No one who reads my writing can deny that I believe in recovery. There is a famous quote by Patricia Deegan differentiating between healing, recovery, and being ‘cured.’ That recovery is a stance, it is no cure from the illness. Chronic illness can be damaging.
Pat Deegan often evokes the metaphor of a hero: ‘I ask students to suspend their perception of people as chronic mental patients and see the individual as a hero. I ask them, could you have survived what this individual has survived? Perhaps this individual has done what you could not do. Maybe they are not weak and fragile, sick people. Maybe those of us with psychiatric disabilities are incredibly strong and have fiercely tenacious spirits. Could you live on $530 a month and cope with a disability at the same time?’
I want to take this passage and get underneath it. I want to carve out the meaning from the selection expressly stated and what needs to be restated for the public to understand what exactly Pat Deegan is saying here.
Here’s my disclaimer: I’m not suggesting there is or isn’t a cure. This is not a conversation about diagnosis or language. My post is just an attempt to invoke a more extensive, more meaningful dialogue about what it means to have an impairment from a mental health disorder or illness. So we can quickly escape a long-drawn-out conversation about ‘level of functioning,’ which I am against as a marker or diagnostic tool.
I am defining functional impairment as an impairment that disrupts and makes the performance of completing a goal either difficult or impossible in the wake of a prevailing mental health disorder. Functional impairments are disruptive. They are also emotionally taxing.
Imagine you are living your life. Picture a typical day for you. On this particular day, your mood is average. Your mood is neither too up nor too down (this is just an example). You generally can plan your next few activities and complete them without incident.
The day is starting to come to a close, and you are internally wrapping things up and doing an inventory of what went right and what went wrong, and for the most part, things are looking A-OK.
As you continue to finalise the day’s plans, you open up some outstanding mail that you left on the counter to deal with later. That’s when you read that this letter requires a response from you personally.
That’s when life stops. Because you know, for you, interacting with the Post Office and writing letters is not happening.
You are afraid of the Post Office and its employees and have been since 2012. This issue has been chronic since your initial diagnosis and the activation of your symptom.
In terms of writing that letter back (with response required)? This is serious; think of the mortgage, the bank, IRS, or a car note. Sometimes correspondence is needed. Some folks are not able to handle their mail, and this is just one example of a common functional impairment. I picked it to use as a case example because I have been, and continue to be, frightened of mail and my mailbox to this day.
While I can provide the aetiology and clinical formulation of how and why this developed, I am still grossly impaired by this issue. It’s simply beyond. Not beyond your education, skill set, training, or anything learned. It is beyond what you can do. Will this always be the case? Can therapy help? Maybe? Sure, in some cases.
Right now, though, throwing therapy at what most clinicians call fixed delusions or isolated instances of contained, episodic psychosis, is like spitting into the wind.
I can think of a thousand vignettes of seemingly ‘normal’ or ‘high functioning’ or people that 99.5% of the time accomplish what they set out to do on a given day. The 0.5% of the population believed to have a diagnosable mental health condition, I later discovered, maybe underneath the radar of friends, family, and most of their collateral contacts (people in their life). Or, it may be the ongoing issues talked about during treatment: ‘How do I deal with this issue?’
To be sincere, people that can ‘pass’ as not having an issue usually do. Money helps and will generally make it a lot easier for these folks to get things done that they can’t do with hired help or toss a few dollars on the problem. People who can ‘pass’ don’t usually qualify for assistance or benefit from the system.
Folks that can usually ‘pass’ but sometimes, can’t – these are the most challenging, from a case management viewpoint, to help as they won’t qualify for the help they need.
People who are stuck in clinical grey areas need our attention for the quality of their life they deserve. Why? You can probably surmise how well they are doing. Not very well if they don’t get the real attention needed every time they have an issue, just superficial oversight or passing the problem along.
In the system, you either get help when you are in crisis or at the onset of a significant incident or diagnosis. There are no emergent needs in between as far as the system is concerned.
I have said it before – it is people in clinical-case management grey areas that are in the most need of our help and whose situation should signal the real crisis in mental health.
Now, back to Pat Deegan’s quote. I never feel like a hero when I can’t open my mail or mailbox. And, when I ask for help, I feel less than human – so much for the humanising Dr Deegan describes as the reason why she writes on mental health.
The hero imagery does not resonate with me.
Max E. Guttman, LCSW is a psychotherapist and owner of Recovery Now, a mental health private practice in New York City.
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