This is the second of three posts on the Recovery movement (part 1 - 17th January) and offers a brief history of what I’ve come to regard as a social movement - an attempt to introduce a particular set of moral, ethical and political values into the behaviour of those in the world of mental health. Here I look at the nature of the Recovery approach itself, whilst the third part will deal with it’s impact on the day to day practice of individuals and organisations. For those entirely unfamiliar with Recovery please read part one and follow the links.
As far as I am aware, I am the only person locally, who having been a recipient or ‘product’ of Recovery-focused care, has then gone on to become a critic. Bemused workers and managers have responded to my observations almost as if they were acts of disloyalty - since my mental health obviously improved over that period. My contention, as hopefully the content of this blog has begun to show, is that it was factors other than those identified by the Recovery approach which were of real importance in improving my life. Nonetheless I believe the Recovery movement is important, not least because it helps to stop some of the damage psychiatry and clinical psychology continue to do.
It needs to be asserted at the outset that the Recovery approach to date has not generated any new theory of human behaviour, understanding of mental distress, of emotions or unusual behaviour, nor has it advocated specific therapeutic interventions. It is principally about the better management and delivery of care, but in this area too, it does not challenge the legitimacy of any of the existing occupational groups within mental health. In essence the Recovery approach sets out to change the way mental health services are organised and delivered in order to be more responsive to the stated needs of clients and their supporters. A set of Recovery values has emerged that are intended to inform the personal conduct of workers in their interactions with clients.
However the way the Recovery approach is experienced or encountered by the worker, client or supporter is self-reported in highly individualistic ways, only later do some appreciate the sources of their new insights or beliefs. Many talk about a journey of recovery, and of who or what placed them on that journey (see the recovery stories at http://www.devonpartnership.nhs.uk/fileadmin/user_upload/publications/Beyond_the_Storms.pdf ) in a way that is reminiscent of many narrative approaches throughout history, particularly the notion of spiritual or religious pilgrimage - albeit with a very secular favour - as if it were a novel and unique experience. But it was never that way for me. My growing ‘wellness’ made me increasingly an outsider looking-in on the Recovery movement, which seemed to be socially constructed by people talking a language of networking.
As yet there is only a very modest evidence base for Recovery-focused care and little that could be claimed as evidence based practice. But there are many ‘interested parties’, committed to Recovery values, who are only too anxious to create an evidence base. Equally there appears to be no systematic critique of Recovery other than the reassertion of more traditional approaches - extraordinary given how pervasive the ideas have become. It is also remarkable given the context of the highly contested nature of knowledge in mental health; within and between the disciplines of psychiatry, clinical psychology, nursing and now Recovery, between competing theories of learning, and the contrasting perceptions of the providers and users of services.
With the exception of the current UK REFOCUS research project ( http://www.iop.kcl.ac.uk/departments/?locator=1073 ) almost all investigations globally have been service evaluations, and almost exclusively quantitative. A recent local example being Alison Moores Report Of The Standards And Outcomes Pilot Project 2008/9 ( http://www.communitycaretrust.org/attachments/File/Standardsandoutcomes2008-9FINAL.pdf ). Qualitative data has been overwhelmingly restricted to collections of users’ writing. The involvement of service users as ‘researchers’ in such quantitative service evaluations is a sensitive and problematic issue in the UK and America. It remains to be seen how much influence they can assert over the current REFOCUS project.
The concept of Recovery may yet turn out to be an example of reification, but nonetheless many people do act ‘in the name of’ Recovery and in that sense it is having a very real impact on everybody’s ‘outcomes’.
Exceptional Clients and Disaffected Workers
The concept which became known as Recovery (in mental health) has its origins amongst a small number of individual consumers (users) in the US in the late 1980’s and early 90’s. Contrary to the folklore of Recovery they appear not to have rejected the medical or disease model itself, but the pessimistic prognosis offered by psychiatry. What they refused was the ‘sick role’ and the notion that they need be ‘disabled’ by mental illness. The client might continue to live with mental distress but it need not limit their ‘life chances’ or opportunities to fulfil goals or wishes. A few exceptional clients emerged who were able to wear as a ‘badge of honour’ both their ‘lived experience’ as well as their educational and work achievements. Readers may care to ‘google’ the following exceptional clients from the US - Patricia Deegan, Priscilla Ridgeway, Shery Mead and Mary Ellen Copeland. Deegan asserted in 1988 that:
‘Recovery is a process, a way of life, an attitude, and a way of approaching the day’s challenges. ..At times our course is erratic and we falter, slide back, regroup and start again. ..the aspiration is to live, work, and love in a community in which one makes a significant contribution’.
Even now, well over 20 years since it’s emergence there is only the broadest of agreed definitions of what Recovery is, allowing for a wide interpretation - and many welcome that. Ironically some also insist that Recovery is, what the individual decides it is. Last year Mike Slade, in the UK’s first textbook on the approach, Personal Recovery And Mental Illness ( http://www.amazon.co.uk/Personal-Recovery-Mental-Illness-Professionals/dp/0521746582/ref=sr_1_1?ie=UTF8&qid=1290062155&sr=1-1 ) selected the following quote from William Anthony in 1993 to serve as a working definition.
‘…a deeply personal, unique process of changing one’s attitudes, values, feelings, goals, skills, and/ or roles. It is a way of living a satisfying, hopeful, and contributing life even within the limitations caused by illness. Recovery involves the development of new meaning and purpose in one’s life as one grows beyond the catastrophic effects of mental illness’.
Unlike the anti-psychiatry movement of the late 1950’s and 60’s however, which offered new theory and practice (though now largely rejected) and the user/ survivor groups of the 1970’s and 80’s, who in their complaining and campaigning focussed on rights and entitlements - Recovery approaches were, and remain highly individualistic. Not only is it assumed, in a moral or political sense, that individuals should be able to determine their own futures, but also in terms of theory - individual determinism is taken for granted, as opposed to more social forms of learning and agency. Part of the approach is for workers to be extremely client-centred with a clear moral imperative to take what clients say at face value. This is one of the senses in which the Recovery movement is best understood as a reaction against previous forms of care, rather than a positive assertion of new insights into mental distress. It emerged in the historical context of public perceptions of what constitutes abuse becoming much wider, and in parallel with a growing sensitivity of government and academia to the use of discriminatory and gender-based language, commonly referred to as ‘political correctness’.
Individual charismatic clients were joined by mental health workers who had gravitated towards community services, having become disaffected by the rigidity of the formal mental health system. The Recovery movement spread outwards from the USA to New Zealand (google Frank Bristol, Mary O’Hagan) and the UK (Ron Coleman). By the turn of the millennium, Recovery approaches were beginning to be considered for inclusion in the formal structures of health care in most western countries.
Recovery Values
From my observations of how the values and ethos of the Recovery approach have been embodied in practice, three underlying themes have emerged, and although their meaning is not made explicit or self-evident in the discourse of workers, they seem increasingly to be taken for granted in their actions. There is of course also a contrast between policy documents (again follow the links in part one) and practice. These are social processes, of working through different ways of being with clients.
What is explicit is the language of Recovery. In the UK, ‘hope’, ‘opportunities’ and ‘social inclusion’ seem to be the emerging concepts around which the Recovery dialogue is structuring itself - indeed advocates are often quite prescriptive about individual choice and freedom of action! From the general conversation of workers I would add; 'active listening’, ‘lived experience’, ‘empowerment’, ‘self-management’, ‘personal journey’, ‘goals’, ‘control’, ‘coaching’, ‘personal story’, ‘choice’ and ‘peer support’ as key words. But the underlying processes I observe are as follows:
Having a future orientation - (hope, goals, opportunities) the promise that tomorrow will be better than today and of acceptance, sometime in the unknowable future, by a society which has rejected them. Yet alarmingly workers often appear not to realise mental distress is only experienced in the present moment and must therefore be confronted today. Hopes and expectations need to be matched to the current situation and current capabilities, otherwise the expectations of others, come to be seen as further evidence of failure. Equally motivation can only come from others, and persists only as long as the client feels some emotional attachment to that person.
The pursuit of individualism - (self-management, personal journey, lived experience, choice, goals, peer support, social inclusion) an essentially anti-social bias; seeking equality in individual rights, entitlements and personal decision making and the formalising of relationships with peers. Clients are urged to set their own goals and needs and take responsibility - if they fail they appear to have ‘chosen’ and relieve others of responsibility. Wellbeing is judged not on the actual outcome of client’s activities, but the story or narrative they tell themselves. Individual merit and skill may be recognised but it is not given value or rewarded, everyone is made an expert to maintain an illusion of equally. Even those exceptional clients and workers who provide charismatic leadership - deny it! The social nature of learning goes unrecognised. Some claim Recovery is about social relationships, but when positive emotional attachments form between workers, clients and carers it is often seen as dependency and a failure to move on.
The illusion of a ‘self’ in control - (control, choice, empowerment, lived experience, self-management) it is one thing to argue that the client should take control back from mental health services and be in control, but this is what clients have always tried to do and been knocked-back by the reality of their situation - by evidence of not being in control. It is the ability to live with doubt, uncertainty, and not being in control, and be able to respond in a flexible way to change, that is mental health.
In short, Recovery values are the embodiment of our commonsense understandings about the place of individuals in modern western societies. They reflect the ideology of liberal democracies built upon a capitalistic economy. In so far as Recovery can be said to have intellectual antecedents then they lie in American humanistic psychology from the 1940’s and 50’s. Indeed at various times Recovery has made an uncritical use of Maslow’s ‘hierarchy of needs’! What the Recovery movement offers is highly conventional, but is offered to the one client group who are most psychologically and emotional alienated from society, the most aware of the difference between ideological valves and practical realities. The characteristics of the client continue to be seen, not as a reflection of modern society’s inability to genuinely accept difference, but of their failure to live within it. We are offered time and support to become more sophisticated conformists.
The clients I speak to every day do not speak the language of Recovery; if the subject is our own mental distress (and most often it isn’t) then we speak of the reality of the present moment and the inadequacies (or occasional virtues) of mental health services. We are suspicious of anything not grounded in the practicalities of everyday life. Workers in their stated attitudes often appear ignorant of our limited life choices. Workers wish to give hope, but do so in a situation where they get little back from the client. Equally they are anxious not to undermine the fragile confidence of the client. Yet in reality, as low paid, low status workers, they must be only too well aware of the limited opportunities of the client. As the number of workers with varying degrees of lived experience increases then the gap between potential life chances (as demonstrated by exceptional clients) and the reality of limited opportunities for most, can only become more visible.
A useful way of making sense of the activity of the Recovery movement is to see it as an example of ‘ideological work’. The late sociologist Bennett Berger ( http://www.amazon.co.uk/Survival-Counterculture-Ideological-Everyday-Communards/dp/0765808056/ref=sr_1_1?s=books&ie=UTF8&qid=1290063625&sr=1-1 ) introduced the concept - for him it was both his object of study and his method. Like myself he was initially personally involved with, and committed to, the subjects of his research, and like them wanting to provoke social change. He was interested in the tension between peoples ideals and the reality of their material existence. How the publicly stated goals of individuals or groups, realised themselves in actual behaviour. But he was also acutely aware of such a tension within himself; between his personal beliefs about the world, and what the results of his research told him. He argued that much of culture was becoming increasingly ideological, but that such symbolic structures were rarely translated into social structures. He studied people with ‘green’ values who wished to pursue a self-sufficient and communal lifestyle, but were confronted by the practical realities of agricultural labour and subsistence farming. He wanted to study the inevitable gap between what they professed and the way they behaved as they adapted to the changing circumstances of their lives.
‘…when groups are caught in contradictions between the ideas they profess to believe in and their day-to-day behavior, is their hurried ideological repair work best understood in an ironic, contemptuous, and cynical manner?’
In part three I consider how ideals have been turned into action in the Recovery movement.
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