The Routledge Companion to Health Humanities

Paul Crawford, Brian Brown, Andrea Charise, Paul Crawford, Brian Brown, Andrea Charise

• Publisher: Routledge
• Year: 2020
• ISBN:
  9780429889639
• Edition: 1
• Topic: Literatur
• Subtopic: Literaturkritik

The health humanities is a rapidly rising field, advancing an inclusive, democratizing, activist, applied, critical, and culturally diverse approach to delivering health and well-being through the arts and humanities. It has generated new kinds of interdisciplinary research, knowledge, and communities of practice globally. It has also acted to bring greater coherence and political force to contributions across a range of related disciplines and traditions.

In this volume, a formidable set of authors explore the history, current state, and future of the health humanities, in particular how its vision of the arts and humanities:

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• Promotes creative public health.
• Opens new routes to health and well-being.
• Informs and drives better health care.
• Interrogates relationships between ill health and social equality.
• Develops humanist theory in relation to health and social care practice.
• Foregrounds cultural difference as a resource for positive change in society.
• Tests the humanity of an increasingly globalized health-care system.
• Looks to overcome structural and process obstacles to cross-disciplinary ventures.
• Champions co-construction, co-design, and mutuality in solving health and well-being challenges.
• Showcases less familiar, prominent, or celebrated creative practices.
• Includes multiple perspectives on the value and health benefits of the arts and humanities not limited to or dominated by medicine.

Divided into two main sections, the Companion looks at "Reflections and Critical Perspectives, " offering current thinking and definitions within health humanities, and "Applications, " comprising a wide selection of applied arts and humanities practices from comedy, writing, and dancing to yoga, cooking, and horticultural display.

PART 1

Reflections and critical perspectives

1

The health humanities, genealogies of health care, and the consolation of understanding

Towards a critique of “recovery” in mental health

Brian Brown

Introduction

Understanding ideas, practices, and sensibilities that shape the present is greatly aided by recognizing where they came from. What may look commonplace or taken for granted nowadays may not have always looked this way. Having a grasp of the stories behind our present-day ideas may help us to critically evaluate them and decide whether, and to what extent, we wish to allow them purchase on our everyday lives. Understanding that things have not always been this way will help us become discerning, self-aware, critical consumers of currently fashionable nostrums and practices. Indeed, as Michel Foucault (1926–1984) argued, phenomena become “things” by virtue of being embedded in a grid of language. One of the capabilities of health humanities is to take forward the critical interrogation of concepts and commonplaces in health care. This can be seen in work that attempts to rethink health care from perspectives in anthropology, sociology, or philosophy, which re-poses how we visualize the human condition, and explores how evidence may derive from creative practice (Crawford et al., 2014). This kind of awareness demands more than just the traditional history of ideas, but rather a genealogy of ideas.

“Genealogy” in this sense comes from German philosopher and cultural critic Friedrich Nietzsche’s (1844–1900) use of the term, and his implementation of the idea, most famously in Genealogy of Morals (first published in 1887). Here he sought to untangle the origin of notions of morality. At that point, many intellectuals, inspired by Darwin’s then fashionable evolutionary theory, had tried to explain actions that were moral or altruistic in terms of how they benefitted others, or contributed to the well-being of the group. As Paul Ree’s On The Origin of the Moral Sensations (1877) described, an action that contributes to the group’s survival, in this view, comes to be seen as moral, altruistic, or desirable. Nietzsche disagreed with this position. Through his detailed knowledge of classical languages, he argued that what came to be seen as morality was in fact closely aligned with the interest of powerful people and elite groups. For example, in ancient Greek the term for “bad” also meant “worthless” or “ill-born”; even in present day language we might describe a desirable course of action as “noble.” Powerless people, by contrast, were apt to adopt a “slave morality,” in which they believed that they would get their rewards in the hereafter. Thus, morality could be argued to derive from particular political, social, and linguistic arrangements. Hence, when a particular course of conduct is recommended as a good way to behave, Nietzsche invites us to consider whose interests this is likely to serve, and who is likely to benefit.

In the twentieth century, this approach was taken up with some enthusiasm by Michel Foucault, who developed genealogy as a historical perspective and investigative method. In this view, genealogy offers an intrinsic critique of the present by enabling the development of critical skills for exploring and analysing the links between knowledge, power, and human subjectivity in contemporary society. Allied to this, a genealogical approach invites us to consider how our existence has been shaped by historical forces. In this respect we might be interested in how patterns of power predispose us to see crime as a result of some sort of deficiency on the part of the criminal, or in why poverty is often seen as the fault of the poor for not making themselves sufficiently attractive to employers. A genealogical approach can help us understand how the limits of what people think is possible have come into existence, such as why psychiatry became a part of medicine, why sexuality became subject to medical expertise, or why punishment became concerned with the reform of the wrongdoer. Once the limits of those worldviews have been exposed, it is also possible to reveal the spaces of freedom people can yet experience and the changes that can still be made (Foucault, 1970).

Foucault’s relevance to the genealogical approach in the health humanities is well known in light of his expositions of madness, sexuality, and selfhood. For example, how did madness come to be a medical matter? In Madness and Civilisation (1965) Foucault argues that the category of “madness” arose as a result of a process of confinement of deviants that began at the start of the Age of Reason: vagrants, the immoral, the blasphemous, and, of course, those deemed mad. As a consequence, doctors gained a key role in the process and in the development of asylums, which provided the opportunity to classify, compare, and attempt to cure those who appeared to lack reason. Moreover, confinement ensured that doctors were in a privileged position to dispense wisdom about the issue, and ensure that their voices were the dominant ones wherever the management of the boundary between normality and abnormality was at stake. This view supervened over former approaches to the issue, where deviance was assumed to be freely chosen, or the result of supernatural or spiritual forces, or where confinement was concerned with protecting society. Now, confinement of the mad involved study, classification, and attempts at cure.

There have of course been many critiques of Foucault’s work, especially where his historical examples are concerned. Was the ship of fools to which he alludes ever a real ship or was it an imaginary notion? Foucault has also been criticized for his “tunnel vision” focus on the West and his failure to acknowledge empire and colonialism (Stoler, 1995). Similarly, there have been many critiques and revisions of Foucauldian thinking from a feminist perspective—if women are turned into “docile bodies,” how are we to understand or facilitate resistance (Fraser, 1989)? If subjectivity itself is merely an effect of power, how are we to make sense of the experiences and stories of people in oppressed groups who are increasingly demanding to be heard (Hartsock, 1990)? Nevertheless, the overall argument concerning the way intellectual life in the human sciences is conditioned by sociohistorical forces and interests has gained traction in many quarters, not least in medicine itself.

It is often difficult to distinguish genealogical approaches from the intersecting, but often distinct, practice of history itself. The exact practice of a genealogical method is hard to pin down. Foucault himself has this to say:

Genealogy is grey, meticulous, and patiently documentary. It operates on a field of entangled and confused parchments, on documents that have been scratched over and recopied many times … Genealogy … requires patience and a knowledge of details and it depends on a vast accumulation of source material. Its “cyclopean monuments” are constructed from “discreet and apparently insignificant truths and according to a rigorous method”; they cannot be the product of “large and well-meaning errors.” In short, genealogy demands relentless erudition. Genealogy does not oppose itself to history as the lofty and profound gaze of the philosopher might compare to the molelike perspective of the scholar; on the contrary, it rejects the metahistorical deployment of ideal significations and indefinite teleologies. It opposes itself to the search for “origins.”

(Foucault, 1980: 139–140)

The history of systems of thought proposed by Foucault is concerned not so much with determining whether the knowledge systems of the human sciences were true, but rather with contextualizing and historicizing notions of truth, knowledge, and rationality. He examined their conditions of emergence, how and why a society in a given era considers some things knowledge, how and why some procedures are judged to be rational and others not. A genealogy of ideas would also attempt to trace the paths of idea dissemination. Ideas diffuse over both time and space in a way that leaves a trace along the path those ideas have taken. Over time, ideas undergo modification in the process of descent, and in space ideas go through adaptive radiation. These processes are not separate from each other, but instead occur simultaneously.

A genealogy of recovery

To illustrate the value of genealogy, let us consider a project I was recently involved in. The United Kingdom’s Arts and Humanities Research Council supported a project entitled “Creative Practice as Mutual Recovery” (2013–2018), which was concerned with a variety of creative activities and their impact on recovery in mental health. A part of this project was a study of the genealogy of the notion of recovery itself. In contemporary mental health practice, the usual starting point is a definition of recovery provided by Anthony (1993: 15):

[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.

Yet what is less frequently explored is the intellectual and practical history of the idea of recovery. The idea can be traced to the “training of the will” advocated by Abraham Low (1950) and the quasi-religious approach to alcohol problems promoted by “Dr Bob” and “Bill W” in founding Alcoholics Anonymous (AA). Interestingly, both of these antecedents took a “medical model” approach to the problems they were addressing. Here I use the term “medical model” to denote a view that human troubles can be defined as illnesses and disorders that are susceptible to diagnosis and treatment and have a basis in underlying physical factors. The idea of alcoholism as an “illness,” and even a disease, has been pervasive in AA, and while Low was keen to promote self-help and non-hospital alternatives for his patients, he remained firmly in charge and the distinction between being well and alcoholism’s various forms of “illness” remained unchallenged.

From a genealogical point of view, I am not saying that the promoters of contemporary recovery policy and practice have deliberately created the movement from the insights of Low, or Bill and Bob. What I would suggest instead is that the process reflects what Nikolas Rose, and before him Foucault, would see as the “capillary” nature of power and influence. Power, they would suggest, has a capillary quality because of its ability to take different forms—from physical violence, to persuasion and expertise, to ideas that are simply ready-to-hand—at different points in its circulation through the social fabric. The practices of recovery are locally implemented and are true in a much more particular sense than if they had resulted from the imposition of some wide-ranging ulterior instruction. They are made up and realized in practice without any explicit history—which is perhaps why the quote from Anthony (1993) is so widely used. This focus on the interior quality of recovery, as critics (e.g. Harper and Speed, 2012) have asserted, can itself be a source of friction between clients and health professionals. As one of our participants remarked:

Pete: I wasn’t getting on well with it and I kept saying to my key worker I’m not getting on well with it, and she said to me, you know what she said to me, was that ‘you’re not psychologically minded’.

(Brown and Baker, 2018: 9)

In a sense, the practice of recovery-oriented work in mental health involves the curation of a particular kind of mindset, further elaborated by Irene:

Irene: I got the sense that they were teaching me how to recover. And most of it was useful. But the thing was it was all on their terms, you know. Living with your illness and all that. So all their ideas didn’t change, it was us that had to change.

(Brown and Baker, 2018: 9)

This represents what Peter Miller describes as the “calculating self,” the continual process of reorganizing and reconfiguring consciousness and the self. This might include activities such as personal growth, well-being and therapy, investing in training and education so as to make oneself attractive to employers, or even changes in how we dress, speak or appear. In our case it is possible to see the origins of this process in early twentieth-century self-help such as AA or Recovery Inc. This, says Miller, is peculiar to the modern age and is part of this task of shaping subjectivity and forms of personhood (Miller and Rose, 2008). While this offers new possibilities for acting on oneself and on the actions of others, it does not always work seamlessly. The “technologies,” as Foucault calls them, with which personhood can be shaped are never fully effective, perhaps through the cultivation of counter-discourses that were evident in our study activity. Some participants had experience of compulsory hospitalization, but even in these cases some of them formulated narratives of resistance:

James: I’ve been reading about hospitals, I’ve been scouring the internet and some of the stuff you find is pretty horrendous. There was that mid Staffordshire case and that other place in Wales recently and that care home that was on the telly, and it is all pretty awful, so it makes you wonder whether putting people in hospital does them any good at all after all.

(Brown and Baker, 2018: 10)

For James, who had described his experience of compulsory hospitalization earlier in the interview, it is as if understanding problems in the health-care system itself provides an intelligible way of framing the difficulties that he personally had experienced. Identifying the problems as systematic and frequent meant that obstacles to recovery could be understood less as the participant’s fault and more as being a societal problem.

Consequently, understanding the emergence of a discourse of recovery, and illuminating its more coercive histories, makes these kinds of experience on the part of participants more intelligible. Rather than glitches in the operation of the therapeutic process, apprehending the discursive genealogy of recovery exposes and reprises enduring tensions in the way care practices have been organized, and its conceptual structures formulated. Indeed, without being formally steeped in this way of thinking about things, it was as if some participants were working towards this kind of analysis themselves. Perhaps through a growing incredulity at the terms used by staff to describe them and their difficulties—“you’ve got to walk before you can run,” “you’ll make yourself ill a...