Is There a Roadmap for Recovery?

Let’s say you’ve committed yourself to do whatever it might take to recover from depression. But then what? There are many forms of treatment to choose from, chief among them these days are medication and cognitive therapy. There are also other forms of psychotherapy, mindfulness meditation, changes in nutrition, regular physical exercise – and those are just the beginning. They always seemed to me like puzzle pieces. No one of them let me see much, yet I needed a big picture to understand how to fit them together.

Is there a pattern or roadmap that could help me stay on track? I had no idea of what recovery required or what I needed to do to sustain the drive that had kept me going through the worst moments. Without that, all I could do was wait for the treatments to work. They didn’t.

This wasn’t what I’d had in mind when full of the hope that comes from renewing the basic commitment to life. I knew that recovery depended on my taking action, that I couldn’t sit back and wait to be cured by the latest treatment. And I knew very well that I’d have a hard time, that many periods of terrible depression would likely recur when I’d feel lost and hopeless. Especially at those times, I wanted to have a reference point, a sense of the overall arc of recovery to keep in mind.

Of course, I would know as soon as I was feeling better, getting mental focus back and losing the many other symptoms. But how could I expect to sustain that improvement if I didn’t understand how I’d gotten there? I didn’t want to keep worrying about relapses. As I’ve written here before, I wanted to get beyond recovery to a full life. I wanted my attention and energy to switch from sustaining recovery to sustaining wellbeing.

The books and theories on depression – and the therapists who put them into practice – provide descriptions of symptoms, explanation of causes, and lists of activities to undo its damage. There are lots of principles to keep in mind, lot of advice to follow, but something is always missing, not just from the books but from the treatments themselves. It took me a while to figure it out.

It’s this: I never felt empowered by them – or at least not for long, despite gaining many useful and important insights from each one. There are many different models to explain causes of the illness, and each model comes with its preferred treatment. In trying to apply them, it’s easy to forget the specifics of your own experience and focus primarily on what the model says. Too often, the treatments are promoted as the best buy in a therapy marketplace, and I wind up feeling like a consumer instead of the driving force behind my own recovery.

I found an example of a pattern of recovery while writing a recent series on Post-Traumatic Stress Disorder. From what I’ve learned, it isn’t used that often – the quality of available care is usually limited to the treatment of those symptoms that respond, sometimes, to medication. Among practitioners of more comprehensive approaches, however, there seems to be a high level of agreement on the phases of recovery. In varying forms, it has been recognized for over a hundred years, long predating the general recognition of PTSD as a disorder with its own DSM criteria.

Judith Herman, in her widely influential Trauma and Recovery Patterns of Recovery from Depression and Post Traumatic Stress Disorder, reviewed the recovery concepts described by several of the researchers who preceded her. They all had found that recovery required three distinct phases. (Some researchers identified as many as ten, but these could be consolidated under three basic dimensions.)

The first phase consists of stabilizing the worst symptoms of PTSD and creating a therapeutic environment that feels safe and encourages a sense of trust. Since personal safety and trust are primary victims of traumatic experience, healing cannot take place until they begin to be restored.

The second stage is an exploration of memories about the trauma and a re-experiencing of the events. The idea is to defuse the memories so that they become less terrifying and no longer have to be avoided. For Judith Herman, this means remembrance and mourning.

It’s the third stage that sets Herman’s pattern apart from the others most clearly. While most researchers talk about the individual’s need to rebuild or reintegrate the personality, learn new coping skills or rekindle an inner drive, Herman goes further and emphasizes the need to reconnect with other people. Once the sense of self has been restored, the task is to rebuild the relationships and sense of purpose that have been undermined by the impact of traumatic experience.

Her names for the three phases avoid clinical terminology and shift the emphasis from the techniques of the therapist to the experience of the person in healing: regaining a sense of safety and the ability to trust; remembering trauma and mourning loss; reconnecting with people. The role of therapy is to empower, and those trying to heal the wounds of trauma need to take the initiative at all times. Nothing can be done for them. The therapist’s role is to offer guidance and support.

This is the sort of basic roadmap that seems essential not only for initial healing but even more for moving beyond recovery to rebuild a damaged life. At every step, it emphasizes what those in recovery have to do for themselves and the conditions for recovery they need to put in place. It’s a whole person approach.

Maybe it’s wishful thinking, but having something like this would have been so helpful early on, long before I had experience of multiple treatments and was living in confusion, fear and hopelessness. At that time, I did the one thing I knew about and went to a psychiatrist. Today, the first thing you’re likely learn about is medication. There’s no context for healing and little sense of empowerment – in fact, passivity is usually expected in response to expert treatment.