East Asian Arch Psychiatry 2014;24:129-33

PERSPECTIVE

郭飞莹

Ms Caroline Fei-Yeng Kwok, MA, Trainer, Across Boundaries, Toronto, Canada.

Address for correspondence: Ms Caroline Fei-Yeng Kwok, Across Boundaries, Toronto, Canada
Tel: (1-416) 250 7203; Email: kwokcaroline@rogers.com

Submitted: 26 March 2014; Accepted: 30 April 2014 

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Introduction

For most of the 20th century in North America and Europe, people with severe mental illnesses were not expected to recover.¹ Until the 1980s and even as late as the beginning of the 21st century, many professionals in North America viewed recovery as meaning adherence to prescribed medications, following the rules as set by one’s doctor, establishing control over symptoms, and avoiding re- hospitalisation. Beyond that, not much was expected from clients. The clinical model of recovery is still based on the same criteria: treatment adherence, symptom reduction, restoration of function (sometimes an attempt at cognitive rehabilitation is incorporated into the clinical model), and staying out of hospital. It emphasises the view from the outside, i.e. the clinician’s assessment, rather than taking the patient’s subjective view into account.²

It was not until 2005, after the report by the 2003 President’s New Freedom Commission on Mental Health, that mental health professionals began to consider the necessity of changing their view on recovery.³ In December 2011, the Substance Abuse and Mental Health Services Administration (SAMHSA) defined recovery as “A process of change through which individuals improve their health and wellness, live a self-directed life, and strive to reach their full potential.”⁴

In this article, I will be using my own case history, a Chinese female immigrant to Canada, diagnosed with bipolar disorder, to illustrate the process of recovery. I will show the limitations of the clinical model of recovery, and demonstrate the effectiveness of the empowerment model of recovery, thus, reinforcing the SAMHSA definition. Every country has its own mental health system. The procedures differ and mental health legislation may vary. But the experience of illness and recovery that I encountered as an immigrant to Canada are in many ways universal, shared by survivors of different races and cultural backgrounds living in different parts of the world. I hope that my first-person narrative will prove helpful to mental health professionals in treatment of their psychiatric clients.

My Illness

My first episode occurred in 1973 when I was 21 years old, after my return to Hong Kong from studying at the University of Minnesota, and after travelling on my own for 2 months in Europe. I had had a fight with my boyfriend and was upset. A doctor at The University of Hong Kong medical clinic prescribed some pills, and I was able to sleep and concentrate on my studies. However, not knowing much about illness or medication, my mother snatched away the pills and would not let me take them. After that, I could not sleep; I frequently lost my temper and yelled at my parents in English (which they could not understand). My mother called a psychiatrist. Against my will, I was sent to the psychiatric ward of a general hospital and was cared for by private nurses during a 2-week observation period. My telephone line was cut. My only visitors were my boyfriend, my parents, and my nanny. My mother told my high school friends that I was fine and not to visit me. The psychiatrist diagnosed me as having an “acute hysterical reaction” in response to my life situation.

I was not taking any medication when I emigrated to Toronto in 1974. As a new immigrant, I had to retrain myself as a teacher by taking a Bachelor of Education degree at the University of Toronto in order to get the “Canadian experience” to be hired as a full-time teacher with the Toronto District School Board. While working, I upgraded myself by obtaining a Master of Education degree from the same university. My husband (my former boyfriend) and I lived with my parents for whom I had to translate because they did not speak much English. I did not realise the emotional stress caused by all these cultural adjustments. At that point, I had no real close friends in Toronto either.

My next episode occurred in 1980 after a long flight from Hong Kong and several sleepless nights of turmoil between my husband and myself. I did not know anything about the mental health system, the different admission criteria, and patients’ rights in Canada. Because I was emotionally upset, I went to the emergency department of a local hospital right after landing in Toronto and was examined by a western psychiatrist. There are cultural differences between easterners and westerners that are sometimes hard to bridge in psychiatric assessment, especially, when the client is agitated and disturbed.⁵ Out of fear, in a totally strange medical environment, I mumbled in English. All of a sudden, my English became jerky and I had difficulty expressing my emotions. I was probably hard to understand. I was asked to name 5 Canadian Prime Ministers (as a new immigrant, I could not think of any), read aloud an article from Time Magazine, and explain an English proverb — a total mystery to me. The psychiatrist gave me a diagnosis of bipolar disorder and prescribed lithium, methotrimeprazine, sodium amytal, haloperidol, and chlorpromazine. He did not explain why or how he reached that diagnosis. He wrote in my file (which I later saw), “behaviour remains very active and uncooperative and demanding.” In his opinion, I apparently had a good relationship with my parents, and my husband was extremely tolerant and supportive. Even though I stayed in the inpatient ward for 3 months, no one noticed that I was extremely unhappy in my marriage. I divorced my husband in 1982.

My next major episode occurred in 1992 when a new romantic relationship ended abruptly. I was hospitalised and treated with a combination of medications. My father had recently died. After my discharge, my mother suddenly disappeared from the house that we shared and none of my relatives would tell me where she was. Her disappearance, perhaps, had to do with the fact that she could not bear the shame of her beloved daughter suffering from a mental illness, but more so, perhaps, because of the burden of caregiving that now fell on her shoulders. She had little knowledge about mental illness, few coping skills, and no support from professionals in the hospital. She must have felt helpless, living in a foreign environment with limited English and hearing only misinformation about my condition provided by my brother and his wife.

This complete lack of familial support made me feel alienated, socially excluded, guilt-ridden, and totally demoralised. I felt as if I were a second-class citizen, the black sheep of the family. I used to make long distance calls to my high school friends from Ying Wa Girls’ School, and to my aunt and uncle in Hong Kong for emotional support and understanding. It was only after a family friend accidentally bumped into my mother on the street that I learnt that she was alive, and we were reunited. Until today, although my mother has passed away, my brother and his wife never discuss the topic of my illness. To them, mental illness is a taboo subject that must be avoided. This experience underscores the importance of family support in recovery. It also makes me advocate for provision of psychosocial education to families to promote better understanding of mental health and to de-stigmatise mental illness.

In 1999, I was in a coma and had to stay in the intensive care unit for 2 weeks after receiving a combination of neuroleptic medications to calm, what the doctor considered to be, my manic state. A tracheotomy had to be performed so that I could breathe; I still bear that scar on my throat.

Limitations of the Clinical Model in My Recovery

Between hospitalisations, I would have been described as clinically recovered. I took my medications (lithium, perphenazine, trihexyphenidyl, triazolam) and, thanks to them, I had no symptoms (“no disturbance of mood,” my family physician wrote in his report to the psychiatrist), and I functioned pretty well (teaching full time). During my hospital stays, obedience and conformity to hospital rules were expected. As long as I did what I was told, I was considered “recovered” enough to leave the hospital. Mental health professionals seemed to be only interested in my illness, not in me as a person. They did not seem to notice that I came from a different culture to theirs, that I communicated verbally and non-verbally in a way that was different from theirs, and that my tolerance to medications was different from that of an ‘average’ Canadian’s. Lu⁶ points out that there are pharmacokinetic differences between Asians and Caucasians, and that “therapeutic dosages are more likely to need considerable adjustment for some ethnic groups such as Asians and Native American people, in contrast to Caucasian groups.” Those who did notice that I was Chinese seemed to think I should comply with the stereotypes of Chinese women: be quiet, submissive, dependent. When I did not fit the stereotype, they gave me more medications. No one noticed that I had lost my passion for concerts and stage plays. No one noticed because no one asked about that. I was no longer motivated to write short stories, as I had done before. I lost my knack for playing the piano. I could no longer think critically. I just listened to other people and did as I was told. The independence and the freedom that I had so enjoyed when I was younger were no longer there. I complained about side-effects of lithium (hand tremor, extreme thirst, skin pigmentation, weight gain) but none of the mental health professionals I spoke to took these seriously. I was not taken seriously by my friends or relatives in Toronto either. They ridiculed me as a “mental invalid.” Asians are not very kind when it comes to mental illness. In Free to fly: a story of manic depression,⁷ I wrote about myself: “A hopeless nut. That was me alright. Dependent on my ageing parents. Misunderstood by friends. Misjudged by relatives. Confidence lost. Self-esteem low. A living corpse with a mental handicap.”

My Eventual Recovery

I did, however, recover fully, eventually. Besides psycho- logical supportive therapy and the right medications, the following are the fundamental elements of my recovery: learning self-care techniques, regaining forgotten dreams, restoring confidence, rebuilding hope, renewed social inclusion, spiritual connections, and leading a life with meaning and purpose.

Understanding my medications and how they work has been a vital self-care technique for me. After the coma, my medications were changed to 1 mg of lorazepam at night and 600 mg of valproic acid daily. With the right dose, there were no adverse side-effects of these medications. I now take an active interest in knowing about different kinds of psychoactive medications and their side-effects. I discuss this in detail with my psychiatrist. I read about the medications and I look up their side-effects on the internet. My hands no longer tremble and my skin is clear. I do not have to drink water every few minutes. I am down to a size 7 instead of the size 16 that I became when I was taking lithium. I get 7 to 8 hours of sleep every night without interruption and do not even suffer jetlag on long-haul flights. I attribute this to having become knowledgeable about medications and holding out for what I know I need or do not need.

I am now aware of my triggers and early warning signs. I realise now that my episodes were mainly caused by a lack of emotional intelligence on my part in terms of interpersonal relationships, not understanding the role of stress in my life, and not appreciating the importance of adequate sleep. I have learned to better handle interpersonal relationships and improve my emotional intelligence by reading Albert Ellis’s Rational emotive behavior therapy.⁸ “Take life easy” has become my motto. With 1 mg of lorazepam, I make sure that I sleep so that I can function well the next day. Awareness of my triggers has helped me to prevent relapses.

I pay attention to nutrition and exercise. I have learned to eat a balanced diet with vegetables and protein (fish and lean meat). I also take omega 3 fatty acids which have been shown to help in stabilising one’s mood.^9,10 Now, I also read the labels on each product. I go to the gym for workouts as often as I can, aiming at 150 minutes per week. Research demonstrates that adequate amount of exercise helps to decrease depressive symptoms.¹¹

I had always wanted to be a writer, speaker, and lecturer. Yet, when I would mention this to health care pro- fessionals, they saw it as “grandiose thoughts”. I was never encouraged. In fact, my aspirations were actively discouraged; they were seen as part of my illness. Nonetheless, I have now regained my dreams and rebuilt my hope due to a number of factors. Most importantly, people I respect believe in me. Ahern and Fisher¹² have pointed out that this is, indeed, an important element of recovery. My current psychiatrist understands my aspirations and encourages me to achieve them. Personal goals, whether or not one is able to attain them, are crucial to recovery.^13-15 Encouraged by an elderly friend, I attended a creative writing course at Yale University and this was a major turning point. My professor, Dr Richard Selzer, motivated and supported me. He believed that I was a good writer. I have since written a book about my illness (both in English and in Chinese) and my recovery. I have also published articles in psychiatric journals.^16,17 Professionals with whom I have worked on panels, conferences, workshops, and educational enterprises have believed in me and my abilities. My confidence has been restored.

Since 2001, I have been working as an ESL (English as a second language) / literacy teacher for immigrant psychiatric survivors at a Toronto centre. Helping those who are in the same boat as I provides me with a sense of usefulness. For a survivor to become a service provider is a big step and it makes me feel valued. In 2001, I was a recipient of the Courage to Come Back Awards sponsored by The Centre for Addiction and Mental Health in Toronto. I spoke in front of 900 mental health professionals, which convinced me that I could present my experience to large audiences. In 2007, I was asked to be a plenary speaker at the World Federation for Mental Health Congress in Hong Kong where I spoke to 1000 international delegates about combating social stigma towards mental illness and promoting the fact that recovery is possible. Since then, I have given many talks and presented several workshops to mental health professionals and survivors in Asia and North America, not only on recovery, but also on immigrant mental health, cultural competence, and women’s mental health.

Exposure to survivors and professionals of various cultures makes me realise that mental illness can strike anyone, regardless of race, culture, age, class, intellectual, or education level. This has changed my previous conviction that I was alone with my bipolar disorder. I now realise that mental illness, especially mood disorder, is widely prevalent.

The readers of my book, the Chinese readers in particular, have taken the initiative to contact me and consult with me about their mental well-being and that of their loved ones. This response is encouraging for me, especially since Chinese people, in general, are quite reluctant to talk about mental health issues. This gives me a sense of purpose and meaning, a well-described element of recovery.^15,18

My social circle has been revitalised. I have reconnected with old friends from high school and I have made new friends among the survivors, nurses, social workers, professors, and physicians whom I have met more recently. This is an important key to recovery.¹⁹ My friends provide me with social support no matter where they live; this is easier now by universal access to email. The fact that I can rely on them for support and understanding when needed is vital for my recovery.²⁰ I am no longer socially excluded.

During my hospitalisations, I prayed to God for comfort and strength and promised that, if only I would recover, I would build a bridge between mental health professionals and clients. Since recovering from my coma, I thank God every day for my life. I find peace and comfort through my prayers. Recently, I have been asked to speak at a Chinese church in Toronto where I will share my experience of God’s blessings.

Implications for Mental Health Professionals

The personal narrative of my recovery from bipolar disorder illustrates, I believe, the limitations of the traditional clinical model of recovery. Remission of symptoms and return to work are not sufficient. I needed to regain my dreams, renew my hope, reconnect with friends, enlarge my social circle, and develop confidence in myself and my abilities. I needed people to believe in me. I needed to re-establish my spiritual connection with God and I needed my life to have a purpose. I needed to feel useful. These are principles of the empowerment model of recovery which mental health professionals should know how to introduce into the care of mentally ill clients. Paying attention to issues of gender and culture is also important for clients. Individualised care has always been the province of mental health professionals and the empowerment model of recovery epitomises, in my mind, the essence of personal care.

Acknowledgements

The author would like to acknowledge the support of Dr Mary V. Seeman, Professor Emerita, Department of Psychiatry, University of Toronto and Dr Larry Davidson, Director, Yale Program for Recovery and Community Health, School of Medicine and Institution for Social and Policy Studies, Yale University.

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