Friday, 30 October 2009

Recovery, values and subjectivity

I’ve been invited by Joana Ferreira, a psychiatry resident in Coimbra, Portugal and lecturer in psychopathology to psychology students at at the Catholic University of Braga and who attended the INPP conference in Lisbon, to submit a paper based on my grouchy presentation on recovery to their college magazine on psychiatry, psychology, philosophy and religious themes.

(PS see also this later published paper.)

So here is a very rough first rough stab (coming in at 3,500 words).
Recovery, values and subjectivity
In the UK, the recovery model has been promoted to guide mental healthcare in reaction against what is perceived to be an overly narrow traditional bio-medical model. It has also begun to have an influence in thinking more broadly about mental health both for individuals and for communities and in the latter case has been linked to policies to promote social inclusion. In this widening application, however, there is a risk that the model (assuming that it is a model) becomes too broad and includes too many factors, severing its connection to health.

In this short paper, I attempt to sketch (although not rigorously defend) an argument for a recovery model that distinguishes it from a bio-medical model through the essential presence of a normative dimension in the values that characterise its goal. Nevertheless, I argue that, by distinguishing hedonic from eudaemonic values, it is still possible to maintain a degree of normative assessment in what should properly be called a matter for recovery.

A recent policy paper published by the Sainsbury Centre for Mental Health called ‘Making recovery a reality’ begins by summarising some key points of emphasis which characterise the approach. These points include:

· Recovery is about building a meaningful and satisfying life, as defined by the person themselves, whether or not there are ongoing or recurring symptoms or problems.
· Recovery represents a movement away from pathology, illness and symptoms to health, strengths and wellness.
· Hope is central to recovery and can be enhanced by each person seeing how they can have more active control over their lives (‘agency’) and by seeing how others have found a way forward.
· Self-management is encouraged and facilitated. The processes of self-management are similar, but what works may be very different for each individual. No ‘one size fits all’.
· The helping relationship between clinicians and patients moves away from being expert / patient to being ‘coaches’ or ‘partners’ on a journey of discovery. Clinicians are there to be “on tap, not on top”.
· People do not recover in isolation. Recovery is closely associated with social inclusion and being able to take on meaningful and satisfying social roles within local communities, rather than in segregated services.
· Recovery is about discovering – or re-discovering – a sense of personal identity, separate from illness or disability.
[Shepherd, Boardman & Slade 2008: 0]
As this list suggests, recovery is not so much an explicit theoretical model of the nature of health and illness as a practical orientation to the kind of care that should be involved and the roles of patients or service users and clinicians or carers. Nevertheless, the points listed do suggest an implicit theoretical model which I will attempt to draw out. A key clue to that is the idea that recovery is to be characterised through a positive goal of health and wellness rather than the avoidance of the negative aspects of pathology and illness. That positive goal is connected to the agency of the individual, to their own situation-specific self management of the process, and to their identity.

The list also connects recovery to social inclusion through the empirical claim that social inclusion promotes recovery. But given the links between policies promoting recovery at the individual level and policies promoting social inclusion at the level of communities this raises a further question that helps shed light on the connections between recovery and values: need recovery promote social inclusion? By stressing individual autonomy as the final arbiter of the values that form the goal of recovery, the model suggests a view of society as a group of individuals satisfying their private preferences. That seems to threaten, rather than support, the notion of social inclusion and the idea of collective values or goods.

But further, if the satisfaction of just any preference can be part of the conception of recovery then the model degenerates into subjective whimsy, unconnected to the notion of health, and the use of the label ‘recovery’ is misleading. It is not so much a corrective of the bio-medical model as a totally different venture.

I will attempt to sketch a justification for a conception of recovery which is distinct from a bio-medical approach but which is still sufficiently normatively charged that it can avoid both of these risks. I will not, however, attempt to defend it against rival approaches to recovery. My aim is to rationalise rather than justify a model of recovery.

The normativity of illness / disease / disorderTo begin, it will be helpful to look back to the recent history of discussion of mental health and illness. In his attack on the very idea of mental illness, Thomas Szasz stressed that the concept of illness, whether physical or mental, carries with it the connotation of deviation from a normative standard, a standard that carries a distinction between correctness and incorrectness. (In what follows ‘normative’ will be used to refer to any such standard; the key contrast is with the merely statistically normal.)

The concept of illness, whether bodily or mental, implies deviation from some clearly defined norm. In the case of physical illness, the norm is the structural and functional integrity of the human body. Thus, although the desirability of physical health, as such, is an ethical value, what health is can be stated in anatomical and physiological terms. What is the norm, deviation from which is regarded as mental illness? This question cannot be easily answered. But whatever this norm may be, we can be certain of only one thing: namely, that it must be stated in terms of psychological, ethical, and legal concepts… [Szasz 1971: 15]

Szasz used this point as the basis for an argument against mental illness. Nothing can both satisfy this condition and the condition of being medically treatable. Thus one possible route to defend that concept would be to disagree that illness need carry a normative connotation. (A distinct defence is to accept the condition but argue that it does not support the conclusions Szasz draws [Thornton 2007: 11-19].) Perhaps illness could be defined in merely statistical terms. But as even as biologically minded a psychiatrist as Robert Kendell realised, such an approach cannot work. Reviewing the history of the debate he commented:

By 1960 the ‘lesion’ concept of disease, and its associated assumptions of a single cause and a qualitative difference between sickness and health had been discredited beyond redemption, but nothing had yet been put in its place. It was clear, though, that its successor would have to be based on a statistical model. [Kendell 1975: 309]

But, as Kendell went on to say, whilst a statistical model may address some of the weaknesses of a single lesion model, statistical abnormality by itself cannot distinguish between ‘deviations from the norm which are harmful, like hypertension, those which are neutral, like great height, and those which are positively beneficial, like superior intelligence’ [ibid: 309]. Some further criterion is needed to address the fact that illness is a specific kind of deviation from the norm and Kendell followed the work of the British chest physician, JG Scadding in suggesting that biological advantage is the key idea.

More recently there has been an attempt to explain this normative dimension using the idea of biological or proper function of sub-personal traits (not just advantage or disadvantage to whole individuals). The hope is that whilst illness or disease may carry the irreducible notion of harm, a core notion of disorder can be fitted within a purely descriptive scientific account, drawing on evolutionary theory. The prima facie normative dimension of disorder can be explained through the apparently normative notion of biological function. But functions can be analysed through the plainly descriptive or factual notion of what best explains their continued presence within evolved organisms.

A natural function of a biological mechanism is an effect of the mechanism that explains the existence, maintenance or nature of the mechanism via the same essential process (whatever it is) by which prototypical nonaccidental beneficial effects... explain the mechanism which cause them... It turns out that the process that explains the prototypical non-accidental benefits is natural selection acting to increase inclusive fitness of the organism. [Wakefield 1999: 471-2]

The aim is thus to milk a normative function from a plain description of evolutionary history. There are, however, two challenges to this approach. First there is the longstanding objection raised elsewhere in philosophy that norms are smuggled back into the particular choice of evolutionary explanation [Godfrey-Smith 1989, Thornton 1998: chapter 2, Thornton 2000]. In other words, functional explanation is not plainly descriptive. More specifically for psychiatric disorder, it is unclear that the necessary distinction between natural and merely social functions can be maintained [Bolton 2008: 124-5].

In what follows, I will assume that there is no prospect of a plainly descriptive account of disorder and hence of illness or disease. If so then to identify some of the behaviour of either a whole person or a sub-personal biological system as expressive of illness is to conceptualise it in normative terms. To put this another way, different behavioural dispositions have to be filtered through some sort of normative sieve to yield a conception of illness or disease.

There have been attempts to analyse the nature of the normativity of illness or disease. KWM (Bill) Fulford, for example, has proposed and defended a model of illness as a ‘failure of ordinary doing’ [Fulford 1989]. Drawing on Austin’s characterisation of ordinary doing as the kind of action that one ‘gets on and does’ without explicit intentions or trying, Fulford argues that a failure to be able to do this kind of thing, in the absence of external constraint, captures the paradoxical character of experiences of illness [Austin 1957]. He suggests that it helps to explain its normativity or, more specifically, values-ladenness because the ineliminable concept of failure (of ordinary doing) itself suggests an ineliminable (negative) value judgement.

It is still a matter of debate whether Fulford’s account successfully accounts for illness. However, even if the norms that characterise illness cannot be reduced to some other normative notions in the way that Fulford, for one, proposes, the failure of a reduction to the plainly descriptive leaves the concept of illness as an essentially normative notion. That, however, may not imply that recovery is, as I will now discuss.

The normativity, or not, of recoveryEven if one assumes that the concept of illness is essentially normative (statistically unusual behaviour is not sufficient for illness, for example), recovery may not be so. On the picture sketched above, one identifies tracts of behaviour (of people, or of their biological systems) as expressive of illness by filtering all forms of behaviour through an appropriate normative sieve. The filter may use other normative terms such as Fulford’s failure of ordinary doing or be a primitive amd irreducible notion such as sufficiently resembling paradigmatic illnesses. Once it has been applied, what remain are normatively selected states or behaviours.

Recovery itself might plausibly be thought of as the return from such states to a state of health. Health itself, however, might be conceptualised in merely statistically normal (rather than normative) terms. If so, whilst the states that individuals have an interest in recovering from are those with particular normative properties (whatever precisely those are), recovery itself might be characterised in non-normative terms.

For physical health, this is at least a reasonable picture although some initial qualifications are necessary. Age, for example, makes a difference. What is a healthy physical state for an 80 year old will not be for an 18 year old. Further, it may even be statistically normal for most members of particular groups of people (small children, the elderly) to have some illness or other in some or other biological system. If so and if health were defined in normal terms, normality would have to be defined for each such sub-system rather than for the wholse person. But given suitable qualification, there is something plausible about such an approach. It avoids any idealisation of health. One can be healthy – that is: not ill – without being at the peak of physical condition. The fact that one would prefer to be fitter, stronger or more muscled does not imply that one is not healthy as one is.

An analysis of physical health in statistically normal (rather than normative) terms helps rationalise a bio-medical approach to recovery. Once the starting point has been identified, a state picked out as an illness, no further mention need be made of normative notions, for example values. Recovery, so construed, would be merely an engineering problem for the human body.

If a non-normative model of physical health helps to justify a bio-medical approach, can a contrasting recovery model be articulated? I suggest one can based on the following line of thought. Although it is plausible to define physical health in statistical terms, in the case of mental health, however, the end point might have to be essentially normatively, or more precisely, evaluatively characterised. According to this line of thought, mental health cannot be construed as a statistically average kind of life but rather, in line with the opening quotation, a particular kind of life autonomously chosen, valued and hoped for by the individual concerned, the kind of life connected to their identity.

If this were the case, there would be no hope of defining the endpoint of recovery for mental health in non-normative or non-evaluative terms. A specific endpoint would be correct for, or suited to, each individual. And thus recovery should be aimed at a specific and normatively characterised or valued endpoint.

Is this the only way of approaching matters? I do not think so. To defend, rather than merely rationalise, a recovery model for mental health so construed would require dismissing a variant of the statistically normal approach. Whilst characterising a statistically normal kind of life seems misguided, the capacities that enable one to live a life so chosen may be more appropriate for that treatment. So, in the service of an autonomously chosen and hoped for life, mental health might be defined in terms of statistically normal mental abilities. I will, however, ignore this possibility in what follows.

To summarise this section, contrasting approaches to physical and mental health help to justify two contrasting approaches to recovery:
Recovery1: a return to normality (albeit from a position picked out by a normative sieve).
Recovery2: a move (from a position picked out by a normative sieve) to a normatively characterised endpoint, for example, a conception of a valued form of life.

Recovery2 suggests that whether someone has recovered or not depends not on the plainly descriptive matter of whether they have returned to a statistically normal state but rather on reaching a normatively or evaluatively characterised state that constitutes wellbeing.

But if there are no constraints on how that endpoint is selected, if it is simply a matter of personal preference, of the expression of individual autonomy, then that suggests that recovery is a matter of subjective whimsy. The idea of recovery is severed from any notion of health. Further, it threatens the aim of social inclusion with which recovery has historically been associated.

The right values for recovery?The key assumption in my rationalisation of a recovery model for mental health is that the endpoint of recovery has to be characterised in normative terms. There is something appropriate or correct rather than merely usual about the endpoint. But, perhaps because of the rise of autonomy as the key medical ethical value, there is a standing temptation to construe this normative dimension in a particular way. That is, in accord with the preferences of the individual concerned. And put like that, it is tempting to wonder whose preferences should be preferred. Nevertheless, if the norms are subjective preferences then the idea of recovery collapses into the idea of individual preference satisfaction and that also puts the idea of social inclusion at the level of communities under pressure.

But that is not the only way to think about the normativity implicit in the recovery model. Consider two contrasting views of wellbeing: hedonic and eudaemonic. On the hedonic view: wellbeing is a matter of satisfying one’s preferences. The normativity of recovery based on this approach is exhausted by the combination of the satisfaction of the preferences (only some ways the world comes to be satisfy an antecedent wish; the wish imposes a normative constraint on ways for the world to be) and by issues of rationing of scarce resources or balancing conflicting wishes.

On a eudaemonic view, wellbeing is ‘activity in accordance with virtue’. It thus builds in the idea that some values are more valuable than others and not merely more (that is, statistically) preferred. By keeping the key connection between eudaemonia and flourishing or wellbeing in focus, an approach to recovery based on it can restrict the kind of values that characterise its aim: values relevant to flourishing and not just subjective preferences.

Thus, in addition to the normative standards implicit in the hedonic view, a eudaemonic view introduces two further degrees for normative assessment. First, the values that characterise the endpoint of recovery are not just any preferences but values connected to human wellbeing. This helps maintain the pre-theoretic notion that recovery is connected to health and wellbeing. Second, values can be better or worse and can be subject to rational criticism and scrutiny. Thus, for example, if human flourishing really does depend on social inclusion then that fact places principled limits on the value of individual autonomy and thus principled limits on the nature of recovery. Not just any preferred endpoint constitutes the proper aim of recovery, so construed.

Having sketched the conceptual space for a normatively charged conception of recovery based on a eudaemonic view I will finish with three clarificatory comments.

First, Aristotle himself held substantial views about the nature of human flourishing. According to his doctrine of the mean, for example, flourishing requires achieving a middle ground across character traits where both deficiency and excess amount to vices. But a broadly eudaemonic view of recovery need not be tied to any particular view of flourishing, such as Aristotle’s. What flourishing is needs to be investigated and subject to ongoing critical scrutiny.

Second, especially in the light of the flight from medical paternalism to patient or service user autonomy, the idea that some values are more valuable than others may smack of authoritarianism. But it need not. Just as the empirical world serves a normative standard for what empirical beliefs we should hold without that implying that science has to be authoritarian, so a conception of real and objective values need not lead to authoritarianism either. Rather, it imposes a standing obligation for critical reflection on the values we hold.

Third, the eudaemonic view of recovery does not preclude a role for hedonic values in mental health care. Sincerely held, harmless hedonic values may indeed play a role in a broader values based practice. The subjective preferences of service users, who indirectly pay for the services, should indeed be taken into account. And thus models for managing competition for limited resources and other values-based conflicts will be needed. But it is surely a point in the favour of the a eudaemonic view that such values need have nothing to do with what we ordinarily understand by ‘recovery’ and its direct connection to health.

I have sketched an argument for (although not fully defended) a model for the goal of mental healthcare distinct from a bio-medical model in which recovery1 is a characterised in non-normative and value-free terms. On the alternative view sketched above, the goal of recovery2 has to be determined through the conception of a life autonomously chosen and valued by the subject concerned. Such a conception is normative or value-laden in so far as it fits, or is appropriate to or correct for, the individual’s self-identity. There is a danger, however, that such a view collapses into a subjective whimsy which severs the connection between recovery and health or wellbeing and may undermine the related goal of social inclusion. For those reasons I have argued for a eudaemonic rather than hedonic view of the values in play. On the eudaemonic view ‘recovery’ can retain a firm connection to health and healthcare, without collapsing back into a narrow bio-medical model.

BibliographyAustin, J.L. (1957) ‘A plea for excuses’ Proceedings of the Aristotelian Society 57: 1-30
Bolton, D. (2008) What is mental disorder, Oxford: Oxford University Press
Fulford, K.W.M. (1989) Moral Theory and Medical Practice, Cambridge: Cambridge University Press
Godfrey-Smith, P. (1989) ‘Misinformation’ Canadian Journal of Philosophy 19.
Kendell, R.E. (1975) ‘The concept of disease and its implications for psychiatry’ British Journal of Psychiatry 127: 305-315
Shepherd, G., Boardman, J. & Slade, M. (2008) Making Recovery a Reality London: Sainsbury Centre for Mental Health
Thornton, T. (1998) Wittgenstein on Language and Thought, Edinburgh: Edinburgh University Press (translated into Portuguese as Wittgenstein - Sobre linguagem e pensamento, Brazil: Edições Loyola)
Thornton, T. (2000) ‘Mental Illness and Reductionism: Can Functions be Naturalized?’ Philosophy, Psychiatry and Psychology 7: 67-76
Thornton, T. (2007) Essential Philosophy of Psychiatry Oxford: Oxford University Press
Wakefield, J.C. (1999) Mental disorder as a black box essentialist concept. Journal of Abnormal Psychology 108: 465-472