85 % recovery rate

Spiritual emergency you have talked previously about the85 % recovery rate achieved by John Weir Perry and Jaakko Seikkula .
I would be interested to know what definition of 'recovery' they used and how that might have differed from the definition of 'recovery' used in studies that point to a significantly lower recovery rate.

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Thanks teejai. I would love to talk about John Weir Perry and Jaako Seikulla!

The first thing we need to understand about these two men is that they were doing something different. Evidence of this difference can be found in the attitude they brought to the issue for it was this attitude that shaped their chosen response; that response appears to have made an enormous difference in outcome. The truly remarkable thing is that both men relied on forms of talk therapy as their primary form of treatment and not neuroleptic medication. The second remarkable thing is that both men worked with individuals who were in active psychotic states -- that is to say, they practiced psychotherapy with individuals who were recognized to be in a psychotic state.

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<font color=#DC143C>Among those who went through the OPT program, incidence of schizophrenia declined substantially, with 85% of the patients returning to active employment and 80% without any psychotic symptoms after five years. All this took place in a research project wherein only about one third of clients received neuroleptic medication.

...

Ongoing research shows that over 80% of those treated with the approach return to work and over 75% show no residual signs of psychosis. Official government statistics comparing 22 health districts in Finland found that Dr. Seikulla's district was the only one not to have any new chronic hospital patients in a two year period and led the National Research and Development Center for Welfare and Health to award a prize for "over ten years ongoing development of psychiatric care".

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"...85% of our clients (all diagnosed as severely schizophrenic) at the Diabasis center not only improved, with no medications, but most went on growing after leaving us."

-- John Weir Perry</font></blockquote>

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This degree of success flies in the face of conventional wisdom wherein psychosis/schizophrenia is considered to be a neurological disorder that necessitates the use of neuroleptic medication, preferably begun as soon as possible. As for psychotherapy, it's largely considered to be a complete waste of time. For example, I recall that young man, lunar_wire noting:

Rather than the current situation of being forcibly injected and when you ask someone to talk to not being given the opportunity....one month into one of my stays at hospital I asked to see a Psychologist. I was there for another two and left not having been given an appointment. That is wrong. [<a href=http://208.69.42.138:8080/jiveforums/thread.jspa?threadID=619&tstart=0">Source</a>]

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Three types of recovery
It’s important to be clear about what we mean by recovery. Many people would argue that there are actually three types of recovery and if a person can achieve any two of the three then they have recovered. The three types of recovery are:

1. Social recovery
This is to do with acceptance by the community in which a person lives. If the people around us don’t have a problem with us then we have achieved social recovery. We become productive members of our society and contribute to the social structure around us.

2. Psychological recovery
If we are not distressed by our ‘symptoms’, such as the voice hearers in Holland, then there is no problem. This is known as psychological recovery.

3. Medical recovery
This is to do with the signs and symptoms which doctors use to diagnose mental illness. If we are free of symptoms of mental disorder then we can be said to have recovered – so long as the symptoms do not return. This is why mental health professionals who are interested in recovery work hard on ‘relapse prevention’. If a person never has a relapse of their mental health problems than that must equal recovery.

[b]Source: Understanding Recovery


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My own definitions of recovery are a little bit different. When I'm looking for evidence of recovery, this is what I'm looking for:

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Recovery means different things to different people -- it must be self-defined. For most people, recovery means some equivalent of "normalcy". People who self-identify as recovered are people who are engaged in productive activity that is meaningful to themselves or others, such as work or school. They are either living on their own or contentedly with others. They have a network of personal and social relationships that are, themselves, relatively stable and healthy. They are either symptom free or whatever symptoms remain are no longer distressing.

Some recovery models state that in order to be considered fully recovered you have to be med-free. I don't agree with that stance because I've spoken with plenty of people who self-identify as recovered even if they still take medication. Being med-free is not the equivalent of being recovered. Being recovered is when you have resumed a place in larger society that brings you a sense of meaning, purpose and value.</blockquote>

It's worth noting that I apply two standards according to who is doing the reporting. I believe that for the individual, the self-definition of recovery takes precedence. If they are engaged in productive activity such as paid employment or volunteer work; if they are contentedly living independantly or interdependantly with others; if they have a social network of reasonably healthy relationships and if they self-define as recovered even if they continue to take medication or experience some symptoms, I still think that's recovery. Likewise, if they're doing all those things but consider themselves to not be recovered because they still take medication or experience some symptoms, that's also for them to determine.

I'm going to apply a higher standard to professionals however, particularly in the area of medication. What I want to see in a professional's recovery rate is either no medication or a very low rate of medication. This is because we know that medication itself comes with a host of side-effects that can inhibit recovery. Can it be said that a client is recovered if they're no longer psychotic but instead, have suffered neurological or physiological damage such as tardive dyskenisia or diabetes as a result of treatment with neuroleptic medication? It may well be that an individual is willing to accept that risk or sacrifice and can still create a life for him/herself that is personally rewarding and meaningful. However I don't consider it acceptable if a clinician imposes those risks on an individual and still calls it recovery. The individual's task is to make the best of what they've got, the physician's is to produce healing. Giving someone diabetes instead of schizophrenia does not equate in my mind with healing, and this is why I insist on a more stringent standard from a professional.

I'm going to follow up this post with two more, detailing some of the differences offered by these two physicians, while keeping an eye to what successful recovery looks like and how successful treatment can produce it.

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Jaako Seikulla</center>

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Jaakko Seikkula, Ph.D. is a professor at the Institute of Social Medicine at the University of Tromso in Norway and senior assistant at the Department of Psychology in the University of Jyvskyl in Finland. Between 1981-1998, he worked as a clinical psychologist at the Keropudas hospital in Finland where he and colleagues developed a highly successful approach for working with psychosis known as Open Dialogue Treatment (OPT). The approach de-emphasizes the use of drugs and focuses instead on developing a social network of family and helpers and involving the patient in all treatment decisions.


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Right away we're seeing some critical differences, namely:

- a de-emphasis on the use of drugs

- the inclusion of the individual's larger social network

- the involvement of the individual in all treatment decisions. They are acknowledged as having insight into their experience and the ability to determine what forms of treatment will be most beneficial for them.

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This article describes the results of a program designed for first episode psychotic patients in Western Lapland, Finland, which has a population of 72 000. The study is part of the national project of Integrated Approach to the Treatment of Acute Psychosis (API), carried out since 1992, by the National Research and Development Center for Welfare and Health (Stakes) in conjunction with the universities of Jyväskylä and Turku. Western Lapland, as one of the six research centers, has had, as its specific task, to organize the treatment by minimizing the use of neuroleptic medication. (Lehtinen et al., 1996).

In the treatment program, a family- and network-centered psychiatric treatment model for the whole area has been developed. This is based on:
[*] An immediate response to the crisis during the first 24 hours;
[*] The participation from the outset of the patient´s family and other key members of their social network;
[*] Avoiding inpatient treatment by organizing home visits as often as needed in an attempt to avoid hospitalization;
[*] Open dialogue at treatment meetings about all the issues concerned.

The basic idea is to organize psychotherapeutic treatment for all patients within their own social support system.


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Once more, we're seeing some very different approaches, specifically:

- Labelling the experience as a "crisis" as opposed to psychosis or schizophrenia. I've spoken before of the value of the language we use: a "crisis" is recognized to be a difficult but temporary stage in life whereas "schizophrenia" is considered to be incurable. This association of "incurability" can translate as hopelessness.

- Home visits. You don't go see them, they come and see you.

- Adaptation by the support team to the individual's social support system.

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The aim of this study was to clarify:

1. Whether the home treatment of acute psychotic patients is a viable option.

2. Whether the therapeutic approach emphasizing open dialogue with adequate social support decreases the need for neuroleptic medication.

3. The effect that the treatment model has in reducing psychotic symptoms, in enhancing psychological functioning and in promoting working capacity during a two year period.

The background for minimizing the use of the neuroleptic medication was not in itself a "non-medication" ideology, but a research task defined in the API project. One task of the project was to study the need and meaning of neuroleptics when first episode psychotic patients are treated with an intensive psychotherapeutically oriented and family-centered intervention from the start. In this respect, three research centers out of six tried to avoid the use neuroleptic medication at the start of treatment. The results of these three were compared with the three other research centers where neuroleptics were used according to the traditional practice. The question of neuroleptic medication is not the main theme of this paper, but an interesting detail. The aim is, rather, to improve information to develop the adequate practice of medication as a part psychotherapeutic treatment of new psychotic patients.


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I think that's an interesting detail. It tells us that these people weren't opposed to medication from the get-go but they were open to examining its role within the experience. There are a number of very valid reasons for avoiding medication if possible including the risk of side-effects and the cost of the drugs. I can't find the report at the moment but I recall reading not long ago that the budgets of some health care regions in the US are being broken by the cost of new atypicals. It's very important that we be willing to consider non-medication approaches that offer success.

Meantime, the article goes on to detail several previous studies that had been done with individuals experiencing their first episode of psychosis before getting into a detailed exploration of the Open Dialogue Approach...

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In all psychiatric problems regardless of the diagnosis, if it is a question of a crisis situation, the same procedure is followed. If there is a question of possible hospital treatment, the crisis clinic in the hospital arranges an admission meeting, either before the decision to admit for voluntary admissions, or during the first day of inpatient treatment for compulsory admissions. At this meeting a tailor-made team, consisting of both outpatient and in-patient staff, is constituted for each case. This team takes charge of the entire treatment sequence, regardless of whether the patient is at home or in the hospital and regardless of how long the treatment period should be. The hospital boundary is thus made flexible in two ways: (1) the team consists of both inpatient and outpatient staff and (2) the same team continues its work after hospitalization has ended.

In the course of research programs and psychotherapeutic training, seven main principles of open dialogue approach have been concluded. They are:
[*] Immediate help: The teams arrange the first meeting within 24 hours of the first contact, made either by the patient, a relative or a referral agency. In addition to this, a 24 hours crisis service is organized.
[*] Social network perspective: The patients, their families, and other key members of their social network are always invited to the first meetings to mobilize support to the patient and to the family. The other key members may be other authorities, including also employment authorities and public insurance authorities to support vocational rehabilitation, fellow workers or chiefs from working place, neighbors or friends.
[*] Flexibility and mobility is guaranteed by means of adapting the treatment response to the specific and changing needs of each case using the therapeutic methods which best fit each patient and his/her family. The first meeting is proposed to organize at patient’s home.
[*] Responsibility: Whoever was contacted is responsible to organize the first meeting in which the decision of treatment is made and the case specific team takes charge of the entire treatment.
[*] Psychological continuity: The team takes the responsibility of the treatment for as long a time is needed both in outpatient and inpatient setting.
[*] Tolerance of uncertainty is focused by means of building up a safe enough scene for the joint process. In psychotic crisis, enough safety means meeting every day at least for the first 10 – 12 days. Too immature conclusions and treatment decisions are avoided. For instance, neuroleptic medication is not started in the first meeting, but, instead, it should be discussed at least in three meetings before starting it.
[*] Dialogism: The focus is primarily on promoting dialogue, and secondarily on promoting change in the patient or in the family. Dialogical conversation is seen as a forum where the families and the patients receive more agency in their own life by discussing the difficulties and problems. The new understanding is built up in the area between the participants of the discussion.

The main forum for the therapeutic interaction is the treatment meeting. Here the important participants in the problem - the patient, his/her family, and other members of his/her social network and other authorities - gather to discuss all the issues associated with the actual problem. The treatment plans and decisions are also made with everyone present and there are no other treatment planning discussions among the staff without the patient. On the whole, the adult sides of the patient are focused instead of regressive behavior.

The task of the conversation in the treatment meeting is to construct a new language for the difficult experiences of the patient and those nearest him/her, which are connected with the psychotic behavior. Psychosis can be seen as a way of handling such difficult and often terrifying experiences in the life of the patient and those nearest him which do not yet have words. Holma and Aaltonen (1997) defined this as the pre-narrative quality of psychotic experience. The therapeutic task is to construct words and new joint language for those experiences. Open dialogue is that in which all those who have seen the problem can participate. The aim is to improve understanding of the problem and its context. In constructing the new language, the treatment meeting has three important functions:

1. To create the space for joint experience through gathering information about the family's life and the events that led to the crisis. All the team members participate in the interview.

2. To comment on the observations the team members make in this interview concerning the family, the team (e.g., regarding different opinions about treatment) and the relationships between the family and the team. Team members discuss what they hear with each other openly.

3. To reflect on the difficult feelings that the problem may awaken in team members. By discussing different ideas arising during the conversation the team can make dangerous issues less dangerous for themselves and for the family. Andersen (1991; 1995) sees the reflective process as a transition between listening and talking. When talking to a listener one is in outer dialogue; while listening to someone talk one is in inner dialogue with him.

Any traditional treatment methods may be used if they are judged necessary. The patient can have individual therapy or other therapies (e.g. art therapy, group therapy); the family can meet for family therapy. Early rehabilitation is focused by means of inviting employment authorities and the local authorities of National Insurance Institute to prepare plans for vocational courses or working training. This approach continues the ideas of Need-Adapted-Treatment developed by Alanen (1997) and his co-workers. The starting point for treatment is the language of each specific family, how each family has, in their own language, named the patient’s problem. The treatment team adapts its language to each case according to the specific needs.


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The above allows us to see how the principles of Open Dialogue Treatment are put into practice. This is a very, very different approach and yet, it is producing outcomes that are substantially superior to most anything produced elsewhere. That's not to say that it is helping everyone or can help everyone -- if you read through the full article you're going to find more details and case studies that demonstrate that. But a very high percentage of those who are going through this program are also working and living contentedly. They have stable relationships within a larger social network and only a small percentage of them remain dependant on medication. This is what recovery looks like.

All of the above quotes were lifted directly from one article, this one: <a href=http://www.talkingcure.com/docs/jaako_seikkula_paper.rtf>Open Dialogue Treatment: A Two Year Follow Up [PDF File]</a>. I encourage those who are interested in the work of Jaako Seikulla and Open Dialogue Treatment to use a good search engine to find more information as related to this approach. When you find them, I suggest that you make copies for your own personal use because websites and links can disappear overnight. Here are a few links to help get you started:
[*] Dialogue is the Change
[*] Learning From Northern Europe
[*] The Space Between People: Seikulla's Open Dialogue Approach

In spite of the incredible success of the Open Dialogue approach, it's highly unlikely that you or your loved one will be able to find a similar or equitable program anywhere in the Western hemisphere. But you can use the above to help guide you in your explorations of treatments offered in your locality. You may also be able to adapt some of the practices for your own benefit. For example, you may be able to arrange for your own psychotherapy, even if it's not offered within your current therapeutic setting. You may find it helpful to review this blurb by Dr. Bertram Karon before seeking out a psychotherapist to work with.

If you're exceedingly fortunate, your "therapist" will fall into your head during a state of psychosis and talk you through the totality of that experience. Which brings me to the work of John Weir Perry and Carl Jung...

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John Weir Perry</center>

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The idea that the inner Apocalypse might - for alienated people - be the guardian of the gate to a sustainable civilisation has a metaphorical ring of truth which I find appealing. To explore it further, I went to California in the early 1980s to meet a man who was especially knowledgeable on the subject. I had first met John Weir Perry a few years before in Boston at the first conference of the International Transpersonal Association (ITA), and was impressed by his compassion, wisdom, and humility.

John Perry was a Jungian psychiatrist who founded an experimental residential facility called Diabasis, in San Francisco, California, during the 1970s. This was designed as a comfortable home where young adults, who were experiencing the initial days of their first "acute schizophrenic break", could live in and be empowered to go through their Apocalypse on the way to greater health and happiness. The results were amazing: without any treatment by medication, electroshock or locked doors, full-blown "schizophrenics" were able to go through their ego-death and emerge on the other side, as Perry puts it, "weller than well." Instead of being sent to the mental hospital and/or taking medication for the rest of their lives, these certified "schizos" would live at the facility for the first three months, spend the following three in a half-way house, and then return to the outside world, never having any relapse of their "schizophrenia" again!

...

Dr. Perry met Carl G. Jung in Switzerland as a young medical student. He then became a psychiatrist. As a conscientious objector during World War II, he served for two years as a medic in the U.S. Army, attending to war victims in China. Here he was impressed by the character of the people and profoundly touched by their ancient philosophy of the Tao. He noticed the similarity between the traditional Chinese view of the universe as a self-organising system, and Jung's idea that schizophrenia is not a disease which the psychiatrist should attempt to control, but rather a spontaneous healing process which a subtle therapist might indeed facilitate through a kind of psychological shiatsu. After the war Perry returned to San Francisco, where he went into practice in 1949.

Source: When the Dream Becomes Real


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I don't know who might have had such an influence on Jaako Seikulla that he developed the approach he did, but in Perry's case, the influence is obvious. Perry was a Jungian trained psychiatrist and like Jung, believed that "schizophrenia" was an indication of a blockage in the psyche of the individual going through the crisis.

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MICHAEL O'CALLAGHAN: How does one define so-called schizophrenia?

JOHN WEIR PERRY: Jung defined it most succinctly. He said "Schizophrenia is a condition in which the dream takes the place of reality." This means that the unconscious overwhelms the ego-consciousness, overwhelms the field of awareness with contents from the deepest unconscious, which take mythic, symbolic form. And the emotions, unless they're hidden, are quite mythic too. To a careful observer, they're quite appropriate to the situation at hand.

The way "schizophrenia" unfolds is that, in a situation of personal crisis, all the psyche's energy is sucked back out of the personal, conscious area, into what we call the archetypal area. Mythic contents thus emerge from the deepest level of the psyche, in order to re-organise the Self. In so doing, the person feels himself withdrawing from the ordinary surroundings, and becomes quite isolated in this dream state.

MICHAEL O'CALLAGHAN: Did Jung really see this as a healing process?

JOHN WEIR PERRY: He did indeed! He believed that "schizophrenia" is a self-healing process - one in which, specifically, the pathological complexes dissolve themselves. The whole schizophrenic turmoil is really a self-organising, healing experience. It's like a molten state. Everything seems to be made of free energy, an inner free play of imagery through which the alienated psyche spontaneously re-organises itself - in such a way that the conscious ego is brought back into communication with the unconscious again.

Source: When the Dream Becomes Real


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Unlike Seikulla, Perry didn't involve the larger network of the individual's social circle. Rather, he focused on the content of the psychosis itself and sought to create "the least toxic environment" he could in which individuals would be allowed to progress through their experience of psychosis with support...

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The Facility: Diabasis was an experimental project in San Francisco. It was a residence facility that lived through three years and more of inpatient work with acute "schizophrenic" episodes in young adults without the use of medications, always as part of the county's community mental health system. Its purpose was to provide a home in which clients might have the opportunity to experience with full awareness their deepest processes during this intense turmoil.

Staffing: The facility was staffed by twenty paraprofessionals who served not only the ordinary functions of attendants, but also provided psychotherapy as counselors. Some of these held fractions of our seven paid positions, while others were volunteers. Although this arrangement brought the secondary benefit of lower cost, it's primary purpose lay in selecting individuals by disposition rather than by professional category; we picked ones who by qualities of empathy and ease with psychic depth were particularly suited to this work, whom we could then educate and train on the job.

Theory and Method: The orientation ultimately derived out of a Jungian approach although not all staff were specifically given to that theory and method; instead, several modalities were drawn upon. There was a consensus on the basic viewpoint that the acute "psychotic" episode under discussion typically contains elements of a spontaneous reorganization of the self and that therefore, if handled well, may result in self-healing. The therapeutic aim was to avoid the damage of labeling and disqualifying attitudes and instead, to respond to all that happens intrapsychically with honest feeling; also it was to validate the efforts the psyche makes spontaneously to effect a transition from a poor state of organization of the self to one that is more suited to the nature of the particular individual's disposition. The processes expressed in the imagery and emotion frequently lead to profound changes in one's outlook and lifestyle, specifically in one's cognitive structures, value system and belief system.

Progress of Therapy: Our most surprising finding in the case of early acute episode was that grossly "psychotic" clients have usually come into a coherent and reality-oriented state spontaneously within two to six days, without need for medications. We have found that our work was most effective with those acute early episodes that were productive of imageful content. With clients who came to us in their third or fourth episode, we often found that their experience was beneficial but the outcome less striking. Chronicity was another matter and the chances of fruitful experiences more uncertain. A history of heavy medication usually made it difficult to do effective psychotherapeutic work.

Conclusions: Returning to the question of what alternative programs can be, we arrived at certain conclusions. Such a program can be much more than benign mileau therapy. It is possible to do effective psychotherapy in the acute episode, since the client's talk is clear and the material of dynamics active and ready to hand. The use of medications can be reserved for backup alone, for the rare times when behavior becomes too hard to handle and after other psychological means have been attempted. Therapy is best conducted in the spirit of nondoctrinaire openess to learn from the clients what the experience of their altered states is, and what it feels like to go through this process, and thus to be of help in facilitating its own aims toward reorganizing the self. When allowed to proceed, we find that a growth process is often underway that can be sustained, with consequent developments in one's system of meanings, value, beliefs and lifestyle. This treatment mode may then help avoid the devastating picture of incapacitation and recidivism that now prevails, and then becomes a burden to mental health systems. The cost-effectiveness of such a program depends entirely upon its use by the community to handle acute and early, if not first, episodes, with the prospect that these clients might be benefited in such a way that they would no longer remain indigents, dependant upon the county for aftercare.

Source: Trials of the Visionary Mind: Spiritual Emergency &amp; The Renewal Process


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More than a year had passed since my own experience of psychosis and when I stumbled across the work of John Weir Perry. It was the first time I was able to say, "This is it. This is what happened to me." Although I feel that Seikulla's approach is more acceptable to mainstream thought, Perry's approach remains nearer to my own heart because it's "my" experience. Like Perry, I also created a space of psychological safety for myself where I could both have and be supported through my experience. In my case, my support came in the form of an "imaginary companion" -- someone I could talk to. Perry would rightly identify that individual as my animus.

As a Jungian, Perry's emphasis was on interpreting the meaning of the content expressed in psychosis and determining where and how that applied to the individual's life. Likewise, I also sought to interpret and understand the symbolic meaning of the contents of my own experience. Understanding brought insight, and insight brought healing. It cannot be said that I am "psychotic" any more. Nor, in spite of my experience spanning more than two years, can it be said that I am "schizophrenic". I am working, my relationships are stable, I am not on medication. I am recovered.

Once more, individuals are not likely to find a treatment program in the Western hemisphere that is built upon Perry's work. However, there is a Diabasis project in Prague. There is also the opportunity to put into practice what we can learn from him.

My own blogs are filled with numerous quotes pulled from the work of John Weir Perry. He has also written a number of books that may help those who have gone through this experience to better understand what their experience means. If you find meaning in anything I've shared as related to him, I would likewise, encourage you to seek out his articles, tapes, books, etc. Here are a few links to get you started:
[*] [b]The Inner Apocalypse
[*] Treatment or Therapy?
[*] Visionary Experience in Myth and Ritual

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Hello once more teejai:
I thought the following excerpt was also appropriate for this topic because it refines even further the definition of recovery. Those of you who are familiar with the article are welcome to skip the link. Those of you who have never read it may find it insightful.

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I have entitled this presentation, "Long Term Outcome for Rehabiliated Psychiatric Patients: Reasons for Optimism". The plan this morning is to look at recovery and the evidence for it among people with very serious mental illness. Let us look at some things that we've learned about rehabilitation and also a little bit about resilience. I'm going to present seven of the ten world studies this morning.

Now, <font color=#DC143C>when we talk about subjects who are recovered, we're talking about no medications, no symptoms, being able to work, relating to other people well, living in the community, and behaving in a way that you would never know that they had had a serious psychiatric disorder</font>. And if you have heard of that old belief that one third get better, one third get worse, and one third stay the same, we found that it was not true. In the Vermont Longtitudinal Study, we took the bottom third of this population and found that two-thirds of them also turned around...

-- Dr. Courtenay Harding

Source: <a href=http://spiritualrecoveries.blogspot.com/2007/01/myth-busting-schizophrenia-is-incurable.html>The Recovery Vision</a>

teejai, since this topic also came up in our brief conversation, I'm bumping this thread up to the top as well. I'm not certain if you had some unanswered questions in regard to the work of John Weir Perry and Jaakko Seikkula. If you did, I would prefer to discuss them in this venue.

Regretably, the software has changed since we first discussed these issues and I can't go back to edit the format from HTML to BBCode. Most of the content is still quite readable however.

~ Namaste