Treating Lean Psychosis

The treatment of people with severe mental illness often means locking them away in large, impersonal facilities or letting them bounce between short stays at in-patient units at major hospitals, followed by a rapid decline of functioning sometimes resulting in homelessness, then back again. This is especially true for psychotic disorders such as experiencing hallucinations and hearing voices. It’s a broken, ineffective system with minimal respect and compassion for the patient, and hasn’t changed much in centuries. The only real change is that the patients are now highly medicated, often further hindering recovery. Many psychiatrists don’t believe a full recovery from severe psychotics disorders is even possible.

My wife is a therapist at a small non-profit organization that operates facilities for the severely mentally ill, usually including psychotic disorders. Their approach is radically different, with “community members” (not “patients”) living in an actual home in a small town, with full-time support via a trained “room mate” and therapists that spend several hours at a time with the community member. Their entire purpose is to help community members help themselves by understanding their issue, confronting it, and overcoming it – while living in society. It’s not traditional therapy, but more just being with them as a supporting companion.  The person is treated as an equal, and respected to the extent that they are included in all treatment meetings.

The program is very expensive, not covered by insurance, and due to the highly respectful and individualized regimen, is difficult to scale.  But it is also very effective, with lasting results.

To further understand the concepts behind the program, my wife is reading one of the foundation texts, Recovering Sanity by Edward Podvoll.  I always like to explore and learn something a bit different, so I thought I’d read it too.  The author tells several stories of people who have been able to fully recover from severe psychotic disorders by becoming self-aware and confronting the psychosis on their own.

One such person was John Perceval, who was an English nobleman in the very early 1800s.  He began to hear voices, started to listen and respond to them, and consequentially was institutionalized in an asylum for several years.  He goes through a cycle of first listening to the voices, responding to and being guided by them, then being self-aware enough to doubt the voices.  Those doubts create moments of clarity that allow him to confront the “spirits and demons,” and after a lot of hard work and introspection he is then eventually able to fully recover.  But the system doesn’t believe recovery is possible, so it takes several more years before he is released.

Upon his release he sues the asylum, various doctors, and even his mother for malpractice.  Perceval publishes the detailed notes he kept (and hid) while institutionalized, leading to public awareness of the problem.  He goes on to found a patient advocacy group that was very successful in changing the English laws to support, respect, and show compassion for the patients.  This included mandating a judicial review before confinement, improved conditions inside hospitals, treatment regimens that include using homes and keeping families and especially children together, and standardized care models backed by outcomes and science, not societal fear and paranoia.

This was in the mid-1800s, in England.  And he was building off of similar changes that had already taken place in France a couple decades earlier.  How little has changed since then, and perhaps we’ve even regressed.

The core concept driving my wife’s organization is a rejection of “asylum mentality.”  Asylum mentality is the traditional method of exerting power over others, in this case “therapeutic power” which leads to “therapeutic aggression” that can thwart the process of recovery.  Instead the patient, the community member, is respected as an equal, and is supported while he or she actively confronts the psychosis.

It’s a much longer process, but far more sustainable as the person learns how to take individual corrective action when relapses occur.  There is also the recognition, and acceptance, that recovery is non-linear.  Setbacks are to be expected, and learned from.

In a way, that’s analogous to a lean transformation (and I don’t really like that term – it’s a journey).  The ones that are the most solid and sustainable take a long time, but the organization understands the underlying concepts.  It is not just a set of tools that can be thrown at a problem, perhaps by a consultant from outside the organization, but a true understanding of why it is being done.  What is the problem or opportunity and what is the appropriate tool for that specific circumstance?  What is the next experiment being run within a scientific PDCA problem-solving framework? It’s the power of owned understanding versus simply being told what to do.

That’s not the only analogy.  Another one has to do with observation, which is critical to both recovering from psychosis and a lean transformation.  Consider what Podvall, and indirectly Perceval, say in Recovering Sanity:

Asylum preserves what is called “non-reciprocal observation.” One is observed without being able to observe properly.  One’s state of mind – mistakes, awkwardness, and transgressions – is catalogued, diagnosed, and studied; whereas one’s own observations are held in suspicion and doubt and are called unsound, resistance, arrogance, transference, and the like.  An examination by the insane of their conditions, including the state of mind and therapeutic intentions of all their caretakers, is more or less prohibited.  It is a situation bound to evoke paranoia.

So when a leader goes to the gemba and observes the process, is it non-reciprocal or reciprocal?  Is just the leader observing or are others involved?  What lenses, or biases, is the observer limited by?  Is the patient, the people working at the gemba, involved?  Are they being heard, respected, and shown empathy and compassion?  Are they being taught to observe, to learn, to own, and to confront and fix the problems?

Supporting, respecting, and encouraging the patient to observe, understand, and take action to confront issues is what makes change effective and sustainable.

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