Treatment should be hopeful, respectful, and authentic. Strong predictors of deterioration within a treatment include lack of therapist-patient bonding; confrontation, criticism, and high emotional arousal; stigma; and low or inappropriate expectations.8 Hope derives from the knowledge that people recover despite difficult setbacks. Respect requires curiosity, consideration, and listening to the patient’s agenda, and acknowledging his or her strengths. Authenticity comes from genuine concern and being straightforward about objectives: people can sense when a therapist is being disingenuous. This is not to say that all feelings should be shared. Respectful boundaries must be observed and impressions should be shared to help only the participant and not the therapist.
Decision making should be a shared recovery perspective. The participant must feel that the clinician is working for him, rather than for mandated, impersonal goals. People may not view their condition as psychotic or addicted and may accordingly reject medications or therapies that target symptoms. Such patients are often labeled as lacking in insight, in denial, or nonadherent. But from their perspective, patients can feel misunderstood, alienated, and let down by psychiatry, their families, and society.9 Instead, therapists must appreciate the individual’s perspective and assist in the clarification of needs, wants, and valued goals within an empowering environment.10 Not all symptoms need to be treated, but certain deleterious behaviors and worldviews can hamper recovery.
In shared decision making, the team joins with the patient. The patient must be listened to and helped to articulate his values and goals. The treatment team can help break these down to manageable and measurable components. Then interventions are proposed that might facilitate the patient’s recovery and capitalize on the patient’s strengths. This way, interventions make sense and can be accepted.11 The goals may not always look traditional. For example, one patient wanted to consummate a relationship with a rock star because he believed this was destined. Interventions were framed to facilitate this, and they included improved hygiene and curtailing his overt responses to auditory hallucinations. Success encourages further collaboration. Skills and confidence permit patients to discover or strengthen other aspects of their personality and broaden their identity beyond just being mentally ill.
Involuntary interventions are sometimes necessary. These certainly challenge collaboration and trust. However, the program must be in alliance with the healthy and successful parts of the person. I let the participant know what actions would worry me and what actions or behaviors would make me commit them. The common goals are to avoid future loss of self-determination and to ensure safety. Of course, such discussion is redundant or even dangerous in an emergency situation. Advance directives can provide a template for collaboration.
Recovery should be viewed as a marathon and not a sprint. Long-term outcomes are good, but recovery is a long and inconsistent process that may take years.12 Identities may need redefining.13 This tough part of recovery will require trading immediate gratification for the pursuit of delayed but valued goals, learning and practicing new skills, and surviving relapses and hospitalizations. A program that provides support, education, and hope needs to accompany the patient through this journey. Ideally, it should provide continuous care through residential and community-based interventions. The patient and his family need to hear the long-term view to avoid being discouraged and feeling negative. Peers who have come a long way in their own recovery can inspire and relate in ways not possible by many staff members; and peer counselors, groups, and recovery organizations must be embraced.