Wednesday 20 April 2011

The recovery model, values and narrative understanding

An edited version of this chapter is forthcoming in Rudnick, A. (ed) The Recovery of People with Mental Illness Oxford University Press. (See also this article on the recovery model and this poster.)

Whilst recovery has been promoted as the proper aim for mental healthcare, there has been little agreement about what it involves. It is, however, often proposed as a contrast to a bio-medical view of psychiatric care, referred to as a recovery model. In this paper I examine what this claim might amount to by exploring the logical geography of a recovery model.
To count as a model, I assume that it must involve a theoretical conception of what ill-health, or health, or something akin to health is. I set out an analogy with a different area of the philosophy of psychiatry. The bio-medical is sometimes claimed to neglect the social aetiology of mental illness and thus be replaced by a social model. But since one could hold that mental illness can have distant social causes whilst still assuming that this is mediated or constituted by local failures of biological function, a distinct social model of mental illness has to hold that it is constituted rather than merely caused by social factors. A recovery model must, similarly, contrast with a bio-medical on some understanding of both.
Using the distinction between a focus on health versus illness and between evaluative versus plainly factual accounts, I suggest that a recovery model can be thought of as an essentially evaluative conception of mental health, or something like health, broadly construed, and examine arguments that that is the most valid or truthful model.
Supporters of the recovery model do not, however, generally proceed this way. They do not argue for the truth of their model, via, for example, the incoherence of rival models, but rather for the value of the recovery model. I thus examine the ground rules for this style of argument and examine whether it undermines the initial analogy with a social model of mental illness.
Finally I consider the connection between recovery and narrative understanding hinted at in, for example, recovery stories. If recovery is aimed at a person-specific conception of a valued way of living, then narrative understanding is particularly apt for articulating the particular reasons for identifying and valuing an endpoint.
Although much recent thinking about the aims of mental healthcare stresses the role of recovery, there is little agreement about what, precisely, that means. Larry Davidson and David Roe, for example, summarise the situation thus: ‘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’ [Davidson and Roe 2007: 450]. Glenn Roberts and Paul Wolfson comment:
The term ‘recovery’ appears to have a simple and self-evident meaning, but within the recovery literature it has been variously used to mean an approach, a model, a philosophy, a paradigm, a movement, a vision and, sceptically, a myth. [Roberts and Wolfson 2004: 38]
In the UK, 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, it is suggested, characterise any broadly recovery-based 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 and Slade 2008: 0]
The Scottish Recovery Network summarises its views of recovery in similar terms:
Recovery is about living a satisfying and fulfilling life.
Recovery is about more than the absence of the symptoms of illness. Some people describe themselves as being in recovery whilst still experiencing symptoms.
There can be lots of ups and downs during the recovery process – some people describe it as a journey.
For this reason people often talk about being in recovery rather than recovered.
Some people consider recovery as being ‘back to the way things were’ or back to ‘normal’ but for others recovery is more about discovering a new life or a new way of being. [Scottish Recovery Network 2007: 3]
As both these lists suggest, recovery is not so much a precisely articulated explicit theoretical account of the nature of health or illness as a practical orientation to the kind of care that should be provided and the roles of patients or service users and clinicians or carers.
Nevertheless, advocates of recovery in mental health often talk of a recovery model, with the implication that it stands in opposition to a bio-medical model of health or illness [Davidson and Strauss 1995]. In this chapter, I will attempt to sketch out the ‘logical geography’ of a recovery model, outline an argument for it but then consider whether it is even appropriate to argue for the correctness of the model. Finally I will outline how a recovery model connects to a narrative form of understanding.
Ground rules
To articulate a recovery model, in contrast, for example, to a bio-medical model, is not simply to say that recovery (construed in some broad way) is a desirable aim of mental health care. That amounts to a recovery approach by contrast with holding a recovery model. One might share the broader aims of mental healthcare as characterised by a recovery approach whilst still holding a narrower bio-medical model of what illness and health is. That would not be a recovery model and would not stand opposed to a bio-medical model. To count as a model, it must offer more than just a broad aim but rather a theoretical conception of what illness, or health, or something like health is. (The need for the qualification ‘something like health’ will become clearer shortly.)
There has also been a recent change in attitude to the possibility of recovery from mental illness amongst mental health professions. This is, in part, the result of changes of empirical beliefs about the prognosis for various illnesses and the development of new therapeutic interventions. But at least some such changes might be accommodated within a bio-medical model in the way that improvements in cancer care have improved prospects for recovery and remission, even construed in specific bio-medical terms. At least part of the change in attitude to the possibility of recovery from mental illness is not due to such changes in empirical beliefs, however, but a change in the way that illness, health and recovery are thought about. Articulating a coherent account of that is articulating a recovery model.
An analogy may help clarify the task. The bio-medical model is sometimes criticised for failing to take account of social factors in the aetiology of mental illness. It is thus contrasted with social approaches to mental illness. But, if such approaches merely stress the fact that mental illness can have social causes in addition, for example, to genetic predisposition, that need not stand in conflict to a bio-medical model which takes mental illness to be caused by, or supervene on, brain biology. Such a bio-medical model would need to insist that the eventual mental effects of social causes were mediated by changes of biology – that is the point of the model – but it need not deny that such changes can have distant social causes as well as local or endogenous causes.
To get a genuinely distinct social model of mental illness (by contrast with what might be termed a social approach: any approach which stresses the importance of social factors), one would need to claim not merely that mental illness were caused by social factors but rather that it were constituted by social factors or relations. It would be like the status of being married which is not a matter of internal physiology but rather a social and legal status (whether or not the status may have subsequent local physiological effects in the health of married men, for example). A model in which social factors constitute illness contradicts a model in which they are constituted by individual biology. If such a social model correctly described the nature of mental illness then a bio-medical model would be guilty of the same sort of error as a martian anthropologist who sought to understand the nature of marriage – of what it is to be legally married – by carrying out physiological examination. That would be simply looking in the wrong place.
Examples of constitutive views of mental illness include those based on Foucault’s work, Bateson’s model of schizophrenia (according to which individuals do not suffer schizophrenia but rather families) and, to an extent, Szasz’ view. Szasz’ account is complicated by the fact that he argues that the combination of a socially constitutive view of the identification of supposed mental illness – in terms of psycho-social, ethical and legal norms – with a bio-medical view of their treatment is logically incoherent and thus results in mere myth. So it is not that he believes that there are mental illnesses but which are socially constituted. Still, the underlying problems of living, which are not mythical but which are, according to him, confused with mental illnesses, are socially constituted.
The analogy with a social model of mental illness, based on a constitutive claim, not only helps clarify the requirement that alternatives models of illness and health must be genuinely distinct from, by conflicting with, one another. It also suggests a way in which the opposition can help clarify what the bio-medical model, as well as its alternatives, might be. That is important because, just as it is far from clear what is meant by ‘recovery’ (or a social model of mental illness) so it is not entirely clear by what is meant by a ‘bio-medical model’ to which it stands opposed.
In fact, later, I will argue that there is an important potential disanalogy between a recovery model and a social model. It is not clear that the former is put forward as a true account of the nature of recovery, whereas I take it that it that a social model is at least proposed as a true account of mental illness, whether or not it actually is. But for the moment, the analogy helps clarify conditions on a genuine model.
(One question on which I will not speculate here is what the relation, if any, might be between a recovery model and a social model. The purpose of the analogy is not to suggest a close relation via a joint opposition to some version or other of a bio-medical model.)
My first aim in this chapter is to set out what a recovery model might be. One condition on that endeavour is thus that it must be a genuine contrast with a plausible construal of a bio-medical model. It does this by having a different theoretical account of what illness, health or something akin to health is. But a second condition is that it must capture enough of what those who support recovery approaches to mental healthcare say to characterise their views. A proposal for a recovery model must respect what is already published in support of a recovery approach.
Two distinctions
How can a recovery model be articulated, distinct from other models in mental healthcare? I suggest that two distinctions help frame a ‘logical geography’ in which to locate it. First, a distinction of focus between pathology and whatever is its relevant contrast, perhaps health. Second, a distinction between what is evaluative or normative and what is merely plainly factual.
The philosophy of psychiatry, and more generally the philosophy of medicine, has tended to focus on the illness end of a spectrum between health and illness. The key concern has been with the notion of illness (or disease or disorder) rather than with health. One reason for that has been the origin of the debate at least within the philosophy of psychiatry in the response to Thomas Szasz’ argument that mental illness is a myth [Szasz 1972]. Szasz’ claim that mental illness was an oxymoron prompted responses by biologically minded psychiatrists who attempted to devise models of illness (or disease or disorder) which accommodated not only physical but also mental illness [Kendell 1975, Boorse 1975]. That in turn has led to an ongoing debate focusing squarely on ill health [Fulford 1989, Pickering 2006, Wakefield 1999]. There was no equivalent Szaszian argument for the mythic status of mental health and hence no incentive for a philosophical defence of that notion.
Against a background focus on the nature of illness, recovery can seem to be simply a return from, or a removal of, that status. Whatever illness or disease is, recovery is its negation. By contrast, concentration first on the health end of the spectrum is at the heart of the recovery approach (thus according with the claim from ‘Making recovery a reality’ that ‘Recovery represents a movement away from pathology, illness and symptoms to health, strengths and wellness’) and thus is a prerequisite of a substantive recovery model. A recovery model will thus need to do more than just take the aim of healthcare to be the removal of illness.
The second distinction is between views of mental illness in particular, or illness more generally, as essentially evaluative. Does the analysis of mental illness contain reference to values or not? Some philosophers and psychiatrists argue that at the heart of the idea of illness is something that is either bad or wrong for a sufferer or is a deviation from a social or moral norm. Both of these are evaluative or normative notions and hence both are ‘values in’ views.
Others argue that it is, what I will call, a plainly factual matter. Typically, they argue that illness involves a failure of a biological function and function – and hence deviation from, or failure of, function – is a plainly factual, biological term couched in evolutionary theory.
Having sketched the two distinctions, I suggest that a clue to articulating a recovery model which genuinely contrasts with a medical model is to locate it on the health-focused rather than pathology-focused side of the first distinction and on the values-in or normative side of the second. That remains just a clue: more work has to be done. But it might be objected that the first of these two distinctions is unnecessary: we can articulate a genuine contrast to a bio-medical model simply by using the second distinction.
The idea is that a bio-medical model construes mental illness as value-free, as, for example, reducible to plain facts about biological function. Adopting the opposite view – that illness is an essentially evaluative notion – stands in genuine contrast. And a conception of recovery from illness, so construed, might be enough to count as a recovery model because of that genuine, substantive contrast.
Whilst such a position is a genuine contrast to a plausible candidate for a bio-medical model of illness, it does not seem to capture an important element of the recovery approach: a particular goal or aim of therapy which is not defined merely as the absence of illness. It is instead captured in specific terms such as a hope, autonomy and social inclusion.
One specific problem is that even if one thinks of illness as an essentially evaluative notion, that is not a sufficient reason to think that health is. It might be the mere absence of an evaluatively identified illness state. Health might be conceptualised in merely statistically normal (rather than normative or evaluative) terms as perhaps the state of most people, or, alternatively, the state one was previously in. If so, whilst the states that individuals have an interest in recovering from are those with particular normative or evaluative properties (whatever precisely those are), recovery itself might be characterised in non-normative non-evaluative terms. And that does seem to fit the way the recovery approach is characterised by its supporters.
What of the other distinction? Could a recovery model be defined simply as one which focuses on a positive conception of health, or something like it, rather than merely the absence of pathology, however construed? Again, no. As the authors of ‘Making recovery a reality’ make plain, they have a very particular conception of the aim of recovery tied to a conception of hoped for and autonomous life connected to social inclusion. That specific content is not captured merely by a focus on health which, as I have just argued, might be thought of in bland statistically normal terms.
To capture what is characteristic of a recovery approach in order to frame a recovery model, it seems that both aspects are needed: a focus on a conception of health, or something like it, and in normative or evaluative terms. A recovery model is thus one which construes the positive aim of mental healthcare to be a state essentially characterised in normative or evaluative terms.
Arguing for the correctness of a recovery model
It is one thing to locate a recovery model in a logical geography that distinguishes it from a bio-medical model (and at the same time partly characterises a 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 will take the form of suggesting that, whilst a non-normative or non-evaluative approach to physical health is at least plausible, it is not plausible for mental health. (In the end, I am not confident that such an argument can quickly be successful.)
A non-evaluative approach is at least a possible picture of physical health and hence for recovery from physical illness. 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. A statistical model of health has an obvious advantage over a statistical model of ill-health based on the idea that illness is a statistically unusual state. The latter model 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, there is no analogous problem.
Nevertheless, to have initial plausibility, some qualifications 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 healthy for the latter but an illness for the former. 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 to be defined in normal terms, normality would have to be defined for each such sub-system rather than for the whole person. But given suitable qualification, there is one plausible feature of 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 what seems plausible to call a bio-medical approach to recovery. Even if illness were construed as an evaluative notion, the aim of recovery could be described in value free terms to return human functioning to a normal state. (That it is an aim, is of course, an expression of it being valued. But picking out what the valued state is need not involve normative or evaluative notions.)
Whilst, however, a non-normative statistically normal model of physical health seems at least to be plausible, it seems less plausible for mental health. Mental health cannot realistically be construed as a statistically average kind of life but rather, in line with the quotation from ‘Making recovery a reality’, a particular kind of life valued and hoped for by the individual concerned, the kind of life connected to their identity. If this is the case, it threatens the idea 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 would properly be aimed at a specific and normatively characterised or valued endpoint.
In setting out a condition on a recovery model, I have suggested that it needs 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.
Whilst a recovery model seems more plausible than a crude statistically normal model of mental health, that is not the only available alternative that would have to be rejected to defend a recovery model as the only viable valid one. Here are 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. Or, second, one could define mental health as involving one’s mental traits functioning in accord with their evolved biological functions.
I will not attempt an argument against these alternatives but will suggest some lines of thought that could be adopted against them and thus in favour of a recovery model. The key line of objection to the second approach is to question whether the articulation of the biological functions of mental traits can really 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: via an understanding of what contributes to a value-laden conception of human flourishing.
It is harder to pinpoint an obvious line of weakness in the other plainly factual account of mental health (possession of normal mental capacities). But one subtle worry runs as follows. 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]. But 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.
Is that the right kind of argument for a recovery model?
Although I have sketched the shape of a possible debate over the correctness of a recovery model, supporters of the recovery approach have not in general proceeded in this way. They have not offered arguments for the correctness of a recovery model as the only appropriate or valid conception of mental health or aim of mental healthcare. Rather, they have put it forward as a desirable approach to mental healthcare. How should that be understood and does it undermine the idea of a recovery model?
The argument sketched above turns on the role of values in an articulation of the content of the aim of mental healthcare. (To repeat, all can agree that the fact that it is an aim means that it is valued. But there can be disagreement on whether the identification of the state to be aimed at itself presupposes any evaluative or normative language.) Thereafter, however, the argument turns on whether the recovery model is more descriptively accurate than a rival non-evaluative or plainly factual model. The best argument for a recovery model is that the alternatives cannot plausibly describe the aims of mental healthcare because, it seems, those aims turn on a conception of a life worth living which will be individually tailored.
Such a view accepts a particular construal of the debate: models are to be assessed as to whether they are valid – in the sense of getting something right – or true. Given an antecedent set of views of health and illness and the proper aims of healthcare, some models capture those views more accurately. But that is not the only way of thinking about the debate.
To explain this, it is helpful to contrast the debate about recovery with philosophical debate about moral values and judgements. In that debate, although there is disagreement about particular ethical judgements in difficult cases, there is sufficient agreement about the broad outline of the practices of making moral judgements to make descriptive accuracy a rational aim of meta-ethical or moral philosophical debate. Although the adoption of a philosophical theory of moral judgements might force the revision of some judgements, the practices serve as a standard for testing the philosophical theories. It is thus a rational claim by rival supporters of Kantian deontology, utilitarianism or neo-Aristotelian moral particularism to say that their particular account, by contrast with the others, is the correct description of our moral practices and, unless we are widely in error in those moral practices, of the moral realm itself. Thus, although the debate concerns the nature of moral values, an approach may rationally aspire to being factually or descriptively correct or truthful account of them.
It may be, however, that there is a key disanalogy between debate about moral judgement and debate about the proper aims of mental healthcare. I have characterised the latter as concerning health (or something like it). But it does not seem that the recovery model simply aims at health. It aims, rather, at a richer conception of flourishing: the living of an autonomously chosen life. That, in turn, suggests that it may not be put forward so much as the most descriptively or factually accurate conception of the (possibly evaluative) aims of mental healthcare as itself the most desirable. If so, it is doubly evaluative. Not only does it claim that the aims of mental healthcare are not simply factual but rather evaluative or normative (right for the particular individual) but it also presupposes that the debate about the nature of those aims is itself a matter of values not just of facts. The recovery model is not so much supposed to be true as desirable. That it should be adopted is a ‘should’ of value rather than of truth or fact.
If so that marks a disanalogy also with the example of the social constitution of mental illness raised at the start. In that debate, the claim that mental illness is a matter not of individual bio-medical facts but rather societal relations is not put forward as a value in itself. The arguments for a socially constitutive view aim to capture or describe the real nature of mental illness (or what is mistakenly confused with mental illness in Szasz’ case) rather than as a desirable way to think about things. When supporters say that mental illness should be understood as constituted by social relations the ‘should’ is the ‘should’ of truth not desirability.
But given that I presented that case as an example of a healthcare model, does the disanalogy threaten the idea that a recovery model could be proposed in this way – as desirable rather than true – but still count as a model?
I do not think so. Even when proposed in that way, it is a theoretically articulated conception of the business of healthcare. It stands to past healthcare practices as idealised political structures (such as a socialist utopias or a fully deregulated market economies, depending on one’s politics) stand to present social and political actualities. Whilst an idealised political model is not simply a description of any present society, it is a complex of fact and value which includes claims about how societies could function and what would be the consequences of that.
Arguments for political utopias have to make the case that we should adopt such systems because they are valuable. Socialism is not true, but desirable, according to its supporters. But arguments for its desirability will involve some claims which purport to truth. One might argue, for example, that socialism promotes equality and that more equal societies tend to be happier societies. If happier societies are to be valued, then that might form the basis for adopting a socialist structuring of society. Opponents might argue that socialist societies tend to generate less wealth including for those at the bottom end of the income level. Given that wealth is to be valued, then that that might form the basis of an argument against that social structure. Both arguments mix facts and values.
Equally, if the recovery model is proposed with the ‘should’ of desirability, arguments for it will mix facts and values. They might concern facts about symptoms, suffering and stigma. But at the same time they appeal to a ranking of one over another which is a matter of value not fact. There is thus no conflict between articulating a recovery model, by contrast with a mere approach, and putting it forward not because it is a true account of the aims of healthcare as they presently stand but rather as an account of desirable possible or potential aims, albeit ones which are recognisable as relevant to current practices. They still concern healthcare broadly construed, for example.
Having now sketched the broad outline of a possible recovery model and distinguished two kinds of argument for it (based either on its descriptive truth or its value) I will now turn to a distinct question. Would such a model require, or at least motivate, the adoption of a different approach to understanding? Would it rationalise the adoption of a narrative approach to understanding, by contrast with the criteriological diagnosis more familiar within a broadly bio-medical model?
The link to narrative
There have been a number of claims that there is a close direct connection between narrative understanding and recovery. One indication of this is the proliferation of ‘recovery stories’ as part of the promotion of the recovery approach. These explore:
the personal and existential dimensions of recovery, taking the form of subjective and self-evaluated accounts of how an individual has learned to accommodate to an illness. These accounts have become the founding stories of the recovery movement [e.g. Chamberlin, 1978; Lovejoy, 1984; Deegan, 1988, 1996; Leete, 1989; Unzicker, 1989; Clay, 1994; Coleman, 1999; Ridgeway, 2000], and anthologies of these personal stories have been used by governments and professions as a means of combating stigma and reasserting a focus on personal perspectives [Leibrich, 1999; Lapsley et al, 2002; Ramsay et al, 2002]. [Roberts and Wolfson 2004: 38-9]
More generally it is claimed that people who have suffered mental illness can be helped towards recovery through a narrative based theory. Pat Bracken and Phil Thomas, for example, cite both Larry Davidson and Glen Roberts.
In their work on recovery, both Davidson and Roberts choose not to use an approach grounded in traditional descriptive psychopathology, but turn instead to narrative theory and methods, seeing this as providing a rigorous empirical and clinical methodology in helping people suffering from chronic psychosis to move to recovery. [Bracken and Thomas 2009: 245]
On this view, narrative theory informs clinical work which is distinct from traditional Jasperian descriptive psychopathology and which, they suggest, is both intellectually rigorous and therapeutic.
Roberts himself makes the connection between recovery and narrative even closer (or at least even more explicit). By contrast with Bracken and Thomas, he sees a narrative view as consistent with Jaspers’ view of understanding (by contrast with explanation).
A narrative view values content, and in seeking to understand delusions and hallucinations, as opposed to explaining them [Jaspers 1974], one is engaged in re-contextualising the illness in the life experience of the individual. This in turn may inform the rehabilitation process and give insight into the complexities of recovery, which for some will include the loss of the compensations of delusional beliefs and re-engagement with the implications of having a severe mental illness and what preceded it [Roberts 1999]. [Roberts 2000: 436]
But he goes on to suggest (or at least, to repeat, to make explicit the idea) that subjects or patients themselves possess a narrative understanding (rather than just clinicians) and it is this which can help or hinder them in recovery.
Patients with self-sufficient, unelaborated, dismissive narratives need to be encouraged to break open their defensive stories and consider other possibilities. Conversely, those who seem unable to find a narrative thread and to be drowning in the chaos of their experience need help to find a shape and pattern that enables them to fit things into place [Holmes, 1999]. In therapy, patients learn to build up their storytelling capacity, their “autobiographical competence” [Holmes, 1993]. [Roberts 2000: 436]
Across the literature there is evidence of an idea that narratives structure subjects’ lives in such a way that partially determines what seems possible to them. Therapists can propose new life ‘plots’ and help map out new possibilities in the face of mental illness and hence new possibilities for recovery. To take a non-mental health example, therapists can propose new plotlines to spinal cord injured patients for whom there is, sadly, no going back to their past able-bodied plots. They have suffered a kind of ‘narrative wreckage’ from which they need rescuing in a dialogue with therapists.
Whilst that direct connection between narrative understanding and recovery is potentially an important clinical one, it is not a necessary connection. Exploring the options for a flourishing life through the idea of stories may in itself be directly therapeutic for many people, but it is possible that such an approach might fail because, for example, it tended to remind people of what they could not do. Since my aim is merely to explore the logical geography for a recovery model, I will sketch a more modest alternative connection between recovery and narrative understanding which is not hostage to empirical fortune. (Sad to say, this makes the connection rather less interesting.)
What is the conceptual or logical connection between a recovery model and narrative understanding? On the proposal I have sketched, a recovery model is health- or wellbeing-orientated rather than illness-orientated and it is evaluative (that is it involves values as well as facts) rather than plainly factual. In sum, it is an evaluatively-rich, person-specific conception of the aims of mental healthcare.
Narrative theorists typically articulate components or aspects of narratives in different, rival ways, albeit with some significant overlap. For example they may divide narratives into: abstract, orientation, complicating action, evaluation, resolution and coda. Or, alternatively: temporality, people, action, certainty (or not) and context. By decomposing a whole story into such elements narrative theorists can arrive at a generalisable sub-structure which still stop, they hope, short of a positivist or reductionist analysis.
On the face of it, there is no obvious necessary connection between these two things. But that, I think, is because this is an overly restrictive conception of narrative understanding. Whilst narratives may often have the elements narrative theorists favour, and whilst this may contingently be true of the kind of ‘recovery stories’ often published in support of the recovery approach, there is no need to link the whole of narrative understanding to any particular theory of the component parts of narratives. But if not that, what does characterise narrative understanding?
I propose a modest account. It is the kind of understanding that connects together beliefs, desires, intentions and so forth in rational patterns. It deploys a framework of propositional attitudes whether this is thought of as codified in an implicit ‘theory of mind’ or more directly applied in response to behavioural expressions or through empathy. It is thus broader and narrower than a particular literary style: narrower, in that it is restricted to the understanding of rational agents rather than any sequences of worldly events. Not all stories are stories of human agency. But it is also broader, in that it is presupposed by any particular story of rational agents.
Indeed, Wilfrid Sellars argues that it runs deeper than that. The central role of this approach to understanding other people stems from the fact that that it employs the very same form of reasoning necessary for being a rational agent oneself.
The ‘manifest’ image of man-in-the-world …is… the framework in terms of which man came to be aware of himself as man-in-the-world… [A]nything which can properly be called conceptual thinking can occur only within a framework of conceptual thinking in terms of which it can be criticized, supported, refuted, in short, evaluated. To be able to think is to be able to measure one’s thoughts by standards of correctness, of relevance, of evidence. [Sellars 1963: 6]
Sellars’ idea seems to be this. Just as to be capable of thought – of rational or conceptual thought – requires an ability to assess one’s reasons for belief and action, so that same ability is what forms the basis of ascription of mental states to others. This is not the same as saying that selves are constituted by narratives. It is a weaker claim that rational agents, who may or may not be the same as selves, are describable by narratives in the sense described here. This is enough, however, to mark an important distinction from the criteriological or nomological explanation that characterises diagnosis of mental illness and thus suggest a distinct role for understanding in underpinning a recovery model.
Narrative judgement contrasts with nomological or lawlike understanding or explanation because it is normative. Narrative judgements thus answer to a different kind of internal logic to non-normative nomological accounts. In the vocabulary John McDowell has developed from Sellars, they belong to the ‘space of reasons’ rather than the ‘realm of law’ [McDowell 1994].
That makes it particularly appropriate for the recovery model, as I have outlined it. If the proper aim of mental healthcare is an endpoint selected as what is hoped for valued by a subject as right for him and her as a mode of being then it is an endpoint that has to be weighed and evaluated for reasons. The characterisation of the endpoint is not independent of why it is wished for. And thus it is tied to a subject’s reasons, explored through narrative understanding.
I have attempted to address the question of what sort of model a recovery model would be. In doing that, I have assumed that to count as a model it must not merely aim at recovery, since any model might do that, but it must involve a conception of what health or a related but broader notion is. Using a pair of distinctions - between health and illness and between an evaluative and plainly factual account – I suggested that the recovery model is an evaluative conception of the mental health, broadly construed, of a subject, a state right for him or her and supported by reasons.
Having sketched the logical space for a recovery model, I considered whether it could be justified. One approach would be to show that no alternatives are coherent accounts of the nature of mental health. But, although, there are promising lines of argument towards that conclusion it is not a simple matter. Furthermore, that is not the way the recovery model is usually supported. Like a political ideal, it is usually proposed not so much as a true account but a desirable one. But that need not undermine its status as a model.
Finally, the outline of a recovery model set out is consistent with the often made connection to a narrative approach. On the reasonable assumption that what marks out a narrative approach – by contrast, for example, with criteriological explanation in psychiatry – is that it is normative, that fits the idea that the aims of healthcare are selected for reasons.
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