[spiritual_emergency]

Editor's Note: What is an empowerment model of recovery? How is it useful, perhaps invaluable, in the daily practice of psychiatry? What data support it? To get to the core of these issues, Randall White, MD, interviewed Daniel B. Fisher, MD, PhD, Executive Director of the National Empowerment Center in Lawrence, Massachusetts.<blockquote>

Medscape: In your publication "Personal Assistance in Community Existence: A Recovery Guide," you write that the recovery model emphasizes that emotional distress is a temporary disruption in life. Can you elaborate?

Dr. Fisher: Our description of mental illness is a combination of severe emotional distress and an interruption of a person's place in the community and social role -- being a worker, parent, student, a participant in overall community life -- which is not dissimilar from what is considered a mental disorder in DSM-IV. The most important finding in our research is that people who have shown significant or complete recovery from severe mental illness -- by that I mean schizophrenia, bipolar disorder, or schizoaffective disorder -- have cited hope as an extraordinarily important component in their recovery. Part of the recovery was being around people who saw their condition as not permanent, a condition from which they could take increasing control of their life and reestablish a place in society.

Medscape: You also write, "It is much more difficult to recover once a person is labeled mentally ill." How have you found that to be true?

Dr. Fisher: If people don't have the internal capacity, and the severity of their distress is too overwhelming, and they don't have the finances, the education, the social surroundings, and family to help them, they end up with the label of mental illness. The severity becomes greater because, in addition to having to recover from the severe distress that interrupted their capacity, they also have to recover from the role of being mentally ill.

The biggest example of that is Social Security; another is the loss of rights and the trauma that often occur in being hospitalized. For many people, it's very traumatic being hospitalized.

Medscape: Your publications make reference to the difference in outcome of schizophrenia in less-developed societies compared with industrialized societies. What does the research indicate?

Dr. Fisher: The evidence is from 2 studies by the World Health Organization (WHO), one in 1979 and the second in 1992, comparing the recovery rate, mostly from schizophrenia, in developing countries with the recovery rate in industrialized countries. In 1979, WHO had about 1800 cases validated by Western diagnostic criteria in developing counties matched with controls from industrialized countries, and they found that the recovery rate was roughly twice as high in the developing countries compared with the industrialized. They were so surprised by this that they said, "Well, this must be a big mistake." So they repeated the study in 1992, and they got the same results.

Medscape: How do you interpret this and what are the implications for us as psychiatrists in industrialized societies?

Dr. Fisher: The implications are profound. It shows that schizophrenia is more pronounced and prolonged in industrialized countries. I've started to gather information from developing countries about how they approach treatment and healing. They have a completely opposite approach from Western countries. They're very socially oriented, and they instinctively recognize the importance of keeping people connected to the community. We have ceremonies of segregation and isolation, which is really what our labeling and our hospitalization process is. They have ceremonies of reintegration and connection.

Medscape: Can you contrast the medical model with your empowerment model in the approach to psychosis?

Dr. Fisher: The first contrast is that we say to the people going through the experience that this is not a permanent condition and that other people have recovered. We try to expose them to people who have recovered and who can be role models. When I'm working with people who are undergoing psychosis or long-term severe mental illness, I share some of my own experience with them and how I too at times heard voices and had the television talk to me.

The second part is that we help them understand that these symptoms are expressions of distress over their lack of a connection on a deep emotional level to the people around them, that they involve loss and trauma and interruption in social development. We go through with them a set of 10 principles of recovery that we have established through our research, which is the qualitative study of people who have shown complete recovery from severe mental illness, mostly schizophrenia.

Through this model we emphasize the reestablishment of personal connections. It's often peers who are the most significant guides for recovery. This is because, if you've been through the experience yourself, you're often able to connect with another person in a verbal and especially a nonverbal fashion that is hard for people to do who have not been through the same experience. That connection is vital to people's recovery.

[...]

Medscape: What is the role of medication in your model?

Dr. Fisher: Ideally we would like to see settings provided -- Soteria House you may have heard of -- where people can go when they need more intensive social supports. We expect that if there were more of these settings, there would not be as much need for medication. The need for medication I tend to see as a failure of the person's world and their own internal resources to sustain emotional equilibrium sufficiently to remain in consensual reality, and I don't know whether it's one or another neurotransmitter, but clearly when people are feeling very frightened or confused, it's hard for them to be reached by another person. During those times I do prescribe medication and say, "This is to help you to gain control of yourself and your life. Hopefully, you won't have to take it for a lifetime."

I think it's very important that people hear that it's to be used as a tool. I always point everything toward how can you learn to be with other people, to make friends, to get a job, to go back to school, and to perform adequate self-care. Because if you don't, and I'm afraid I see this a lot of times the way medication is used today, people start to believe that the medication will solve their problems, and that's a kind of magical thinking. And it takes away responsibility, motivation, initiative.

Source: An Empowerment Model of Recovery

See also: [*] Believing You Can Recover is Vital to Recovery[*] Learning From Northern Europe</blockquote>

[mlyn]

Did they live it or is it what they just say?

[spiritual_emergency]

I don't know about the interviewer, Randall White, but Daniel Fisher was diagnosed with schizophrenia as an early adult and has since made a full recovery.