THE MENTAL HEALTH RECOVERY MOVEMENT AND FAMILY THERAPY, PART II: A COLLABORATIVE, APPRECIATIVE APPROACH FOR SUPPORTING
MENTAL HEALTH RECOVERY
Diane R. Gehart California State University
A continuation of Part I, which introduced mental health recovery concepts to family therapists, Part II of this article outlines a collaborative, appreciative approach for work- ing in recovery-oriented contexts. This approach draws primarily upon postmodern thera- pies, which have numerous social justice and strength-based practices that are easily adapted in recovery-oriented contexts. The model outlined in this article includes an over- view of the recovery partnership (i.e., therapeutic relationship), mapping recovery (i.e., assessment and case conceptualization), recovery planning (i.e., treatment planning), facilitating recovery (i.e., intervention), accessing resources (i.e., case management), recovery maintenance, and service contexts as well as a case study.
Increasingly, family therapists and similarly trained clinicians are working in recovery- oriented environments yet little has been written on how best to apply their skill sets in this context. In this article, I outline a collaborative, appreciative approach that I have developed in my practice for supporting persons diagnosed with severe mental illness in their recovery process. This approach is based upon postmodern therapy theories and practices—specifically collaborative, narrative, and solution-focused—which are closely aligned with the philosophy, values, and assumptions of recovery models for working with severe mental illness (see Part I of this article for discussion). While certainly not the only way to apply the family therapy knowledge base to recovery, this approach draws upon some of the field’s best practices to create an approach that harmonizes with and supports the principles and ethics identified in the consumer-based, mental health recovery movement.
A COLLABORATIVE, APPRECIATIVE APPROACH FOR SUPPORTING RECOVERY
I developed the collaborative, appreciative approach using the recovery model elements identified in Onken, Craign, Ridgway, Ralph, and Cook’s (2007) analysis of existing recovery models, which have numerous parallels with postmodern therapies (see Part I of this article). The collaborative approach of Anderson and Goolishian (1992; Anderson, 1997) describes the quality of working relationship in which consumers’ voices are honored and equally valued in the recovery process. Arguably, the entire recovery movement can be seen as a consumer move- ment simply asking to be heard and treated as a partner in the recovery process. The profun- dity and import of developing a sincere collaborative stance with consumers cannot be overestimated; recovery is virtually impossible without it. Thus, the therapist’s collaborative positioning is the foundation of the approach.
Diane R. Gehart, PhD, Professor, Marriage and Family Therapy Program, California State University.
The literature review was supported in part by a grant from the California Board of Behavioral Science that
funded the creation of a bibliography for the new MFT curriculum that is available at http://www.bbs.ca.gov and
http://www.masteringcompetencies.com. Portions of this article were presented at the 2009 American Association for
Family Therapy Annual Convention.
Address correspondence to Diane R. Gehart, Marriage and Family Therapy Program, California State
University, 18111 Nordhoff, Northridge, California 91330; E-mail: email@example.com
Journal of Marital and Family Therapy doi: 10.1111/j.1752-0606.2011.00229.x July 2012, Vol. 38, No. 3, 443–457
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The appreciative aspect of this approach refers to recognizing and valuing the strengths and abilities of consumers, which generates the necessary momentum for recovery. Developed for organizational settings, appreciative inquiry practices use questions and coconstructive exploratory processes to identify and reinforce strengths and maximize positive potentials (Cooperrider & Whitney, 2005). The utilization of strengths in therapy can be traced to early systemic family practices, including the work of Milton Erickson (Erickson & Keeney, 2006), and has been most clearly articulated by solution-based and narrative therapists (O’Hanlon & Weiner-Davis, 1989; de Shazer, 1988; White & Epston, 1990).
Although this is a strength-oriented approach, it is naı̈ve to assume that the work is easy, straightforward, painless, or without crisis and drama. Working with the severely mentally ill can be exceptionally challenging, even when using a recovery-oriented approach, and perhaps is more challenging than traditional approaches (Davidson, Tondora, O’Connell, Lawless, & Rowe, 2009). A Pollyanna approach is quickly shattered by the numerous and varied obstacles in every journey of recovery. Thus, practitioners should quickly realize that the collaborative and strength-based elements of this approach are perhaps even more critical for them in maintaining hope and positive vision as it is for the consumers.
The remainder of this article will detail the practical elements of this collaborative, appre- ciative approach, which includes the following:
• Recovery partnership (i.e., therapeutic relationship) • Mapping the landscape of recovery (i.e., assessment and case conceptualization) • Recovery planning (i.e., treatment planning) • Facilitating recovery (i.e., interventions) • Accessing resources (i.e., case management) • Recovery maintenance (i.e., aftercare planning) • Context and format (i.e., treatment team and work contexts)
Partnership The therapist in recovery-oriented settings is best described as a partner in recovery (Adams
& Grieder, 2005) or recovery guide (Davidson et al., 2009) who provides support for the recov- ery journey. This partnership is similar to the conversational partnership described in collabora- tive therapies (Anderson, 1997; Anderson & Gehart, 2007; Anderson & Goolishian, 1992): the therapist is not a ‘‘change agent,’’ using a standard set of intervention techniques, but instead joins the consumer on a unique journey toward recovery. The motto ‘‘the client is the expert’’ (Anderson & Goolishian, 1992) befits recovery but is exceptionally challenging to implement with those diagnosed with severe and persistent mental illness, requiring a unique set of skills and extraordinary patience.
Typically, consumers have difficulty communicating their ideas; their thoughts may be un- usual, unrealistic, or impractical; and ⁄or they may not trust the therapist enough to say much of anything. In many cases, consumers and their families report feeling victimized and ill-trea- ted by mental health professionals, some referring to themselves as ‘‘survivors’’ or ‘‘ex-patients’’ of psychiatry (Loveland, Randall, & Corrigan, 2007); in such cases, the therapist needs to send a convincing message that this professional relationship will be different from their past experi- ences. Successfully building an effective partnership involves radical hope, human connection, and a strengths focus as well as promoting consumer agency and family involvement.
Radical Hope Hope is the foundation of recovery. Without it, recovery is impossible. To have hope for
those diagnosed with severe mental illness is radical, at least at this time in history. Only recently has there been evidence that recovery is possible; up to this point, professionals have assumed that certain psychiatric diagnoses were a lifelong sentence. Arguably, the therapist’s most important role is to convincingly and consistently serve as a beacon of hope and to main- tain unwavering faith that recovery is possible, even though days, weeks, and even months will go by where recovery seems impossible—even to the therapist. The importance of hope has
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been highlighted in solution-focused therapies and common factors research (Miller, Duncan, & Hubble, 1997), but its applications with severe mental illness are not for the faint of heart. To conjure the radical hope necessary for recovery-oriented work requires that the therapist have a profound and almost spiritual faith in recovery and that the therapist meaningfully communi- cates and sustains this faith for the persons with whom they work. Academic knowledge of recovery research is insufficient to fuel this type of hope; this is not a skill that can be taught but rather a quality of person that must be sincerely cultivated. For this reason, many public agencies use peer advocates, persons well on their way to recovery, who provide hope as role models of recovery.
Human Connection On one level, the recovery partnership is between a service provider and a service recipient.
On another, it is between two human beings sharing a unique and highly personal journey that inevitably touches the rawness of the human condition and tests the limits of the human spirit. No textbook or lecture can prepare therapists for this type of work. Consumers will not partner with a therapist on this type of journey unless they sense the therapist’s sincerest caring, feeling a strong connection as humans on the journey of life. With each consumer, therapists must demonstrate their humanity before a recovery partnership can begin. The therapist’s sincere investment in the consumer’s welfare includes the ethical mandate to do no harm and extends to do whatever it takes to meaningfully assist in the journey of recovery. Thus, a more personal and human level of commitment is required than is common in traditional family therapy prac- tice.
Strength and Person Focused Family therapists have a long history of relating to consumers using a strengths and person
focus (Minuchin, 1974; O’Hanlon & Weiner-Davis, 1989; de Shazer, 1988; Watzlawick, Weak- land, & Fisch, 1974; White & Epston, 1990). In strength-oriented work, the focus on cultivating and appreciating consumers’ strengths has two effects: (a) reducing the effect of problem behav- iors and symptoms and (b) increasing their ability to manage these issues. Relating to consum- ers from a strengths perspective is far more challenging than initially anticipated because persons diagnosed with severe and persistent mental health issues often have few friends, do not talk to their family, do not hold jobs, and have unusual talents and hobbies if any. Clini- cians need to be keen observers and practice appreciating micro-achievements and successes (such as making an appointment on time; having a friend to call) that may be taken for granted in other contexts.
A particularly applicable technique with this population, the narrative approach of meeting the ‘‘person’’ apart from the problem can be used to help both the therapist and client develop rich descriptions of client as a person, often one that the consumer has not heard in decades (Freedman & Combs, 1996). When consumers have a sense that professionals ‘‘see’’ and value the person that they are—apart from the diagnosis—they will be more likely to take actions that confirm this broader and generally preferred definition of self. Furthermore, cultivating a context of appreciation and celebration of small successes creates a strong relational bond as well as motivation for taking the steps necessary for recovery. This emphasis on strengths is used as a foundation for the recovery partnership and is also central in the mapping recovery and facilitating recovery processes described below.
Agency and Empowerment The therapist’s role in collaborative (Anderson & Gehart, 2007) and narrative therapies
(White & Epston, 1990) is to create a space where consumers feel free to exercise their agency. Anderson (1997) emphasizes that promoting agency is different from empowering consumers: for the notion of ‘‘empowering,’’ consumers assume that therapists are in a position of giving power (and therefore potentially withholding it) when they are not. Instead, Anderson explains that consumers are inherently agents with the power to take action in their lives; therapists are simply in a position to relate to consumers in a way that allows them to experience and effec- tively exercise that power. Similarly, systemic therapists also do not conceptualize therapy as
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empowering consumers; instead, consumers and families are viewed as already possessing intrin- sic autonomy and that they cannot be controlled or otherwise manipulated into change: instead, change always comes from within the system (Watzlawick et al., 1974).
In contrast, because of its roots in consumer and social justice movements, the recovery discourse often frames the recovery process in terms of empowerment, and clinicians are encouraged to empower consumers. Historically, family therapists have performed this by enter- ing the therapeutic relationship with the assumption that consumers already possess power and agency; the therapist’s job is simply to interact in such a way that this power is experienced and realized in useful ways. Thus, although family therapy and recovery models describe issues surrounding power differently, they ultimately promote the same dynamic, which is to relate to consumers in such a manner as to promote their sense of agency and autonomy.
Family and Significant Others Similar to family therapists, recovery-oriented practitioners actively involve family members
and significant others in the recovery process. When working with persons diagnosed with severe and chronic mental illness, therapists should be aware that their ‘‘families’’ may not only involve blood relations, but also roommates, peers, social service workers, religious personnel, and even pets (Davidson et al., 2009). In many cases, the person diagnosed with mental illness has been estranged from biological family members, and these relationships may need signifi- cant attention to be repaired and serve as a supportive force in the recovery process; family therapists are uniquely equipped to address these issues and should make this a priority early in the recovery process.
MAPPING THE LANDSCAPE OF RECOVERY
Mapping the landscape of recovery is a form of assessment that involves not only the stan- dard mental status evaluation and diagnosis, but also, more importantly, the larger social and meaning 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 as an assessment but also as intervention, helping consumers envision recovery, have hope, and take meaningful action.
Mapping a Person’s Sense of Purpose When meeting persons diagnosed with severe mental illness, recovery advocates emphasize
that professionals should begin by obtaining a rich description of their sense of purpose and sources of life meaning (Davidson et al., 2009). These statements of vision and mission deter- mine the direction, approach, pacing, and style of services offered. Family therapists can employ several narrative and solution-focused questioning techniques to assess a person’s sense of 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 and in some cases, use the Ericksonian technique of presupposition, assuming that recovery will happen (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 that
something 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 of meaning and fulfillment for persons recovering from severe mental illness (Eklund, Hansson, &
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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 of the 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 recov- ery is 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’’ context in which consumers feel warmly accepted.
One common spiritual belief is particularly useful in coping with severe mental illness: the belief that things happen for a reason. Consumers who hold this or a similar belief inevitably construct 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’s illness provides a hopeful and resourceful frame for managing one’s symptoms. Therapists can help 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 in new 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 recov- ery 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 connec- tion 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 these contexts 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
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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’s hope 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 con-
sumers come 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, times when 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, obses- sive optimism is an especially useful skill—arguably a prerequisite—when working with the chronically 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 fundamen- tally 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 particu- lar 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 on life’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. Per- sons 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 have
the most fun? OR When are you the least unhappy? • What unique skills and abilities have you discovered in your current situation and ⁄or
on 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-
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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 Leadership 5. Temperance: Forgiveness and Mercy, Humility and Modesty, Prudence, and Self-
Regulation 6. 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 top 3–6 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 abili- ties 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.’’
Akin to treatment planning, recovery planning involves developing goals and strategies for recovery, a collaborative process between the consumer and therapist. Contrasting recovery planning with the traditional mental health treatment planning, Davidson et al. (2009) emphasize that in recovery approaches consumers identify their goals and desires, while professionals help them remove barriers to these goals. Furthermore, recovery planning is person centered, rather than disease centered, meaning that not every goal is related to a symptom or problem—a tenet echoed by brief solution-focused therapists who have long claimed that the solution is not neces- sarily related to the problem (de Shazer, 1988). Also paralleling solution-based treatment plan- ning, Wellness and Recovery Action Planning (WRAP; Copeland, 2000) promotes wellness using
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small, concrete steps. Finally, the dictum in recovery planning is ‘‘nothing about us, without us’’ (Davidson et al., 2009, p. 113), a collaborative therapy practice that is at the heart of Seikkula’s (2002) Open Dialogue approach in which all conversations about a consumer—including clinical staff meetings—involve consumers and significant persons in their lives.
Open Dialogue for Collaborative Planning The Open Dialogue approach to working with psychosis and other psychiatric crises was
developed in Finland using principles of collaborative therapy developed by Tom Andersen, Harlene Anderson, and Harry Goolishian (Haarakangas, Seikkula, Alakare, & Aaltonen, 2007; Seikkula, 2002). In this approach, once a call is received about a psychiatric crisis, a team consisting of a psychiatrist, therapist, and social worker is sent to the home within 24 hr; this team continues to work with the consumer until services have ended. The team asks to meet with the consumer (typically unmedicated) and any significant people in the person’s life for an initial meeting that lasts one-and-a-half hours.
They begin by asking the consumer and the significant others about their concerns and how best to deal with them using a curious, nonassuming stance (Anderson, 1997). After 45 min to an hour, the team has an ‘‘open’’ staff discussion in front of the family about their thoughts, concerns, and possible courses of actions while the family listens, using a reflecting team format (Andersen, 1991). After this discussion, the consumer and the significant others share their thoughts and reactions to the team’s discussion. From there, the team, consumer, and significant others work together to develop a plan that addresses the safety issues, prefer- ences, and hopes that have been discussed. Together they decide whether hospitalization, medication, therapy, social services, and ⁄or other options should be part of the recovery plan, the consumer’s desires, family’s preferences, and professionals’ opinions used to develop an arrangement that everyone believes is reasonable. This approach can be adapted for other contexts by maintaining the key elements of having ‘‘open’’ discussion about recovery options with consumers and their families and collaboratively working together to decide on the best course of action, even or especially in the case of a psychiatric emergency.
Collaborative Goal Setting and Risk Management When promoting recovery, the goals should first and foremost target creating a meaningful
life for the consumer, emphasizing wellness and broader areas of life functioning than therapeu- tic goals have done historically (Copeland, 2000). These meaningful goals may be ‘‘riskier’’ (Davidson et al., 2009) than typical goals for persons diagnosed with severe mental illness and may include developing friendship networks, returning to work, changing living arrangements, and ⁄or reducing medications: whatever the consumer believes would lead to a more satisfying life. Often the increased risk involves engaging in activities that may trigger symptoms or setbacks, which historically professionals have strongly advised against. For example, as noted earlier, in standard psychiatric practice, consumers were not encouraged to work until after their symptoms were stabilized; however, such ‘‘risks’’ are encouraged if it is what the consumer desires and if there are no imminent safety risks (Davidson et al., 2009). Goals should not be avoided if there is only a general concern of relapse and the client is willing to take that risk. Relapse prevention plans, symptom management plans, and ⁄or safety plans must be in place if riskier goals are pursued.
Micro-Steps Once these broad, quality-of-life goals are set, therapists break these down into small,
attainable goals, as advocated in solution-based therapy (Bertolino & O’Hanlon, 2002; De Jong & Berg, 2002). In Wellness and Recovery Action Planning, therapists work with consumers to identify a ‘‘wellness toolbox,’’ a list of activities that a consumer identifies as helpful, as well as a daily maintenance plan that identifies how and when to use the activities (Copeland, 2000). Mapping out a daily maintenance plan involves helping the consumer plan his or her day, activity by activity, developing preventive measures for potential pitfalls. The key to recovery is often found in making micro-adjustments to daily routines and habits that ultimately reduce stress, ensure safety, and promote wellness. Similarly, small steps are identified to achieve long-
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term goals. For example, if a consumer wants to return to work, the first step may be showing up every day for a support group to work on attendance; then perhaps add volunteering; then registering for a job assistance program. The therapist’s role is to then do ‘‘whatever it takes’’ to help achieve the goal, whether that involves assisting with filling out forms, identifying community resources, and ⁄or looking up information on the Internet.
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 a wide range of therapeutic styles and models as well as extratherapeutic sources to help consumers develop a uniquely tailored plan. Several common family therapy practices are readily 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 embark upon 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 role in 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? Why or 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 circum- stances, 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
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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 peo- ple? 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 non- assuming, exploratory questioning invites consumers to join the therapist in a process of mutual inquiry that opens new possibilities for interpreting life events and creatively and more resource- fully responding.
In this subtle process of mutual inquiry, the consumers’ internal dialogues about the prob- lem 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 mental
illness 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 a person’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 if the 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
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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. For example, peer support groups can begin or end by participants answering questions such as the following:
• 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 or 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 bulletin board 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 simi- lar 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 fami- lies, and their friends.
Accessing resources involves helping consumers navigate larger social systems to obtain the resources they need to successfully meet their goals; these may include housing, medical care, legal resources, food, job assistance, social support, etc. The MFT Core Competencies (Nelson et al., 2007) include identifying resources and case management in several places, indicating that in actual practice MFTs do far more of this than has generally been described in theoretical lit- erature. Case management requires MFTs to attend to needs that are not readily identified as emotional, psychological, or relational but are inherently and often passionately so. One way to understand case management is that therapists are responsible for helping consumers meet their needs that affect the consumers’ ability to do what is necessary to achieve their goals. For example, if a young mother who is experiencing psychotic symptoms needs childcare, medical coverage, and job assistance, it is the therapist’s job to help her access these services so that recovery is possible.
Recovery-oriented care should be designed with a clearly defined end (Adams & Grieder, 2005; Davidson et al., 2009). The goal in recovery is to help consumers live a personally meaningful life, which may be achieved through full recovery (i.e., no symptoms) or social recovery (i.e., satisfying social life using medications or other strategies to manage symptoms). Based on the work of Seikkula (2002) and his colleagues in Finland, substantial recovery from psychotic disorders can be expected in 2 years using a recovery-oriented, collaborative approach.
Services should wind down or end when consumers are maintaining meaningful relation- ships, employment, and social interactions, having attained a generally satisfying life with stable housing and financial resources. At this point, therapists, consumers, psychiatrists, and concerned others should discuss whether or not medications are likely to be useful and desired for sustaining recovery as well as identify various possibilities for using medications to support recovery over the long term. Similarly, consumers should also consider which types of
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supportive services are most likely to be useful in maintaining recovery and which will be the first reaccessed should difficulties arise in the future. When consumers end formal services, they and significant others in their lives should meet with the therapist to identify the plans for sustained recovery, warning signs of relapse, and action steps in case of relapse.
CONTEXT AND FORMAT
Therapists working in recovery-oriented programs, especially those provided in public men- tal health systems, should be prepared to provide services outside the traditional therapy office, working in consumers’ homes, community centers, parks, and cafés. In addition, their duties may involve accompanying consumers to medical appointments, shopping trips, or other tasks. Family therapists have several models for in-home and community-based services to draw from that can be used in alternative settings (Boyd-Franklin & Bry, 2001; Coffey, 2004; Rojano, 2004; Walton, Sandau-Beckler, & Mannes, 2001). Most recovery-oriented programs employ a team approach in which a multidisciplinary team works together in supporting a consumer in recovery (Davidson et al., 2009; Linhorst, 2006). Unlike some forms of multidisciplinary teams, in recovery work, the roles are less distinct. Thus, the therapist is expected to also assist with a variety of tasks that may be outside the traditionally expected role; similarly, other profession- als may engage in therapeutic tasks. For many therapists, the greatest difficulty is in defining the role of ‘‘peer advocates’’ (persons in recovery helping others in recovery, often without formal training), who may run support groups or provide adjunctive ‘‘counseling’’; family therapists must learn how to effectively coordinate peer counseling and mentoring with the more formal services they provide.
Mary was referred to me by her mother’s caseworker because they believed she was depressed and were concerned that she had never been able to make friends. Mary was 33, was attending community college, and lived with her mother, 67, who had been treated for psycho- sis on and off since young adulthood. Mary had seen various therapists for depression, ‘‘odd behavior,’’ school failure, and social difficulties since early childhood. They have been in and out of homeless shelters and were currently supporting themselves on the mother’s social secu- rity income; however, they maintained an ongoing relationship with her caseworker from the shelter. Mary did not want to see yet another ‘‘useless’’ therapist; but her mother made it a condition of her continuing to live with her.
She came to the first session with intricate face paintings and dressed in a dramatic black leather outfit. Rather than comment on her dress, I began by asking about how she spends her days and what she hopes for from our time together. During our meeting, when discussing how she often felt misunderstood by ‘‘everyone,’’ she explained that her dress was inspired by her participation in an online religious group, a place where she felt meaning (sense of purpose) and acceptance (sense of belonging). Her sense of independence and spirituality were assets that she later drew upon in her journey of recovery (strengths and resources).
I began by discussing whether she wanted to be there or not—she didn’t—and then explored why she thought her mother wanted her there; I also suggested that the mother join us for part of the session to figure out what needed to happen for her mother to think that she no longer needed to come. The mother wanted her to ‘‘act normal,’’ finish school, and get a job to help with bills. Mary agreed to the last two items, and we had begun to develop a pur- pose for our meetings (recovery plan) and a believable course of action (sense of hope). In the next few meetings, I learned that she always felt lonely although she hung out with people (whom she didn’t like), had a long history of sexual abuse (trauma that had been unaddressed), and had been having visual hallucinations since she was seven. She had many gruesome halluci- nations, but was aware that they were not real: ‘‘If there was really a dead, rotting body in the middle of Starbucks, everyone in the room would be responding differently.’’ She was able to identify numerous times when she could distinguish between what was real and what was not (another significant strength), even though the hallucinations looked entirely real to her. The
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better she became at recognizing but not responding to them, the less frequent and severe they became.
As her symptoms decreased, she was able to articulate new life dreams (revised life pur- pose)—to become a nurse, get married, and have children—and what it would take to achieve them (revised recovery plan). We identified small steps for each week, such as doing homework, going to her academic advisor, and volunteering at a local hospital, and explored ways to select better friends, which soon led to her developing a close friendship with another woman from class (sense of belonging). I referred her to a psychiatrist for an evaluation; although he prescribed medication, she stopped taking it after a month because it made her ‘‘feel weird.’’ Meanwhile, as she became more active in school and her friendships, she reported fewer and fewer psychotic episodes. At one point she stated, ‘‘I sort of miss them; they made me feel special somehow.’’ I took this comment as a sign that we needed to meaningfully restory the role of these hallucinations in her life. In our mutual exploration about their role, she began to see them as helping her cope with her earlier sexual trauma and abandonment by her father and that now she didn’t need them to feel good about herself. We invited her mother in period- ically to provide family psychoeducation (intergenerational issues in mental illness) and to strengthen and repair their relationship (sense of belonging). Over the course of a year and a half, Mary finished her nursing program and secured a job. We agreed that she should continue her sessions for the first few months on the job to make sure the hallucinations did not return. Two years later, Mary contacted me through my Facebook page and shared that she was engaged and still using many of the strategies we developed to manage symptoms when they arose, which were rare but did still occur. She achieved a meaningful and thus far sustainable social recovery, ending a painful intergenerational pattern.
Family therapists are uniquely prepared to promote recovery in persons diagnosed with severe mental illness. In many ways, the rise of the recovery movement is a renaissance for many of the radical views of early family therapy pioneers who focused on strengths, the broader social context of an individual’s symptoms, and the relational function of symptoms and based their work on the assumption that recovery from severe mental illness was possible (Fisch, Ray, & Schlanger, 2009; Ray, 2009; Ray & Watzlawick, 2005 ⁄2009). In addition, the newer collaborative, nonpathologizing, and appreciative postmodern family therapy approaches provide a comprehensive and highly compatible foundation for recovery-oriented work, espe- cially in areas related to social justice and stigma related to mental illness. As family therapists become more active in newly conceived recovery programs for severe mental illness, they are ironically more likely to practice family therapy in the spirit as it was originally envisioned.
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