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Clinical and Research News
Psychiatrist Won’t Accept Assumptions of Hopelessness
Psychiatric News
Volume 39 Number 2 page 42-42

All around Mark Ragins, M.D., people with serious mental illnesses are achieving the "impossible"—they are working, living independently, and involved in healthy relationships. Although they may not be symptom free, they are, in essence, recovered

Ragins is the medical director of the Village Integrated Service Agency in Long Beach, Calif., and author of the book A Road to Recovery.

Recovery is a natural developmental process that follows the onset of an illness, Ragins told Psychiatric News in a recent interview, such as heart disease or schizophrenia, or an adverse event, such as the death of a child, a bitter divorce, or a rape.

A person who has recovered has regained the purpose or meaning in his or her life that was once lost, he said.

If a man is said to be recovered from a heart attack, it doesn’t mean his heart muscle regrew, Ragins said. "You say he recovers if he gets his life back and can function again."

Similarly, people who recover from serious mental illnesses may still experience some psychiatric symptoms, but are able to lead meaningful lives.

Just as Elisabeth Kubler-Ross theorized that there are separate stages of grieving, Ragins has found distinct stages in recovery from serious mental illness. For someone to recover from a serious mental illness, he or she must first experience hope, empowerment, self-responsibility, and the ability to achieve meaningful roles.

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People with serious mental illnesses need hope to recover, Ragins said, and part of the psychiatrist’s job is to promote hope in his or her patients. "Frankly, we’re not very good at this one," Ragins said. "We’ve been taught that these disorders are hopeless."

Ragins 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’s 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.

"It occurred to me," Ragins continued, "that the best way to ensure that someone is permanently disabled is to have a hopeless psychiatrist."

What Ragins and others call the "clinician’s illusion"—that patients with serious mental illnesses such as schizophrenia tend not to improve over the long run—stems from the fact that psychiatrists spend the majority of their time with the patients who need the most help. The patients who do well, he said, "are not the ones that are in my face during the day or in my thoughts when I go home at night."

Ragins stressed that "hope is not this vague notion of a light at the end of a tunnel." For patients, this may mean being able to visualize themselves achieving their goals.

One of the reasons for employers to hire people with serious mental illness, Ragins said, is "so they can be this vision" for other people with mental illness.

Most patients with serious mental illness "have a hard time believing in themselves," he said. "We have to believe in them until they can believe in themselves again."

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Psychiatrists can help their patients recover by empowering them during the treatment process, Ragins pointed out. One way to do this is to help them play an active role in their own treatment—educate them about their illnesses and the medications used to treat certain symptoms, and help patients to use that knowledge and make informed choices about their treatment, he said.

The most empowering thing psychiatrists can do is to treat their patients as partners in their treatment, Ragins said.

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 date women, 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, Ragin’s first question was not "How are the voices?," he said. It was, "Did you date any women?"

He hadn’t. Although the voices had diminished, Ragins said, the man was now embarrassed to approach women 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—dating women—by finding a balance between symptom relief and side-effects.

"We’re not the state department of mental hygiene trying to scrub the world clean of mental symptoms. My medications are part of improving patients’ lives, not just treating their illnesses."

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To recover, patients must take responsibility for themselves, Ragins pointed out, but it is difficult for them to do so if psychiatrists play the role of caretaker. When this happens, he said, "we’re often protecting them from the very experiences that lead to recovery."

Although psychiatrists’ first instinct is to relieve patients’ pain and suffering, it should be to help patients learn from their pain and suffering to get better. "These two goals are often at odds with one another," he said.

Ragins compared the psychiatrist’s role in helping patients achieve self-responsibility to an experience with which many can identify: driver education.

When it was time to teach his oldest son to drive, Ragins said, "I couldn’t teach him in a classroom or in a simulator, or by asking him to watch me drive...I sat next to him while careened down the street—I’m along for the ride."

During the lessons, Ragins thought about his role as a passenger. "I realized I was helping him to see what I would see if I was in the driver’s seat," he said. As psychiatrists, he added, "we try to help patients see what we would see in order to navigate life successfully."

In addition to helping patients take responsibility for themselves, Ragins said, psychiatrists must encourage them to assume meaningful roles to recover, beyond those of "psychiatric patient" or even "mental health survivor." Some of these roles may be employee, spouse, or family member, he said.

Ragins noted that many people who are recovering from mental illnesses reconnect with family members, including grown children who were long ago taken away from them.

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Ragins said when treating patients, psychiatrists’ strict adherence to boundaries can limit the possibility of recovery. "Sometimes we hide behind boundaries," he said. "When we ask our patients, ‘What did we do that really helped you?,’ they don’t tell us it was that clever combination of risperidal and depakote and paxil," Ragins said.

"They tell us, ‘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.’

"Those are the moments of healing," Ragins said, "and if our boundaries are so high they prevent all that healing, that’s too high a price to pay."

More information on the Village Integrated Service Agency and the full text the book A Road to Recovery can be found on the Web at www.village-isa.org.

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