Innovations in Mental Illness Recoveryby Robert A. Yourell, MA | February 3, 2008
The mental health field is like conjoined twins. Of course one is the evil twin, and the other is nice. But since they’re joined at the hip, life is a struggle. The mental health field has been painfully extracting its humane mission from old school authoritarian and medical thinking, along with a big dose of cruel moralism since ancient history.
Please allow me to offer some encouraging news; constructive innovations in the mental health field.
Dialectical Behavior Therapy
Consider the work of Marsha M. Linehan and her approach called Dialectical Behavior Therapy. This work, which has shown favorable outcomes in research, is best known for treating people with borderline personality disorder (BPD). She developed it initially for treating suicidal people. Research began in 1989.
BPD is confusing as a diagnostic term because, as with many diagnoses, it is based on early observations and theories. People with BPD have a difficult time “self soothing,” that is, staying objective and feeling okay with the world. They are easily upset by any kind of rejection, and may go out of their way to put you in a position in which you are really compelled to pay attention to them. One way is called “splitting” which Eric Berne referred to as a game of “Let’s You and Him Fight.” Splitting unifies you and them against someone else. It isn’t exactly intimacy, but it’s an approximation, at least. People with BPD can become very wrapped up in resentments, and may feel very justified in getting revenge in some way, perhaps in an emotional way, or worse.
People in the mental health field can be quite wary of people with BPD, unless they are well-trained with this challenge. Even then, people with BPD can be very difficult to work with. I suppose it is fear, and the tendency of some in the mental health field to victimize, demonize, or ignore people it does not understand, that has led to BPD being one of the last diagnoses to get much good clinical attention.
This makes dialectical behavior therapy (DBT) a really exciting breakthrough. It relies on “psychosocial education” using workbooks and classroom style instruction. This is a breakthrough, because a normal group treatment would involve a therapist doing group therapy and getting people to develop healthy relationships within the group. That would be expecting too much of people early in their treatment for BPD, though.
Now that DBT has more acceptance, the approach is being used with additional challenges.
Serious Mental Illness
This innovative mindset is also influencing services for people with chronic mental illnesses such as schizophrenia and bipolar disorder. A very exciting, innovative organization called Recovery Innovations has been quite prolific in developing its own workbooks and slide presentations for people with serious mental illnesses. Their WRAP manual for training people with mental illnesses is adapted from Mary Ellen Copeland’s Wellness Recovery Action Plan workbook. I have spoken with a few of their clients and a couple trainers and there is a positive feeling that is nothing like I’m used to sensing from people about other treatment venues, such as county mental health agencies. Fortunately, mental health systems are increasingly using this company’s services or otherwise being influenced by a recovery approach.
One of their concepts is to hire clients of the treatment agencies to provide training and other services as “peer support specialists.” Of course, the clients must be able to fulfill the role. These peer support specialists refer to the agencies’ clients as people (or some other phrase that does not create a professional/non-professional differentiation, since they are peers). Their “key pathways,” or core values, are hope, choice, empowerment, recovery environment, and meaning & purpose. Rather than being in babysitter or counselor roles, they roll up their sleeves and focus on key areas that are most likely to make a difference. The discussions they have with their people are very solution-focused and empowering. The training provides very concrete and systematic ways to help the specialists have this kind of discussion.
In order to avoid creating unnecessary resistance, and in order to help build empowerment, the program is influenced by motivational interviewing, which was originally developed for substance abuse treatment. Every counselor should incorporate this approach.
Cognitive Impairment and Skill Loss
They deal with what I consider to be the current biggest secret in mental health–cognitive impairments and related skill loss. They will take clients through activities that build their independence by gaining or reclaiming the skills they need, such as banking or social interaction, to be independent. Their positive approach has, according to their statistics, reduced violence dramatically in their facilities. The founder, Eugene Johnson, says that the issue of violence was one of the things that got him thinking more deeply about his work in mental health. He felt that much of the “acting out” and violence was a reaction to the clinical environment and approach, rather than something inside the client that needed to be controlled.
But perhaps the greatest breakthrough of all is their first “pathway” or core value of “hope.” The solution-focused approach is based on the belief that their clients can be included in and contribute to society, and that the goal is to reach their potential for this. Their mental illness is not their identity. Aiding their people in developing self advocacy skills and overcoming stigma are critical here. Research has shown a serious risk of depression in people who become honest with themselves about having a mental illness. But with an approach like this, would that hold true?
One of my first blogs deplored how little the word “innovation” was used with psychotherapy compared to engineering as shown by Google searches. It was hardly scientific, but the point was to call for people in the mental health field (who aren’t already doing it) to transcend their preconceptions and traditional ways of doing things. I was tickled to come across this company with the word “innovation” in its name.
Reading and Resources
What is psychiatric rehabilitation? by Tom Craig
Prof. Til Wykes, Royal College of Psychiatrists. This podcast focuses on “Cognitive remediation therapy in schizophrenia. Randomised controlled trial” from the May 2007 issue of the British Journal of Psychiatry.
Til Wykes, Clare Reeder, Sabine Landau, Brian Everitt, Martin Knapp, Anita Patel, Renee Romeo. Cognitive remediation therapy in schizophrenia. Randomised controlled trial. The British Journal of Psychiatry. 2007(190):421-427.
Glenn Roberts, Sarah Davenport, Frank Holloway, Theresa Tattan. Enabling Recovery: The Principles and Practice of Rehabilitation Psychiatry. The Gaskell Press. 2006.
Frank Holloway. The Forgotten Need for Rehabilitation in Contemporary Mental Health Services. A position statement from the Executive Committee of the Faculty of Rehabilitation and Social Psychiatry, Royal College of Psychiatrists. October 2005.
Implementing evidence-based supported employment, Dr Miles Rinaldi. This podcast focuses on ‘Implementing evidence-based supported employment’ from the July 2007 issue of the Psychiatric Bulletin.
Marsha M. Linehan. Dialectical Behavior Therapy in Clinical Practice: Applications across Disorders and Settings. The Guilford Press. 2007.
Skills-Based Intervention Resources
Marsha M. Linehan. Skills Training Manual for Treating Borderline Personality Disorder. The Guilford Press. 1993.
Marsha M. Linehan. Cognitive-Behavioral Treatment of Borderline Personality Disorder. The Guilford Press. 1993.
William R. Miller, Stephen Rollnick. Motivational Interviewing, Second Edition: Preparing People for Change. The Guilford Press. 2002.
Recovery Innovations (includes a video of President and founder explaining their approach).
Service Components (flash graphic showing their system).
Coaching Overview (PDF document with development history and principles of the coaching approach).
L Ashcraft, WA Anthony. Factoring in Structure. Behavioral Healthcare. 2006.
L Ashcraft, WA Anthony, M Zeeb. Transformation Can Happen Anywhere. Behavioral Healthcare. 2006.
Mental Context – A Delicate Subject
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