The “4 Ps” of Mental Recovery: Medical Care and Healthfulness

Sunrise over the Atlantic Ocean. Welcome to Cocoa Beach! (Photo by Phillip Martin)

PATIENT PERSPECTIVES

In his new book, Healing: Our Path From Mental Illness to Mental Health, renowned psychiatrist and neuroscientist Thomas Insel, MD, underscores that although medications and healthy living may be necessary for recovery from mental/brain illness, they are not sufficient. For effective recovery that is built to last, the individual’s life must be constructed upon a social foundation of “people, place, and purpose”—what he calls the “3 Ps.”¹ To this, I add a fourth P: perseverance.

This article illustrates and animates the 4 Ps by analyzing my ongoing recovery from acute bipolar crisis, which was based upon medication, therapy, and healthy living, anchored into the 3 Ps and infused with perseverance (Figure 1).

Figure 1. Timeline to Recovery. (Illustration by Cate Ryan)

My recovery efforts were conceived and initiated in 2016, after studying recovery and how to construct a successful retired life—years before I had heard of Dr Insel’s 3 Ps in 2022.

What I discovered then is that recovery requires:

• The right medical care and healthful lifestyle
• Building a vibrant network of friends and individuals you love being with
• Living in a place that makes you happy, is energizing, and is safe
• Constructing a life of meaning and purpose that inspires, drives, and fulfils
• Infusing everything with perseverance, and never giving up the will to recover

My story offers an example of the 4 Ps (Figure 2) and how someone recovering from mental illness can employ this concept.

Figure 2. Structure of Recovery. (Illustration by Cate Ryan)

Background

I was struck with bipolar disorder in 2003 at age 47, when the intense stress of leading thousands of soldiers in the Iraq War triggered my genetic predisposition for bipolar. For the next 11 years, my condition went unknown, undetected, and undiagnosed. My mania surged higher, and my depression sank lower, until I went into full-blown mania in 2014 as a 58-year-old 2-star general, was removed from my command of the National Defense University, and subsequently crashed into severe, hopeless depression with terrifying psychosis.

After 3 misdiagnoses as “Fit for Duty,” in July 2014, I was properly diagnosed with bipolar 1 4 months later, 11-plus years after onset. Then for 2 years, I was dysfunctional, in crisis, and in a fight for my life, tortured by “passive” suicidal ideations—vivid images of my own morbid, violent, bloody death, which was anything but “passive” for me. I did not wish to kill myself, but I believed my family and I would be better off if I were dead, and I would gladly die to escape the bipolar hell of my depression and psychosis.

I was hospitalized in March 2016 at the superb Veterans Administration (VA) hospital in White River Junction, Vermont. Although I was still months away from the start of “recovery,” this hospitalization marked the embryonic beginning of my path to wellness. My VA care team prescribed medications, therapy, electroconvulsive therapy (ECT), and other treatments, but all to no avail until we tried lithium, which caused my severe depression to lift within days and for me to begin feeling like my old, pre-bipolar self. The combination of my earlier prescribed bipolar medications of Lamictal and Latuda, along with bringing in the “heavy artillery” of lithium, were absolutely necessary and provided the biochemical basis of recovery.

For my recovery to be built on solid ground, however, I needed to construct my own 4 P foundation. With the combination of the right medications, a healthful lifestyle, my expert and compassionate VA care team, and the 4 Ps, I have been steadily rebuilding my bipolar-shattered life and continuing with my recovery (Figure 3).

Figure 3. Road to Recovery. (Illustration by Cate Ryan)

My wife, Maggie, and I realize how very fortunate we have been, and we are most grateful!

People

Connection creates hope, and hope saves lives. People are the engine of hope, which is critical for recovery. When Maggie and I left New Hampshire and arrived in Cocoa Beach, Florida, we had each other, but knew no one else. We still had our family and good friends, but virtually no one nearby. We decided to connect with people and make friends in our new town. Our strategy was to “make a friend and be a friend” (MAF-BAF) every day. Making a friend is as easy as saying “hello”—being a friend is a lifelong endeavor. We learned this powerful concept at a retreat shortly after moving to Florida.

We organized our people-meeting efforts and targeted MAF-BAF in our neighborhood, church, and community gym. To our surprise, the gym—particularly the group-dancing “Gotta Dance!” and fitness classes—has been the greatest producer of friends in terms of quantity, common interests, and depth of friendship.

Maggie and I talk about MAF-BAF every day: Did you make any new friends today? What did you do to be a friend and strengthen existing friendships? These friendships have been critical in my recovery efforts.

As a mental health advocate and mental wellness warrior, I have also made dozens of new friends and colleagues around the country through sharing my story, writing, and speaking. My network grows by the week.

On the inverse side of MAF-BAF, I have also eliminated or contained a number of toxic relationships—people who generate agitation, anger, stress, or anxiety—that were a threat to my recovery and stability. Cutting out or building “guard rails” around friends and toxic subject areas was not pleasant, but it has been necessary and constructive for recovery.

Place

Since I was diagnosed with bipolar in 2014, Maggie and I have moved from Army housing in Washington, DC, to our vacation home in New Hampshire, then ultimately to Florida. For a variety of health, climatic, social, and economic reasons, neither Washington, DC, nor New Hampshire was the right place for my recovery.

Our vacation home in New Hampshire was low-cost and it had beautiful views, clean air and water, no traffic, and low crime. We had taken numerous vacations in New Hampshire—skiing, snowshoeing, swimming, boating, and hiking—and had thoroughly enjoyed it. Unforeseen, however, was that my severe bipolar depression, exacerbated by seasonal affective disorder (SAD) was made worse by the long, dark, cold winter. New Hampshire was also too remote for us—not enough people nearby. And, of course, my depression made everything miserable, hopeless, and dead. I found no pleasure in my previously enjoyable outdoor past times.

We researched SAD, consulted with doctors, took an exploratory trip to Florida, then decided—pending my doctor’s “green light” for biochemical stability—to move, in the hope that the warmth, the bright sun, and the laidback culture would help me recover. We left home, family, friends, and familiar ways behind. It was not easy. But what a great move! We rented for the first 2-and-a-half years, then bought the house next-door—a terrific home in a beautiful, safe neighborhood, in a fun, friendly, happy city.

We have loved our new life in Cocoa Beach! The place strengthens the people dimension.

Purpose

As an Army officer, I must have a mission. From the time I was stabilized on lithium in September 2016 and arrived in Florida, I thought, prayed, and worked on developing a clear, inspirational mission, or purpose, that guided and energized my life. I wanted a purpose that was of eternal value, was bigger than myself, and made a positive difference in the lives of others.

I was drawn to the “Golden Rule”: to “do unto others as you would have them do unto you.” Drawn from the Gospels, which command us to “love your neighbor as yourself,”this mission lifted, fueled, and inspired me, and it helped empower MAF-BAF.

As I shared my bipolar story, I encountered a hunger for boldness, honesty, and authenticity regarding mental illness. As a result, my life mission, or purpose, transformed into “sharing my bipolar story to help stop the stigma and save lives.” The more I shared my story, the more positive and encouraging the response. I believe my sharp, clear purpose is of eternal value, and is making a difference in people’s lives.

I assess my life through the prism of this purpose and prioritize and allocate my time and efforts accordingly. The result is that, along with my wife, I have built a new life that inspires, energizes, connects me with people, and gives both myself and others hope.

Perseverance

One of the most underrated of human virtues, perseverance is “continued effort to do or achieve something despite difficulties, failure, or opposition.”² Recovery is hard! Sometimes you take 1 step forward and then are knocked 2 steps backwards. Nothing is easy. It can be discouraging.

Perseverance and willpower are no substitute for the right biochemical balance in one’s brain or for healthful living, but they are necessary ingredients for fighting through the pain, difficulties, and challenges of recovery. Perseverance must infuse and animate all that you are and all that you do—continuously and in force. You must embrace the spirit that never quits, always fights, and always perseveres.

Perseverance binds together, energizes, and synergizes the right medications and therapy, a healthy lifestyle, and the 3 Ps: people, place, and purpose.

Concluding Thoughts

Lithium, other medications, and therapy have been fundamental to my ongoing recovery from acute bipolar disorder—but just as important has been my 4 P social foundation. The combination of medical care, healthy living, and the 4 Ps has enabled me to construct an ongoing recovery that is built to last and gives me a healthy, happy life of meaning, with wonderful people, in a beautiful place, inspired by eternal purpose, and energized with perseverance that infuses and ties it all together.

Dr Martin is a 36-year Army combat veteran, a retired 2-star general, and a bipolar survivor, thriver, and warrior. The former president of the National Defense University, he is a qualified airborne-ranger-engineer and strategist who has commanded soldiers in combat. He has led organizations from a platoon of 30 soldiers, to a base of 30,000 military and civilians. A graduate of West Point, MIT, and both the Army and Naval War Colleges, he is an ardent and full-time mental health advocate. He lives with his wife in Cocoa Beach, Florida, where he writes, speaks, and confers. His forthcoming book is entitled Bipolar General: My ‘Forever War’ With Mental Illness.

These views are those of the author and do not necessarily represent the views of the US Department of Defense or the US government.

References

1. Insel T. Healing: Our Path From Mental Illness to Mental Health. Penguin Press; 2022.

2. Perseverance. Merriam-Webster. Accessed June 20, 2022. https://www.merriam-webster.com/dictionary/perseverance