Mental health articles

OF mental health care and mentally ill

How to facilitate recovery

Facilitating recovery involves working with consumers to codevelop action steps that meaningfully advance the recovery journey. In this shared process, the therapist’s role is to help identify possibilities for removing obstacles to the consumer’s having a meaningful, fulfilling life(Davidson et al., 2009). Consumers are equally engaged in identifying options and committing to action plans that they believe will be most fruitful. The therapist and consumer develop a‘‘reasonable’’ course of action based on (a) what the therapist knows is likely to be effective based on theory and research, (b) what the consumer is willing and able to commit to, and (c)what is reasonably safe but not necessarily risk free. Thus, therapists are likely to draw upon awide range of therapeutic styles and models as well as extra therapeutic sources to help consumers develop a uniquely tailored plan. Several common family therapy practices arereadily adapted in recovery-oriented contexts, including narrative restorying, curiosity and mutual inquiry, re-membering conversations, and communities of appreciation.

Restorying Identity and Illness Narratives

Identified as one of the key areas of intervention when promoting recovery (Kirkpatrick,2008; Roberts, 2000), rewriting identity narratives is central to the recovery process. To embarkupon a journey of recovery, consumers must first believe in the possibility of recovery, which often requires a significant revision to the discourses they have heard up to this point about their condition. Although some consumers are eager to believe recovery is an option, many others, especially those who have been diagnosed for decades with a disorder, are slow to warm to the possibility and may even resist it, fearing a loss of support, benefits, and identity.One way that therapists can begin to introduce the possibility of recovery is to enumerate the effects of being labeled as mentally ill. Using deconstructive and externalizing questioning(Freedman & Combs, 1996; White & Epston, 1990), therapists help consumers explore the effects of being labeled on their behaviors, beliefs, relationships, life goals, and overall health.

Through this process, consumers can reidentify with strengths and life dreams.Examples of questions to promote restorying of identity narratives include the following:

• How has being diagnosed with mental illness changed how you see yourself, your rolein relationships, and ⁄ or your role in society? Where did you get these ideas? Do you think they are fair and accurate?

• Do you think being diagnosed with [diagnosis] changes your value as a person? Whyor why not? How? Where did these ideas come from?

• How did you define yourself before the [diagnosis or symptoms] began? How did you develop these ideas about who you were? Did others see you this way? Do you think this depiction is still true today in some ways?

• Do you believe that you can still lead a meaningful life with the symptoms you are experiencing? If not, where did you get this idea? If so, how can you make this happen?

In this process, the impact and reality of being diagnosed with a serious mental illness is not ignored, but rather contextualized by many other aspects of personhood and life circumstances,so that consumers develop a richer, multidimensional understanding of their identity rather than a narrowly defined identity based on their diagnosis alone.

Curiosity and Mutual Inquiry

Anderson’s (1997; Anderson & Gehart, 2007) conversational practices of curiosity and mutual inquiry are particularly well suited for working with persons diagnosed with severe mental illness and are perhaps the best mainstay ‘‘interventions’’ in recovery work. When trying to understand a person’s perspective—whether it sounds psychotic, neurotic, or ‘‘sane’’—Anderson assumes nothing (i.e., a not-knowing stance) and curiously asks for rich descriptions and personal interpretations. Using sincerity in asking curious questions, such as ‘‘why do you think these people are following you?’’ the therapist is not trying to manipulate, trip up, or convince the consumer of anything, as historically could have been the case when working with psychosis and other extreme behaviors. Using a collaborative approach, the therapist continues to explore the consumer’s thinking, fears, and hopes and listens for the inner logic and personal meanings using questions such as the following: What do you think they would say or do if they were to catch up to you? What makes you think this? What are your plans if this happens? What if they did something else, such as tell you you won the lottery? Has anyone else seen these people?

What do they believe about these people? What might be done to address your concerns?When asked without an ulterior motive of changing the consumer’s perception, this type of nonassuming,exploratory questioning invites consumers to join the therapist in a process of mutualinquiry that opens new possibilities for interpreting life events and creatively and more resourcefully responding.In this subtle process of mutual inquiry, the consumers’ internal dialogues about the problem inevitably change even if their bottom-line belief does not (e.g., someone is following me).The internal dialogue about why, by whom, and how they are being followed shifts through the process of mutual inquiry, even if slightly (e.g., these people may or may not have ill intent;they may only be bill collectors; or they are the ‘‘You’re On Candid Camera’’ recording crew and normal behavior might make them go away). Through an ongoing process of mutual inquiry, new options for responding naturally evolve, often seeming ‘‘obvious’’ courses for future action because they evolved from the consumer’s internal dialogue.

Re-Membering Conversations

One of the more challenging aspects of working with persons diagnosed with severe mentalillness is creating a vibrant community of support. Many are estranged from family and friends because of problems and incidents relating to their symptoms, and often these support people are not willing, interested, or available to participate in the recovery process. White’s (2007)

re-membering conversations can be particularly useful in these situations.Re-membering conversations helps consumers develop a multivoiced personal identity that is based on multiple and various associations of life, significant people and identities from aperson’s past, present, and future. In these conversations, consumers are encouraged to identify who and what has had influence on their identity and to make conscious decisions as to whether a particular person’s influence should be expanded, decreased, or eliminated. These questions typically address the following types of issues:

• Identifying a person’s contribution to the consumer’s life.

• Identifying how the consumer may have affected another’s life.

• Articulating how another person may have viewed the consumer’s identity.

• Defining the implications for the consumer’s identity (e.g., I am a person who cares about others’ feelings).

By giving voice to significant relationships from the past, present, and future, re-membering conversations with consumers can help them feel more connected to significant people even ifthe people are not actually involved. As consumers feel more connected, they will be better able to appreciate current and future relationships and to be more effective at maintaining relationships, including the need to set limits in relationships that they find unsupportive in their recovery process.

Communities of Appreciation

Recovery-oriented programs often involve ‘‘wellness centers,’’ peer support groups, and similar programs where consumers interact formally or informally. In these communities,therapists can guide interactions with some of the basic principles of appreciative inquiry(Cooperrider & Whitney, 2005). Developed for organizational consultation, appreciative inquiry and related practices involve a coevolutionary search for the best in people using questions that strengthen and highlight the positive potential of individuals and their organizational systems.

Adapted to recovery contexts, appreciative practices have numerous possible applications. Forexample, peer support groups can begin or end by participants answering questions such as thefollowing:

• What do you most appreciate about this group, the person sitting next to you, this center, etc.?

• What positive changes have you noticed in the person sitting next to you [or yourself for XXX] recently? How has this affected you, this community, etc.?

• Who or what are you most appreciative of today? How will you express this appreciation?

Asking questions that focus consumers’ and professionals’ attention on things that are appreciated and positive changes in self and others encourages a culture of appreciation that brings out the best in everyone.

In addition to structured questions such as those above, therapists can create a bullet inboard where consumers can use their creative energies to express appreciation with a thank-you note, a piece of art, etc.; such a board allows for a person to express appreciation as well as be the recipient of appreciation. Talent shows or organized plays are another way to encourage and recognize consumers’ often surprising abilities in a wellness center context. These and similar activities create a context where people are more likely to notice and comment on—and therefore nurture and develop—positive qualities in one another; such a shift in focus typically has a dramatic impact on persons who have been routinely marginalized by society, their families,and their friends.

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