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help_1.docxBy: Alan Lunt
Acknowledgement:
Introduction
Though references to the “recovery model” are increasingly emerging in the literature, and the model itself is evolving, it did not begin with a single definitive explanation, theory, or rigorous formulation that once and forever made explicit what the model is or is not, and how it works. It is arguable that even today, the recovery model does not have the clarity, agreement, or influence that the medical model has commanded within the treatment of mental illnesses.
This article is aimed at explaining the impact, as the author sees it, of the recovery model for the clinician who daily interacts with people with severe and persistent mental illnesses. Though the implications delineated in this paper are not exhaustive, as others may find additional results from this truly broad and encompassing model, they may prove useful in adapting one's practice to principles already outlined elsewhere. The focus of this paper is to outline clinical practice, which allows self-determination for the client in a process that contrasts with the psychiatric process of applying the medical model. For a reading on the conceptual basis or principles of the recovery model, the author suggests Anthony (1993), Jacobson and Greenley (2001), Adams and Partee (1998), or Lunt (2002).
The Role of Choice in Assertive Treatment
In the process of assertively advocating for services with clients often described as “treatment resistant,” or with clients who exhibit “limited insight,” as we do in case management, it can become very difficult to avoid adopting the attitude that 1) we professionals know more than the client and 2) that our (professionals') spiritual solutions are superior to the client's own spirituality. The former is material superiority and the latter is spiritual superiority. From this dual superiority it becomes easy to conclude that the client's thought, feeling and action is baseless, “fatally” flawed, just plain inferior, or even mistaken.
Having or perceiving material and spiritual superiority, one runs the risk of treating adults as infants, of relating to clients as parents relate to children. We must acknowledge that our clients are adults capable of independent judgement. Further, we must encourage independence of judgement, even when the result is that clients disagree with us.
Though the scenario of dual superiority seems to require one to ignore the client's wishes and to develop a plan of action quite independent of the client's wishes, such action not only treats adults as children, but also is not in accord with client-centered treatment. As Mark Twain has said, “The proper office of a friend is to side with you when you are in the wrong. Nearly everybody will side with you when you are in the right.” The role of assertive treatment is not to impose control over circumstances of error and chaos, but rather to offer companionship that highlights options while respecting the client's right to choose. The notion is not to impose professional will, but to offer a resource.
The purpose of accompanying the client along the journey of life is not simply to be present should the client become imminently harmful to self or others, but rather to shine a light on options and choices along the way of the client's chosen path. Note that “options” is plural, suggesting at least two alternatives to the one the client tends to lean toward. The idea is to avoid the dilemma of two choices, one the client's and another the professional's.
For the client whose perceptions are clouded by the presence of thought and/or mood disorder, the professional's role remains the same. Imposing professional will on clients only builds resentments, even if the result is simply to overrule clouded judgement. If the message a client receives is that their judgement is hopelessly flawed and their will is essentially disordered, then the effect of such message can only be disempowerment. Such disem-powerment may be avoided as people whose thinking is distorted in one area often retain rational potential in other areas.
The dominant role of community integration is to get beyond seeing clients as disordered individuals and seeing them instead as people with significant choices. The process gets beyond procedures dictated by disorders, and gets to uncovering alternatives and making choices. Beyond conceiving of choices, the goal of interaction extends to enabling the client to develop a vision of the future, a dream to pursue. Consumers have preferences; people have dreams. A dream involves a system of beliefs that supports action — action that extends into the future.
When it comes to dreams, among the ones Americans are most familiar with is one forever tied with the memory of the man who championed it. It is a dream that has changed the face of America forever, in a positive way. Of course, I refer to the dream of Martin Luther King, Jr.
The nature of the best dreams, as with King's, is that they extend to others more than oneself. Thus King dreamed that “my four little children will one day live in a nation where they will not be judged by the color of their skin but by the content of their character.” By implication, King was speaking of something for the next generation that our children will live with blessings that were denied to our own generation. This is the age-old American Dream. The lesson here is that, even for people with mental illnesses, dreams should be about what we can offer the world, not just what we ourselves might gain. Dreams which focus upon what we do for ourselves have their place, but for example, vocational dreams are of what we may accomplish for others; about what we may offer the world.
Thus, the best of dreams are about actions that benefit more than ourselves; they are about how we may benefit others. This does not exclude dreams that benefit us personally. Still, as some say in AA, you must “have it” in order to “give it away.” Or you must be selfish in order to be unselfish. Here, AA's are talking about sobriety and serenity. You must gain sobriety or serenity for yourself before you can give others or help others gain sobriety or serenity. The same expressions may generalize to other virtues.
Getting back to the nature of dreams, a dream rests on a system of beliefs, and translates those beliefs into an agenda of actions. Thus, King believed that the Declaration of Independence should be applied to all men equally, regardless of color. Further, he believed that extending those rights to people of color does not lessen the rights or opportunities granted to anyone; rather, it enhances the vitality of the nation. The act of discrimination, King believed, degrades those who perpetrate it no less than those toward whom the act is aimed. There are far more beliefs operating here, such as a belief in nonviolent change in the face of violent opposition. Clearly, King's dream rests on a complicated system of beliefs.
These observations on the nature of preferences and dreams, which we employ in order to control our consequences, are the dynamics of a recovery model. In order for the professional helper to optimally impact the recovery of his/her clients, he/she must appreciate the dynamics of the recovery model outlined here. The temptation for the helper is to become dominant and controlling, forcing matters along. It is frustrating to see good advice ignored and serious mistakes made. But such behavior fails to identify with the client, fails to understand the shoes the client wears.
To restate the implications, recovery is a process and decision-making is a process. It is the thesis of this author that for the recovery process to work productively, these two processes must become one and the same, putting the individual client in control of their consequences. In order to have a personally chosen purpose in life, and by implication in recovery, one must have decision-making power in one's own affairs. It is by making decisions that one learns to control one's outcomes, one's consequences. One's consequences determine one's outcomes. Only through control of one's outcomes can one become whom one wishes, can one effect whom one is: one's identity, one's self-definition. Thus, by the following definition of recovery from catastrophic mental illness, self-redefinition is the central task of recovery:
The key concept to recognize is that mental illness is an affliction that often, if not always, results in a catastrophic loss of self. This means that one's previous sense of meaning and purpose has been made pointless, no longer viable, or impossible to continue to pursue. Whether or not one realizes it, one has been set on a journey; the point of which is to define new meaning and purpose in one's life. This quest is the single unifying aspect to recovery. (Lunt, 2000, p. 44)
The argument that must be made here is that our consequences shape who and what we are. In planning our course of action aimed at controlling our consequences, we initiate the process of the redefinition of the self. If others control our consequences, then others shape who and what we are.
Of course, it is not possible to control all the variables that impact on our consequences. But it is possible to maximize our control over such variables. Thus, through the exchange of experience, strength and hope, it is possible to enlist the assistance of others in controlling these variables in accord with our own agenda.
Ambiguity and Choice
As professionals, we often are confronted with situations that are ambiguous, or at least, that are portrayed or perceived as ambiguous by our clients. Our options in responding to these situations, however, are often “black and white.” Further, these black and white options that we confront clients with are designed to impel clients to make a clear choice: Do they stand with the “black” or do they stand with the “white?” I speak not in terms of race or color, but simply of “option A” and “option B.” Such choices amid ambiguity create controversy, but as Martin Luther King, Jr. once said, “The ultimate measure of a man is not where he stands in moments of comfort and convenience, but where he stands at times of challenge and controversy.” We mean to challenge our clients to make rational and concrete choices amid ambiguity. Some clients, when so confronted, will make clear choices while others will retreat saying, “You choose for me!” Still others will opt for the third choice, to remain amid the ambiguity.
It is precisely in this manner that theories and truths are discovered amid circumstance and facts, which are often ambiguous or even contradictory. Truth and theory go beyond what fact and circumstance will strictly support, as they require hope and faith in some higher “reality.” This higher reality is often only intuitively sensed rather than unquestionably stated.
In constructing dreams and visions, one is commonly guided by values and ideals. By aiming for and achieving these dreams one acts to live or experience one's values and ideals rather
than simply believing them. Thus, the self-actualizing individual goes beyond dreaming and believing to experiencing.
Morality of Choice
In selecting what choices to offer and in advocating for one choice or another among the options, both parties make ethical decisions: the client and the professional. For in choosing from a range of options, or in envisioning which options to offer, one's values come into play. These are, on the one hand, the values of the client; and on the other hand, the values of the professional.
There are all sorts of reasons and motivations involved in how and why choices are made. There is, for example, the influence of delusional thinking or extremes of emotion (high or low) on decision-making. But more to the point, there is an influence of different value systems on decision-making.
It is important to recognize that differing values on behalf of the client in comparison to professionals will frequently result in “noncompliance.” This is the term we use when the client's choices differ from the choices advocated by the professional. Though the term is most frequently applied to issues of medication, the term may have a broader applicability.
The danger here is expressed in terms of consumer independence, particularly in the phrase employed within the consumer movement, “Recovery begins with noncompliance.” The danger is one of learned helplessness (Deegan, 1992), as the client learns to let the professionals make the choices. Professionals must leave room for the client to disagree on important issues if learned helplessness is to be avoided. To illuminate this principle, Evangelista (1999) has written, “A compliant person, as this analysis implies, is one who has lost his or her ability to do or act.” “Dependence is expected to occur as a result of compliance” (p. 8). Evangelista here refers to medication compliance in general, not simply within psychiatric rehabilitation. But it is quite simple to see that dependence occurs whenever clients let professionals make all the important decisions.
Learning requires making mistakes, requires trial and error. Error is part of the learning process, not an evil to be avoided at all costs. Further, insulating clients from the negative consequences of choices, unless it can be clearly demonstrated that the client has a distorted perception of the nature of the choices, also leads to learned helplessness. Thus the following definition of recovery hinges on control over one's consequences (Lunt, 1999):
Recovery means learning to make decisions over matters materially, conceptually, and spiritually affecting one's consequences, in the face of risk and uncertainty. That is what life is about.
Morality and Social Service
The choices that professionals make necessarily and deliberately confront a client with a system of values. For one, we subscribe to a code of ethics, which represents a value system. Further, we organize our practice around the principles of psychiatric rehabilitation, which represents values also. We counsel our clients not only according to the lessons of our education, but also from our life experience. If we bring wisdom to our experiences with clients, then we also bring values. As Hasenfeld (2000) has written, “Work on people who are themselves imbued with values cannot be value neutral.” He goes on to say, “fundamental to [our] work are such decisions about the allocation of resources to clients. These include money, time, and expertise. Inevitably, the demand for these resources outstrips their supply, resulting in a system of rationing….” Hasenfeld is saying that such rationing is based upon a moral judgement of the deservedness of clients. The values imposed may be those of the caseworker, the treatment team, the agency, or the funding source. The mere suggestion of adopting one or more alternatives while neglecting another represents a value judgement on some level.
What makes choosing so difficult is not simply uncertainty, but risk and adversity. The presence of a severe and persistent mental illness represents a considerable level of adversity above that encountered by the individual without a disability. Adversity, however, is an ever-present fact of life for all, with or without a disability. To quote a few words of wisdom:
Only dead fish swim with the stream.
It is always possible to sail against the wind.
Adversity is not something to which to succumb, but of which to overcome.
A ship in port is safe, but that's not where ships are meant to be.
Conclusions
We would do well, in considering our recommendations to clients, to recall the words of Ralph Waldo Emerson: “The value of a principle is the number of things it will explain; and there is no good theory of disease which does not at once suggest a cure.” Our DSM defines numerous diseases, but the definitions both fall short of a theory, and fail to suggest a cure. The solution to this dilemma falls along the line described by Albert Einstein (who himself had a son with a mental illness): “All that is valuable in human society depends upon the opportunity for development accorded the individual.” Thus, the same principle that predicts that totalitarian states will fail to develop optimally also predicts that the future for people with mental illnesses depends upon their ability to seize tangible personal opportunities amid adversity. The role of the service provider is not to make rational choices for the client, but to offer support that can manage the risk and lessen the adversity.
Lunt, A. (2004). The implications for the clinician of adopting a recovery model
