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November 01, 2006

A few days ago, Jenny stopped by META Services to say hello. As we watched her approach the steps leading to our office, we realized something was wrong. Her gait was slow and defeated, her head hanging low. The last time we had seen her she was full of life, chattering a mile a minute, excited about graduating from peer employment training at META Services and looking forward to her first day of work. We had received e-mails from her since then, in which she expressed exuberance about her new job and delight at the chance to make a difference in the lives of others who had similar circumstances.

This vibrant Jenny was a sharp contrast to the woman we had met four months earlier. The Jenny back then was broken, both physically and mentally. She barely had survived a suicide attempt that left her in constant pain, with a prognosis that she might never walk again. Mentally she was no better: deflated, depressed, and completely hopeless. Yet she had support. Her family loved and helped her, and gradually her physical injuries began to heal. Her spirit, however, was quite another matter.

Jenny's doctor prescribed an antidepressant, which helped somewhat. But the deeper healing began only when she acquiesced to her family's coaxing that she attend a WRAP class (for details on WRAP, see our article in the July issue, page 19). Once she sensed hope and accepted encouragement from others who had been through similar experiences, she began to blossom.

She completed her WRAP class and went on to take other classes, eager for help along her path of recovery. Enrolling in training for peer employment constituted a huge step for her, yet she sailed through the instruction and landed a job shortly after graduation. With her doctor's help, she had even weaned off the antidepressant, and felt well and excited about life.

But now the Jenny sitting in our office looked more like the defeated woman of months ago. We saw none of the self-confidence and hope that we had seen thrive in her. We asked her to tell us what she was feeling. Jenny expressed to us that she felt sadness, fear, and uncertainty. This led to her feeling shame, remorse, and defeat related to her recovery, and now she was convinced that she wasn't well after all and might never be. She had returned to the crisis clinic and had restarted antidepressant therapy.

As we listened, Jenny slowly confided that she recently had ended a close relationship, had moved to a different part of the city, and was having financial difficulties. We sat with her for some time, letting her talk it through. In doing so, Jenny began to gain a sense that maybe she had been hasty, that perhaps she wasn't sick again after all. That perhaps these recent difficult, stressful, and worrisome events would have caused anyone to have the feelings she experienced. That in fact, the feelings she was having were a normal human reaction to stressful circumstances, rather than a psychiatric crisis. As these realizations came to her, her eyes brightened again; her face regained a beam. She gave herself permission to experience and forgive natural human frailty.

This story illustrates a trap we professionals easily can fall into when we connect with the person's problems instead of the person. We work within the context of illness; therefore, that is the lens through which we view the people we try to help. We focus our time and energies on seeking out feelings and behaviors that indicate something is abnormal, so that we may diagnose and properly treat. Yet when we see those signs, we actually may be witnessing normal human reactions to life circumstances rather than symptoms of mental illness. Instead of labeling these people as ill, we should shower them with accolades for surviving trying times and fortify any signs of resilience we can find in them.

Let's explore a hypothetical case that, unfortunately, you may recognize as all too common. Jack, who might or might not have a mental illness, is having a bad day. Yesterday his girlfriend left him. He is distraught, and he missed a doctor's appointment and did not take prescribed medications. Jack is sitting on his front porch when a squad car pulls up. He hasn't done anything wrong, so he doesn't try to evade the officers. They inform him that they are taking him to the crisis clinic on an amended court order. He doesn't understand and wants only to be left alone, so he resists. The more he resists, the more the officers are convinced that something is wrong with him. They pull Jack's wrists to his back and handcuff him, toss him in the back of the squad car, and later unload him at the clinic. By this time Jack is not only disturbed about losing his girlfriend, but is growing angry over being confined against his will without an explanation.

At the clinic, the situation only gets worse. Jack's appearance might have some influence on how he is being treated. He didn't have time to "dress up" for his "appointment" (he is dressed in his stay-at-home attire: a not-too-clean tee-shirt and cut-off jeans). In other words, he looks a lot like most people on Saturday mornings at Home Depot. (Look around the next time you're there, and you'll find that most of us relatively normal people don't dress in ways that inspire confidence in others when we are in a relaxed setting.)

When his case worker appears, Jack refuses to listen to her. Instead, he yells that she betrayed him and that she is lying when she says she wants to help. He doesn't want to be there, feels he can't trust anyone, and grows angrier. First his girlfriend betrayed him, and now his caseworker and the system that swore they only wanted to help betrayed him, he thinks. But the more he defends himself and speaks up, the more everyone is convinced that he/she is doing the right thing, however difficult. Against his will, Jack is medicated and calmed, and everyone involved feels better, but perhaps for the wrong reasons.

Can any of us say we might not act like Jack in that situation? Given the circumstances, did he have a relatively rational response? Did Jack have a normal human reaction to a frightening and aggravating situation, or was he ill? We submit that his reactions were more healthy than not and required attention, not restraint and treatment.

If anyone interacting with Jack had asked him why he was reacting that way and stopped long enough to let him calm down so he could explain, the outcome might have been very different. He might have regained footing on his recovery path after enduring a reasonable time of grieving over the breakup. Instead, he earned a black mark on his psychiatric record and lost faith in his case worker and the system she represents. His recovery was set back considerably, possibly irrevocably.

What can we as professionals learn from this? That our job is not an easy one. That although we are clinicians trained to diagnose and treat illness, we also must step aside and look for human strengths. We must not only sift through what we observe, but also gain additional data to accurately discern what it is we see. This involves tremendous subjectivity on our part and, frankly, additional work. It is easiest to view symptoms as consistent with an illness and apply treatment. But if we intend to provide optimum aid to persons on their path of recovery, at times we need to look beyond the symptoms and help people build resilience.

Many service-related professions have detailed criteria by which they may assess client needs and arrive at specific service delivery interventions. In dealing with subject matter as complex and intangible as someone's mental health, we have no such rigid grid. However, we remain concerned that the pressure to use guidelines and algorithms to promote evidence-based treatment will obscure the necessity for understanding the person's current situation and strengths.

Algorithms and guidelines are usually diagnostic or symptom-driven and ignore the person's presenting situation and resilience. If we make the effort to get to know the person, we can be more confident that our treatment suits the ailment, even if that treatment involves simply taking the time to listen and empathize with another person's experience.

In our next column, we will look at the traumatizing effects of forced treatment.

Lori Ashcraft, PhD, directs the Recovery Education Center at META Services, Inc., in Phoenix.
William A. Anthony, PhD, is Director of the Center for Psychiatric Rehabilitation at Boston University.
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