Recovery and Empowerment in
Bipolar Disorder
Alfredo Zotti
Adopted and modified, with permission, from
partnership for consumer empowerment of
Canada by Alfredo Zotti
•
This presentation is all about how and
why I have learned to cope and function
well with my mental disorder beginning
with social and environmental issues and
moving to the personal.
What Matters
• What matters towards recovery is not how
severe our mental disorder is but how we travel
inside: towards recovery and hope; or towards
hopelessness and despair.
• In my experience, the majority of sufferers in the
world today travel towards hopelessness,
because they have been convinced that there is
no hope for their condition
A New Paradigm Shift in Power
Relations
• Prognosis of Doom is to be replaced with the
Reality of Hope: the message is that Well-being
is Achievable!
• Persons with psychiatric disorders are no longer
passive recipients of behaviour & symptoms
management oriented services.
• Choice, self determination, and personal
responsibility are key elements of recovery.
• Expertise of consumers is recognised and
valued.
Stigma and Myths
• Dangerous
• Irresponsible
• Dependent
• Incompetent
The person and the physical and social environment: healthy integration
PERSON
Unhealthy integration of the person and the environment
History
Mental
Illness
Education
Negative Impact of ideological
mental illness on the person 1
* Self-concept
• Self-efficacy
• Hopes and Dreams
• Emotional Impact
• Major Social Roles
• Engagement with “helping systems”
Negative Impact of ideological
mental illness on the person 2
•Loss of Sense of Self
•Loss of Connectedness
•Guilt
•Shame
•Isolation
•Loss of Power
•Loss of Valued Role
•Loss of Hope
Spaniol et al., 1999
Negative Impact of ideological
mental illness on the person 3
People are trying to cope with:
• The catastrophe of mental illness and
multiple and recurring traumas.
• Trauma from the illness and trauma from
how we are treated.
• Negative professional attitudes.
• Lack of appropriate assisting skills of
professionals.
New Paradigm
•“The social power to define and categorize
another person’s experience is not a power to
be ignored. … in order to support persons
who are trying to recover, we must attend to
the fullness of their experiences, and not be
distracted by their medical diagnoses.”
McGruder 2001
What helps and what hinders
•“The science of psychiatric diagnosis and treatment
is neither objective, nor neutral nor value free.
Rather, it is a social process open to bias and
influenced by the larger social, political, and cultural
milieu.”
McGruder 2001
Relevant book and article
The Hermeneutics of Medicine and the Phenomenology of Health
http://books.google.com.au/books?id=9DFKn3xNAY8C&dq=shamanic+practices+in+Taiwan
+mixed+with+western+psychology&source=gbs_navlinks_s
Mental health, culture, race and ethnicity http://www.ncbi.nlm.nih.gov/books/NBK44249/
Empowerment
• Empowerment is an issue of social justice
and refers to the process that people go
through to gain or regain the power and
control over their own lives that is necessary
for dignity and self-determination. It requires
that people have access to the means and
opportunity to assume responsibility for their
own lives and well-being.
The Right Attitude Towards
Recovery
•The person most likely to get well – to become empowered – is the
person who feels free to question, to accept or reject treatment, and to
communicate with and care for people who are caring for him… Ultimately,
patient empowerment is a matter of self-determination; it occurs when a
patient freely chooses his or her own path to recovery and well-being. It is
the job of mental health services to provide an environment of personal
respect, material support, and social justice that encourages the
individual person in this process.
Clay (1990)
http://alfredo123.wordpress.com/2013/09/16/1573/
The Belief That One Cannot
Recover
•“the
obstacles to recovery
are enormous, but the
greatest obstacle is simply
that people think one
cannot recover!”
Can people with bipolar learn to
control moods and symptoms?
• Yes. I have done it, my wife has done it,
and so have many hundreds of cyber
friends whom I help most days as a
volunteer online helper for sufferers.
How to control symptoms
•
Many factors are important for
controlling one’s symptoms but not one, in
itself, is sufficient. We need a variety of
methods that combined can help us. In my
personal opinion, therapy is always
necessary because it is important for a
sufferer to discuss difficulties that rise due
to the mental disorders no matter if the
disorder is biological or due to PTSD.
What helps?
•
Medication can help; a support group is
helpful; an ideal environment is important;
access to education, work and leisure is
important; creative activities are important;
avoidance of recreational drugs, such as
alcohol or marijuana, or other recreational
drugs, is extremely important; good
nutrition and adequate sleep are all
important.
What has made it possible for me to learn to
cope well with my bipolar disorder
•
I have been able to develop full
resilience and self awareness about 2
years ago at age 53 for a variety of reason
that I will divide into factors:
Relevant Factors 1
•
I have always been a little self critical,
in a constructive way, and I feel that this is
linked to my creativity and the fact that I
am an artist. Positive self criticism is vital
in the recovery process.
Paolo Freire
http://www-rohan.sdsu.edu/~rgibson/freirall.htm
Expressive writing
http://homepage.psy.utexas.edu/HomePage/Faculty/Pennebaker/Reprints/Pennebaker&
Chung_FriedmanChapter.pdf
Relevant Factor 2
•
I have been able to identify my
trauma, or what triggered my Bipolar
Disorder, and resolve it.
•
Childhood Trauma see ACE study
http://www.cdc.gov/violenceprevention/acestudy/
Relevant Factor 3
•
I have been fortunate to meet many
psychologists and psychiatrists that today
are friends. This has given me a chance to
really learn about the mind and therapy
and to become a kind of self therapist.
Relevant Factor 4
•
I have an extensive support group
today made up of academics, mental
health professionals, online friends from all
over the world, my wife, my therapists and
my close friends. These people not only
support me but also provide much needed
feedback so that I can become fully aware
of my perceptions and distorted thinking.
Relevant Factor 5
•
I don’t drink alcohol
and I don’t use
recreational drugs.
Relevant Factor 6
•
I eat highly nutritious food
and sleep well.
Relevant Factor 7
•
I read a lot and I study
about 3 hours each day.
Education and knowledge is
essential to stay well.
Relevant Factor 8
•
I always let emotions and
feelings out. I make sure
that I cry occasionally and I
let myself become
emotional but in a controlled
manner.
Relevant Factor 9
•
I make sure to have enough time to
compose music, create visual artworks,
write poems and complete some creative
writings.
• The creative process is my greatest
therapy.
DABROWSKI
http://homepage.psy.utexas.edu/HomePage/Faculty/Pennebaker/Reprints/Pennebaker&
Chung_FriedmanChapter.pdf
Factor number 10
• Perhaps the most important factor is that I
have come to accept my Bipolar 2
Disorder as part of me. I do not become
anxious when symptoms rise and moods
change. I remain in control and try to use
these to my advantage. If I was to panic,
as I did in the past, I would not be able to
cope and I certainly would not be on the
road to recovery. Acceptance is perhaps
the most important factor of all.
What sort of person am I today?
• Because of the above mentioned factors, I
am able to function very well today. It has
taken me a lot of work, tremendous effort,
and none of this would have been possible
had I not resolved my past trauma. In my
case, and also in my wife’s case,
medication alone therapy would not have
been helpful for us in terms of achieving
the kind of recovery that we have
achieved.
•
Today I only take medication (about three
months per year) when I feel absolutely high.
When I become excessively high (hypo-mania),
usually before Spring, I start doing a million
things: I am a musician so that I will play many
instruments and then go off to other activities
such as painting, drawing, writing poems and
academic writing and also do many other things.
My wife is the first to notice that I am high so
when this happens I take Epilim, which is
Sodium Valproate which is an anticonvulsant. I
only take a very small dose but enough to help
me control my more severe moods.
Anti Depressants and Anti
Psychotics
• Antidepressants are not usually indicated for
Bipolar, unless there is persistent and dominant
depression. But, generally speaking,
Antidepressants tend to precipitate manic
attacks so that they are not really indicated for
people with Bipolar Disorder. Anti psychotics can
have severe side effects so that, while they are
at times necessary, it is important to be careful
and try everything possible to take the least
dose possible that will help.
How efficient is medication?
• “…Despite major research efforts on
understanding the biological and genetic
basis of Bipolar Disorder (and other
mental disorders) and over 5 decades of
intensive development of new drugs for
these conditions, psychopharmacology
has not yet provided a full solution to
severe mental disorders.” (Wright et al.
2006)
Medication continued
• For example, the degree of improvement
in positive symptoms of schizophrenia with
anti psychotic medication is typically less
than 20% (Khan et al. 2001)
• The relapse rate for Bipolar Disorder is in
the range of 30% to 40%(Geddes et al.
2004; Ginsberg 2006).
Medication continued
• Remission rates for treatment of Major
Depression with the use of antidepressants
range from 27% to 13% (Rush et al. 2007).
• It is clear that medication alone is not a suitable
long term treatment.
• In certain cases, while medication can save lives
in the initial stages of the treatment, it can also
become an agent of trauma (Whitfield, 2010).
The Biopsychosocial Approach
• It is clear that the Biopsychosocial approach is the one
that will give us the best results. But are we really using
it?
• No matter if the mental disorder is biological of traumatic
in nature, therapy is an important part of the treatment.
• I see a problem online, when I try to help people: they
often tell me that therapy does not work for them and
yet, the way in which I help them, supported by
psychologists and psychiatrists, is a kind of therapy so
that what they are saying is a contradiction. They often
suffer with distorted thinking and I try to help them with
this problem.
What causes distorted thinking?
* Emotions and moods can affect cognition
in such a way that the sufferer perceives
distortions of reality. This distorted thinking
becomes mixed with anxiety and even
panic attacks and is influenced by past
traumatic experiences, by ongoing trauma,
by Stigma and Prejudice. Emotional
thinking is not a sign of lack of intelligence.
How do I cope with distorted
thinking?
• I rely on my support group and I never
believe the perception. If I can get
feedback from my support group
immediately then I do so, but if not I put
my perception and related emotions on
hold and move on with my life until I can
get feedback, usually within one or two
days. This is extremely difficult to do but
necessary for me.
The importance of being aware of
distorted perceptions
• Cognitive behavioural therapy (CBT) does not
always work, especially in cases of PTSD. That
is why we need a support group that can offer
feedback because distorted thinking operates in
combination with emotions, feelings and past
traumas and because of this it is not as simple
as attempting to think differently. The kind of
emotions here involved operate at the
subconscious level and often bypass cognition.
•
Mick Cooper http://www.booktopia.com.au/essential-research-findings-in-counselling-andpsychotherapy-mickcooper/prod9781847870438.html?source=pla&gclid=Cj0KEQjwyrqgBRDepamtLWA2oABEiQAV7nwwDtv5ynXdsfrM4XMjjSqAi5bGDUavQ0-Y1hoWQr-H8kaAi348P8HAQ
What sufferers say about CBT
• A psychologist from the USA writes:
• “Alfredo, I really do not believe that CBT would help me
because the problems are much deeper than just
learned, thoughtless behavior. Trauma changes
everything and I sometimes feel like the effects are in my
bones. However, that has improved a lot with
therapy. Working with EMDR has given me a lot of hope
and I couldn’t have gotten as far as I have without the
help of my therapist, who is very skilled in this treatment
method. I think CBT would be fine if you’re just dealing
with simple incorrect ways of thinking and there’s no
underlying trauma. Just my opinion, of course, but one
based on personal experience and learning from various
literature on the subject.”
What sufferers say about CBT
• A Social Worker, from Ireland, writes:
• “I think that CBT is in effect, a bit of an insult to people like us who
have a good knowledge and insight into our own condition. CBT is
very 'quick cure -all' and has been heralded as a great help to
people who suffer from Social phobia/Depression/Anxiety. To me it is
nothing short of Pop psychology why ?
• Well CBT is basically about changing the script, the message that
we got as kids, that we are no good, hopeless etc., and we are to
change our thinking, but it completely fails to address the human
spirit. It fails to address the fact that many people who are labelled
with Borderline and indeed with Bipolar 1 and 2, are in fact suffering
from PTSD and there are, as you know, varying degrees of PTSD.”
What sufferers say about CBT
• A therapist from the USA writes:
• “Our whole lives we have been raised without any
attention to distorted thinking or perception. How is it
then are we ever going to see what is true, identify
thoughts which have been used many times and
accepted as true, with only minimal effort and 1
appt/week? For CBT to work one must immerse
themselves in it daily. Now does that sound
easy? Myself, it does not work or does not really work
well. I can stop and identify thought distortions but they
are automatic and sometimes running in the background
unnoticed.
What sufferers say about CBT
• I know what thoughts, what chain of
distorted "reasoning" results in me feeling
a certain way, having a certain perspective
and perceiving the world around me past
and present. I see that they are distorted
and can identify some of the sources of
the distortion. Knowing all this does not
change easily what I have engaged in for
many years.
What sufferers say about CBT
• “Rest easy, there are very few in this world
that see with clarity, many of which have
spent a lifetime in this pursuit.”
Types of Psychotherapy Approaches
•
•
•
•
Four Major Categories:
Psychodynamic Psychotherapy
Humanistic Existential Psychology
Cognitive Behavioural Therapy
Transpersonal Psychotherapy
Other types of therapy
• EMDR Eye movement desensitization and
reprocessing (EMDR) is a fairly new,
nontraditional type of psychotherapy. It's
growing in popularity, particularly for
treating post-traumatic stress disorder
(PTSD). PTSD often occurs after
experiences such as military combat,
physical assault, rape, or car accidents.
Other Types of Therapy Continued
• Narrative therapy
• Narrative therapy seeks to be a respectful, nonblaming approach to counselling and community
work, which centres people as the experts in
their own lives.
• It views problems as separate from people and
assumes people have many skills,
competencies, beliefs, values, commitments and
abilities that will assist them to change their
relationship with problems in their lives.
Narrative Therapy Continued
• Curiosity and a willingness to ask questions to
which we genuinely don’t know the answers are
important principles of this work.
• There are many possible directions that any
conversation can take (there is no single correct
direction).
• The person consulting the therapist plays a
significant part in determining the directions that
are taken.
From the Book What is narrative therapy?
By Alice Morgan
Writing Therapy
• Writing therapy is a form of expressive therapy
that uses the act of writing and processing the
written word as therapy. Writing therapy posits
that writing one's feelings gradually eases
feelings of emotional trauma. It can be
administered in person with a therapist or
remotely through mailing or the Internet.
• Woolston, Chris (2000-03-16). "Writing for
therapy helps erase effects of trauma". CNN.
Creative therapy
• Creative arts therapies are based on the
premise that when someone works
creatively under the guidance of a
qualified therapist, they become more
expressive and communicative. This
raises their awareness of issues and
brings impetus for change. The creative
work can involve music, art, dance,
movement, and other creative activities.
A final word
• Epictetus wrote:
Happy Ending
• I am here , I am happy 
and I am a person just like
you. My bipolar disorder does not define who I am or
what I do. I have moods and symptoms but I am no
longer at the mercy of these but in control and use
moods and symptoms to fuel my creativity. I use my
bipolar to become a better person. In fact, today, I am
happy to have bipolar disorder II because this disorder
has made it possible for me to achieve good things in my
life. And I wish that other sufferers, carers, and mental
health professionals, could see the problem from this
perspective. Today I see my Bipolar 2 disorder as a very
sophisticated intelligence and I think that, evolutionary
speaking, it serves a tremendous purpose that we do not
want to eradicate but learn to manage in our society.
The usefulness of Bipolar
• I have been able to control my bipolar
disorder and use it for personal
growth. Anyone can potentially do this
even those with more severe mental
disorder than mine such as
schizophrenia. For me the problem is
not the disorder itself but our society
and our ideology.
Some of my art
•
•
•
•
•
I am a visual artist
I am a professional musician
I am a cartoonist
I have worked as a cook/chef
I have an honours degree in sociology and
anthropology and I have studied some clinical
psychology
• I am now writing my second book that is going to
be published sometimes next year.
None of this would be possible if I
did not suffer with bipolar disorder
• Bipolar Disorders fuels my art and I know that if I
did not suffer with it, my art and my talents would
not be as developed and diverse as they are
today. Bipolar 2 Disorder is a gift to me, a gift
that is very powerful and needs to be treated
with respect. Would I like it if there was a way to
genetically or biologically eradicate my Bipolar 2
Disorder? Absolutely not, it is part of me, a part
that I have come to love and respect.
DSMV Cartoon
The Bush
Blue Room
• Painted while depressed
Blue Room 2
• Painted while a bit high