Filed under: Uncategorized
The last time I wrote on this blog was over a year and a half ago. I had written about not having a story. I had become increasingly fatigued over the proliferation of stories, and specifically the use of stories as a means of liberation. In effect that was my last story for a while too and this blog – and by extension me – had become consumed by silence, or at least I had run out of stories to tell.
More accurately I had become consumed by the bigger story of my PhD and in telling that story I had no time for any others. But also in the process of telling one story, all other stories become relevant and related in some way. It as though the more your story expands and becomes all encompassing the more one-pointed your focus becomes and you end up seeing and listening to very little that is new. That is the persuasive power of narrative.
Now in post-doctoral life I am revising that same story again and again in slightly different formats so that hopefully one day I can start thinking about new stories again.
My feeling then – and now – was that stories were not enough. Telling one’s account is not in itself liberating. A story shouldn’t be used in place of lasting social change. Giving someone a ‘voice’ can be lazy quick fix remedy to avoid shifting social structures, changing laws and bringing justice. Giving everyone a platform might be the beginning of equality but it certainly is not the end of it. I felt that stories were pointless when what we should be really thinking about is building spaces people can inhabit without hate or prejudice.
In a way that was the sociologist in me responding to arguments that had forgotten the emotional is always social, and political. The personal account is not more true than other knowledge because it is emotional. Truth is not measured in tears. We remain trapped in a different version of the same story if, for example, we view the personal experience of an illness as more significant than the clinical diagnosis and description of what is happening in a body. The point is: both matter.
Anyhow I had been reconsidering the importance of stories as I have been wondering about the role of sociology in the contemporary world. As I dip in and out of various social media it’s a question that is apparent if not explicitly posed. I decided that the role of sociology was to tell better stories. To provide a narrative to events. To put events, ideas and people into context. Inevitably this might be a long and complex story. How to tell stories of the present to an audience accustomed to 140 characters?
Personal stories are often assumed as true. But it seems nowadays any story that is published in black and white can be assumed as truth. The response to “fake news” signals that popular culture has yet to even reach the postmodern phase, as all social constructionist know that it is not about ‘truth’ being ‘fake’ but rather truth is always a social construct.
For Foucault things don’t just exist ‘out there’ but emerge as identifiable objects through various social structures – including language. The task is to examine how things come to be seen as truth; to critically engage with all claims to truth. In other words, we need to all do our homework.
This becomes increasingly hard when wading through partisan news agendas. Journalists I am sure wouldn’t be keen on referring to themselves as ‘story tellers’, even as the news is fed to us in ‘news stories’. Journalism has to believe in an objective truth and fight to convey that as best as possible. But media often presents a point of view, and too little diversity in points of view and we start to accept opinion as truth.
Often in academia we bend over backwards to ensure our work is untainted by bias and opinion. We engage in reflexivity, acknowledge our sources, cite references, and undergo peer review. Perhaps because of our rigour we are better placed to provide better stories. In which case the whole structure of academic publishing needs to change dramatically.
Not having a story can mean you get consumed in the dominant narrative, whether you like it or not. Like not voting, the choice is made for you. The problem with dominant narratives is that the story expands and becomes all encompassing. It becomes harder to listen and see and critique. Depending on the vision the narrative provides we might join and work towards that, or reject it and argue that its not working. In such a climate of destructive narratives, an alternative vision is needed, which could begin with telling sociological stories. But there has to be the offer of a future. Foucault never made any claims on how society should be run, but he did provide the gift of critiquing repressive structures. Once that repression is visible, the question remains: what makes a life worth living?
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: Uncategorized
Theorisations of grief serve not only to capture grief but define the appropriate ways it is approached and performed. The theories that currently dominate the way grief is understood and managed are theories and studies of a largely psychological nature. As Granek (Granek, 2013) has argued, grief theory has been over-psychologised, with on over-emphasis on identifying the dysfunctional aspects of grief. This has produced a contemporary understanding of grief that tends to cohere around the idea that grief is an experience that impacts on the psychological well-being of a person and needs to be recovered from through processes of detachment from the deceased. Successfully detaching from the deceased will enable the reintegration of the grieving person back to ‘normal’ functioning through adjustment and acceptance and help them relearn healthy patterns of attachments to the deceased (Kubler-Ross, 1970; Lindemann, 1979b; Parkes & Weiss, 1983). Currently neuroscientific data is shaping present understandings of grief by exploring how grief affects the brain (O’Connor, 2005, 2012). This is opening up new avenues for viewing grief not only as a matter of the psyche but also as possessing biological and somatic markers.
Whether as a matter of chemical imbalance or a disorientated psyche, grief, despite the many claims to its ‘natural’ occurrence, is posited as an experience that requires reorganisation. Though the stages of grief so famously outlined by Kubler-Ross (Kubler-Ross, 1970) have been critiqued following empirical enquiry (Konigsberg, 2011; Maciejewski, Zhang, Block, & Prigerson, 2007) the continual search to capture grief in scientific terms and the proliferation of self-help literature on grieving suggests grief is still considered as something to be ‘worked through’(Worden, 1991), and significantly an activity for which individuals are responsible. Studies that have explored the social constructions of grief have highlighted the social structures and contexts that shape perceptions of grief (Jakoby, 2012; Lofland, 1985; Walter, 1999; Wambach, 1985). This work has illuminated how grief can be understood as a social emotion and not only as an individual psychological experience. Sociological explorations of grief have also discussed how hierarchies of grief exist that demarcate appropriate presentations of grieving (Robson & Walter, 2013) and can act to ‘disenfranchise’ certain types of grief (Doka, 1989). For example, the relationship with the deceased, the type of death, and the age of the deceased all factor in to how much or little grieving is appropriate. This is to argue that not all losses can be understood as being equal and further that different social settings or structures demand different responses (Charmaz & Milligan, 2006). Grieving then becomes not only an internal psychological task to work through but an active presentation of self.
But where and how do these norms, these ‘feeling rules’ (Hochschild, 1983), emerge? In my research I will be exploring how factors such as the impact of government policy on healthcare practices as well as empirical data on grief patterns and behaviour, shifts in counselling practices (for example the shift in popularity to cognitive behavioural therapy) and changes in psychiatric diagnostic manuals all contribute to how the norms on grief in contemporary Western societies are shaped and interpreted. The norms that ‘police’ and regulate grief (Walter, 2010) in a modern neo-liberal society that has witnessed the ‘secularisation of death’ (Mellor & Shilling, 1993) are arguably far more fluid where the priority is individual choice and autonomy. This is reflected in healthcare services where patients are increasingly viewed as consumers of what is claimed to be a democratic system in which the voice of the service user is far more central. In particular, policies concerning recovery are becoming progressively more popular (Department of Health, 2001; McPherson, Evans, & Richardson, 2009). Recovery began as a radical movement, drawn from a melange of beliefs and values that emerged from anti-psychiatry, the psychiatric survivors movement, and the consumer rights movement, that critiqued the paternalistic nature of health care and sought to reclaim power back to the patient or service user (Braslow, 2013; Roberts & Wolfson, 2004; Travis, 2009). The introduction of recovery into health care policy, the growth of narrative approaches to health care, and the growth of online user directed forums are all attempts to remedy what is considered to be the ‘epistemic injustice’ at the heart of the way health care services have been administered (Carel, 2013).
Though the initial move towards recovery sought to bring acceptance to living with an illness and to broaden the notion of recovery outside of medical requirements, as recovery has been co-opted and incorporated into mainstream practices the radical demands have gradually coincided with, or indeed diluted by, a government agenda of autonomy and individual responsibility (Braslow, 2013). This is perhaps a result of the ‘plastic’ nature of recovery which originally was designed to be inclusionary rather than the exclusionary nature of the healthcare of the past. Indeed for grief, what recovery means and entails has been contested (Balk, 2008; Paletti, 2008; Rosenblatt, 2008; Sandler et al., 2008; Shapiro, 2008) and the divergent conceptualisations have done little to dent the belief in the stages and phases of grief in wider culture. A possible cause for the failure of recovery to bring about the radical demands it set out to achieve is that in trying to expand what was viewed as normality, it became incorporated by the norm itself, without that norm experiencing dramatic change.
Recovery has come to rely on assumed notions of what it means to be a functional citizen yet the criteria of what is deemed to bring quality of life are rarely questioned. A Department of Health policy document entitled ‘The Journey to Recovery’ (2001) describes recovery from mental illness as including the following: having an acceptable place to live, a meaningful occupation, access to further education and training, access to information on entitlements and benefits, and engaging in ‘ordinary social activities’. This vague list of components of the happy recovered life (an ‘acceptable’ place according to whom? What are ‘ordinary social activities’?) appear to point towards an ideal life, a normality to which everyone should live by or strive for. In grief literature there are similar notions found as Shear (2012) describes the aims of successful mourning are: to be re-engaged with daily life, to be reconnected to others, to be able to experience hope for the future, for grief to be transformed and integrated, and to ‘effectively regulate’ emotions. As Arnason & Hafsteinsson (Arnason & Hafsteinsson, 2003) argue, the way in which grief is dealt with can be linked to permutations in government rationality. The types of bereavement therapies offered, mainly versions of cognitive behavioural therapy and increasingly mindfulness therapy, are part of broader government interests in well-being and happiness. These types of choices that are made available to a person following bereavement can be seen as processes of subjectification (Foucault, 1975). That is to say the adoption of behavioural therapies or mindfulness within the NHS in UK healthcare to treat grief both shapes how grief is defined but also shapes the subjectivity of the person who is grieving. This process of subjectification is not a simple process of disciplining from above, but as the incorporation of the recovery movement has shown, it is a process composed of two vectors where individuals are encouraged to undertake activities of self-governance, just as they are being encouraged to treat or work through their grief with the help of external services and interventions (Hacking, 1986).
Increasingly the resilience of people in the face of loss has become a popular focus in grief as well as across healthcare research (Bonanno, Moskowitz, Papa, & Folkman, 2005; Bonanno, 2009; Edward, 2005; Mancini & Bonanno, 2009; Miller, 2002; Richardson, 2002; Stokes, 2009; White, Driver, & Warren, 2008). George Bonanno and colleagues (2005) argue that most people tend to remain resilient in the event of losing a loved one. Bonanno (2009) dismisses the idea that people go through stages instead proposing that for most people grieving does not become a serious problem, and that if there is no real devastating sense of loss there are no stages to go through. This argument also brings into question the focus in grief theory on attachments and bonds to the deceased. Whereas the continuing bonds thesis (Klass et al., 1996) promoted the idea that ‘getting over it’ did not mean having to ‘let go’, an emphasis on resilience rather enforces an idea of our self-sufficiency; the belief that our autonomy remains intact even after losing a close family member or friend. The growth of research into resiliency also sits neatly within the broader emphasis in health care on recovery, where recovery is defined as an individual self-determined process. Yet the acknowledgement of the complicity between how people report themselves as resilient, and the wider societal discourses that promote and favour resiliency and rapid recovery from grief is notably absent in studies promoting the power of resiliency.
Seen through this lens then, resilience appears a simple gloss that ignores the complexity in how agency is formed and obtained. Resilience and recovery rely on an autonomous subject, and therefore the inability to ‘bounce back’ can only be a failure of the individual. So while grief is construed as a potentially problematic occasion, it is equally one where an individual is seen to be capable of rising above their suffering, using it productively to transform their lives. The transformative potential of grief has been highlighted (Balk, 1999) and stories of dramatic fighting against adversity proliferate in self-help books and memoirs (Dennis, 2008, 2012). When autonomy and choice are promoted as desirable qualities and when recovery from grief is depicted as something that is the responsibility of the individual, recovery becomes an obligation and a normative requirement. The failure to perform recovery thus becomes a moral failure of will.
Yet this presumption of autonomy gets confused in the instance of grief where commonly people who are grieving are considered not to know what is best for them; they cannot be autonomous (Parkes, 1972). As Butler (1997) highlights, subjects come into being through recognition, through being interpellated by language. If a subject is deemed vulnerable – and that is in contrast to the desired autonomy – then the very viability of the subject is questioned. It is in this instance when the person who is grieving is seen as requiring intervention to get them ‘back on track’. The grieving person is a ‘risky’ individual who needs managing (Rose, 2007). Yet to be deemed a risk there needs to be a normality from which abnormality is identified. The knowledge of the normal mind that the psychological disciplines claim to possess (Rose, 1985) provides the condition and basis for the application of techniques and measures such as diagnosing complicated grief. Complicated grief or prolonged grief disorder are categories that seek to explain and treat the 7% who do not cope ‘effectively’ with bereavement (Shear, 2012). Complicated grief is what occurs when the natural healing process is ‘impeded’ ‘derailed’ ‘delayed’ due to ‘interference’ and complicating factors (ibid). Some of the symptoms of complicated grief are intense yearning for the deceased, numbness, detachment, avoidance, trouble accepting loss as real, intrusive/preoccupying thoughts, sense of loss of meaning in life, and ruminating. Yet who decides what is sanctioned in grief and what is not? Shear describes the intention behind treating complicated grief is to stop ‘unnecessary suffering’ but often it would seem this more a matter of easing the suffering or discomfort of others around the person who is grieving. After all, it is family members who tend to be the ones who refer their grieving relatives for treatment (Shear, 2010).
What is interesting in this search for the pathological is the ambiguity of what makes up normal patterns of grief. Complicated grief is described as something that ‘derails’ the ‘normal healing process’ (Shear, 2012), yet what the ‘normal healing process’ actually entails remains vague. Studies that focus on the meanings the bereaved make about their grief and the deceased are widespread and narrative approaches to studying grief have sought to tackle the idea that there is only one or right way to grieve (Bury, 2001; Charmaz, 1999; Gilbert, 2002; Neimeyer, 2005; Valentine, 2008). In these narrative explorations, grief is depicted as a unique and individual experience. Telling stories about grief is seen to help bring voice to the multifaceted and varied nature of grieving. Yet this seems to fit uneasily with a preoccupation to identify the biological and psychological markers of grief, where bereaved people can be slotted into typologies and composed of lists of symptoms.
Furthermore there is an odd contradiction in that the aim of complicated grief treatment to promote ‘natural healing’ neglects to see how external intervention automatically undermines the possibility of a natural order of grieving. Perhaps rather this failure to perform natural recovery or tap into resilience reserves is in fact the ‘natural’ state of grief insofar as it is an equally valid manifestation of a state that is still undefined. Perhaps it is the norms through which grief is defined that need expanding; the definition needs to shift to fit the person, not the person to fit the definition. This is evermore salient for grief where the state of normality is constantly in flux, it is only by delineating failed performances can the desirable norms be selected and reinforced. As Maciejewski et.al. tellingly note:
The identification of the patterns of typical grief symptom trajectories is of clinical interest because it enhances the understanding of how individuals cognitively and emotionally process the death of someone close. Such knowledge aids in the determination of whether a specific pattern of bereavement adjustment is normal or not. Once the normal patterns of grief are known, individuals with abnormal bereavement adjustment can be identified and referred for treatment when indicated (2007, p.717).
But of course individuals are identified and referred for treatment without the normal patterns of grief being known. This suggests then that the norms through which grief are guided are not so much a way to stay faithful to a natural mourning or healing process, for this process is not known or at least cannot be identified. Rather then the norms of grief do something else; they prevent against and constrain the possibility of not recovering. ‘No recovery’ is chaotic and open-ended; there is no transformation of self or resolutions available in this experience of grief (Kauffman, 2007). The risk of no recovery is not just to the person who is grieving; it is a risk to the very idea of the vision of the good life the recovery narrative promotes. According to the diagnostic criteria of prolonged grief disorder, showing symptoms of grief for six months or more can potentially be cause for intervention (Prigerson et. al., 2009). The popularity of research into resilience further fosters the idea that grief is something to be recovered from quickly (Balk, 2008). Time then becomes one of the key indicators in managing grieving. ‘Technologies of temporalisation’ (Binkley, 2009) is one of the strategies Foucault (Foucault, 1975) argued institutions use to produce docility in its workforce. Borrowing Foucault’s concept, the experience of grieving has become something framed by time, by an imperative to recover within socially acceptable parameters, which thus may induce a sense of docile adherence to guidance promoting the ‘natural’ healing process. There are clear and immediate incentives and obligations for a grieving person to recover in order to get back to work and to re-engage with ‘ordinary social activities’ which all take place within a routinised daily pattern. To refuse to conduct oneself in this way, or to fail to conduct oneself in this way, is to willingly or forcibly enter into the unfamiliar space of no recovery.