Filed under: Mental health, Recovery, Uncategorized | Tags: good life, recover college, recovery
Talk presented at recent seminar at the Faculty of Health and Social Care at The Open University.
Recovery has become popularised in mental health care as a means of empowering service users to construct their own identity and meaning of recovery. Recovery is a term often used indiscriminately but what does it mean to recover? The strength of recovery apparently lies in its ability to mean different things to different people allowing people to construct their own version of a meaningful life. However I will argue in this presentation that the shift in emphasis to the individual in the rhetoric of recovery has meant that recovery becomes the responsibility of the individual. As recovery becomes an individual obligation or requirement, the promise of recovery rather than freeing people to construct their own meaning serves to reaffirm existing norms on how to function and manage mental distress in order to obtain the good life.
Recovery, as I am sure many of you are aware, has become increasingly popular in mental health care services. Services now describe themselves as ‘recovery-focused’ and ‘recovery orientated’, Recovery colleges that provide a variety of courses for service users are being set up across the country. An increasing academic interest in recovery in mental health care has lead to the creation of a number of seminars and conferences and research networks, and is what has brought us all here today.
In my own PhD research I am exploring how recovery from grief is understood and experienced. My interest in recovery has led me to learn about the uses of recovery more broadly in mental health care and also to speak with several current and ex-mental health service users each with differing views on recovery.
So what does recovery actually mean? In brief the use of recovery appears to have emerged from the psychiatric survivors movement, where recovery referred to the right to live with mental distress rather than see it as something to overcome.
However many definitions of recovery have been proposed with no universal agreement on what recovery should look like. This is in part because recovery was intended to be self-defined.
Most descriptions tend to focus on building hope, creating a new identity, having a meaningful life, and taking control over one’s life.
South London and Maudsley’s (SLAM) Recovery College prospectus defines recovery as:
Recovery is about people with mental health difficulties having the same opportunities in life as everyone else. It is about a personal journey towards a meaningful and satisfying life. It is about hope, control and opportunity. It is about living as well as possible.
Another example taken from a report entitled ‘Making recovery a reality’ published in 2008 by the Sainsbury centre for mental health describes:
(Recovery) can only be resolved if the person can discover – or rediscover – their sense of personal control (‘agency’) and gain a belief in the future (hope). Without hope they cannot begin to build their lives.
However since recovery’s incorporation into mainstream mental health care a number of more specific models such as the ‘recovery star’ have been developed which predefine the parameters of recovery.
The Recovery star includes the following dimensions:
- Managing mental health
- Physical health and self care
- Living skills
- Social networks
- Addictive behaviour
- Identity & self-esteem
- Trust and hope
There is also the new ‘Wheel of well-being’ which contains 6 elements: body, mind, planet, place, people, spirit. And another model called the Tree of life, all of which are taught at the recovery colleges.
The point I wish to highlight here is in these models recovery is given outcomes and priorities that are not set by the service user themselves but by the NHS trust delivering the service.
I would argue these priorities are reliant on an assumed understanding of what constitutes a good life and living well. The recovery colleges for instance deliver courses on how to stop smoking, how to eat better, and how to get a job. In these models of recovery there is an implicit judgement over how one should successfully live out their personal lives.
As one participant I interviewed in my research commented, in the recovery model it is as though you need to recover from being yourself. Daily activities such as taking a shower, or walking outside, and eating a balanced diet become ‘self-care activities’ rather than just living.
By establishing markers of recovery such as the recovery star it becomes possible for the relevant medical authority to make a judgement on whether or not someone is recovered.
People then become responsible for adhering to prescribed ways of governing their lives, but the medical authority still remains in tact – as psychiatrists become recovery experts and mental health care becomes ‘recovery orientated’ and ‘recovery focused’.
A contradiction then arises as recovery is described as a unique individual journey to self-control and autonomy over one’s life yet it is taught and learnt via a set of experts and in adherence to a set of predefined criteria.
As SLAM’S recovery college prospectus states:
“The workshops and courses we run aim to provide the tools… to help you become an expert in your own recovery.”
And whilst recovery is claimed to be a co-production, if someone fails to reach recovery the blame is squarely on the individual.
Again from the SLAM Recovery college prospectus:
“Treatment and support from mental health professionals can be helpful but every person with mental health problems can become an expert in their own self-management. Whatever challenges you face, recovery involves ﬁnding the personal resourcefulness and resilience to take back control over your life and what happens to you.”
If something bad might happen then, something that might not fit within the recovery model, the blame will then fall on the individual because in this understanding recovery is always possible, no matter how serious the person’s difficulties you just need to find your inner ‘resourcefulness’.
This is the promise of recovery: you can get better according to pre-existing normative ideas of what a satisfying good life is, because the only thing that needs changing is you and how you currently live your life and we (being the relevant medical authority) are here to tell you how to do that.
This obligation to recover thus becomes a way to abdicate responsibility for mental distress elsewhere, that is to the person experiencing the distress themselves.
It is for this reason amongst others that the recovery model has come under criticism from service users and others working within mental health care. Recovery is seen as a way to cut back on services, to eradicate long-term care, where referring people to recovery colleges is a way to discharge them quicker.
For an increasing number of people then, recovery is a shiny gloss on an unchanged system that remains unequal in practice and which shifts responsibility to live a certain way on the service user.
A group of people have formed on Facebook to express their disapproval at the way recovery has been appropriated in a group they have called ‘Recovery in the bin’. The members of this group contend that ‘recovery’ has been colonised and used to discipline and control people with mental distress and argue for a ‘Social Model of Madness’, placing mental health within the context of the wider class struggle.
Some of the group have claimed the title of “UnRecovered” to replace “Recovered”, to express their rejection of what they see as a neoliberal intrusion on the word ‘recovery’ that has been redefined, and taken over by marketisation, an capitalist values.
To recover from mental illness, to adhere to the model of recovery, involves a considerable amount of work on behalf of the service user. To recover involves a range of activities such as attending recovery colleges, completing recovery plans, taking medication, getting a job, sustaining good relationships with others, eating well, not smoking, creating a new identity, being mindful and taking walks in nature.
People using mental health services are increasingly finding themselves obligated to undertake this sort of ‘recovery-work’ in the promise of becoming well.
Yet the promise of recovery possesses a cruel contradiction in that the highly prized ability to become autonomous and have self-control to manage one’s life is only possible through submitting to experts who help people navigate their way through to recovery.
The service user is taught how and what to desire all in the name of self-fulfilment and individual freedom.
And because recovery is always possible it can only be the individual’s failure of will or resilience if they are seen to relapse or fail to recover in the terms that have been proposed.
Filed under: Grief, Mental health, Recovery, Resistance | Tags: diagnosis, freud, normalcy, posthuman, recovery, sovereignty
Paper presented at Theorising Normalcy and the Mundane, University of Sheffield, July 2014.
I’ve always been interested in people who don’t do as they’re told. They excite me, intellectually and personally. In my PhD research I am interested in those that are seen to have failed to recover from their grief following bereavement.
The failure to recover from grief is defined in contemporary society by bereavement theories and increasingly by psychiatric diagnostic categories that place a time limit on the appropriate length of mourning as well as delineating what behaviours and emotions are normal and acceptable in grief and those which are not.
In grief and bereavement research there was much controversy over the publication of the Fifth edition of Diagnostic and Statistical Manual of Mental Disorders (DSM-5) last year that saw the omittance of the bereavement exclusion in the diagnosis of Major Depressive Disorder, which was included in previous editions of the DSM. What this means is that someone who is bereaved could potentially be diagnosed with depression as little as two weeks after bereavement. Further the DSM-5 also included the diagnosis of ‘Persistent Complex Bereavement Disorder’ for further consideration in the next edition of the manual. ‘Prolonged grief disorder’ has also been proposed for the revised version of the International Classification of Diseases (ICD-11).
There are overlaps and inconsistencies in each diagnostic category, but the push toward what has been seen as a medicalising of grief relies upon claims that there are a number of people (research varies from 7-20%) who have ‘complications’ or fail to recover from grief. These complications are described as a ‘derailing’ of ‘normal’ grief or a ‘delay’ in integrating loss. The markers of someone failing to grieve properly are overwhelming time specific – people should be moving toward healing in a few months, struggling 6 months on is classified as complicated. The diagnosis are also structured – in vague psychiatric terms – in accordance with the degree to which behaviour is deemed inappropriate or out of line with the dominant cultural and social norms in which the bereaved person is situated.
As a commonplace and yet problematic event, grief marks the line between normal (does not require medicalising) and abnormal (intervention is necessary to ease suffering) emotional behaviour.
The search for the pathological in grief also presumes a normative mode of grieving yet this is never made explicit, or been proven. The normal way of grieving is instead defined by the ways in which the line between abnormal and normal grief is drawn. My focus has been then to uncover who draws the line, who has the power to draw the line, with what claims and with whose interests at stake.
Those that do not recover within these paradigms risk being read as resistant, problematic and in need of psychiatric treatment. The failure to recover is often seen as a failure of the individual rather than the individual being a victim of the ever-expanding field of psychiatric diagnosis. For example in the current era of the DSM-5 and the future world of the ICD-11 the bereaved person might be considered mentally ill but in the era of past editions of the DSM or before psychiatry began to make claims on grief, bereavement and grief were experiences situated within the normal side of the line.
The developments in grief treatment can be seen as a reflection of broader changes in mental health services and psychiatry. The Recovery Model is the current popular model of providing mental health services that has been met with much enthusiasm and success.
The recovery model encourages people to find their own individual path to life without mental illness.
Recovery Colleges have been set up to provide courses for people with mental health difficulties on recovery and how to recover from mental illness. These colleges also run courses on ways to well-being, how to find work and how to manage one’s diet.
Recovery began as a radical movement to reclaim power back to the patient from the psychiatrists, but in being co-opted by the mainstream the vision has become a conventional one that places emphasis on the individual and their responsibility to change. The recovery model relies upon an idea of the ideal person as being a functional citizen, someone who gives back to society, someone who has the capacity to make the right choices.
However many patients and service users have now turned their back on the recovery model due to what they feel is a lack of acknowledgement of the social factors that contribute, create and maintain mental difficulties. When recovery is ‘always possible’ failing to recover can only ever be the fault of the individual. Critics have also argued how the recovery model is still one very much dependent on the deficit model – where people with mental illness are in some way deficient and require fixing. The recovery model was adopted in order to remedy this; an attempt to allow people to uncover their own unique individual journey to recovery, to the good life. But the journey to recovery is filled with yet more normative fantasies.
The obligation to recover is one of the obligations we encounter when the human is considered to be a sovereign subject. Experiences such as grief can work to unsettle our sense of sovereignty, problematising what it means to be able to choose, how capacity is defined, revealing instead a self that may be incoherent, ambivalent, not in control of themselves. I will talk about how and why grief has the power to make us come undone, but first a note on sovereignty.
Sovereignty, in a truncated form, is about having the power over one’s life and having the ability or capacity to decide how you live your life. Sovereignty is mostly used in political and legal terms when discussing the sovereignty of the head of state where sovereignty is understood as having the power over life and death – that is to permit life and to take it away. There is much debate in political philosophy over the uses of sovereignty, but here I am picking up the concept in a similar way to Lauren Berlant but in a perhaps somewhat more crude fashion and placing it in an individual context to refer to a way of being which has capacity to make decisions, is consistent, intentional, and has coherent explanations for actions.
In many ways I am also talking largely about capacity – and the capacity to make choices and decisions for oneself (to be autonomous) is arguably the paradigmatic feature of what it means to be human in a contemporary neo-liberal society.
After all it is often when sovereignty is taken away that we feel injustice is taking place. It also reveals the rights we assume to have by virtue of being human (which may or not be supported in law). As I work within the field of death and dying I have been exploring the ways this sense of sovereignty is interrupted and destabilised through the act of death. Sovereignty is not necessarily something we have simply by virtue of being human but something that is granted or taken away.
It also serves to pathologize those that deviate from these expectations.
As Berlant describes:
Without attending to the varieties of constraint and unconsciousness that condition ordinary activity, we persist in an attachment to a fantasy that in the truly lived life emotions are always heightened and expressed in modes of effective agency that ought justly to be and are ultimately consequential or performatively sovereign. In this habit of representing the intentional subject, a manifest lack of self-cultivating attention can easily become recast as irresponsibility, shallowness, resistance, refusal, or incapacity; and habit itself can begin to look overmeaningful, such that addiction, reaction formation, conventional gesture cluster, or just being different can be read as heroic placeholders for resistance to something; affirmation of something, or a world-transformative desire. – Lauren Berlant, Cruel Optimism, p.99.
When the intentional, positive active subject is considered to be the truest enactment of being human, emotions such as grief – which may leave the subject irresponsible, unemployed, and ambivalent – are devalued and are seen as negative, unproductive, something to be recovered from.
The over-psychologisation in grief theory has meant normal grief tends to involve integrating the loss, claiming that in order to recover, the relationship with the deceased has to be reconfigured in some way, either as a process of detachment or reinstating and/or continuing bonds in order to accept the loss.
Sigmund Freud in ‘Mourning and Melancholia’ (1917) is often attributed as the first thinker to promote the idea of the need to detach from the deceased, and that ‘hanging on’ to the deceased is pathological and an obstruction to healthy mourning. The melancholic figure persists as an example of what happens when people fail to mourn successfully, when they are unable to let go of the deceased. This at least has been the way in which Freud’s ideas have been interpreted by later theorists.
The melancholic is one who is never sure what he or she has lost. That is to say, what has been lost remains unconscious to the melancholic, they do not know what they are missing. The melancholic knows whom they have lost but not what is lost in him/her. The melancholic does not know what they have lost in themselves because the melancholic incorporates the lost person into his/her ‘ego’, so that he/she never fully experiences the loss, since the loved one, even in absence, becomes merged with the self. What this suggests therefore is that people who are seen to be ‘stuck’ in grief do so perhaps unknowingly because they are not fully conscious of how they are still tied to what they have lost. This is because the lost person has been incorporated into, in Freud’s terms, the ego. In other words the deceased person still makes up a large part of how the grieving person understands their sense of self.
To understand how someone could get stuck unable to face the ‘reality’ of their loss requires a refiguring of how the self is understood and how the sense of self is composed. It is to look upon identity as not something that is shaped and constructed autonomously, but composed in relation to others. Grief theories which describe continuing bonds or building biographies of the deceased attempt to explain how and why people talk about keeping the deceased inside themselves. However these theories often do not elaborate further on how grief and loss become an instance that reveals the one who has been lost already existed inside the subject. To say that the deceased person already existed inside the subject is to point towards the fact that people are shaped by one another, often perhaps ambivalently, in ways that do not presume two atomized autonomous individuals making an attachment, but rather a more intimate and intricate interface of being entwined into one another’s lives and sense of self. But the ways in which people are bound to one another is often not known until an event such as loss or the risk of loss that allows the recognition of how the sense of self is invested in another person. Grief therefore destabilizes the ‘I’ of autonomous thinking through a process of coming undone, being confounded by loss, in which the self, and not only the one who has died goes missing.
Certain types of attachments act to impede the ability to move on, even if they provide a sense of self, a sense of place in the world. The bereaved person is then suspended in the space of liminality, for to let go and leave the object of desire is to leave the anchor for optimism, and yet staying with this fantasy produces unhappiness. This sense of ambivalent attachment is captured by Lauren Berlant’s concept of ‘cruel optimism’ which describes how any form of attachment can become cruel when they become obstacles to flourishing. Berlant’s example is instructive for grieving for whilst recovery is constructed on the understanding that detaching from the lost object leads to successful mourning, the lost object is the very anchor that sustains hope.
This ambivalence also reveals a more complex view of agency, where the bereaved may desire and not desire to become attached to something that makes them lose control, a desire and lack of desire to become sovereign. Discourses that promote recovery often assume autonomy, choice and agency are desirable traits that everyone should wish to achieve and vulnerability is weakness and undesirable. What the sustaining of cruel attachments suggests on the contrary is that people often wish to not be sovereign, (and proposes further that sovereignty can never be anything but a fallacy) by violating their attachment to intentionality and give themselves over to something larger than themselves.
Melancholia and the refusal to recover or let go of attachments to the dead can not only be read as a sign of pathology but might be understood as an active choice to not be sovereign. This presents a contradictory twist – the right of choice we have over our lives can also be used to reject those choices. But there is also something more subtle taking place, it is about injecting the unconscious into the intentionality of the subject. It is suggesting that certain affective experiences such as grief can reveal to us we often do not know to what we are tied and why, the one who refuses to recover might not be aware of the ways they are attached to something that is actually becoming an obstacle to their ability to live a life.
To tell someone to lose the object of their desire and face up to the reality of their loss – the reality that is apparently evident to everyone but them – is to neglect to see how certain fantasies that people invest in provide a sense of belonging all of their own.
What if we do not presuppose the sovereign subject? How do we account for the self?
Should not the whole theory of the subject be reformulated, seeing that knowledge, rather than opening onto the truth of the world, is deeply rooted in the “errors” of life? – Michel Foucault
Borrowing from Judith Butler and Lauren Berlant I have been working with a description of grief as an instance which can make a person ‘come undone’. This is a coming undone of a self that was already not the sovereign person they took themselves to be. What this means is not that grief or loss merely breaks people down before they put themselves back together again (a recovery narrative that relies upon the self as normally integrated) but rather an instance that reveals the relational nature of their sense of self; the capacity to affect and be affected.
Injecting some incoherence, ambivalence, resistance into the subject then, the interest lies less in how people come undone – if we alternatively assume the subject is always somewhat prone to incoherence – but rather how do they hold themselves together, and what form this holding together takes and why. Or to take a Deleuzian line: how do we hang together when we are multiple?
The task remains for me to discover the discourses that mould the form of the grieving person into an identifiable recovering/recovered/not recovered subject. That is to say what are the discourses, structures, norms that may impinge, limit, obstruct the capacity for flourishing or for becoming otherwise.
There’s a labour to remaining within the bounds of normal, of which some feel more acutely than others. And yet there’s also a comfort to passing as normal because it means staying under the radar. Expecting or demanding a level of sovereignty over one’s life can serve a protective or liberating purpose but it can also enforce an unworkable and limited vision of what it means to be human. I’m not so sure about whether we need throw out the concept of the human and become post-human and I know too little to make a biological claim on things that are indisputably human. Rather I make the modest proposal that it is not the vision of the human that needs transforming but the world we inhabit so that is capacious enough to hold all the multiple ways of being human.