Mar 31, 2013

Recovery is a process, not a thing

Let’s get recovery right.

Recovery is a process, not a thing. A process (like learning), not a thing (like a diploma).

Recovery is experienced, like jumping in a pool is experienced, like driving a car is experienced, like washing your face is experienced, like hanging out with friends or praying is experienced. Recovery is the experience of  making decisions, learning from successes and mistakes, asserting control, making progress. Living meaningfully.

In the world of sobriety, recovery is doing what it takes to  avoid that next drink. In the world of mental health, recovery is coming to terms with the world, finding strengths,  figuring out what helps, confronting limitations, handling risks.

If recovery were a thing, clinical systems could be optimized to deliver it. People could buy it, hang it on their wall. Institutions could control it, install it in people, restrict access to it, audit its functioning, tinker with it, put it in a can. These days, we would see it branded, with a social media onslaught and offbeat commercials. 

But no one can deliver recovery.

If recovery were a thing, it might get written up into a technique. But as soon as an experience or process becomes a technique, people start quibbling about whether the technique adequately embodies the process, and about the wording of the instructions that go with it. Technique-users who go through the motions would have the experience of following instructions. Would technique-users find recovery? Maybe sometimes.

Mental health recovery as a concept (note: a concept is a thing) started as a revolution, a liberation movement from institutionalization. Institutionalization steals people’s decision-making capacity. It is inherently coercive. Inmates are controlled. That’s the whole point of living locked down,  observed 24/7, shackled,  restrained, the usual process through the 1960s, 1970s, some places even today.  Recovery showed up as the process of getting power back. The context of institutionalization may offer some historical context, but is now understood to be optional.

A person can experience recovery no matter what the starting point.

Recovery is people achieving success, the way that works for them.

Institutions have trouble understanding recovery because they are optimized to deliver things. Clinical things. Technical processes accumulate around those things. People test for consistency in delivery. Institutions have outcomes, logic models, levels of expertise, formality, rules, committees. People in the process of recovery may or may not have any of that.

An institution that is truly recovery-oriented is more like a hair salon than a hospital. Do we ask hair salons to report on the amount and quality of beauty they delivered in the course of the last month? Hair salons have licensed experts and techniques. They try to deliver positive experiences. Many of the objects and materials in hair salons are sharp or toxic, so there are rules people follow, and procedures that make the visit safe for the customer. Big deal. When customers show up, they follow the rules, and often they get what they want. Not just the haircut, but the experience of it, and even more important, the experience that follows. A compliment, a feeling of confidence, a second date, a job.

During Recovery Month, look for people experiencing the process of recovery. What do you see going on?  It's always a process, never a thing,

I learned this notion, that processes are not things, from Dominic Barter, in the course of a conference call this past week. 

Mar 25, 2013

How scientific is our mental health policy?

At some point we must confront what we really understand about the science of mental health.

I found an opportunity for a refresher in the “science” of social science in the form of Jim Manzi’s 2012 book Uncontrolled: The Surprising Payoff of Trial-and-Error for Business, Politics and Society.

Manzi has made a pile of money doing statistical research for corporate America. His book talks about the scientific method and how it is used for business, economic and policy decisions. Manzi’s a right-winger whose policy ideas I mostly don’t agree with, but I do agree with his take on the predictive value of most social science research.

Manzi finds most of the research available to social scientists today inherently limited. People get as far as pattern-finding, which is not far enough to count as science. Within systems of “high causal density,” (the term Manzi uses to describe complex systems) the best we can do is apply a nonexperimental paradigm and make declarations about what theories a pattern that we find might support.

This is not enough to be predictive. Too many factors lurk within the data. As Manzi puts it: “Nonexperimental social science currently is not capable of making useful, reliable, and nonobvious predictions for the effects of proposed policy interventions.” Social scientists create models, but Manzi reminds us repeatedly that “the model is never the system.”

The best model we have for clinical work is the Randomized Field Trial, the technique used for evaluating whether medications should reach the market. Manzi notes that most of these studies are conducted over too short a term to be predictive of their overall benefit to people with chronic conditions. The appropriate measurement period for medication used to treat chronic conditions should be the lifetimes of all patients and all controls, and should measure all significant health indicators. In other words, we should aim to measure “holistic” wellness.

Even when an experiment finds a causal connection, we can’t always apply the results to new situations. To get a result that’s reasonably predictive in business settings, Manzi tests for whether causal connections change from neighborhood to neighborhood, from culture to culture, and over time. He runs hundreds of tests. He uses experts to identify new areas for additional testing, then he runs hundreds more tests.

Manzi’s bottom line: For reasonably useful predictive testing in a corporate environment it takes three key components: (1) senior political sponsorship; (2) an independent testing function led by an articulate, politically savvy and analytically inclined leader; and (3) a repeatable process that makes experimentation a part of how the organization makes decisions.

None of these three components have ever been present with respect to mental health and related public policy.

Mar 21, 2013

Lessons from my Social Security caseload

Madness and I have been hanging out together a long time. Close to forty years now.

I met my first certifiably insane person in the late 1970s. After graduating from American University’s School of International Service, where I focused on political economics, cultural issues and bureaucratic process, I passed the Civil Service exam and found a job with the Social Security Administration. I worked on retirement, disability and SSI claims, and interviewed about a thousand people every year for eight years. One of my duties involved interviewing people being discharged from the former Longview State Hospital in Cincinnati.

Our staff paid an annual Christmas visit to the hospital. One year we hosted a small party on an inpatient ward for about twenty long-term residents, older adults with severe tardive dyskinesia (uncontrolled mouth and tongue movements). Four or five of the residents, seated in creaking old rocking chairs, advanced towards a young secretary as they rocked back and forth. When my co-worker started freaking out, the residents laughed like children caught by teacher in the middle of a grade school prank. We handed them glasses of punch.

One gentleman I interviewed in the office was being discharged after more than four decades in the hospital. He seemed kindly but a little disconnected, offering a small Southern town address when I searched for census records to establish his age. I later learned he was a forensic case, a child murderer sentenced to the institution decades earlier.

I also remember a young disabled Vietnam vet who wanted to re-establish contact with his estranged family. He returned to the office to thank me for forwarding a letter that helped them reunite. A few days later, his wife visited. I learned that my client was in the hospital, paralyzed after shooting himself, a botched suicide attempt. The reunion I thought was a success was merely a step along a self-destructive path. I had been taken in.

Social Security showed me how public policy decisions play out for people with mental illness. At one point the Reagan Administration changed evaluation procedures, stopping disability checks for thousands of people without any change occurring in the law itself. People with mental illness suffered greatly as their cases for reinstatement progressed through the court system. Many of these claimants failed to appeal their benefit terminations. Years later, the courts took note of their plight. Stacks of file folders were delivered to our office, each one representing a family who suffered with their benefit checks cut off unjustly.

My experience at Social Security helped me build my approach to recovery. I learned to focus on skills and capacities my clients retained, not on what they lost. I learned the value of supportive family members advocating for people they love. People who had allies were better able to cope with the demands of a complex bureaucratic system.

Social Security also taught me several key truths about systems: No matter how generous or effective they are meant to be, our systems are designed and operated by fallible people. Those of us who work in systems underestimate the people we serve, misjudge their capacities, make errors that lead to fatal or near-fatal consequences, act or fail to act with imperfect information. We can get stuck in formalistic thinking, hit limits with respect to our discretion, or improvise.

But even in the midst of systems burdened with errors, we can absolutely get things right. For every one of the trouble cases I remember, there were dozens of cases that we processed routinely and correctly. Good results pile up, but sometimes they accumulate in our blind spots.

Mar 19, 2013

Did violent videogames cause the Newtown massacre?

The simple answer is, of course, no. This is not Videodrome. On the other hand, violent videogames are part of the context of this terrible incident. They can’t be ignored – just as the death toll of guns in America can’t be ignored, and the shooter’s mental state can’t be ignored, and the family’s disregard of risks can’t be ignored.

The Newtown tragedy was a complex event. Every part of it has meaning.

We know that people in the midst of the process of committing suicide are capable of anything.  The actions of suicidal people display emotions, elements, themes, messaging and motivation surrounding the incident and within their lives. Sometimes the urge to self-destruction is so strong the suicidal act can be deliberately manipulated by outsiders, but that does not appear to be the case here.

The Newtown massacre was a suicidal death storm that was one hundred per cent preventable.

No weapon, no dead children.

No weapon, no dead children.

No weapon, no dead children.

Mar 10, 2013

Deploy the Barefoot Psychiatrists!

What if professional mental health resources can’t be made to stretch across the whole country? The US has had a Rural Health Clinic program since the late 1970s. Download a description of this program here.

Like all US programs of that era, the rural healthcare system de-emphasized mental health. The clinics can opt to hire psychologists or clinical social workers, but are not required to do so. Through 2013, Medicare beneficiaries even pay a larger copay for mental health care.

How can we change the experience of mental illness in rural America? One possibility is to try a Chinese healthcare innovation – the itinerant rural healthcare worker, known until the early 1980s as the barefoot doctor.

Starting in the late 1950s, the Chinese sent thousands of health workers into the countryside trained to deliver preventative medicine, speak about hygiene, and treat common chronic illnesses.  When health workers encountered more complicated medical situations, they referred people to more formal facilities. The effort improved Chinese rural health significantly. Variations on this strategy are used throughout the world today.

There is no reason why this strategy could not work for mental health. Most mental health issues are not so complicated. Health workers could deliver basic education, start support and self-help groups in schools and churches, create linkages for more formal services, and even work out suicide prevention protocols with healthcare and law enforcement. These low-cost efforts can help preserve the health of people in rural communities, and preserve economic capacity put at risk when people cannot access the basic help they need.

Mar 7, 2013

Mentalizing, mental health and the restoration of community

People have talked through problems since time immemorial. At about the turn of the 20th Century we documented and formalized this communication process, turning human-to-human dialogue into modern psychotherapy. The practice became professionalized, expert-focused, with the expert more empowered than the patient.

The century we spent professionalizing psychotherapy did not deprive ordinary people of their capacity to talk through tough problems and help each other through tough circumstances.  Communication still helps. Dialogue helps. At the heart of any therapy session is a person who knows that he is being heard.

In recent years I have come to realize that simple human-to-human communication process is an overlooked item in the American problem-solving toolkit. There is something about dialogue and "mentalizing" - the process of interpreting how another person is reacting to your communication - that solves problems better than an email or text.

Think about the processes that incorporate sitting in the presence of each other and talking through an issue. Not a lecture. Not a demonstration. Not receiving an order. Not a slideshow or a pageant. A person-to-person, full-body exposure to emotion-laden, meaningful, content.

What helps people work through the hardest situations?

An example I want to start with is Restorative Circles. I have been writing about this on my new blog project, Grassroots Educator. Here's a video featuring Dominic Barter, who developed the process in Brazil. Barter's work proves that ordinary people can take hold of a justice process, and work through pain and violence using simple dialogue.

What capacity do each of us have to communicate with our relatives, friends and neighbors, to detect problems and offer comfort? Is it possible to restore mental health as a validated competency of ordinary people in families and communities?