Recovery, Mental Health and Inequality

Chinese Ethnic Minorities as Mental Health Service Users

Lynn Tang

• Publisher: Routledge
• Year: 2017
• Print ISBN: 9781138849976
• eBook ISBN: 9781317532880
• Edition: 1
• Topic: Medicine
• Subtopic: Health Care Delivery

Mental health has long been perceived as a taboo subject in the UK, so much so that mental health services have been marginalised within health and social care. There is even more serious neglect of the specific issues faced by different ethnic minorities.

This book uses the rich narratives of the recovery journeys of Chinese mental health service users in the UK – a perceived 'hard-to-reach group' and largely invisible in mental health literature – to illustrate the myriad ways that social inequalities such as class, ethnicity and gender contribute to service users' distress and mental ill-health, as well as shape their subsequent recovery journeys.

Recovery, Mental Health and Inequality contributes to the debate about the implementation of 'recovery approach' in mental health services and demonstrates the importance of tackling structural inequalities in facilitating meaningful recovery. This timely book would benefit practitioners and students in various fields, such as nurses, social workers and mental health postgraduate trainees.

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1 What recovery? Whose recovery?

Recovery as a disputed approach

Introduction

This book critically interrogates the concept of recovery and the elements of the recovery approach, through exploring the way social inequalities shape the journeys of Chinese mental health service users in the UK. Recovery as a movement originating in the US has gained impetus internationally and has been adopted as a mental health policy paradigm in many different countries (Ramon et al., 2009; Slade et al., 2012). In the UK it has been a frequent discursive feature of policy documents and has been adopted by governments as their ‘vision’ of mental health services (DoH, 2001, 2009, 2011).

The recovery movement has its roots in new social movements and has concerned itself with asserting the rights of mental health service users to control their own lives in the face of the dominance of psychiatric power. However, criticism had been made of the way recovery has been mainstreamed and appropriated by mental health policies. Such criticism questions the extent that social-structural inequalities leading to, and resulting from, distress and mental ill health, can be addressed in a neo-liberal political economy and policy context (Pilgrim, 2008; Spandler and Calton, 2009; Edgley et al., 2012; Morrow, 2013).

It is against this background that this book aims to problematise the concept of recovery and argue for the central role of social justice at the heart of a recovery paradigm – one that addresses and tackles multilevel inequalities. It aims to achieve this empirically by exploring the lived experiences of a marginalised group of mental health service users. Incepted from my experiences as a Hong Kong Chinese woman who has used mental health services in both the Hong Kong and UK, this book is based on my doctoral research on Chinese service users living in the UK, which illuminates how structural inequalities contribute to their ill health and shape the social conditions in which they recover. This study privileges service user knowledge and illustrates their agency throughout the recovery journeys. Through understanding their struggles of recovery, this book will shed light on the cultural as well as structural factors that facilitates or hinders recovery in a multicultural society for this ethnic minority community.

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What recovery?

The first question to be asked about the concept of recovery is, ‘What do people recover from?’ Recovery as a proposed new paradigm in the philosophy, management, and delivery of mental health services suggests a change from the dominant, pessimistic view of the possibility of recovery from severe mental health illness. Since Kraepelin (1919) formulated the concept of schizophrenia, the bio-medical classification with its pessimistic prognosis has been widely adopted, despite evidence suggesting more optimistic recovery rates (e.g. Warner, 1994; Harrison et al., 2001). Service users receiving a diagnosis of severe mental illness, e.g. recurrent psychotic episodes, are often told they will never be free from psychosis (e.g. Clark, 2007). It is proposed that a recovery approach can move from this notion of chronicity and deficit to therapeutic optimism (Allott et al., 2002; Lester and Gask, 2006; Ramon et al., 2007). Instead of cure and a return to the pre-illness state, Anthony (1993) argues that recovery should be a way of living a meaningful life even with the limitations caused by distress and mental ill health. Therefore, recovery is about social inclusion, being accepted as part of society (Repper and Perkins, 2003). Some service users argue that recovery is a process in which a new life purpose is usually developed (e.g. Deegan, 1988; Clark, 2007). This is a self-defined route of recovery with real choices about accepting or rejecting certain treatment options, including the choice to define recovery in your own way (Coleman, 2004). Spandler and Calton (2009) argue that the dominant recovery discourse being mainstreamed into the mental health policies ‘fails to question the dominant ideas about what people have recovery “from”, whilst social inclusion has no critique of that which people are supposed to be included “in”’ (p. 251, my emphasis).

Despite the potential of the recovery approach for empowering service users to achieve quality lives, its implementation in different countries has been criticised for its limitations. For example, its individualistic tendency and its lack of a commitment to tackle the inequalities mental health service users face. These limitations, as Morrow (2013) highlights in a critique of the recovery paradigm in Canada, can be traced to the political economical context in which health and social policies are formulated and embedded. Mental health services and policies do not take forms incompatible with neo-liberal logic. The version of the recovery approach that has been mainstreamed lacks the progressive power to challenge the social determinants of mental ill health, including the inequalities upheld by neo-liberalism that contribute to distress. Those elements that aim to tackle inequalities, including existing power inequalities, tend to be marginalised in the mainstream recovery paradigm. This is in spite of the literature that evidences the impact of social determinants on mental health inequity (Weisser et al., 2011).

This same critique is applicable to the context of the UK. Carpenter (2009a) points out that the New Labour changes to the English and Welsh mental health legislation saw an increase in the control of service users and a reduction in their rights. This is contrary to the ethos of self-determination in the recovery approach. As Pilgrim indicates, the growth of consumerism in health care services appropriates some of the service user movements’ claims for choice and rights (Pilgrim, 2008), but it has increasingly moved away from the participatory version of choice that the service user movements envision. Services that were effective in promoting social inclusion for service users, for example, day centres, have been closed down in England by the Coalition and the subsequent Conservative government in the name of austerity. Such closures serve to reduce the choices of services users. The government’s cut on disability benefits and concerted moral attack on disability claimants, amplified by the demonising discourses of the tabloids, has fuelled the dominant paternalistic, narrow definition or outcome of recovery and social inclusion, which means recovery to work. Harper and Speed (2012) and Rose (2014) warn that the mainstreamed recovery discourse has lost the liberatory and emancipatory element originally proposed in the recovery movement. As recovery is increasingly experienced as a disciplinary force to urge service users to get paid employment and mask persisting coercion, e.g. community treatment order, service user advocates become critical to the recovery discourse, with some even propose an abandonment of the rhetoric of recovery (Pilgrim and McCranie, 2013; Recovery in the Bin, 2016).

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Pilgrim (2008) delineates three competing versions of the recovery approach, which are helpful in explicating what the recovery of service users means and entails, and why these meanings may contradict each other. The three meanings of recovery include ‘recovery from illness, i.e. an outcome of successful treatment’, ‘recovery from impairment, i.e. an outcome of successful rehabilitation’ with an emphasis on obtaining social skills and ‘recovery from invalidation, i.e. an outcome of successful survival’ (Pilgrim, 2008: 29). These three meanings can serve as ideal types of recovery discourses in exploring what the recovery paradigm for mental health services is. They can co-exist with each other, for example, in understanding the bio-medical model and the social model of mental health care as ‘complementary and synergistic’ as outlined in the joint position paper of the Care Services Improvement Partnership (CSIP), Royal College of Psychiatrists (RCPsych) and the Social Care Institute for Excellence (SCIE) (2007: 2). They can also be in tension with each other. For example, the second discourse which promotes the building of social skills that are fit for society could conflict with the third discourse which promotes the reclaiming of full citizenship and freedom from potentially coercive services and self-determination in life choices (Pilgrim, 2008). Such tensions are predicated upon a contradictory feature of mental health services: individual user’s choice and risk reduction to serve the public interest, with the latter exemplified in the 2007 Mental Health Act (Carpenter, 2009a). The power to declare recovery resides in mental health professionals to whom the state confers powers to exercise coercive social control. This conflicts with users’ choices to be service avoiders, rejecting the notion that mental distress is an illness or choosing to live lives that deviate from social norms. The first and second discourses adopted by mental health services and main professional bodies, mask the imperative to change oppressive and excluding social structures that can invalidate service users, an imperative that is central to the third discourse.

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A sociological understanding of the interplay of structure and agency helps take the question of ‘What is recovery?’ further (G.H. Williams, 2003; S.J. Williams, 2003; Yanos et al., 2007). Simply put, structure refers to patterned social arrangements, in the form of institutions and power relations. Agency refers to the capacity of an individual to aspire, make choices and determine the direction of their life. The relationship between structure and agency is dialectic. Patterned social arrangements shape individual’s actions and identities to varying degrees, while individual’s actions, individually and collectively, can change social arrangement to differing extents.

The dominant recovery discourse underplays social factors and emphasises the agency side of recovery, i.e. promoting empowerment with an emphasis on a hopeful life, as advocated by the proponents of the Recovery Movement (e.g. Anthony, 1993, cited in DoH, 2009). It fails however to address the structural forces and social inequalities leading to ill health in the first place. These are factors that constrain and facilitate the development and exercise of agency during the recovery process. Such inequalities manifest themselves in a variety of forms, for example, class relations, gender, ethnicity, psychiatric power, ableism and sanism (Weisser et al., 2011). Ableism and sanism are ideologies and practices that assume ‘normativity’ against a divisive notion of abled body/mind (Campbell, 2009) as well as madness and irrationality (Chamberlain, 1978; Perlin, 2000; Morrow and Weisser, 2012). Perlin (1999) referred to ‘sanism’ as an irrational prejudice against people labelled as ‘mentally ill’. ‘Sanism’ as a systematic form of oppression is often likened to racism and sexism. It is a structural inequality for its ‘valuing of rational thinking and socially acceptable forms of behavior, and the subsequent ostracisation and/or punishment of people who do not or cannot conform’ (Morrow and Weisser, 2012: 31). Thus analysis on sanism goes beyond a focus on stigmatising practices and attitudes at social interactional level. It looks at what social structure breed and sanction such stigma (Poole et al., 2012). Sanism, ableism and other inequalities can limit an individual’s life chances and capacity to exercise agency in making life decisions. Therefore, to take agency seriously, we need to look at what structural changes are necessary within and beyond mental health services (Hopper, 2007; Pilgrim, 2008). To put structure into the recovery approach is to turn what people recover from into an empirical enquiry.

In this study I draw on the Capabilities Approach as a heuristic framework (Sen, 1999; Nussbaum, 2000; Jackson, 2005; Sayer, 2012) to empirically inquire into what recovery is by exploring the interplay of structure and agency. The Capabilities Approach was devised by Amartya Sen for development studies to evaluate a country’s development in terms of well-being and quality of life instead of gross economic gain. Later it was adapted to studies in ‘developed’ countries for policy development and evaluations in areas such as education, health, disability and employment (e.g. Walker, 2006; Saleeby, 2007; Ruger, 2009; Orton, 2011; Lewis, 2012). It has been taken up in mental health studies by a variety of authors concerned with exploring the importance of social context in recovery as well as agency development (Hopper, 2007; Ware et al., 2008; Davidson et al., 2011; Barrow et al., 2014). The Capabilities Approach understands capabilities as the substantive freedom an individual has rather than the ability they possess. The process of exercising choice is one dimension of substantive freedom. But for such freedom to be substantive it is necessary to consider the opportunities available to an individual. The Capabilities Approach also identifies how an individual is able to convert ability and resources into forms of doing and being that are valued by them (Robeyns, 2005). Such conversion factors could be the environments, institutions, social policies, and the welfare regime individuals live in (Robeyns, 2005; Hopper, 2007; Orton, 2011). In other words, conversion factors are the facilitators or the structural barriers that enable or disable an individual from achieving a valued way of living.

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Used as an evaluation tool, the Capabilities Approach is not concerned with what an individual eventually chooses to do. Rather, it focuses on whether an individual has the life chances or ‘exercisable opportunities’ (Daniels, 2010) to live the life they want. Instead of using one specific benchmark as the outcome of progress, i.e. recovery in this study, the Capabilities Approach looks at the multi-dimensional nature of an individual’s quality of life. To empirically address the questions ‘What is recovery?’ a service user’s capabilities set can be seen as the evaluative space that shows what capabilities have increased and what capabilities have decreased along the recovery process. This formulation not only addresses Pilgrim’s third meaning of recovery. It also has the potential to transcend the debate as to whether the social model of disability is applicable to mental ill health (Wallcraft and Hopper, 2015).

Adaptive preference is another key concept in the Capabilities Approach, which helps to address the interplay of structure and agency by not taking what recovery is at face value (Sen, 1984; Nussbaum, 2000; Khader, 2011). Adaptive preference refers to an individual’s perception of the scope of life choices and preferences in life decision-making, both of which can be shaped and restricted by the disadvantages that they face. This resonates with the idea of the temporal process of structural conditioning in exploring the way structure shapes individual actions (S.J. Williams, 2003). In the mental health context, Wallcraft (2011) has shown that in studies of quality of life measures, people diagnosed with severe mental illness, such as schizophrenia, tend to underrate decreases in their quality of life compared with researchers using ‘objective’ quality of life measures. This underrating could be a result of service users adapting their aspirations because of their experiences being invalidated and excluded.

Thus, the concept of adaptive preference prompts a look beyond the face value of service users’ answers to the question ‘What is recovery?’ If hope is an important element in journeying to recovery then an examination of the process of how individuals form their hopes or preferences is important in tracking how their valued ‘doing and being’ changes over time. This focuses attention on the symptoms, impairments, or social invalidations that arise from structural inequalities and become the barriers that result in the adaptation of preferences in life.

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Whose recovery?

One way to turn the question ‘What do people recover from?’ into an empirical enquiry is to ask ‘Whose recovery is it?’ (Social Perspectives Network, 2007). The Social Perspectives Network’s report shows how the recovery approach has both addressed and failed to address, issues of diversity such as gender, sexuality and ethnicity. Challenges in different areas of life include and go beyond mental health discrimination. Structural constraints for different groups of people are constituted of barriers arising from a range of power inequalities. The dominant recovery discourse in mental health policies fails to address the diversity of lives that people want to live. People who face, or are marginalised by, different inequalities have different answers to the question ‘What is recovery?’ These answers have implications for identifying the structural barriers that need to be removed to achieve the capabilities necessary for meaningful recovery. For this reason, this book explores what recovery entails for Chinese mental health service users in the UK as a case study that identifies the structural barriers they face in their recovery journeys.

There are three main reasons for choosing to study Chinese mental health service users living in the UK. First and foremost, as a Chinese woman from Hong Kong who lived in the UK for 7 years and has been a mental health service user in Hong Kong and the UK, my personal history drew me to this topic. While Chinese people form the majority in Hong Kong and are a minority in the UK, I realised that there are common experiences shared by service users in both places due to the dominance of Western bio-medical psychiatry in both societies. I find resonance in some of the critiques of psychiatric power raised by the service user movement, but I am equally aware that Chinese people’s experiences differ from other service users in the UK and this is a relatively unexplored topic. What Chinese people need to ‘recover from’ could be shaped by their positioning as an ethnic minority in the UK and their quality of life, and their envisioning of what constitutes the good life could be restricted as a result. My awareness of the issues that service users and Chinese people may encounter in the UK means that I am well positioned to undertake my chosen case study and draw on my service user experiences in the production of knowledge. My linguistic ability and cross-cultural experiences as a service user enabled me to communicate, understand and relate to other Chinese mental health service users as an insider.

Second, not only are Chinese people invisible in the UK service user movement, they remain marginal in academic studies including those on mental health. This is despite the fact that Chinese people in the UK are a visible community in terms of their skin colour, their cuisine and the Chinatowns that have been established in major UK cities since large-scale immigration in the 1960s. Chinese community has settled in the UK for more than 150 years. In 2011 the size of the UK Chinese population was approximately 400,000 forming 0.7 of the total population, an increase from an estimate of 250,000 in the 2001 Census.

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Invisibility could be due to Chinese people living in UK often being portrayed as a homogenous group who live independently and can cope for themselves. Chinese people have migrated from d...

Table of contents

• Cover Page
• Recovery, Mental Health and Inequality
• Routledge Studies in the Sociology of Health and Illness
• Title
• Copyright
• Contents
• List of Tables
• Acknowledgements
• 1 What Recovery? Whose Recovery? Recovery as a Disputed Approach
• 2 Exploring Social Inequalities with the Capabilities Approach and Intersectionality Analysis
• 3 When Things Start to Fall Apart: Social Conditions and the Loss of Capabilities
• 4 Becoming a Psychiatric Patient
• 5 Life After shipwreck: Social Conditions for Capabilities (Re)Development
• 6 Stubbornly Strive to be Human: Meanings of Recovery, Hope and Adaptive Preferences
• 7 Social Conditions for Recovery: Towards a Social Justice Agenda
• Methodological Epilogue: Developing the Service User Knowledge of Chinese Communities
• Appendix: participants’ biographical data
• References
• Index