Mental health articles

OF mental health care and mentally ill

MAPPING THE LANDSCAPE OF RECOVERY

Mapping the landscape of recovery is a form of assessment that involves not only the standardmental status evaluation and diagnosis, but also, more importantly, the larger social andmeaning systems, including (a) sense of purpose, (b) sense of belonging, (c) sense of hope, (d)strengths and resources, and (e) mental health status. This mapping process serves not only asan assessment but also as intervention, helping consumers envision recovery, have hope, andtake meaningful action.

Mapping a Person’s Sense of Purpose

When meeting persons diagnosed with severe mental illness, recovery advocates emphasizethat professionals should begin by obtaining a rich description of their sense of purpose andsources of life meaning (Davidson et al., 2009). These statements of vision and mission determinethe direction, approach, pacing, and style of services offered. Family therapists canemploy several narrative and solution-focused questioning techniques to assess a person’s senseof purpose (Bertolino & O’Hanlon, 2002; De Jong & Berg, 2002; White, 2007; White & Epston,1990). These future-focused questions help consumers envision a life without mental illness andin some cases, use the Ericksonian technique of presupposition, assuming that recovery willhappen (O’Hanlon & Martin, 1992).

• If your problems were totally resolved, what would you be doing with your life?

• What do the symptoms seem to keep you from doing that you would rather be doing?

• Before the symptoms became a problem, what did you enjoy most in your life? Is thatsomething you want to get back to? OR When do you think you will be ready to get back to it?

• Once you have overcome the problems caused by [your diagnosis], what do you most look forward to doing? Can you describe this in vivid detail for me?

• Do you think there is anything you have learned from having these symptoms that has helped you in any way? Is there anything you want to teach others based on your experiences?

Employment.

Research identifies employment as one of the most important sources ofmeaning and fulfillment for persons recovering from severe mental illness (Eklund, Hansson, & Ahlqvist, 2004). Historically, employment has been seen as an option only after a person has‘‘fully’’ recovered from mental illness, which for many has meant never returning to work.However, both consumer reports and professional research now indicate that work is part ofthe recovery process and is increasingly a central part of recovery-oriented services (Anthony,Brown, Rogers, & Derringer, 1999). Therefore, in the process of identifying purpose and meaning, therapists should carefully explore issues of employment and encourage consumers to consider supported employment, volunteering, and similar options for returning to work as soon as reasonably possible.

Spirituality and religion.

Another source of meaning and purpose frequently cited in recoveryis spirituality and religion (Hugen, 2007; Walsh, 2003). Similar to recovery in substance abuse treatment, spirituality and religious practice can be a particularly powerful source for finding meaning in suffering and reasons to embrace life even when life has not unfolded as hoped. Religious affiliations often offer vibrant communities of support and a ‘‘normal’’ contextin which consumers feel warmly accepted.

One common spiritual belief is particularly useful in coping with severe mental illness: thebelief that things happen for a reason. Consumers who hold this or a similar belief inevitablyconstruct meanings related to purpose: either their personal purpose or their role in a larger,divine plan. In either case, believing that there is a ‘‘reason’’ or greater meaning related to one’sillness provides a hopeful and resourceful frame for managing one’s symptoms. Therapists canhelp consumers identify what role their illness may be playing in the broader scope of their life,such as teaching compassion, being a role model for others, or serving their community innew ways.

Mapping a Sense of Belonging and Intimacy

The second area mapped is the consumer’s sense of intimacy and belonging to a community,whether involving family, friends, religious organizations, support groups, or other network of supportive people (Davidson et al., 2009). As community is highly correlated with recovery and a general sense of well-being, therapists should identify sources of connection early in the recovery process. If the consumer does not have a strong support system, this becomes an initial area for attention. As relational experts, family therapists have numerous resources for assessing belonging and intimacy in nuclear and extended family systems that can be easily adapted for assessing connections with other support persons, which are often the most realistic ‘‘family’’option for a person who has been diagnosed with a chronic mental illness. When their parents or siblings are available, consumers often need extensive family sessions to repair what may be years of distrust, abandonment, and ⁄ or betrayal on both sides; in these cases, family therapists have ample skills for working with families to restore trust, hope, and family cohesion. Questions for mapping belonging and intimacy include the following:

• From whom or where does your most meaningful social support or sense of connection come?

• Are there relationships that can be repaired or nurtured to increase your sense of feeling cared for and connected?

• Where do you feel that you fit in the best? Now? In the past? What about the second texts makes you feel comfortable? How can you build upon these connections?

• Who do you consider your best friend? With whom is it easiest to share your inner thoughts and feelings? With whom do you have the most fun?

• To whom do you think you matter most? Who would miss you the most if you were gone?• Do you have relationships with any relatives? If not, who might you want to reconnect with? Who might want to reconnect with you? What would need to happen to begin this process?

Mapping Hope

Cited as one of the four common factors correlated with positive clinical outcomes (Sprenkle,Davis, & Lebow, 2009), hope is also a central focus of recovery-oriented work (Davidson et al.,2009). Historically, professionals have not had much hope for persons diagnosed with severe mental illnesses, such as schizophrenia or bipolar disorder, often advising patients and their families that medication must be taken indefinitely and rarely predicting a return to normal functioning. Recent studies have not supported such a poor prognosis but instead indicate that recovery in some form—full or social—is a reasonable expectation for the vast majority(Hopper, Harrison, Janca, & Sartorius, 2007). In recovery-oriented approaches, the consumer’shope for recovery is critical to beginning the process. Questions for mapping hope include the following:

• Do you believe you can lead a normal life again? Do you want to?

• What elements of your life do you believe will be the first to improve? The last to improve? Why?

• What would be some of the first signs that things are getting better?• What have you read on the Internet or heard from others about your illness? How much of this do you believe? What do you question?

Mapping Strengths and Resources

Mapping strengths is more difficult than assessing pathology (Gehart, 2010) because consumerscome in prepared to discuss problems and are often at a point in their lives that seems‘‘saturated’’ with problems. They may have difficulty identifying areas that are going well, timeswhen the problem is not a problem, or when the problem is less severe. Solution-focused and narrative therapists as well as appreciative inquiry practitioners have developed the extensive techniques for mapping strengths and resiliencies, which include starting therapy by getting to know the person apart from the problem, doggedly pursuing lines of questions that identify exceptions to the problem, using unconditional positive questions, and focusing on small signs of change and progress (Bertolino & O’Hanlon, 2002; Cooperrider & Whitney, 2005; De Jong& Berg, 2002; White & Epston, 1990).

I playfully refer to these relentless styles of strengths assessment as neurotic (or obsessive)optimism, and I recommend therapists work hard to cultivate it. Related to radical hope, obsessive optimism is an especially useful skill—arguably a prerequisite—when working with thechronically mentally ill because their strengths and resources may not be readily apparent, thus requiring a strong belief that all people have strengths and resources. On this issue, therapists should be reminded that one cannot not have strengths because most attributes are fundamentally double-edged: they are a strength in one context and a liability in another. I refer to these as shadow strengths (Gehart, 2010).

When working with persons diagnosed with severe mental illness, therapists often need to carefully listen for shadow strengths, strengths that are the flipside of the problem or a particular symptom, often identified when elements of the problem are considered in another context.For example, the shadow strength associated with depression may be the ability to reflect onlife’s meaning or the motivation to set goals and have aspirations; similarly, the shadow strength for anxiety may be the ability to identify pitfalls or the ability to manage details. Persons who experience psychosis or mania often have the shadow strengths of creativity, artistic ability, spirituality, and independence.

Questions for mapping strengths include the following:

• When, where, and with whom are your symptoms less severe or not a problem?

• What are your hobbies and interests, either now or in the past? When do you havethe most fun? OR When are you the least unhappy?

• What unique skills and abilities have you discovered in your current situation and ⁄ oron your path of recovery thus far?

• Which relationships have been most supportive to you in your journey of recovery thus far?

• What habits or elements of the problem behaviors and thoughts are strengths in another context or in smaller doses?

• What types of problems would arise if the problem were solved?

Positive psychology and character strengths.

For therapists preferring a more structured approach to mapping strengths, positive psychologists Peterson and Seligman (2004) have iden-tified 24 character strengths that are readily identified in major world cultures and can be used for mapping strengths in recovery-oriented care. These are divided into six major areas:wisdom and knowledge, courage, humanity, justice, temperance, and transcendence.1. Wisdom and knowledge: Creativity, Curiosity (openness to experience), Open-Mindedness(judgment, critical thinking), Love of Learning, and Perspective (wisdom)2. Courage: Bravery, Persistence (industriousness), Integrity (authenticity, honesty), and Vitality (zest, enthusiasm, vigor, energy) 3. Humanity: Love, Kindness (generosity, nurturance, care, compassion), and Social Intelligence (emotional and personal intelligence)4. Justice: Citizenship (social responsibility, loyalty, teamwork), Fairness, and Leadership5. Temperance: Forgiveness and Mercy, Humility and Modesty, Prudence, and Self-Regulation6. Transcendence: Appreciation of Beauty and Excellence, Gratitude, Hope (optimism,future-mindedness), Humor and Playfulness, and Spirituality Therapists can review the list of character strengths with consumers to identify their top3–6 strengths and explore ways to build upon and utilize these in the recovery process.

Mapping Mental Health

Like two overlapping circles in a Venn diagram, the recovery model incorporates certain aspects of the medical model while rejecting others. Similar to the medical model, mental health diagnosis is an important step in the recovery process; however, in contrast to the medical model, the diagnosis does not drive the recovery process (Davidson et al., 2009). The diagnosis is used to help better understand the consumer’s situation and to identify potential resources that may be useful, such as medications and the evidence base related to the diagnosis.For example, the research on schizophrenia supports family psychoeducation interventions(McFarlane,Dixon, Lukens, & Lucksted, 2003); thus, if a person is experiencing schizophrenic symptoms, a recovery orientation includes identifying this as a potential option. However, if the consumer does not want family involvement, the issue would not be forced. Similarly,therapists identify a referral to a psychiatrist for a medication evaluation as an option and discuss the benefits and limitations in a language that the consumer can understand; however,consumers are not coerced to take them (e.g., ‘‘If you don’t take your medications, I will not see you for therapy’’). When consumers want to pursue recovery without medications, the recovery-oriented practice is to respect their wishes while balancing the need for safety.For example, when working with a woman diagnosed with bipolar disorder who had been on medication for over a decade and wanted to get off medications, I began working with her to identify what would realistically need to happen in her life for her to feel stable without or with significantly less medication. Together with her psychiatrist, we developed a plan that required significant effort and focus on her part, which brought forth a determination and abilities that she had not demonstrated prior, and she eventually was able to get off of her mood stabilizing medication. Conversely, another chronic bipolar consumer also expressed an interest in getting off medications, but when we began developing a realistic picture of how to achieve this, she quickly said, ‘‘I’ll stick with my meds for now.’’

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