How Do We Define Recovery? An Exploration of Co-Option, Normalization, and Universalism Within Recovery Literature

Former service-user and researcher Diana Rose intertwines personal reflection and critical discourse analysis to shed light on dominant discourses within recovery literature.

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A recent perspective paper published in Community Psychology in Global Perspective written by former service-user and researcher Diana Rose explores the complexities of the “recovery” discourses within the psy-disciplines. Weaving her own reflections into a critical discourse analysis, Rose highlights how user-generated narratives of recovery differ from those of academic researchers and practitioners, who frequently co-opt the concept of “recovery” to fit within mainstream treatment models.

The concept of recovery gained traction in mainstream psychology as a counterpoint to the biomedical model of mental illness. Rose explains:

“The idea of recovery arose in mainstream work in response to the biomedical notions of ‘cure,’ or its impossibility, claiming to bring hope for a meaningful life to the ‘chronically mentally ill.’ It is familiar to most in the mental health field as a counter-position to the focus on symptom control in biomedical psychiatry. It holds that people can lead fulfilling lives even in the presence of ‘symptoms.’”

A small flower growing through a crack in the pavementRose points to the ways that the recovery narrative has been re-framed by psychologists to align with Western values and ideals: “…in terms of an individual secure in work, a family, with social networks but retaining autonomy, and resources to sustain this.”

This definition hinges one’s recovery on their capacity to live independently and achieve outcomes and goals that are sanctioned by psychologists (e.g., to establish “social networks” with individuals who do not experience mental illness, to hold a job). Rose highlights how mental health policies such as the closure of day treatment centers and user-led organizations in the UK exemplify the prioritization of autonomy and discouragement of co-dependency.

To analyze the ways in which the recovery approach has been co-opted by mainstream psychology researchers and practitioners, Rose lays out three central questions: “Is the approach a normalizing one? Is it claimed to be universal? Are there different perspectives on the parts of researchers, practitioners, and survivors?”

To explore these questions, Rose synthesizes multiple qualitative articles focused on the “recovery approach” with participants who have been engaged in long-term psychiatric services. Rose samples pieces predominantly written by psychiatric survivors and uses Critical Discourse Analysis to identify dominant discourses and themes across publications.

Does recovery entail normalization?

Following her analysis of writings from prominent scholars in the field of recovery from psychiatric disability (e.g., Larry Davidson, Mike Slade, Pat Deegan), Rose argues that recovery does “seek to normalize the distressed individual.” She points to a consistent theme that emerges across recovery literature from the perspective both of service users and service providers: “you are to want what normal people want.”

Is recovery universal?

Rose’s analysis reveals that many proponents of the mainstream “recovery” approach do consider recovery to be a universal model of gaining autonomy. As evidence of this, Rose points to the powerful international funding agencies (e.g., the World Health Organization, the United Nations) that promote the “scaling up” of Western approaches to recovery from psychiatric disability across the world.

However, Rose’s textual analysis also highlights the critiques of this universalist perspective from authors residing outside of the Global North, for example, in India:

Bayettti (2016) and colleagues argue that to implement the approach in India would be counterproductive because family and community are intrinsic to ways of living and factors such as poverty further compromise policy. In particular, the idea of individual autonomy makes little sense in many cultures, where actions and thoughts are understood to be shaped by structural, familial and social relations: they are not the activity of an individual Cartesian cogito.”

Additional counter-narratives to the dominant model of recovery as achieving personal autonomy come from Brazilian and Maori authors, who also promote re-establishing social and community connections over ego-centric models.

How do survivors think about recovery?

To examine survivors’ perspectives, Rose reviews a systematic review of 21 papers on survivors’ views of recovery in Australia.  In doing so, Rose reflected on her own work as a user-researcher in Australia, where she witnessed how most “knowledge-makers” with lived experience were expected to adhere to traditional standards of recovery:

“Unrecovered persons cannot get published; it seems. Or otherwise be active. It is a form of power to expect people to sanitize their experience in the name of being ‘recovered’ and therefore acceptable.”

Two main themes emerged across studies included in the review article: recovery is “rebuilding self and life” and “personal agency and hope.” Re-building self and life is largely characterized by participants across the studies as the establishment of life for themselves in their community. Rose reflects on the ways in which survivors’ understanding of “personal agency and hope” relates to the mainstream recovery discourse:

“The second—agency and hope—resonates with the language of the recovery literature but ‘personal agency’ is defined as claiming ownership of your experience. These do not seem to me the same thing and claiming ownership of your experience also fits with those who saw the psychotic episode positively and as an opportunity to integrate the experience into a new self.”

In centering ownership over one’s own experience, survivors are advocating for a model of “recovery” that cannot be universally defined or solely tied to “good outcomes” such as employment and independent living. Furthermore, some survivor-led literature proposes that notions of “distress” and “recovery” should not be understood as treatment or intervention targets at all, but rather, should exist outside of psychiatric services.

Importantly, Rose describes how user and survivor perspectives on the recovery movement are not uniform, particularly across cultural and racial differences. For example, she describes how the writings of many Black survivors focus on collective healing and experiential learning, while white survivors are more inclined towards the mainstream ideal of recovery as individual autonomy.

How do staff practice recovery?

To examine how mental health professionals understand and practice recovery models of mental illness, Rose first summarizes the results of the REFOCUS randomized controlled trial, in which no benefit of recovery-oriented practice was seen over the control condition. Authors of this trial hypothesize that the lack of an intervention effect may be attributable to staff’s failure to adhere to the REFOCUS manual, which Rose sees as a potential sign that staff may be reticent to implement the recovery model in their practice.

Rose then turns to a systematic review of 22 qualitative studies focused on staff understandings of recovery-oriented mental health practice. Three conceptualizations of recovery are defined in the review paper: clinical recovery, personal recovery, and service-defined recovery. “Clinical recovery” is focused on traditional biomedical understandings of symptom reduction and functioning. “Personal recovery” was rooted in the ideas of client autonomy and personalization and is therefore consistent with broader discourses on normalization and individualization. The final concept—“service-defined recovery”—is driven by the policy, financial, and administrative priorities (e.g., cost-effectiveness) of mental health organizations. Rose argues that this service-defined recovery “model” may be better understood as a barrier to recovery-oriented practice.

Another qualitative interview study of mental health workers in the US recovery principles yielded a theme: recovery-oriented practice is more likely to be implemented with patients perceived as “high functioning” by staff, who they think will be more “compliant” to the principles of recovery.

Conclusion

In conclusion, Rose’s critical synthesis and analysis of recovery literature demonstrates that there is no one singular consensus definition of recovery as a model or practice. However, Rose asserts that, in general, service users and survivors tend to focus their definitions of recovery on the social and collective aspects of their lives. Meanwhile, academic researchers and mental health practitioners largely uphold a definition of recovery as an individualized “personal journey” towards normative independence.

Rose concludes her perspective piece with a message of hope, highlighting emerging alternative ways of thinking about recovery that move away from “individualistic, a-contextual and ahistorical thinking” and towards a focus on community healing:

“Is the wish to transform the recovery approach just a dream? The research covered here has shown that people do not give up…there is an emergence of new forms of connectedness, within and between marginalized groups; new practices of community involvement even in Western countries; and new knowledges that can be vibrant and perhaps violate some of the principles, epistemologically and in terms of values and practice, that characterize(d) this episteme in the Global North… counter-narratives can flourish, new concepts and methods can emerge for understanding the experience of those deemed mad, from the standpoint of those who live under that description, and the foundations can be, and are being, laid for change.”

 

 

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Rose, D. (2022). The fate of the idea of Recovery today: A user-centred analysis. Community Psychology in Global Perspective8(2), 103-119. (Abstract)

14 COMMENTS

  1. Consider how utterly vacuous and meaningless ‘recovery’ is conceptualised within the worlds largest and most expensive revolving door known as IAPT- Increasing Access to Psychological Therapies service. Here the personal, nuanced and changeable concept of recovery is largely based on two drug company funded tick box questionnaires the PHQ9 and GAD7.

    These questionnaires have also led to massive gaming of the data, by manipulating clients to reduce their scores or by therapists themselves filling them in. So the well advertised and claimed 50% recovery rate is a multifaceted fantasy.

    Most people that work in IAPT are aware of this, yet carry on as if it’s something to celebrate. This is understandable considering management have made it so it is beyond criticism and woe betide any therapist that doesn’t reach the 50% fantasy, for this person will risk being managed out of a job and or bullied.

    This is partly why staff are overwhelmed and burning out left and right.

    Imagine that mental health services destroying the mental health of its workers and doing nothing but produce empty data.

    Another cultural disorder made possible by the hard work and ignorance of thousands.

    • Same! I also visualize their term “approach” like a pack of lions approaches gazelle:

      I.e “well MY approach is (somehow better) because (iteration of blame/ demands for fealty)”

      this is when they circle.

      “we have determined your complaints against us to mean that YOU need ( punishment for profit) more intensive care!”

      this is when they feed

      I personally dislike the MH’s seizing of and enforcing of language they have almost no stake in: The person hurting me demands that I remind them of how they are morally evolved… this is modern therapy. It’s more than moral exhibitionism, it’s more than co-opting, it’s spiritual torture.

      I’d just like to be left alone/ no longer approached.

  2. ““Is the wish to transform the recovery approach just a dream? The research covered here has shown that people do not give up…there is an emergence of new forms of connectedness, within and between marginalized groups; new practices of community involvement even in Western countries; ”
    == Thank you for the nice article! I wonder what the “new practices of community involvement even in Western countries ” are.

  3. YES to this:

    “In centering ownership over one’s own experience, survivors are advocating for a model of “recovery” that cannot be universally defined or solely tied to “good outcomes” such as employment and independent living. Furthermore, some survivor-led literature proposes that notions of “distress” and “recovery” should not be understood as treatment or intervention targets at all…”

    This is one of my favorite points. To the part about lack of uniformity: I like how you’ve explained the diversity of ideas held within survivors groups. I want to add that those divisions are points of pride for many of us. There are no boxes in which to jam us in, we cannot be divided and conquered because we exist without uniformity.

    The mental health system regularly criticizes psych survivors’ movements for a lack of cohesion, but the lack of uniformity in our objectives is a strong cohesive.

  4. Like all words, there is nothing wrong with the word, “recovery.” However, like all words, it can be over-used, until it becomes meaningless. When I see the word, “recovery” I also think of the word, “success.” “Success” like “recovery” can be over-used and can also be manipulated against another in both clinical and non-clinical situations. In my stupid but silly opinion, “recovery” like “success” can only be defined by the individual involved. It is NOT a corporate, collective type of word. My “success” and my “recovery” may be different from someone else’s and vice versa. As I have said before, there is “no one size fits all.” Our society rests with the individual and the family uniquely composed of individuals. If there is failure in psychiatry and much of what I read and experienced seems to reflect that, it is because we do not consider the validity of the individual. However, psychiatry only reflects the rest of society and this problem is rampant in education, government, healthcare, etc. Until we begin to treat the individual with dignity, we will “succeed” at little and suffer much. Thank you.

    • Rebel,

      Awesome comment!

      ‘”Success” like “recovery” can be over-used and can also be manipulated against another in both clinical and non-clinical situations.”

      This and your points on dignity were crystal. The clinicians should be trained in dignity and how to genuinely understand people outside of their well-insulated bubble of degreed privilege. They don’t see how limiting are their interventions when they have never been personally limited. By “limited”, I refer to the socioeconomic maligning endemic to SMI diagnoses: loss of career and career opportunities, extremely stigmatized disabilities caused by doctors which causes further targeting by doctors, ad nauseum..

  5. Recovery can be anchored in symbols of wellness such as a nice home, steady job, trophy husband, trophy wife. In rural parts of Africa it may be measured by other things like having abundant livestock, and being physically able. The symbols of one groups understanding of “getting better” may differ dramatically from another groups idea of normal. Indeed, if one groups recovery is being thwarted by another groups oppressing style of recovery there can be a wish to invert or mock or smash up the symbols of the recovery of that group or culture.

    A culture can have bounty or spoils that are symbols taken from another culture. Or it can have trashed those symbols and be triumphantly parading them and ridiculing those symbols, or a culture can build its own symbols from scratch, lovely symbols untainted by war.

    A symbol of culture may be just originally “a reaction against” another culture? And if it is a reaction, like a finger gesture or mooning, can it be called a symbol?

    A Christain has the cross as a symbol. People who disagree with Christainity take the symbol and desecrate it.

    There is a lot of toppling of symbols these days. As cultures crack apart and want nothing to do with bowing to old symbols.

    Is desecration now a factory production line of insults traded against any culture? Is desecration of a prior symbol now superceding as the new symbol?
    When desecration, which can be a liberating factor, becomes deemed a helpful new suite of symbols, people can start to worship desecration for its own sake. This then brings cultures to war with each other. Until a baby gets broken for being a symbol requiring desecration.

  6. In addition to my earlier comment I have more to say.

    “In Praise of Irrelevance” is a book title I should like to see on a shelf since we are living in an era where everyone is frightened to be bored and so are searching for relevance, relevance, relevance in everything, even, so it seems, in cabaret spandex panty elastic. When everyone is seeking relevance it is easy for “desecration for its own sake” to become excitingly relevant. Desecration stops the tedium of stultifying predictability. But there are more healthy ways to thwart predictability than going around in a spree of mindless desecration.

  7. The hubris of expecting recovery from people who have been systematically ostracized, traumatized, isolated, rejected, traumatized, drugged, silenced. In my experience, the pressure to and talk of recovery is all part of the same monster that left me sick, broken and alone.
    Maybe for me recovery is accepting that there is no help. And stopping with all of the “cry for help bs” as my son called it.

    • Oh yeah!

      Well said. They’re tying stones to people and demanding that they swim.

      If they want us to be like them with their “services”, we should get practical services akin to the support they received to obtain their cushiony judgement jobs in mental health. We should get scholarships, paid positions for *us* to speak on *our* lived experiences, the right to fix retaliatory medical records, the right to clear our medical records.

      Do they think someone can get rich and successful only by being terrorized and chemically assaulted by totalitarian thought police? …

      As of now, the real recovery is recovery from them.

  8. Imagine a culture where “unconscious” and “childhood experience determining your adult experience baseline” mantras do not exist and one does not have the burden of carrying everything you do is because you had/have a traumatic childhood.

    I grew up in such culture somewhere out there. Adult is the beginning and end. It is harsh if you have trauma. The understanding of adulthood is expanded to include a lot of behaviours that we consider here abhorrence like getting angry, or refusing to work etc.

    Community dependence was higher. Relationships are not commodity at all but are from mainly by blood or by marriage.

    Now, I recovered from childhood trauma here in the west by starting to believe the two mantras above.

    The only thing I can add to the discussion here is that believing these two mantras as an adult had some advantage and I can still see clearly how it may paralyze any recovery talk. What I did know gave me whole new ways of coping with my trauma that are not suitable for our collective culture here.

    The crux of my recovery is shown two areas: my physical senses are heightened than they were before – my vision, my hearing, my touch sense, my smell and my muscle movement are all softer and better functioning (though I did not know they were dulled before). Second, my consciousness is much higher than it was before to the point of becoming conscious about the gap between my sensations and feelings and my perception and cognition (which was malfunctioning unconsciously)…knowing that gap has changed my impulse control which again I was not even knowledgeable before. It also unleashed some energy that makes me learn things faster than before. Before I was not a good learner or it would take me ridiculous amount of time to learn little things.

  9. For me, recovery would mean being exposed to hate speech about “borderlines” and to feel nothing. To understand that the people engaging in the hate speech are lower life forms and know that they can’t hurt me. I’m not there yet. I may never be.

  10. As I’ve always told my wife from the start: we deal with the trauma and dissociation: the rest will take care of itself. We don’t have an ‘end-goal’ of how she will be once we are done with the healing journey (should we reach the end). To me, any focus beyond the trauma and dissociation is manipulative.
    Sam

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