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How persons recovering and clinicians can promote self-managed care

By Daniel Fisher, M.D., Ph.D.

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Recently a number of professionals have been asking us, "how do we apply the values of empowerment and recovery in our practice?" The National Empowerment Center has developed a new approach to clinical practice, based on the experiences of people recovering from mental illness. We call this approach self-managed care. As a person recovering from mental illness who works as a psychiatrist, I feel I have some insight and much necessity to find a role for clinicians in promoting peoples' recovery rather than increasing their dependency.

What is Self-Managed Care?

I see the primary goal of all contacts between staff and persons recovering as the building up of the person's capacities to manage their own life. That is the essence of self-managed care. We psychiatrists are often the worst offenders and in our presence people become willing victims to our supposed power to heal them. We have no such power. We do have the power to create together with the person the interpersonal conditions which facilitate the emergence of the person's own capacities to heal through self-management. In that process, we heal ourselves a little more because we are made more whole in the relationship with a person who is emerging. I see a creative tension in the application of these approaches by a conscientious clinician. The tension arises from the often contradictory pulls in one direction by the person receiving services to emerge and take greater control over his or her life and in the other direction by the provider's need to establish sufficient control over the person's life that they conform with societal expectations and billing requirements. To date, the providers' classifications and treatments have far overshadowed the consumers' voices and aspirations. The consumer movement has highlighted the words and perspectives of those recovering to counter- balance the providers world.

Self-Managed Care is the Goal of Managed Care

Under managed care the least costly, most effective approach is to assist people's recovery. Under the fee for service system the subtle incentive was to have the consumer remain in therapy for extended periods, thereby encouraging dependency. Many well intentioned professionals delayed recovery by this approach. Now under managed care the goals of people labeled with mental illness to recover and regain control over their lives, often through peer support, are close to those of the managed care companies paying the bills. These companies and their provider networks and a number of consumers and their families, however, need to usher in a major change in the values and structure of the mental health system to realize these goals.

Machine Model of Existence Interferes with Recovery

I believe that there is an underlying assumption in our society that people are nothing more than complex machines. This means that psychological problems are mechanical problems, and that going to the doctor is the same as going to a car mechanic. The brain is seen as the seat of emotions and thoughts, so fixing the electricity, chemistry, or structure of the person's brain is the way to repair their break down. Therefore, the first order of business when a person is presented to a hospital or clinic is the design, by the expert professionals, of a repair or treatment plan. This model was first developed for people diagnosed with major mental illness, who are now described, even by the lay public, as having a chemical imbalance. This is the medical model of mental illness. The medical model seems now to be spreading to all people and that is why I would call it more broadly the machine model of existence. Now an increasing array of less serious conditions, such as obsessive-compulsive disorder, depression, panic etc, are also being described as chemical imbalances which also require a chemical solution. We cannot segregate off a portion of society as different from us, as machines, and be surprised when we view ourselves as machines as well.

Humanistic View of Existence

I therefore propose that even the most severe emotional problems be viewed as very human problems rather than mechanical ones. Harry Stack Sullivan had this in mind when he described schizophrenia as a human process. This approach is based on a humanistic view of people as full beings, existing at all levels of body, mind and spirit. People remain just as human, or more so, during times of severe emotional turmoil. No magic drug can solve human problems. They can temporarily relieve some pain, but then the person develops his or her self through real emotional and interpersonal learning.

Self-Management Planning Comes First

When a person suffering emotionally seeks help, he or she still enter as the expert in the running of their life. Even though they may experience a temporary impairment or delay in that ability, they are the ones who know their experiences and they are the ones who need to learn how to improve the management of their lives. Professionally designed treatment plans are done to and for the person and generally remove the person's capacity to run his or her own life. The more comprehensive and long-term the treatment plan, the more likely it will create dependency and institutionalization, regardless of the setting. In fact, the word treatment, which implies an externally imposed process, itself is contradictory to the essence of recovery as a self-directed activity. I would propose that we start by helping people to improve the design of their own self-management plan, Treatment plans, which are for now required by third party payers, would then be a component of the larger self-management plan. Holistic health would be seen as a complement to a single dimensional clinical treatment rather than its present status as it alternative.

Elements of a Self-Management Plan

A self-management plan would consist of elements at each of a person's three major levels of self-relationships:

  1. Self-to-self level: this is the level of self-help, coping strategies:
    1. Self-help manuals, tapes, and videos produced by people in recovery on topics such as coping with voices and a description of what helped others heal
    2. Exercise, diet, meditation, biofeedback, visualization
    3. Journal writing

  2. Self-to-helper level:
    1. Clinical treatment: such as psychotherapy, medication, rehabilitation, and some innovations:
      1. Advance directives and health care agents: persons can extend their decision making beyond the usual point at which a clinician takes over by describing the types of services and medications a person wants when he or she is in a crisis. It is also helpful to designate a health care agent to assist the person with decision making during a crisis.
      2. Peer-oriented psychotherapy: it is often difficult to refer people directly from individual or group therapy to a peer support group. One means of assisting that transition is through a different form of group work which we call peer-oriented group therapy. The group ideally should be led or co-led by a person recovering from mental illness who is comfortable with prudent disclosure.
    2. Holistic treatment: acupuncture, massage, guided imagery.
  3. Self-to-peer level: self-help groups running the gamut from broad based mutual support, to support by diagnoses, warm lines, to consumer-run social clubs.

Training and Resources for Helpers

The following items and activities can be obtained through the National Empowerment Center.

  1. Videos, tapes, and papers on self-managed care, empowerment, and recovery.
  2. Workshops, including one which is a simulated experience of hearing voices.
  3. We are developing a multimodular curriculum for teaching professionals the self-managed care approach.
  4. Our staff can be reached directly at 1-800-POWER-2-U (800-769-3728). They can access our national data bank of self-help groups.