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.’”
Rose 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.
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.”
Rose, D. (2022). The fate of the idea of Recovery today: A user-centred analysis. Community Psychology in Global Perspective, 8(2), 103-119. (Abstract)