Innovations in Mental Illness Recovery




Psychiatry_Psychology.jpgThe 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.

Motivational Interviewing

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?

Innovation

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

Rehabilitation

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.

  • Elli Davis

    Absolutely great and instructive article. There are so many people who don`t realize that they are suffering from a mental illness they just feel strange as they express when you ask. I think that the most important thing not to feel shame by explaining what bothers you.

  • George

    Profitable cognitive behavior techniques employed by psychotherapists (psychologists) in Greece in order to extend indefinitely the length of therapy (Taken from A. Beck and distorted in a Greek style).

    (renewed)

    1. Spotting the negative thought (cognitive error), for instance, examining if the therapy followed is a cognitive behavior therapy or a charlatan therapy. Writing it down. In case such a spotting of the negative thought is not producing any results, the therapist asks the patient to discuss about negative thoughts related to obesity, even if the patient is not oversized at all.

    2. Giving to the patient a page with a childish outline and drawings and explanation of the usual negative thoughts, which doesn?t make any sense at all, probably because the person who drafted it, was in a mental disarray. Discussing about the patients inability to understand what in the hell all these mean. The therapist is assuring the patient that 99% of his patient understand the meaning of the particular page and cooperating fully, writing down their negative thoughts. In addition the //Established Authority// uses them.

    3. The therapist is proposing the patient to start reading books (bibliotherapy). However the recommended books describe a cognitive therapy which is totally different from the followed one at this time. The patient is understanding that he has a lot of negative thoughts. He is writing them down. He is presenting them to the therapist. The therapist feels embarrashed. (“I told you that with a difficulty I extract one single negative thought from my patients and you already brought me so many!”). The therapist forgets what he told about 99% understand at once and cooperating fully with the therapist analyzing their negative thoughts.

    4. The therapist makes remarks to the patient about putting the negative thoughts in one column, while using other columns for the assumptions, intermediate core beliefs, reinforcing events, alternative suggestions, how he feels after his own suggestions. Spending a whole session on trying to explain to the patient the fact that the word “core” in core beliefs is translated into Greek with “nuclear”, “nuclear beliefs” and not core beliefs, as the ignorants believe. This is supported by two arguments. First it is translated in such a way in the Eginiteion Psychiatric Hospital, where disagreement is not favored (May be,as part of the decentralization program, the Eginiteion Psychiatric Hospital assuming the task of keeping and elaborating the Greek Language, replacing the Academy of Athens). The second is that it is translated in such a way in the Divry?s English-Greek dictionary, written by George Konstantopoulos from the village of Divry in the mountain Parnassos.

    5. Without analyzing and elaborating the produced and stored negative thoughts, the therapist asks the patient to look for some more. The patient?s list is continually rejected by the therapist with the recommendation to make the columns more and more stylish.

    6. Self disclosures of the therapist, so that the patient can grasp them and write them down as an exercise. He has to challenge his own thoughts, and write down how he feels about doing all the work himself. The therapist asks the patient no to take any more pictures with his digital camera because she has put cream in her face and is glistening.

    7. At the request of the patient, discussion is being made about Judith Beck and her book “Cognitive Therapy, Basics and Beyond”, relating to the need for structuring the sessions, need for extracting some conclusions at the end of the session, bridging with the previous session, need for resuming at the end, realizing what the patient understood and what he didn?t, about the process followed in order to arrive to a negative thought, intermediate belief, core belief etc. After having completed approximately 65 hours of sessions the patient realized from the words of his therapist that all these are not absolute. (“Yes, there are some colleagues of mine that follow this strict procedure. However it is written (where?) the patient is tired out of this, and in fact all my patients have come begging me, imploring me to talk freely, because they can?t sand the structuring of the session. An as I am interested in their welfare, I don?t structure my sessions”). A therapist that respects himself never reads the following

    8. Discussing about any other therapies that the patient is aware of and related to the cognitive and behavior therapy model, which might give the patient ideas that he is being cheated by his therapist.

    9. Discovering that in the dossier kept by the therapist there are numerous negative thoughts given by the patient which have not been elaborated for months. The therapist can disarm the patient by saying “the structure and the time used during the therapy is your responsibility. You shouldn?t produce so many ideas during the session, Ha, ha ha, look how I smile like a “Spontaneous Child”!”

    10. The patient could eventually contact thought email another cognitive behavior therapist, an ex cop, and receive the following answer: “In the cognitive behavior therapy there is always a structure, professionalism, and a clear timetable. The word “clear timetable” sounds like a bell in the patient?s mind. He contacts his therapist.

    11. The therapist could eventually send an SMS message to the patient asking him not to ask for a “clear timetable”, because he has been diagnosed as “borderline” (the diagnosis is sent though SMS) and there is a lot, a lot of work be done. The differences between psychologists/therapists from psychiatrists/ therapists is that the psychologist have a low self esteem and a disguised mental handicap. In Greece the majority of the mental patients are women. The majority of psychologists/therapists are also women. That means that a mentally handicapped woman would make an option, either continue to be a mental patient for the rest of her life, or become a psychotherapist. With psychiatrists we see something different. They have clinical experience in clinics and hospitals, while the psychologists have little or nothing. The //Established Authority// offers them supervised sessions that end in a few months with the therapist saying “We have now concluded our therapy, Good-by!”)

    12. The therapist, without following the method described by Judith Beck, for moving from negative thoughts, to intermediate beliefs and core beliefs, could eventually throw to the patient?s face whatever “nuclear” beliefs (what Americans call “core beliefs”) the patient should have (yes! Should have!) by virtue of the diagnosis of borderline personality disorder being already made. That means that in Greece first the therapist makes the diagnosis –usually at the bank when waiting for a bank loan- and afterwards looks for the “nuclear” beliefs that the patient was supposed to have. The diagnosis should be what the therapist has presented in her //Established Authority// as a difficult case, with imaginary behavior of her patients and has received with a general applause from the participants in the meeting. The patient is not entitled to disagree. If he objects the “nuclear” belief “the world is hostile and dangerous” he has to live with it. The therapist is never mistaken, especially if the patient?s objection can make the therapist loose his diploma from the //Established Authority//.

    13. The patient could contact by email another therapist. She might answer “you should go back to your therapist and discuss again the issue with him. You shouldn?t break the relationship”. If you go to another one, the first thing to discuss in the disagreement with your previous therapist.

    14. The patient could eventually visit another therapist (male) who is the boyfriend of the previous female therapist and one of the supervisors of the //Established Authority//. The established practice requires every cognitive therapist to contact every colleague of his or hers to find out whether the patient has escaped from them and seeks therapy elsewhere. When a patient escapes therapy, he is treated in a way resembling neutrality of foreign ships during a war blockade. They give description not only of his name, but also of his face, his height, weight, hair etc, so that they exclude that the escapee uses a false identity. The supervisor, after collecting the fees of two visits (2X70=140 Euros, or $ 100) could say to the patient:
    THERAPIST (male): I can?t accept you for therapy because I shall be treating your wife in the same time.
    PATIENT: No, my wife has told you that she doesn?t like to initiate therapy with you.
    THERAPIST: But she might change her mind!
    PATIENT: So you don?t accept me?
    THERAPIST: You should go back to your previous therapist.
    The therapist can disguise herself when rejects an escaped patient by saying “I noticed that you eat meat more than twice a week. I know a therapist that is suited for you. There is no point of discussing other problems. I don?t want to hear anymore. Go!” (Something similar happened to me!)

    15. The reason for such a procedure followed is obvious: Solidarity is the key for the survival of the incompetent professionals. A therapist should never accept anybody who has undervalued the colleague?s opinion.

    16. The therapist can accept the patient?s proposal for a cognitive behavior therapy through email. In the cost of one hour e-mail session the patient is charged for 40 minutes that are required for receiving the message and 40 more for sending the answer, because the therapist?s laptop is very slow and will be replaced later in May. The messages include material totally depleted of cognitive behavior material , for instance “ I should teach you how to remember names. For Mike Goof, you should remember Mikey and Gooffy.”

    17. Judith Beck says in her book Cognitive therapy, Basics and beyond that “when there is a negative thought that is true –related to a fact –the therapist, instead of challenging the thought, should concentrate on how to help the patient solve the problem”. This is very embarrassing for the therapist because he or she has learned in the //Established Authority// only a photocopied textbook of 90 pages that includes all the cognitive therapy and no-one has ever heard of Judith Beck in his life. The usual symptoms treated by the cognitive therapist is “Oh my God I can?t wake up at 7,00 in the morning”, “I can?t stop eating”, “My boyfriend the supervisor doesn?t like me” etc. They are unable to deal with real human problems.

    18. The therapist has the ultimate argument that present to the patient after completing about 70 hours of therapy: Since you are not pleased by my approach (nice word!) you should go to another therapist. Of course at the same time the therapist undermines all attempts of the escaped patient to be admitted to therapy by another therapist, as described above. If the patient asks the therapist for a recommendation the therapist might claim that she came to Greece after a lengthy stay in Madagascar for studies and doesn?t know any other therapist

    19. Therapists should never feel bad when they are dealing with patient?s negative thoughts in such a way. By using the above procedure the patient shall forget the initial cause that brought him to therapy (it could be a sort of homeopathy treatment). When the patient ceases to feel indignant of his therapist, that means he is close to the end of therapy.

    20. Generally speaking, the cognitive behavior therapist must be Spontaneous Child, free from any feeling of guilt, loved by his friends and colleagues, that would examine everything with a smile and would never keep bad thought in his/her mind.

Robert A. Yourell, MA

Robert A. Yourell, MA, has extensive experience in the mental health and social services dating back to 1975. His training includes Ericksonian communication and hypnosis with John Grinder, Eye Movement Desensitization and Reprocessing with Francine Shapiro, PhD, Body Integrative Psychotherapy with Jack Rosenberg, PhD, and solution-focused psychotherapy. He provides free audio experiences on his site that include bilateral sound and Shimmering.
See All Posts By The Author

Do not miss out ever again. Subscribe to get our newsletter delivered to your inbox a few times a month.