis that they are no longer whole, or normal, or well, but that it is “OK”, they can learn to move on with what they have left. To me, if is more about accepting someone as a unique, whole individual. Not flawed; just different. Instead, they have something that is a part of what makes them who they are. They (and we) need to embrace that idea, and then help them learn how to live in a symbiotic relationship with that part of themselves. The slogan reference comes from mental illness being viewed as a thing, an ‘it’ to be treated like a boil; something to be removed, something bad. That is like viewing blonds as good and ‘normal’ and redheads as ‘freaks’. One does not choose that part of themselves for themselves, they just know it to be a part of what makes them themselves.
I think the prevailing etilogical theories in psychology are that mental illness is random. It can be from a genetic anomaly, environmental factors, unknown reasons or any combination of the above. There is no known set if identifiable factors that can tell us ‘Aha! Bob has q,x and z so he will develop schizophrenia’. It is more of recognizing symptoms of a disease or condition that one already has, and making the person aware that the disease exists.
My other less than popular views have really nothing to do with the use of any theoretical modality, but with some (I am sure well-meaning) clinicians. I see many counselors trying to change their clients. They are not embracing their clients and asking their clients what they want for themselves. When we no longer listen to our clients, we are doing a great disservice to our clients. It is easy to fall into the trap of wanting to help, or to fix what is wrong, etc. Some counselors use motivational interviewing (MI) to address ambivalence, but are not content with the idea that is,e people do not want change, do not see a need for change, etc. In these situations, we need to accept the client’s wishes.
OK, my soapbox is put away. I apologize if any comments I made were viewed to be inflammatory. These are just my professional opinions.
Liz,
DeleteI think the issue of trying to change clients is one that Dr. Deegan addressed. The pathologizing of anyone who does not fit into the mainstream is one that requires a
major shift in thinking.
Nancy
Today the etiological theories of psychiatry have proven that recovery is possible, when in the past if you were diagnosed with an illness, you had it for life.
ReplyDeleteThese theories show us to recognize the struggles of the person, and go deep within to find a remedy towards their recovery, or even a place where they can be part of a community, and live out a full life with others and supports.
As Dr. Deegan would say, we need to use our wisdom to be able to help others recover. Another strong point she mentioned was hope, a person needs to have hope for themselves, and the belief that they can heal, if they are willing to put in the work.
Beatrice, I'm a little confused by your initial statement here. Do you mean to say recovery means you no longer have an illness?
Delete- Jess Fossett
When moving into to recovery one always has the condition, but they are able to function to the degree that they are comfortable with...if we label the person as always sick why would they even want to works towards recovery? I guess we need to be careful how we speak about recovery to someone whom is actively struggling with their illness.
DeleteI think being in Recovery implies the illness is still present. If one says "cancer survivor" it has a different connotation than "cancer recovery." Though neither is indicative of future return of illness. When someone says in recovery from substance use disorder, that can have so many meanings depending on what stage of recovery they might be in. Perhaps they have been sober for years, or perhaps they are still actively using, but have made progress about recognizing they have a problem. While I would say they can be labeled as in recovery at these various phases, I wouldn't say they are no longer ill if symptoms are still present. In the AA model, they teach that it is a life-long condition. There is a lot of contention between the AA community and the Recovery movement community on this front.
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ReplyDeleteWe have come a long way from the early etiological theories of psychiatry that included demons and supernatural forces. Today, the theories include hereditary, biological makeup and stressors or trauma. As counselors, we need to assess each individual and determine a treatment path that takes the patient and his/her unique factors into consideration, while working with the patient to meet his/her needs surrounding a treatment plan. This can take months, but we do not have months to come up with a diagnosis for the DSM-5, even though it is required by insurance companies. Part of the assessment is to get a sense of what has brought the patient to us, even though s/he might not know what that reason is right away. And, through the initial assessment and interactions, building trust is important. If there is trust, the patient will be more inclined to come back again and share more of their story.
ReplyDeleteInstilling hope was mentioned more than once in the work we did this week and I believe it is a very important part of what we do with people with mental illness. In order to instill hope, we need to build the trust and work toward a plan for recovery, and continue to do so every time we meet with a client. Perhaps we are the only constant in their lives and it is important to remain vigilant in instilling hope.
Hello Lisa:
DeleteI agree that instilling hope is so important to our work. It is not about trying to make them feel better, but rather knowing that we are willing to witness and support their process of recovery, whatever it may be. There is no one path, only one that is right for each individual.
Your point about unique factors is well made. When considering all that we viewed and read this week, one word that I saw often was culture. Many years ago when I did a master's in mental health counseling, we had one class that talked about cultural differences-- Power, Privilege, and Oppression. This was the first (and the last) I came across in my studies. In the current coursework, understanding an individual's culture is so much more prevalent in all aspects, whether we are talking about theories of counseling, assessment and evaluation, counseling interventions, or research. The fact that there is a greater understanding of the impact of culture, both in terms of our interactions with clients and in comprehending and being empathetic about their world, provides a whole other level to the idea of genuineness and transparency. Also, culture is now understood in terms of race, ethnicity, culture, socioeconomic status, gender, sexual orientation, religion, ... and the list is growing. Not only can we provide hope in our work with clients, but continuing to shift the culture of human and health services as well.
Hi Lisa,
DeleteI 100% agree with you when you say that we need to assess each individual and put together a unique treatment plan that works for them and meets their needs. Though people may have the same mental illnesses, it's crucial to keep in mind that that does not mean their symptom or their context are homogenous. As you bring up, this individualization of treatment plans can be made more difficult by insurance companies needing a diagnosis in order to cover the treatment. It's a tough balance between wanting to be careful and not misdiagnose a client and trying to get their treatment covered as soon as possible. I think the best way to handle this situation is to give the client the least severe diagnosis as possible while still making sure you cover all their symptom clusters.
Noelani,
DeleteHope is one of the biggest pieces to this. I often feel as though I'm the cheerleader, I always point out the differences I when people start to do the work. I ask for permission when giving someone feedback, so if it is positive or negative I feel a little assured that they are open to hearing it. I can't wait to continue to learn more about these theories as it is so fascinating.
Cindy
For some people with diagnosed mental illness, the one thing that they have, that they can hold on to, when they feel like everything in their world is out of their control, is hope. No one can (or should) take this away. Hope can give someone the strength to fight, to live, to perservere. It is sometimes all a person has to hold onto. When we as professionals believe in a person and in hope, and their hope, we are telling them they are worthy, their life has meaning, they can succeed, in whatever form that takes, and that there can be something beyond (err better, different) than what their current experience is. We are also saying we find them important and want to support them in the recovery process and in obtaining the goal of recovery.
DeleteI just watched Jim Jeffries' most recent stand-up comedy special on Netflix and towards the end he talks about his intense and everlasting battle with depression. He flippantly suggests that the presence of hope actually makes things worse. He's joking of course. Except, he really isn't. I believe that psychiatric disability and mental illness may have two different etiologies and can be defined largely in their duration, intensity, and impacts on our ability to live. A psychiatric disability perhaps should be viewed like other permanent disability in that we don't suggest to a double amputee that he should hope that both of his/her legs will grow back. But we could suggest that a range of goals and hobbies and jobs are still achievable and should be sought after with or without adaptation.
DeleteI think the prevailing etiological theories for mental illness in psychology today are biological and environmental. Biological factors such as genetics, chemical imbalances, infections and brain damage, and prenatal issues have the potential to lead to mental illness depending on each individual who has any or a combination of these factors. The environmental factors that can lead to mental illness are broad, but include adverse childhood experiences, traumatic experiences, abuse, chronic stressors, substance use, and family/relationship problems. Mental illness can also be caused by both biological and environmental factors working together. If a person already has a genetic risk factor for mental illness, an environmental factor being added can be the cause of symptoms becoming noticeable or worsening.
ReplyDeleteThese theories lead us to do a variety of things to and with people who have a mental illness. In many cases, people are prescribed medications to combat their symptoms. However, there are often side effects that go along with taking these medications that can negatively affect the individual’s life just as badly or worse than their mental illness did. I think in a lot of cases, clinicians can be too quick to prescribe medications based on symptoms alone, rather than hearing the whole context of the symptoms in the patient’s life. This is not at all to say that medications don’t help many individuals with their mental illnesses, just that clinicians need to be mindful when they are prescribing them. These theories also lead us to view mental illness as an individual problem that the individual needs to figure out for themselves. This mindset leads to limited resources, funding, and support for these individuals who desperately need it. I think that the stigmas surrounding mental illness are also to blame for the limited supports and resources. It’s hard to garner support for programs and policies when people don’t understand mental illnesses and have preconceived notions of what having a “mental illness” means.
Noelani, I think you have explained the causes of mental illness very well here. I also like that you brought up the issue of side effects. I think that is a huge issue because people with mental illness already have a life expectancy of an average of 10 years less than the not mentally ill counterpart (National Institute of Mental Health, 2015). So it is alarming that the standard treatment for these individuals involves adding more health risks.
Deletehttps://www.nimh.nih.gov/about/directors/thomas-insel/blog/2015/mortality-and-mental-disorders.shtml
Noelani, excellent point about medications, I feel this is such a tricky matter to discuss and follow through with. As you mentioned side effects, this is a real concern and can cause symptoms to worsen or even develop new symptoms. I totally agree with often times medication is the first option many clinicians jump to but for the consumer it can be daunting and I have seen clients struggle during med management appointments or with providers to get their concerns and feelings across to them.
DeleteIn the past there has been a variety of etiological theories, some not so great, but today I feel that some of the most prevailing is environmental and biological. Many models take an individual’s environment such as home life, work, habits, etc into consideration, along with their biological background such as medical history and family history of mental health. In many cases this leads the provider to focus on wanting to assist the client in changing the current environment of the client, it gives them a focus to work on. This can sometimes feel like the provider is trying to fill some void for themselves than the actual client. As with the biological factors, I suppose it is important to know and understand what mental health related illnesses runs in one family but once again the focus shifts, from the client and their symptoms and concerns to what their family members symptoms are and what their mental illness looks like. Etiological theories serve a purpose but can also somehow manage to shift the focus from the client.
ReplyDeleteVessa, you bring up an important concept here when you mention the provider wanting to assist the client in changing their current environment.
DeleteThere is the line of thinking that one must be removed from their current environment in order to recover. The textbook describes it as a popular model which Dorthea Dix supported, where "people with serious mental illness needed to be extracted from their everyday and interpersonal context in order to recover" (pg 10). This perspective is seen in AA they teach stop going to bars and in the Rat Park experiments where we see how powerful a healthy environment can be. The group home alternative to institutionalization was also popular, but then the thinking changed to removing them from a problem will do no good if they will be returning back to the environment with the same problem. I think it's interesting that Meyer calls illness "problem in living." I think that is a super accurate description. It seems to me all mental illness occurs due to an inability to cope. However, I think both treatments are valid and useful - that is, removing someone from their stressrs for respite before returning to face them, as well as supporting the patient as they navigate their everyday stressors.
What us Recovery
ReplyDeleteIf we had a round table for all of us presently in HCE 619 this topic of discussion could go on for hours. Recovery or the recovery process can differ from client to another. Recovery is looking at ones resiliency and acting upon all the positivity that the client has. Take that positivity and show the client how they can improve their skill sets or manage their mental health condition through medication management,. During the recovery process finding that right balance for a client is key for forward progress. In addition getting the client comfortable using coping skills that will work for them will determine how soon a client will be able to carry out individual tasks such as gainful employment and independent living. This should not be a rushed a event. If a client senses during the recovery process that something is being sped up he/she might clam up which can lead to counter productive efforts. Recovery is essential to assist or aide in giving back confidence to a client.
Gary - I like what you've said here because I really appreciate that a person's recovery is not linear. I think the medical community gets very frustrated with the "revolving door" of "repeat customers," but I think if we understood recovery in a different perspective these patients would be met with more compassion than frustration at each return visit. That being said, the argument about not wanting patients to get "too comfortable" while inpatient in order to discourage future return visits is real. I like when outpatient providers work together as a team to form a plan individualized for that patient to try and curb return visits. For some (most) patients they simply don't have as much social support as they are wanting or perhaps even aware that they want. I think transportation to clubhouses and day treatment & community centers, etc. is helpful, but still more is needed, including during weekend and evening hours.
DeleteGary
DeleteRecovery is a process and it is a unique process for each person. It is helpng to rebuild a person's life in a positive way. It includes rebuilding social supports and confidence.
Nancy
Jess, great points having social supports does amplify you are not alone and can render big help when a client has any questions or when they simply begin to spiral down emotionally. I agree with you on the revolving door perspective. All work with a client must try to move forward and not be counter productive. Just as Dr. Deegan stated on her video her advocates did not leave her alone they stayed by her side through small steps, big steps and prescription management. Clients tend to make more strides when they are in a caring environment. Fantastic points on your post.
DeleteNancy, correct and also to establish a strong bond while learning how to use coping skills to lessen any educational gaps that may exist with the client. Essentially recovery is a building period that a client can learn a lot about themselves and accomplish tasks that they thought they were not capable of doing. Absolutely, recovery does play a big part in building ones confidence.
DeleteGary,
DeleteBuilding a sense of self-efficacy and confidence can help clients build the skills they need to enjoy a full and meaningful life.
Nancy
Nancy self efficacy and coping strategies are of the same theoretic framework they both serve of measures of predictors of how well a person is capable of learning and processing information independently to make their own choices to live a life not dependent on others.
DeleteThere are currently two theories of recovery which are: the empowerment vision and the rehabilitation view. The rehabilitation view believes that once an individual has a mental illness, they will always have it. Therefore, the individual may have recovered at that point, but the thought is that it will always be there in the background. The empowerment vision believes that the individual can fully recover with the proper resources. Mainly, it is the labeling and discrimination of the mental illness. The society labels them because they are different from the “norms” of society.
ReplyDeleteAs an associate counselor it is important to meet the client at where they are at. Everyone goes through a process of grieving or accepting of their disabilities. For instance, I work with the visually impaired and I have two consumers with the same acuity, but each individual’s level of independence is completely different. It is recognizing and accepting with where they are at.
By the way, this is Taya Tarr.
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