Recovery and Mental Health

A Critical Sociological Account

David Pilgrim, Ann McCranie

• Publisher: Bloomsbury Academic
• Year: 2013
• Print ISBN: 9780230291386
• eBook ISBN: 9781350313163
• Edition: 1
• Topic: Psychology
• Subtopic: Applied Psychology
• Index: Psychology

For most of us, the term 'recovery' in mental health implies hope and normality for those suffering from emotional distress. It is understandable why recovery has therefore become a significant goal for mental health services.

But what does recovery mean for those who are struggling to see it through? Is the emphasis on recovery always a positive thing. This book takes a critical sociological look at personal and public assumptions and understandings. In particular:

- It explores what the recovery movement signifies today, offering readers a critical, reflexive view of its scientific, policy and political consequences
- It considers what recovery means from social, medical and patient perspectives, and the implications of these conflicting views
- It reveals some of the risks and benefits for people with mental health problems encountering a system that expects them to recover

Offering a comprehensive and thought-provoking overview of the concept of recovery from mental illness, this book is a must-have for students studying mental health across a range of subjects, including sociology, social work, psychology and nursing.

1 Recovery from what?

The best way to cheer yourself up is to cheer someone else up.

Mark Twain

Though they go mad they shall be sane
Though they sink through the sea they shall rise again

Dylan Thomas

Introduction

The notion of recovery from mental health problems springs from a post-Enlightenment assumption that madness and misery are undesirable pathological states amenable to improvement. As Twain suggests above, ‘cheering’ someone else up could even have a benefit for the self. ‘Recovery’ suggests a return from an unhappy place of alienation from others or even from the self. The recovering person may be seen as one who is undertaking an existential journey in the resurrection imagery of Dylan Thomas’s verse above. They have travelled to that unhappy place and they are now awaiting, or already using, a return ticket to ‘normality’. That return to the moral territory of everyday reasonableness, expected of adult citizens, could be attributed to the efforts of patients or to their informal or paid carers or to some negotiation between these parties. However, along with the notion of recovery comes the assumption that the return ticket is actually available. Recovery is now on offer to – perhaps even an expected undertaking of – all of those deemed by themselves or others to be mentally disordered.

In this book, we explore the common assumptions attending mental disorder and recovery. This opening chapter starts with an examination of the assumption that recovery is indeed desirable, as well as achievable, and it is about mental pathology. In very recent times, presumptions about a therapeutic entitlement to rationality and happiness have mainly focused on our health, and health service, policies being directed towards curing misery and promoting well-being. Unhappiness has been codified medically, and by a fair share of non-medical therapists, as objective or factual conditions such as ‘depression’, ‘anxiety states’, ‘post-traumatic stress disorder (PTSD)’, ‘obsessive–compulsive disorder’ or simply ‘common mental disorders’ or ‘common mental health problems’. Therapeutic optimists in the mental health industry now aspire, through some combination of chemicals, conversations and tailored social support, to end the unhappiness of those deemed, usually by sufferers themselves, to be disordered. Questions of happiness, unhappiness and everything in between are truly age-old human concerns. Is it any surprise that where science intersects with the ‘good life’ matters become complicated, even more so for those whose difference or disorder sets them apart?

Moreover, after many years of therapeutic nihilism after the 19th century, these therapeutic optimists have turned their attention increasingly to the incorrigibility of madness. As we will note below, until well into the 20th century, madness, not misery, preoccupied mental health specialists, but predominantly in a pessimistic manner. With these opening thoughts in mind, in this first chapter we will examine the common threads and distinctions that have been apparent over time and place in relation to our topic. By standing back to overview the ethical and historical context of the nature of recovery, our explorations in later chapters are provided in a context of appreciation for us and for the reader. First we will deal with misery and happiness and then move on to madness and recovery.

Two important caveats, however, must be made before we begin. First, in this chapter and at different points in this book, we refer to what many call ‘severe mental illness’ (alternatively styled ‘serious’ or ‘chronic’ in the United States) as ‘madness’. This is an intentional choice to draw the reader away from what are currently well-anticipated cultural, political and medical understandings of the ‘problems’ from which a person is to recover. We are mindful that the term has a particular pejorative connotation to some, but it has also been reclaimed in some politically active circles, particularly in the United Kingdom, for exactly this distinction and for its rejection of a biomedical model of the phenomenon.¹ It is in this sense that we adopt it for some of our discussion, as it is an ordinary word that has been used by lay people for a long time. It brings with it none of the professional ideological baggage of seemingly sanitised medical connotations.

Secondly, while we adopt a very common critical sociological stance of approaching ‘mental disorder’ as socially determined in part and socially defined in whole (because it is about a form of deviance from norms), this stance does not deny or belittle the very real and experienced misery that individuals can suffer. Taking a similar critical approach to ‘recovery’ is likewise not a denial of its experienced reality for many.

However, before we attempt to crack open this great ‘black box’ of either of these concepts (Latour, 1987) and use them to understand the great many theories of madness and recovery that are currently circulating, we must first admit that these concepts are largely in that box. In other words, at one point, neither madness nor recovery was understood as ‘scientific’ truths. Madness attained that status as it gained acceptance as a medical ‘fact’. Recovery is perhaps still a work in progress, but it is buoyed by an interest in adopting an optimistic approach to the rather dour reality of ‘mental disorder’ and its often depressing history of living without hope and social acceptance.

Misery and happiness

In his comprehensive historical overview of happiness, McMahon (2006) begins with the tale of a conversation in the ancient text of The History of Herodotus. The wealthy ruler of Lydia was Croesus. He summoned Solon to help him understand the nature of happiness. Solon was a lawgiver from Athens and widely travelled.² Because of his exceeding wealth, Croesus believed himself to be the happiest man in the world, but he wanted to hear Solon’s opinion. Croesus found Solon’s opinion bizarre – the happy men in his account were neither rich nor alive. Tellus, a soldier from Athens, was killed in battle in the prime of his life. Two young muscular brothers, Cleobis and Biton, passed away in their sleep after pulling their mother in a cart to a village festival for the feast of Hera.

Croesus was not impressed, but Solon pursued a form of logic that typifies ancient wisdom about happiness. These three deceased men lived in fortuitous circumstances. Tellus died virtuously in battle for a good cause. At home in Athens he lived in a good time and place and saw his sons and grandchildren growing healthily. Similarly with the two young brothers: they honoured their mother with their efforts, acting like oxen for her comfort. They were already recognised athletes, envied by men who knew their reputation, and local women congratulated their mother on her luck at bearing such fine offspring. Thus happiness was bound up not just with an emotional state for the individual but also with a set of social relationships of honour and recognition. Happiness then for Solon was bound up with relationships and with social solidarity.

Put simply, Solon suggested two major aspects of happiness. First, it is a matter of fate or fortune (eutychia).³ Some of us are fortunately blessed with happiness more than others, while some of us are unfortunate in life. Second, happiness is an atypical state. Our normal state is to suffer. The material reality in antiquity (and for many still today in developing countries) was of infants propelled into a hostile war-torn world, with pestilence and crop failure common and with lives on average being short and brutish. Poverty and disease killed off most people before what we now view as middle age. On their short journey to an early death, people were frequently sick and had to tolerate multiple privations and loss of loved ones.

The tension between the rich arrogance of Croesus and the humble wisdom of Solon revealed a contradiction about the pursuit of happiness. For Solon it was a form of flourishing or favoured life (eudaimonia) and something that could only be taken at full measure and in balance at the end of life. However, that flourishing had a small basis of credibility in the crass wealth of Croesus. To use the current vernacular, ‘poverty sucks’. Money is not everything unless one is in a state of absolute poverty and cannot afford to fill bellies or shelter from the elements. However, beyond a certain point, getting richer will not, in itself, provide happiness, a point we return to later about current debates. For Solon happiness was about virtue not just wealth. The latter without the former is not a path to happiness.

These tensions and contradictions can also be found in a deviation from the world’s oldest religion of Hinduism. Buddhist teachings echo the same interplay of arguments between Croesus and Solon. Over 500 years before Christ (as with the legend of Croesus and Solon), Siddharta Gautama of the Indian tribe of Sakyas began a tradition of thought that normalised suffering. From a rich aristocratic family, he was young and handsome, indeed by Solon’s Greek criteria he was very ‘blessed’ (a hybrid translation of olbios or makarios). At 16 he married a beautiful young princess. Rich, young, healthy and sexually active, to use a materialistic cliché of today, he seemingly ‘had it all’.

And yet, as with the implied doubt about the self-contentment of opulence in Croesus’ fate, the man to be called ‘Buddha’ was restless to find the meaning of life and so he abandoned his riches. Faced with sickness, ageing and death in those he witnessed in ordinary life, his path to Enlightenment began. The Buddha suggested that not only is suffering normal but it might also be transcended through a discipline of quiet reflection or meditation and by habits of renunciation: accepting impermanence; letting desire flow away or not clinging; and abandoning the delusion of the importance and reified existence of our individual egos.

Buddhism not only has now found its way explicitly into modern techno-centric psychological therapy (especially in ‘Mindfulness’ and ‘Dialectical Behaviour Therapy’) but also has resonances in existential therapy and psychoanalysis. In the first of these, we see meaning in suffering in the work of the holocaust survivor and psychiatrist Frankl (2004) and prefigured in Freud’s aspiration to transform ‘hysterical misery into common unhappiness’ (Breuer and Freud, 1895/1955). Freud recognised the social norm of seeking happiness in modern life but saw it as futile in the face of the outer reality of guaranteed sickness and death and the inner forces of self-deception. Frankl’s confirmation of the centrality of meaning for flourishing is typified by his view that ‘Ever more people today have the means to live, but no meaning to live for.’ Freud tells us in Civilisation and Its Discontents that ‘It is impossible to escape the impression that people commonly use false standards of measurement – that they seek power, success and wealth for themselves and admire them in others, and that they underestimate what is of true value in life.’

The above story of eudaimonia, in which suffering lives, cheek by jowl, with a virtuous or blessed life, for those who are lucky, can be contrasted with another version of happiness recognised in antiquity that referred to happiness in joyful or sensual hedonic terms (‘hedonia’, as such, was not used in Ancient Greek but is sometimes now used in recent discussions about well-being to distinguish it from eudaimonia). Indeed, today so much of the confusion about the ordinary English word ‘happiness’ is because our reflections about life or about any entitlement or not we have to be happy do not draw exactly the distinctions of hedonic and eudaimonic aspects of happiness. If in Greek antiquity eudaimonia was about a virtuous and meaningful life that accepted death and suffering, its hedonic aspects to be sometimes experienced contingently in our lives included joy, pleasure, being thrilled enjoying intoxication and acting with gusto on our lust for work, play, sex and food. But note that although the Epicureans were committed to a version of hedonism, this was not what we now think of (as simple and selfish pleasure seeking abandon). Instead, Epicurus, the father of hedonism emphasised the need for moderation as a pathway to ataraxia (peace of mind or tranquillity).

Although we may seek pleasure and sometimes find it, there will always certainly be pain. Given that mixture, this becomes less about our sensual experience and more about the meaning we find in that or any other experience encountered during our finite existence. Our ancient philosophers would remind us that to approach experience without a sensibility about its meaning is a missed opportunity for wisdom.⁴ To seek pleasure on its own and without a eudaimonic frame of reference is an option in life, but not necessarily a wise one. As we see below, an unbalanced emphasis on hedonic concerns, promised to us so readily by consumer capitalism, culminates not in happiness but dissatisfaction: egotism and disaffection, not solidarity and an acceptance of life’s ups and downs, tend to accrue.

To return to our opening statement about the notion of recovery as a journey, when one considers the recovery ‘journey’ as a return to a happier normality, one must also consider what undergirds this promised happiness. Is it a eudaimonic or hedonic one? Is it a rare condition seen only in the balance of life, as Solon suggested, or is it a way to release from the suffering of life? These questions may seem far removed from the day-to-day realities facing people working with people who have ‘mental disorder’, who may simply be aiming to assist their clients in improving living skills. They may also seem intellectually indulgent to the individual who is grappling with how to lessen their personal misery and the social consequences of it. However, these are undoubtedly the questions that ‘recovery’ has raised for modern mental health services. In fact, these essential human quandaries have become the object of the scientific gaze and the services community. They have become the subject of policy directives and the reasoning behind funding shifts. They motivate new service initiatives – they are the ‘policy drivers’ that shape decisions and actions of clinical staff.

Happiness since antiquity: raising and rising expectations

The shortcomings of a limited hedonic definition of happiness are reflected in diverse moral frameworks advising moderation, abstinence and renunciation (from the ancient world religions and even from the father of ‘hedonism’, Epicurus) and in more recent secular humanistic concerns about social justice being in tension with selfish indulgence. If we only attend to our ‘right’ to pleasure, without conceding the authentic reality of suffering, then we are entering a world of delusion, encouraged by our current context of mass consumerism.

In today’s times of consumer capitalism, the dubious promise of, and so elicited need about, removing psychological pain from our lives comes in two forms. One notion of warding off unhappiness is simply about the direct consumption of products and services. However, this creates a ‘hedonic treadmill’ and leads to the paradoxical outcome of remaining permanently dissatisfied with our lot, because another product is always being marketed to improve on our current possessions: the present is always lacking fulfilment (Layard, 2005; James, 2007). Some critics go further and argue that consumerism creates a state of infantilisation in the population, with adults defining their identity purely by their ability to buy short-term satisfaction (Barber, 2007).

A related critical attack on late capitalism has not focused mainly on consumption but on the status envy and the loss of social capital that emerges from unequal societies (Marmot, 2004; Wilkinson and Pickett, 2009). This view is confirmed by cross-national longitudinal comparisons, with the richest countries not being the happiest (Inglehart et al., 2008). These authors note the curvilinear relationship between wealth and happiness: being very poor certainly brings misery, but with rising wealth the curve flattens out. The trend was established after the Second World War. By the 1990s, Inglehart and his colleagues collecting longitudinal data across the world about reported happiness could confirm this curvilinear relationship (see Figure 1.1).

Although the ‘league position’ of happiness has varied slightly from nation to nation at each time point that Inglehart and his colleagues have conducted their survey, the basic relationship in the figure is repeatedly confirmed. An implication of this is that the happiest societies tend to be more equitable and they privilege ‘post-materialist values’.

The second idea that unhappiness can be rectified in the marketplace paradoxically comes from one of these critics. Layard and his colleagues have suggested that although unhappiness is a product of upstream socio-economic forces, downstream victims who have been made ‘mentally ill’ can be cured with the technological fix of evidence-based psychological therapies. The policy advantages of this promise were not just about the amelioration of distress but also of enabling those disabled by mental illness to return to the labour market (London School of Economics, 2006).

Moving from therapeutic aspirations about recovery from ‘common mental disorders’ back to the conceptual tension between eudaimonic and hedonic delineations of happiness or unhappiness, we find a range of positions in the psychological research literature (Ryan and Deci, 2001; Huppert and Baylis, 2004; Diener et al., 2009). When authors emphasise hedonic features the focus is on subjective well-being and frequency of experienced pleasure or enjoyment in life. However, some studies veer more towards eudaimonic features and emphasise notions such as ‘self-actualisation’, autonomy, personal growth, quality of social relationships and self-acceptance. Together these generate what Seligman (2002) calls ‘happiness-plus-meaning’. This combines existential c...

Table of contents

• Cover
• Title
• Copyright
• Contents
• List of Illustrations
• Preface
• Acknowledgements
• Introduction
• 1: Recovery from What?
• 2: The Different Meanings of Recovery
• 3: The Landscape of Recovery-Oriented Services and Their Evidence Base
• 4: Recovery, Risk Management and Fiscal Burden
• 5: Evaluating Recovery Policy
• 6: Reflecting Sociologically on Recovery
• Notes
• Bibliography
• Index