When treatment supports the life a person is trying to build, engagement and hope may improve.

Finding fit between treatment and what matters most can strengthen a person’s sense of agency.

Rigid health systems can prevent person-directed care.

Even when all the right things are in place for psychiatric treatment, that doesn’t always equal engagement. There can be rapport, an accurate diagnosis, and effective medication, but that still doesn’t mean someone will engage in the treatment plan. That’s because sometimes there’s a mismatch—not of skill but of fit. A mismatch between what’s being offered and the kind of life the person is trying to build.

Research shows that when treatment supports the life a person is trying to build, engagement and hope tend to improve. That’s not rocket science, but in rigid health systems, it’s not always happening.1

Psychologist Patricia Deegan was one of the pioneers of this approach. Her recovery model isn't just person-centred, but person-directed. Instead of fitting people into treatment, treatment is shaped around their lives.

When I talk about fit, I mean questions like:

Do side effects interfere with identity or motivation?

Do appointments compete with meaningful parts of life?

What does that look like in real life?

Is being a proud grandparent compromised because medication causes too much morning sedation to babysit grandkids in the morning?

Is the outpatient group held at the same time as a soccer practice?

Supports what matters most to the person

Makes daily life more possible

Strengthens identity, roles, purpose

Feels relevant and worth the effort

Competes with or disrupts daily life

Undermines motivation or identity

Feels disconnected from what's important

Becomes something to avoid or drop

Even when someone lacks insight—they can’t recognize they have a mental illness, or don’t believe they do—does fit still apply? The answer is yes. Because fit doesn’t require insight—it requires connection. Treatment should connect to the person's priorities. And even without insight, people still have preferences, values, and things they care about.

My own experience from misalignment to fit

I can speak from my own experience. My first psychosis happened at a meditation retreat. What started as an incredible personal awakening morphed—over the period of several hours—into a florid psychotic episode. I continued to have episodes, on and off, for several years, and they all had profound spiritual meaning for me.

With each psychosis, I was involuntarily admitted to the hospital, and each time, doctors told me I had bipolar disorder and wanted me to take medication. They labelled everything as part of the illness.

They pathologized the entire experience—both the awakening and the psychosis. I don’t know about you, but given a choice between spirituality and mental illness, I know which one I would choose. And I did.

When I told a psychiatrist I was meditating before the episode, he said: “Well, we don’t want you going down that path now, do we?" I don’t know what ‘we’ he was referring to, but I would have been very happy if he stuck that ‘we’ right up his butt. That's an example of when treatment didn't fit.

I wanted a life that included meditation, that included growing my relationship to something bigger than me. But no one in the medical system asked what was important to me or what was significant in those spiritual-psychotic events, or why I didn’t feel medication would help.

That is, not until I met a nurse in the loony bin (she was working there, she wasn’t a patient—in case that wasn’t clear) and later when I met with a psychiatrist, both of whom helped shape treatment around me instead of the other way around.

I told the nurse how my meaningful meditation experience escalated into something out of control and was labelled bipolar disorder. Instead of insisting that I had a mental illness and meds were the optimal way to treat it, she listened, without an agenda—or at least with a well-hidden agenda.

She didn’t interrupt, or sigh, or imperceptibly roll her eyes. When I finished, she said softly, “When you touch that limitless part of yourself in meditation, it can be overwhelming."

That sentence helped me see someone from the medical model could understand what I was going through and might be able to hear my side of the story without shutting me down. It was the first time I trusted someone in the health system. As a result, I asked her if she knew a psychiatrist who thought like her. She did.

During the appointment with the psychiatrist, I shared with him the importance of what happened at the retreat and other episodes. He paused thoughtfully and said, “Hmm, sounds like you went into an altered state.” We went on to discuss other experiences. He learned what was significant and why, and then suggested I might want to check out books by Carlos Castaneda. He never said my viewpoint was wrong. He explained I could have a mental illness and profound experiences. Neither one had to cancel the other out. He didn’t say don’t meditate; rather, we strategized how I could become aware when I was becoming ungrounded.

Both he and the nurse helped me hold both—have mental illness and spiritual experiences simultaneously. That's what I mean by fit. That fit motivated me to become proactive in my own healing. I had agency. The life I was creating was at the centre, not the system.

If you have a mental illness, you can advocate for this fit. You deserve no less. If you need support or further understanding in this process, research Dr. Patricia Deegan. She has resources to help people be, as she calls it, the 'author of their own life.'

1 Jørgensen K, Rasmussen T, Hansen M, Andreasson K, Karlsson B. Recovery-Oriented Intersectoral Care in Mental Health: As Perceived by Healthcare Professionals and Users. Int J Environ Res Public Health. 2020 Nov 26;17(23):8777. doi: 10.3390/ijerph17238777. PMID: 33255970; PMCID: PMC7734578.

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