Friday, 27 May 2011

Arguing for the correctness of a recovery model

I have been working on the middle section of my draft chapter for the OUP collection on recovery (Rudnick, A. (ed) The Recovery of People with Mental Illness Oxford University Press) plonked previously on this blog. Originally - as is obvious in the Thornton & Lucas JME paper - I was far from convinced that an argument for the model articulated worked. (That I was not was a bit of a surprise. Whilst I do not go around advancing theories of things, I have always taken illness to be normative at all levels.) I think I am now more convinced and I think this passage now makes that a bit clearer. Comments to my email would be very welcome.

Arguing for the correctness of a recovery model

It is one thing to articulate a possible recovery model distinct from a bio-medical model (and simultaneously partly to characterise the bio-medical model). It is another to argue for it. I will now try to sketch the beginnings of an argument for a recovery model for mental health, construed on these lines. To do this, I will employ a contrast with physical health.

The argument is as follows. A non-normative or non-evaluative approach seems initially at least to be a promising approach to physical health and the aims of physical healthcare. That however can safely be conceded providing that there are reasons to distinguish between mental and physical health. Since there such reasons, these can be used to argue for a contrasting recovery model for mental health.

Note two preliminary points about the strategy. First, there are plausible objections to a non-normative conception even of physical health. But does not undermine the argument for a recovery model for mental health. If anything, it strengthens it. Second, however, the overall argument is open to counter-attack. I will sketch some lines of defence of the recovery model against this but concede, in the end, that it is an ongoing debate.

A non-evaluative approach seems to be a possible picture of physical health and hence for recovery from physical illness which does not amount to a recovery model. It could instead be thought of as a bio-medical approach to physical health. On this view, the aim of physical healthcare is a return from a state of illness – whether evaluatively or non-evaluatively understood – to a state identified in non-evaluative or plainly factual terms. One version of this approach would be to define the state in statistically normal terms (I will return to a second version, shortly).

Whether or not it is successful in the end, a statistical model of health has at least an obvious advantage over a statistical model of ill-health (based on the idea that illness is a statistically unusual state). Such a model of ill-health has the problem that for some features of human nature, deviation from the norm in one direction may not be, in itself, unhealthy at all. Having a very high IQ or being able to run very quickly is not equivalent to having a very low IQ or low mobility. Since a statistical model of health – by contrast with its lack – can be based on what is normal rather than abnormal, it does not face an analogous problem. Furthermore, it avoids a implausible 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.

Nevertheless, to escape some obvious problems for it, some qualifications to a statistical approach would have to be built in. Thus, for example, what is normal for a 20 year old may not be normal for an 80 year old. The same state of health may be expected for the latter but an illness for the former. So health would have to be what is normal relative to an age. 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 (and/or perhaps psychological) system. If so, health would have to be defined as what is normal for each such sub-system rather than for the whole person at any one time.

Whether this strategy of careful selection of an appropriate reference group can work across the board is, however, open to question. Take the cases of obesity across whole affluent communities or dental cavities across whole populations. These are cases where what is statistically normal for the group in question does not seem to fit pre-philosophical intuitions about health. It is hard to see how a particular sub-group or other reference population could be selected to set the standard for physical health without begging the question: without, that is, the group being selected for being healthy.

For present purposes, I can, however, park that question since, on one assumption about the nature of mental health, then whether or not a statistical model of physical health can be defended against the objection just raised, it seems much less plausible for mental health. If, in line with the quotation from ‘Making recovery a reality’ at the start, mental health has something to do with living a particular kind of life, then it cannot – absurdly – be construed as a statistically average kind of life. It has instead to be thought of as a particular kind of life, valued and hoped for by the individual concerned, the kind of life connected to their identity. If the starting assumption is granted (that mental health has something to do with living a particular kind of life), it threatens the idea of defining the endpoint of recovery for mental health in statistical and hence non-normative or non-evaluative terms. A specific endpoint would be correct for, or suited to, each individual. And thus recovery would properly be aimed at a specific and normatively characterised or valued endpoint. This serves as a partial argument for a recovery model.

(In setting out a condition on a recovery model, I have suggested that it has to offer a substantive conception of health, or something like it, so as to count as a model rather than merely an approach. The need for the qualification – ‘or something like it’ – should now be apparent. The recovery approach – on which I am basing an articulation of a model – takes the aim of mental healthcare to be more than a narrow construal of health but a significantly richer mode of being. Not just a state or capacity but something like an ongoing set of choices and practices. Whether this is a broad conception of health or a conception of something broader than health such as wellbeing I will leave aside.)

This line of argument for a recovery model is not decisive because a crude model of a statistically normal kind of life is not the only potential alternative that would have to be ruled out. I will briefly outline two more.

First, one could define mental health not, absurdly, as the living of a statistically normal life, but as the possession of statistically normal mental capacities: capacities, for example, to make autonomous life choices. This approach might face the same kind of objection to the statistical approach to physical health I left parked a little earlier. Anxiety, for example, may well undermine the capacity to make rational choices but if it is normal in industrial countries it will count as a healthy state. But there is a more fundamental problem. How can mental capacities be so much as identified without presupposing a notion of human flourishing that they support. What, in other words, are the capacities for?

This general objection is connected to a specific issue raised elsewhere in philosophy. Key capacities for mental health, as exemplified in the recovery approach, surely include the capacities for autonomous choice. But the identification of such capacities – before the issue of considering what is statistically normal – cannot itself be a plainly factual matter. Such capacities are governed by what Donald Davidson calls the Constitutive Principle of Rationality [Banner 2010, Davidson 1980]. Rationality is not merely a statistical normal pattern of reasoning [McDowell 1985]. It involves, essentially, a notion of what one ought to think in the face of such and such reasons, evidence and values. And there is thus no hope of identifying the capacity for choice in neutral terms.

A second rival to the recovery model for mental health can be articulated by returning to another issue left hanging a little earlier. The statistical model is merely one form that a non-normative, non-evaluative approach might take for physical health. A more promising approach would be one based on biological function. Familiar in the case of illness or disease through the idea of failure of function, accord with function could serve as the correlative definition of health. On this approach, one’s physiological systems are healthy insofar as they are behaving in accord with their biological functions. And the same approach might be applied in the case of mental faculties.

The key line of objection this approach is to question whether the articulation of the biological functions of mental traits can be viewed as independent of, rather than presupposing, a conception of human flourishing. The challenge for a plainly factual account is that only some of the actual evolutionary history of happenings accord with the normative account of what a trait is selected for. So by what principle of choice are some picked out to exemplify the trait’s purpose? The obvious answer is not available to a non-normative account: via an understanding of what contributes to a value-laden conception of human flourishing. This remains a matter of lively debate. On it turns the issue of whether an account of health based on accord with biological function is an alternative to the recovery model I have articulated or merely a disguised form of it.