STAGES OF RECOVERY

Every once in a while, someone speaks with such clarity and vision, that they seem to sum many of the thoughts that one has been ruminating over, and because of the experience one can see one's life and work in a new way. This happened to me one day last February.

I was in a day-long seminar not expecting anything particularly remarkable. I had been invited because I am on the Alameda County Mental Health Services anti-stigma speaker team. The speaker was Dr. Mark Ragins, Medical Director & Staff Psychiatrist at 'The Village' an Integrated Service Agency, in Long Beach. As I was to learn, The Village has become well known for being successful in treating many of the most difficult psychiatric cases, often involving homelessness and schizophrenia. Dr. Ragins was there to tell us how they do this. They use an approach different from many other medical treatment facilities: by having all the services required in one location and by a 'recovery-based' treatment philosophy which guides how they treat their residents. I found his approach to be refreshing, fascinating and helpful. Many of the others taking this seminar with me were mental health professionals in more traditional settings, and I could see that his ideas were challenging the way they thought of their work.

In a recent Mission Peak newsletter column I outlined one of Dr. Ragins' concepts, the 'Stages of Recovery' from mental illness. Several people from our congregation responded saying that these had been very helpful to them. Today, I'd like to share more of what I learned with you, and give you my reflections on how this work fits in with our liberal religious principles.

Many of you are familiar with work by Dr. Elizabeth Kubler-Ross who identified 5 stages of death and dying: denial, anger, bargaining, depression and acceptance. The stages of recovery from mental illness are an analogous concept. They are phases that people go through - generally one after another, sometimes several at once, sometimes in different order. But the stages are a conceptual framework that can help us understand what might be helpful at a given time in recovery, and it can give us hope because we can see that recovery is a process with a known trajectory.

When I listened to Dr. Ragins talk about the different stages, I could envision several of the people I have come to know in my mental health ministry, seeing where they were, and understanding what they might need at that point in their lives. As I have talked to others about this model, I can see that this reaches a responsive chord with them, as well. Some people have offered me their commentaries and additions to Ragins' stages, which I will try to reflect in what I say here. Recognize that the model is just a model, and as such is not a perfect determiner of human behavior. Also, recognize that there can be back-sliding, and repeated learning of lessons previously learned.

Prerequisites

I'll begin with something that is not part of Ragins' model but, in my opinion as well as that of other mental health clients and care givers I have spoken to, is necessary for recovery to begin. Before the first stage are the prerequisites that the person's physical needs, including housing, food, care and medication are being met that, and further that the person accepts that there is a problem with their mental health. These prerequisites may not be a problem with many of us here, but in my experience are real problems for many of the chronically mentally ill in our society without insurance, medical care or even homes. You can't even begin to recover without these. So, I've added them before the start of Dr. Ragins' list.

The first stage identified by Dr. Ragins is HOPE.

He describes it like this:

During times of despair, everyone needs a sense of hope, a sense that things can and will get better.
Without hope, there is nothing to look forward to and no real possibility for positive action.
Hope is a great motivator. But for hope to be truly motivating, it has to be more than just an ideal. It has to take form as an actual, reasonable vision of what things could look like if they were to improve.
It's not so much that people with mental illness will attain precisely the vision they create, but that they need to have a clear image of the possibilities.

Speaking to our audience of practitioners last February, Ragins told us stories from his experience at The Village. He spoke of a former patient who had been living on a bench at a bus stop for more than a year. "That's the last place he saw his mother before she went to the hospital to die," and he was waiting for her to return. He saw demons in trees and was suicidal when Ragins met him.

Under Ragins' care, the man began to improve. When asked about the patient's prognosis on an application form for disability income, Ragins wrote about the patient's difficulties but also that he was hopeful that things would improve.

The form came back to Ragins with a request. "The mental health advocate asked me to change the part about hope because otherwise the patient would be denied disability - he wouldn't be considered permanently disabled." Ragins made the change so not as to hurt his patient, but it gave him pause. I agree with him that there is something wrong with a system that encourages a hopeless prognosis.

Ragins told our seminar, "Most people with serious mental illness have a hard time believing in themselves. We have to believe in them until they can believe in themselves again." He believes we're not very good at promoting hope in psychiatric patients, because we have been taught that these disorders are hopeless. We need to demand and create a system where hope is allowed, indeed encouraged.

I believe that peer support groups are a very powerful tool in helping people to get hope. I remember being in the psychiatric hospital with major depression and the first time I started believing that maybe my life was salvageable was after I talked to another patient who had been quite ill and was now ready to be released. Through her example, I saw it was possible to get better and this was the start of hope for me.

The second stage in recovery is EMPOWERMENT

People need to have a sense of their own capability and their own power. Often, they have been injured in this area.
Their hope needs to be focused on things they can do for themselves rather than on new cures or fixes that someone else will discover or give them.
To be empowered, they need access to information and the opportunity to make their own choices.
They may need encouragement to start focusing on their strengths as well as their losses.
Often people have to experience success before they believe they can be successful.
Sometimes they need another person to believe in them before they're confident enough to believe in themselves.

Ragins believes that the most empowering thing psychiatrists can do is to treat their patients as partners in their treatment, including making decisions on medications. The medications prescribed for treatment should be a part of improving the client's lives, not just treating the illness.

Before treating one patient with auditory hallucinations, Ragins asked him what he would like to accomplish if his voices weren't present. The patient replied that he would like to meet people and make friends, but the voices often prevented him from doing so. After educating the patient about the range of medications that would diminish the voices and the side effects of each, Ragins and the patient decided on a medication.

At the next appointment, Ragins' first question was not "How are the voices?" he said. It was, "Did you meet any people and make friends?"

He hadn't. Although the voices had diminished, Ragins said, the man was now embarrassed to approach people because the medication caused his hands to shake.

Ragins continued to work with the patient to find the medication and dosage that permitted him to reach his goal - making friends - by finding a balance between symptom relief and side-effects. That is, he focused on the improvements in the client's life rather than only the symptoms of the illness.

The third stage in recovery is SELF_RESPONSIBILITY

As people move toward recovery, they realize they have to take responsibility for their own lives. We realize this even as we know that we continue to be social beings and need others.
This means they have to take risks, try new things and learn from their mistakes and failures.
It also means they need to let go of the feelings of blame, anger and disappointment associated with their illness. Anger is something we all face, along with the challenges of containing it and expressing it appropriately. This is a particularly difficult stage for people with mental illness and their caregivers. Old patterns of dependency must be broken.

And, the fourth stage in recovery is A MEANINGFUL ROLE IN LIFE

Ultimately, in order to recover, people with mental illness must achieve some meaningful role in their lives that is separate from their illness.
Being a victim is not a recovered role and, frankly, neither is being a survivor.
Newly acquired traits like increased hopefulness, confidence and self-responsibility need to be applied to "normal" roles such as employee, son, mother and neighbor, apart from their mental illness.
It is important for people to join the larger community and interact with people who are unrelated to their mental illness.
Meaningful roles end isolation and help people with mental illness recover and "get a life."

Ragins tells of meeting a new member of his rehabilitation program. She was 22 years old, had been using a variety of drugs beginning at age 15, became psychotic and after an arrest for prostitution at age 21, was hospitalized in the forensic ward for four months. She returned home and had spent the last year "resting" at home, taking medication without any symptoms. Her parents were controlling all her new SSI money; she was not using drugs or getting into any trouble. She wanted to know why Ragins was hassling her about going back to ballet, or college, or 12 step groups, or getting a job, or a car, or dating, when she was satisfied; her family was satisfied, and her psychiatrist was satisfied. He replied that just because she'd had some serious mental and drug problem didn't mean she had to give up on the rest of her life and that it was much harder to get going again if she waited until she was 42 instead of 22.

Human Kindness

Ragins relates another story about a client named Pam. The Village team took Pam out to a celebratory lunch to celebrate the "A" she got on her first test. At the lunch, Pam said she wanted to thank Ragins. He asked Pam what he had done. It seemed to him that she'd done all the hard work. She said that every time she came to see him and started complaining about her boyfriend, her agitation, her medication or Ragins himself, he talked about how he could see her as a student at Long Beach City College. He'd remind her that registration was coming up or offer to call a friend of his in the disabled student's office for her. After a while, it seemed like a real possibility. She started to see herself as a student, too. Pam said that once she could see it, she could go out and do it.

The Village has been successful in treating many of the most seriously ill mental health clients. Ragins says that after they recover, and he asks them what made the difference, the answer almost always comes back saying something like "It was when you believed in me when no one else did," or "When you let me sit in your car when I was dirty," or "When you hugged me and I knew you felt how hard it was for my kids to be taken away from me." In other words, it was when they were the recipient of an act of human kindness, or a time when we believed in them. These moments are what help in healing. Ragins believes that the psychiatric system in general has too few such moments. He believes that if the boundaries between practitioner and client are so high that "they prevent all that healing, that's too high a price to pay."

Here is where the church comes in. Religions major in human kindness. We can believe in people. We can see something inside them that they aren't able to see. They can impart a state of acceptance and love when an illness isn't treated, or even when a person is utterly hopeless. We may not even realize this is happening, although it may be the most central factor in a recovery.

I know this to be true in a very personal way. When I started going to a Unitarian Universalist church in Hayward shortly after being released from a psychiatric hospital, I didn't tell anyone but the minister about my hospitalization. Even though they didn't know about my illness, the people in the church showed me many kindnesses; they involved me in church projects; they liked the bread I would bake for coffee hour and told me so; they were interested in my ideas. In other words, they treated me as though I was a person with inherent worth and dignity; they treated me with compassion; they offered ways that I could explore my emerging spirituality, searching for what was meaningful and true in my life. If those last few words sound familiar, they should. They come from the Unitarian Universalist Principles and Purposes. Those people in that church lived out their religion to a very wounded person and it helped me to heal. It changed the course of my life and I am eternally grateful.

I was telling a minister colleague of mine about the four stages and I saw a look of recognition pass over his face. He said that there was one of his congregants who had recently had a serious mental health episode, and everyone in his life was unsuccessfully trying to get him to do this or to do that activity. My colleague realized that this man was back at stage 1 where his friends were treating him like he was at stage 3 or 4. He didn't have any hope, and that until he had hope, these activities weren't going to do any good. My colleague realized that the man was coming to church primarily to find hope. And, my friends, I submit that this is what we are here for - to get and to give hope.

After reflection, I've come to believe that these four stages of recovery that I learned at that seminar last February don't apply only to people with serious mental illness. I believe that they are true to a greater or lesser extent of people with the many disappointments that one has in one's life. It might be a bad grade on an important test, the loss of a job, a divorce, or a serious accident or illness. In learning how to go on, it seems to me that one needs to start with hope, then move to understand one can do something to get over it, then move to doing something and finally move to creating a meaningful life living with the fact that a disappointment has happened in the past.

I believe that this congregation is a community which lives out its religion. Acts of human kindness abound here. This community has the power to change lives, helping us to all recover from the wounds, however deep that we may have acquired. No matter what stage of recovery we happen to be on.

So be it.
Amen.

Note on Sources:

Reference papers by Mark Ragins from his web-site www.village-isa.org were used for quotes in writing this sermon:

History and Overview of the Village
An Overview of Recovery
Sewing a Mental Illness Recovery Banner
Recovery with Severe Mental Illness: Changing From a Medical Model to a Psychosocial Rehabilitation Model

and an article about Ragins' work:

"Psychiatrist Won't Accept Assumptions of Hopelessness" from Psychiatric News, Jan 16, 2004 by Eve Bender at

I gratefully acknowledge the contributions of Karen Ilkka in developing the ideas in this sermon.