The role of recovery in modern mental health policy

1. The role of recovery in modern mental health policy David Pilgrim PhD Professor of Mental Health Policy, University of Central Lancashire dpilgrim@uclan.ac.uk

2. Preview of published paper Longer paper with same title to appear in Chronic Illness (2009) with commentaries by Kim Hopper and Larry Davidson Critical overview of the emergence of the �recovery� concept in the Anglophone Anglo-American literature

3. History of the concept (1980s+) Fiscal burden Technical fixes for madness and misery (e.g. �pharmacological revolution� + CBT) Consumerism in health and welfare policy Human-rights critiques from �anti� and �post� psychiatry & disaffected consumers

4. Optimism in late modernity The possibility of full citizenship for all Chemical and conversational correctives for madness and misery But.. new therapeutic optimism is not unique

5. The countervailing discourse of risk Recent therapeutic optimism has been constrained by a preoccupation with risk aversion: Ullrich Beck�s �Risk Society� The very point of �mental health law� is the lawful social control and exclusion of mental disorder- a risk minimisation goal

6. Contested concept Davidson and Roe (2007) �There is an increasing global commitment to recovery as the expectation for people with mental illness. There remains, however, little consensus on what recovery means in relation to mental illness� (emphasis in the original)

7. Vague & hopeful consensus Everyone agrees it to be a worthy aim but what do we aim for? �Recovery from� and �recovery in� (Davidson and Jacobson) Disaffected consumers, social psychiatry and biomedical psychiatry

8. Three communities of interest 1. Recovery from invalidation (survival) 2. Recovery from impairment (rehabilitation) 3. Recovery from illness (treatment)

9. Consumer distrust of professional rhetoric Understanding the use of language is important if we are to understand the failure of the mental health system to achieve sustainable recovery on a large scale. [Its] framework is littered with the language of mental illness rather than the language of recovery. Throughout words and phrases such as coping strategies, professional interventions, supports, medical care, medication, symptoms, assistance, treatment facilities, crisis, distraction and ongoing coping monitoring and responding strategies are used�(Coleman, 2004)

10. Consumer definitions of recovery Meagher (2004): remaining hopeful for a future of growth and personal development; having the right to choose; knowing that you are person not a diagnosis; speaking for yourself, rather being devalued by others speaking for you; living in a place of one�s choice; emphasising the need for personal support and intimacy These features are at odds with a professionally-centred discourse of accurate diagnosis, medication compliance, risk management and care plans, indeed some of these features are ignored or specifically challenged

11. Social psychiatry and rehabilitation Applies the biopsychosocial model and focuses on �relapse prevention� and a combination of compliance with medication and tailored social skills training Although social integration is central to this model of recovery, it emphasises professional interventions to reverse impairments (Lillehet, 2002) Psychiatric expertise is reconstructed; it is not about the traditional bio-medical focus on diagnosis and medicinal treatment but instead is about an elaborate version of social skills training. Patients are brought back into the fold of society by a new version of moral treatment

12. Biomedical psychiatry: old wine in new bottles? Though Kraepelin was pessimistic about recovery by mid 20th c. obvious that about a third recover completely and another third partially. This permits �business as usual� to make claims about treatment success in creating recovery from mental illness.

13. Services as problematic sites of social engineering Social exclusion may not be combated by the social inclusion of individuals The very existence of coercive mental health law may work against social inclusion and recovery Services need to be appropriate & acceptable to consumers, not just accessible, in order to justify claims of true recovery

14. Begged questions for the research community about recovery Are professional paternalism and the force of mental health law (parens patrie) a help or a hindrance to recovery? If recovery can mean different things to different people, does it mean anything? What does recovery mean for the full range of people with mh problems? To what extent can the social inclusion of recovering individuals reverse the constraints of social structure (race, class, gender and age)?

15. New dialogue possible Risk of spurious consensus about meaning of �recovery�� But an opportunity for new dialogue between reason and unreason to give meaning to the experience of madness and misery. Meaning has been lost for now in the bio-medical monologue of diagnosis and treatment.

16. The politics of hope Risk of obscuring economic exploitation, racism, sexism and ageism�. But it reflects a politics of hope- Gramsci�s �pessimism of the intellect, optimism of the will� or Marcuse�s �great refusal� of economic and other forms of rationalism. Recovery helps us to focus on the possibility of squaring the circle of social justice and human rights for excluded people. �It is only for those without hope that hope is given to us� (Walter Benjamin)