Jul 26, 2012

Stop recovering. Start flourishing.

I propose that we ditch the word “recovery” as a goal for people with mental illness. We can do better. Let’s aim to “flourish” instead.

Recovery was a revolutionary concept when it emerged in the writings of mental illness activists some 30 to 40 years ago. Recovery meant that people could make progress, and get better, and control their own lives. This was a real affront to traditional psychiatric thinking. It challenged the coercive forces of institutional life. Nobody put patients in charge of asylums. Nobody put patients in charge of their care. Nobody gave patients a choice.

Check your history. In the harsh pre-World War II asylum days, one in five hospital residents had tertiary syphilis. This population had terrible, often horrific outcomes. Their illness was connected to shameful sexual behavior. Asylums also cared for people with tuberculosis affecting the brain and people with other dementias. People with schizophrenia and other modern-day “mental illnesses” had comparatively better outcomes, but only if they were supported in their daily institutional lives. When institutions lost resources, coercive practices dominated daily life, and people suffered.

After World War II, medications emerged. Not only penicillin for patients with syphilis (which quickly reduced asylum populations) but true psychiatric drugs like lithium, antidepressants, and antipsychotics.  These were difficult medications that were pretty much improvised. Modern testing protocols were not in widespread use. There were few ethical concerns. This was the 1950s, a time when the first polio vaccine was being field tested in state institutions for crippled children, with zero regard for informed consent.

Still, the new drugs seemed to have positive effects on people. This changed the prevailing notion of the life course of people with mental illness. People could do better, and even survive in the world with some support. And simply walking out of an asylum implied some degree of recovery. It was an achievement.

People who emerged from institutions began hanging out together and reflecting on their experiences. They were confronting a new way of life that was not dominated by institutional confinement or coercion. Groups of former patients coalesced around creating a better life for themselves. One spectacular thing that emerged was that people refused to relate to each other only as broken. They accommodated mood swings and symptoms short of dangerousness.

And as people moved forward, they felt entitled to a different, upgraded identity.

People invent new labels for themselves all the time. When people work together, they use words that incorporate characteristics of shared culture. So, in the 1960s through 1980s, new terms emerged. Psychiatric survivor. Mental health consumer. The authors’ writings exemplify what they had in common, which was their reaction to sickness, difficult symptoms, labeling, conflict with family, the experience of coercion, the desire for self-direction, and the process of getting better. What emerged was the concept we know today as recovery.

But now it is several decades later. Recovery is a mature concept. But I believe recovery is quickly losing its appeal, because there’s just not enough hope and power in it.

For one thing, most people with mental illness no longer share a coercive institutional experience as a frame of reference. Most diagnosed people never get admitted to a psychiatric hospital. We have always been outpatients if we have ever gotten treatment at all. We get pills, like we do for anything else. We might get a stern look from a person in an office building if we quit taking medication, but that is nothing compared to a scary syringe-wielding nurse and a locked door at the end of the hall.

There is still some coercion, of course, especially for people who have symptoms that are difficult to manage or people who have some safety risk. I also hear of case managers who hijack recovery, blaming people for not adhering to their recovery plan. People get scolded for not writing in their journal or the way they are filling out their notebooks. Coercion again. (Criminalization is a topic for another day.)

What I find inadequate about the word recovery is that no matter how I approach it, the word still implies a connection to a stigmatized problem. Recovery drags the medical model behind it, but does not even guarantee symptom relief. Thinking of recovery as mere process implies the medical system is not done with you yet, and keeps the medical issue at the center of your life. At some vague level, I think the term has now become a standard that resonates with clinicians. It promotes system-compatible actions. Perhaps this connection to enforceable standards is what made SAMHSA finally issue an official definition of recovery. Now at least there is something to use to design compliance protocols around.

Do people really want to remain connected to sickness? Should the connection to sickness be the most important thing in a person’s life, the thing that defines a person?

I don’t think so. Speaking as a person who has had a comeback from a tough experience of illness, I’ll do what I need to do to stay healthy, and that may require pursuing a focused process of recovery, taking my medicine, seeing my doctor or whatever. But the pursuit of recovery is not my goal.

Recovery is a means to an end. It is something I have had, a task I have more or less completed.

Don’t get me wrong. I am grateful for my recovery.

But what I really want to do is flourish.

Flourishing means expressing my strengths and capacities, doing well, living a full life, having my family, participating in community life, succeeding in my work. I want to be effective.

Sure, I know I have my limits. I have wobbly moods and my own collection of medical issues. I have my faults and hang-ups. I do take pills as directed, but I am bad at getting exercise. I am comparatively non-productive. I piss people off. I watch too much TV. I am bad at maintaining social connections. I can’t remember my students' names. I’m not disciplined enough. I know I am a sinner. I can’t do everything I want to.

But so what. I am flourishing.

In my crazy,  partially compliant, well-meaning, left-wing, half-assed way, I am working on goals that are not connected to my illness. I have an identity and a future not determined by my diagnosis or whatever might get published in the DSM-5.

The people who designed the term recovery did a wonderful job mapping the way to journey out of madness. Let’s complete that journey. Let’s flourish.

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