The Difficult Conversation of Cost in Windhorse

The intention of this paper is to identify the dilemma of working within a modality of treatment that is notoriously expensive. Residential treatment centers, inpatient hospitals, and acute psychiatric wards are all either very expensive or face the challenge of delivering affordable services based on grants, managed care, etc. Both options have pitfalls and can leave a person feeling marginalized, traumatized, isolated, and mistreated. Unfortunately, the more expensive, private-pay centers are typically only accessible for wealthy families. This challenge becomes something of a dilemma for staff at times, struggling to balance the wish for accessibility with dedication to the people we do serve. The following paper is meant to bring some awareness to this dilemma as well as ways to navigate the conversation with staff, providers, and clients alike.

The Dilemma

Recently I was at a conference speaking about what we do at Windhorse: the approach, the challenges, and the formation of deep, meaningful relationships that provide a ground for the opportunity to learn, heal, and grow. The conversation itself was rich, meaningful, and explorative. As we were weaving through the many different experiences of suffering and moments of insight and warmth, I recognized in myself a compassionate sense of connection to the many different people sharing space in the room. Some people with have lived experience of extreme states in the typical sense, others were practitioners who are passionate about learning and connecting, others were parents or loved ones of people who have experienced extreme/turbulent mind states or other life challenges. As we began to connect regarding the trauma some had experienced while hospitalized or institutionalized, a deep sense of sadness and heaviness overwhelmed the room.

“We explored this experience together and the conversation shifted into the collective wish for there to be something else, a treatment option that is more humane, less disempowering, more dignified, less restrictive, more open, and less humiliating.”

The people there were gathered from all over the country. Many of them are in, or are just starting, programs and were seeking to create something that they felt was lacking in other places. People began to ask about Windhorse. They had read about the work of Edward Podvoll and discussed feeling a sense of excitement about what Windhorse is trying to do, what it is doing, and what it is dedicated to. I too felt a sense of excitement talking about the Windhorse approach and the roots and the ways in which it has changed my life and the lives of so many others. Many people expressed an interest in coming to Windhorse, to work with Windhorse, to learn more about it and themselves in the space of relationship and with an intention of self-awareness. 

We, as a group, explored the accessibility of these certain models, alternative healing communities, approaches, etc. and it became clear there are limitations for some: the challenges of the lack of availability, lack of accessibility, lack of resources, and lack of funds. The dilemma emerged at the same time; just as people were experiencing hope they also experienced something unexpected, something I didn’t expect, the dissolution of hope. What they wanted and hoped to accomplish felt outside of their reach. For many, the money wasn’t there. I felt many feelings all at once: sadness, guilt, anger, and a feeling of unfairness. I have experienced this moment at many times before and since this conference and have begun to realize that many groups and people experience this. How do we talk about the cost of this program in a way that is true and while also acknowledging the expense of such a program as Windhorse, an expense that puts it outside the realm of possibility for many mentally challenged in our country? Does this barrier make it any less effective, less valuable, or less real? 

The Discussion

Here is the discussion: how do we as Windhorse people talk about this notion of cost and accessibility to ourselves, to each other, with the clients we work with, their families, other providers, etc.? Edward Podvoll speaks in Recovering Sanity of Windhorse work as a “well-funded research project.” We can talk about the importance of exploring and gaining “useful information about relating to mind and environment of someone in crisis” in a more humane, contemplative, and open way. In exploring the history of the hospitals and asylum mentality, Podvoll points to Perceval speaking about the opportunity for patient advocacy, for providing good, compassionate care to patients, and that even being able to do this for one patient can have great consequences on the overall system. We begin to change the paradigm from the inside out, small bits at a time. In unpacking this further we see the importance of the notion that we are in a constant state of learning about ourselves and other in the space of relationship and with the intention of creating sane healing environments based on compassion, skill, holistic awareness, and allegiance to interpersonal exchange and basic goodness. This, as we have learned, is an art, a practice, which takes research, which is, in essence and truth, a project. 

I often hear questions about accessibility. Staff members, social advocates, parents, other family members, and clients have all asked about cost and accessibility. We are hoping for a day when these types of services, this type of intensive relational and environmental attention, will be viewed by managed care companies as “successful and empirical” and will therefore allow for payment and/or reimbursement of the services. The predicament is that this may perhaps come with its own pitfalls: insurance companies contracting allowable rates may drive down the cost of the tuition therefore limiting the ability to maintain the integrity of the model and its staff-intensive approach. It may direct and require medical-necessity updates and remove some of the most important parts of the treatment: ideas of mutual recovery and contemplative approaches and the avoidance of stark and rigid diagnostic labels which create environments of hierarchy and treatment that focuses on “doing to” a person rather than “being with” them. We may indeed have a choice to make at some point about the direction we take with the future of this alternative treatment modality. 

When I began at Windhorse as a team leader these conversations seemed simple enough to have as I worked to balance the deep care with good clinical work to help justify the cost to my clients and their loved ones. Many of them lived in a financial world I didn’t understand or know, which, truthfully, made me wonder how I could fully connect with them or their child. What I learned, very quickly, was that mental illness affects everybody regardless of their socio-economic status, and that, in many cases, this disruption had torn their families apart. After years of pain, trauma, hospitalizations, family discord, substance use, etc. they were seeking the type of care that could help recognize sanity and health as well as re-connect their loved ones to other people once again and to find a place of balance within themselves. 

With that in mind, I was able to just focus on what I did know, my own understanding of how this type of work could affect somebody and impact their minds and environments as well as their family system. I realized over time that what I am doing is becoming highly attuned to the details of my clients mind and their intersection with the world around them. No detail seems too small or unimportant to me. It is my responsibility to help create a team culture that is giving the client and their family everything they are paying for, and more, hopefully. I want the clients and loved ones to feel, to know, that I believe in them and believe in this work, and that we will do everything we can to find a way in, to locate the micro processes that interfere with balance, that disrupt relationships and create disharmony. Likewise we will remain committed to and aware of the many moments of sanity and clarity that exist throughout each day and every extreme cycle. This is my dedication to each individual, to the project, and to the field of psychology. 

As my journey at Windhorse evolved into more of a leadership position, eventually becoming Executive Director for a Windhorse center, the conversations became a bit more complicated. I was now not only having the conversations with family members, but also with staff, who crave the same thing we all do: for this approach to be accessible to those we see on the street, or know through personal networks, or who we meet in hospitals. I no longer work as a team leader and find myself working to see the original vision through a different lens: teaching others to hold that same attention to detail. I search for staff who have a deep capacity and willingness to touch into their compassionate selves as well as a fierceness about this work. I am able to see from many different perspectives now. When we are paying attention to detail in this way, there is an immersion into another person’s mind state and inevitably there is confusion and exhaustion. When we offer ourselves to another person or family in a vulnerable way, we can experience deep pain and sadness. As western practitioners we are taught to take care of ourselves in the traditional sense: not to work harder than our clients, to practice self care, to keep ourselves boundaried. At Windhorse we intentionally work to challenge these notions in order to deeply feel and connect with those we serve. In order to balance this a person needs extra support and supervision so they can find their way back to a place of replenishment, so they don’t miss the opportunity to recognize exchange, and so they can find a place of curiosity, space, and openness again. This type of contemplative supervision is provided to everybody and is a part of the tuition a client pays for. It is part of the service we provide to our clients. It is a re-investment into the project—to maintain the sanity of the staff as well as to create conditions for the best type of work to take place. It is also something that sets us apart from other psycho-social programs. Contemplative supervision is expensive, it is exhaustive, and it is immensely self-reflective. It is not about the clients solely, as is traditional in clinical supervision, but about pushing ourselves and our supervisees to notice the minutiae of tiny details that string together and affect our sanity or insanity, to open out to different possibilities, and see other ways.  

The conversation of cost then becomes an organizational one, with many different views into it. Ultimately we are tasked with trying to create conditions for people to find their way back to a balanced state. We are part of this research project and must remain dedicated to its cause. For the people we serve, we must seek to spelunk into their minds and our own minds while providing them with a team that considers as much as they possibly can. As staff, we are the ones who can justify, through our diligence, commitment, and hard work, the cost of this program. We are the ones who can give them more than what they have been given at other treatment facilities.

Commitment

Ed’s vision of Windhorse as a well-funded research project is interesting and on point. Like other groundbreaking treatment approaches throughout history, we are a part of a project, researching its efficacy, taking part in its study, and acting as participants (due to mutual recovery), accomplices, and witnesses. Effective research projects take time, participation, belief, and scrutiny. They ultimately are very expensive. Our commitment as participants in this project must be to the integrity of the research vision, to recognizing and remembering there are thousands of people with extreme mind states and various other ailments and disorders who have embarked on their healing journey through the landscape of this project and found some path towards recovery.

“Their investment in this project has helped pave the way for others and has become a part of the narrative and parables that make up the foundation of the project.”

Research projects take shape and become valid and powerful with discussion and passing on of information. We must seek to write about our experiences, to present our stories and the stories of others, to connect and share these stories, to remain dedicated to the vision of the project. In a way, this is what we signed up for: to bring about change we have committed to participating in the project.

The quality of the work embedded in this model is unquantifiable in many ways. How you quantify the depth, the skill, and the commitment to basic goodness, sanity, and health speaks to the idea that good treatment is expensive. We could provide less, ask less of our staff and our clients, and still be a “really good psychosocial program,” but we do more, we access the mind on a different level, engage the body in a healthy, rhythmic way, create healthy environments of sanity and curiosity, and bring balance to turbulent and extreme states. It is important for those of us who speak with families and other providers to be aware of these things, to have a humble confidence with the work of the project and the intentions behind it, to help fund the on-going project both in heart and financially, and to remain inheritors and collaborators to this research and to those we serve, in the most open way possible.