xxAACP Newsletter, Volume 11,
Number 1, Winter 1997
Promoting Self Managed-Care
How Clinicians Can Promote Self-Managed Care
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 psychiatraist, 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. 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 provider's world.
Self-Managed Care is the Goal of Managed Care
Under managed care, the least costly, most effective approach is to
assist peoples' 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 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 meant that
psychological problems are mechanical problems. Then 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. 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.
It was 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.
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 being 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 their self through real
emotional and interpersonal learning.
Self-Management Planning Comes First
When a person suffering emotionally seeks help, they 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 their 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 its 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:)
- Self-to-self level: this is the level of self-help, coping
strategies:
- 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
- Exercise, diet, meditation, biofeedback, visualization
- Self journal writing
- Self-to-helper level:
- Clinical treatment: such as psychotherapy, medication,
rehabilitation, and some innovations:
- Advance directives and health care agents: persons can extend their decision making beyond usual point at which a clinician takes over by describing the types of services and medications a person wants when they are in a crisis. It is also helpful to designate a health care agent to assist the person with decision making during a crisis.
- Peer-oriented psychotherapy: it is often difficult to refer people directly from individual or group psychotherapy to a peer support group. One means of assisting that transition is through a different form of group work, which we call "peer oriented therapy." The group ideally should be led or co-led by a person recovering from mental illness who is comfortable with prudent disclosure.
- Holistic treatment: accupuncture, massage, guided imagery
- Clinical treatment: such as psychotherapy, medication,
rehabilitation, and some innovations:
- Self-to-peer level: self-help groups running the gamut from broad based mutual support to consumer-run social clubs.
Training and Resources for Helpers
The following items and activities can be obtained through the National Empowerment Center.
- Videos, tapes, and papers on self-managed care, empowerment, and recovery.
- Workshops, including one which is a simulated experience of hearing voices. Our staff is conducting a two and a half day conference called "Learning from Us, " March 19-22, 1997.
- We are developing a multimodal curriculum for teaching professionals the self-managed care approach.
- Our staff can be reached directlly at 1-800-POWER2U. They can access our national datebank of self-help groups.
- The Center's website is http://www.power2u.org/
Daniel B. Fisher, MD, PhD
Co-Director
The National Empowerment Center
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