The paper starts with the pre-history of the recovery movement in mental healthcare, when the conception of recovery was, as one might have expected, simply getting better, sloughing off illness but when the best that seemed likely was, in Kraepelin’s phrase, ‘cure with defect’ (or ‘healing with scarring’). For example research in 1928 suggested a 20% recovery rate, meaning that that proportion were able to return to expected social roles. More recently, however, what Hopper calls ‘social recovery’ has been found to be more common than previously expected ‘outside the hospital, when measured by independent living and gainful employment’ [ibid: 869]. But he stresses the importance that targeted help can make to such social recovery. This in turn led to the development of a widespread literature about recovery with four key themes.
1. Renewing a sense of possibility
2. Regaining competencies
3. Reconnecting and finding a place in society
4. Reconciliation work
But, Hopper argues, this list of themes significantly neglects social context: the difference that race, gender, poverty etc can make to mental health. The neglect of systematic treatment of such features undermines the right to call recovery a ‘model’.
To speak of a ‘model’ of recovery is thus misleading. Movements are not peer-reviewed. Mobilizing committed forces means hoisting rallying cries at odds with one another, tamping down potentially divisive demands, and capitalizing on working misunderstandings. In making the case against therapeutic nihilism, rethinking services, and embracing patients as active agents in their own recuperation, this inclusive approach served well, making common cause of potentially discordant constituencies. But the same medley of affirmation, reckless hope and wide appeal made for later difficulties when converting emancipating creed into actionable policy. [ibid: 871]
Hopper goes on to argue that the open ended and moral crusading aspects of recovery have prevented it from being put into practice. He gives the example of Jacobson’s anthropological study of Wisconsin in which institutional inertia has prevented significant change despite explicit support for recovery programmes.
It is difficult to escape the conclusion that operational specificity was unwisely sacrificed in the interest of more efficiently spreading the good news. The movement’s watchwords—voice, authenticity, process, settling old scores and filing fresh grievances—proved ill-matched to the grind of institutional sway and regulatory reform. Recovery had merit, morals and the tempered weight of science behind it and so it sashayed into political battle unarmed. [ibid: 873]
Thus the second half of the paper looks to try to address this lack by unpacking the notion of recovery in such a way that it can be ‘operationalised’. Hopper’s suggestion is to understand recovery on the lines of a capabilities approach. There seem to be two key elements to this.
First, a capabilities approach contrasts with an even (‘utilitarian’)distribution of resources by looking instead at needs.
Instead of satisfaction or utility or some package of ‘primary goods,’ Sen proposes that we consider not resources but rather the valued things people are able to do or to be as a result of having them—the capabilities they command. Actual welfare depends less on what I own or have access to than the real opportunities open to me as a result. [ibid: 874]
Second, mental health and illness are modelled on a two factor view of disability: on the one hand, original impairment (here, psychiatric disorder) and on the other, the disability which is constituted by the social reception and consequences of the impairment. Combined, this gives a model of recovery on these lines:
A capabilities-informed ‘social recovery’ will speak to citizenship as well as health. It will worry about what enables people to thrive, not simply survive... Recovery asks not what such people should be content with but what they should be capable of, and how that might be best achieved and sustained. [ibid: 874]
As my colleague, Karen Newbigging, pointed out, this gives a picture of recovery as not so much a model of healthcare but as a meta-level theory into which healthcare slots as one thing among others. Given the two-factor model, it also allows for a natural position for a technical, biological psychiatry to address the ‘original impairment’. That seems to be an interestingly conventional feature of his thinking. More radically, one might think that the ontological status of the first factor was derivative of the second. That is, one might think that there is no theory neutral set of original impairments. What is so deemed depends on social values.
Two other features of the way this broad structure is elaborated are notable. First, and reflecting the criticism in the first half of the paper, Hopper suggests that the capabilities version of the recovery movement has to be operationalised if it is to be effective and this requires some sort of universal, a priori list of human necessities:
Any application of capabilities must therefore first define/defend a (full or partial) list of valued functionings..., or specify a process for identifying/weighting them..., and then devise provisional means for assessing real opportunities for achieving them (capabilities proper). [ibid: 876]
The obvious worry this raises in the context of the history of mental healthcare is paternalism. Now, I think that that is a price worth paying (cf my criticism of Fulford’s pure procedural version of Values Based Practice) but others might not and Hopper does not seem to notice that this may be an issue. Further, it may be in tension, at least, with one of the things that he thinks will be on the list: the opportunity to exercise autonomy and agency. Here he suggests, in effect, the right to make unwise decisions.
With respect to formal interventions, a capabilities- informed approach to recovery would stress enhanced agency—not public safety, stable placements or reliable program-participation. This means asking under what circumstances exercising reasoned choice should be prized over foreseeable bad consequences in one’s life. Can a poor choice, assessed in terms of compromised well-being, be preferred if the foregone benefit could have been won only if imposed? [ibid: 877]
The tension is that the stress on agency and autonomy and the right to make unwise decisions at the level of the individual pulls against the idea that a policy maker might articulate a universal list of what is good for people. Now it seems plausible on an Aristotelian conception of flourishing, for example, that agency will be important, will be on any such list, but if so the value of agency has to be constrained by the other features of the list and vice versa.
This tension is present in a list of potential difficulties towards the end of the paper with the suggestion that ‘Deprivation and disgrace can so corrode one’s self worth that aspiration can be distorted, initiative undercut and preferences deformed’ [ibid: 877]. That seems right and suggests – correctly in my view – that there should be some element of normative assessment of individuals’ values (I am that paternalistic!). One may be wrong to value something. But Hopper continues: ‘Sensitive work will be needed to recover that suppressed sense of injustice and reclaim lost possibility’ which suggests that he already knows that if anyone, ever, thought that their mental healthcare had been good then they must be wrong. That seems overly paternalistic to me.All that said, there is something admirable, and rare, about a paper which explicitly addresses the underlying conceptual model of recovery. By connecting recovery to a two factor model of disability and then addressing the consequences of this for what people do and should value, Hopper provides a model which is distinct from a conventional biomedical model.
Hopper, K. (2007) ‘Rethinking social recovery in schizophrenia: What a capabilities approach might offer’ Social Science & Medicine 65: 868–879