Recovery: Mental Health Without Models?

This article was written a few years ago and is reproduced with kind permission of Dr. Pat Bracken, who is delivering a talk entitled “A Psychiatrist’s Reflections on Art, Surrealism, Mental Health & Recovery” in the West Cork Hotel, Skibbereen @ 7:30pm on Wed 4th June (Tickets €10).

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In mental health circles, the word ‘recovery’ has increasingly come to signal an alternative agenda in mental health. The word was first employed in this way by service users but in recent years has been taken up by many professionals who are seeking change in how we think about mental health. In Ireland, the concept features prominently in the Vision for Change document, and the Mental Health Commission gave very clear support to the idea in their discussion document A Vision for a Recovery Model in Irish Mental Health Services.

Sometimes it is argued that what is needed is a shift from a ‘medical model’ to a ‘recovery model’. In this article, I want to show why I think that this is wrong. First, I will argue that problems with the current way of thinking about mental health go deeper than simply the use of the medical model. Second, I will suggest that the recovery movement represents a truly radical development, in that it involves getting us to move, not just beyond the medical model, but away from models altogether. When we start to think about recovery as just another model, we rob it of its real challenge to the status quo.

We are familiar with critiques of the medical model. These argue that the medical framing of experiences of madness and distress is wrong and destructive and that this leads to the unnecessary and harmful use of drugs and ECT in a misguided attempt to treat ‘symptoms’. While this is obviously a major problem, I believe that the medical model is only one manifestation of a more fundamental problem: the tendency to see human problems as technical difficulties of one sort or another. I call this the ‘technological paradigm’ (I am using word paradigm to indicate the background assumptions that we bring to bear when we are dealing with a particular issue). In the 20th century, technological thinking came to dominate our understanding of ourselves and the nature of health and healing. This paradigm frames the way in which problems ‘show up’ for us. Essentially it promotes a ‘model based’ way of looking at human difficulties. Through this, it underscores not the just the medical model but also most psychological and managerial approaches to mental health. Alongside biological models of ‘symptom’ production we have cognitive-behavioural models, psychoanalytic models, even social models of different sorts.

The technological paradigm puts things like the development of models, classification systems, comparisons of different interventions etc at the centre of the mental health discourse. This is obvious when we look through the pages of most psychiatric and psychological journals. In this technological paradigm, issues to do with values, meanings, relationships and power are not ignored but they are always secondary to the ‘more important’ technical aspects of mental health. In this paradigm, these technical aspects are primary. Furthermore, this paradigm underscores the centrality of ‘experts’ (professionals, academics and researchers), codes of practice, training courses and university departments. Service users might be consulted and invited to comment on the models or interventions or the research but they are always recipients of expertise generated elsewhere.

For me, the recovery agenda and the emergence of a mental health discourse that is user/survivor led presents a radical challenge, not just to the medical model but to the underlying technological paradigm. This user/survivor discourse is not about a new paradigm or a new model but reorients our thinking about mental health completely. It puts issues to do with power and relationships, contexts and meanings, values and priorities at the forefront. In the literature of recovery, these become primary. This literature does not appear to reject or deny the role of therapy, services or research, but it does work to render them all secondary. For example, when it comes to drugs and their use, the user/survivor literature seeks to prioritise access to information about side-effects and claims to efficacy and works to ensure that drugs are only administered with consent. It has also exposed the huge profits made by Big Pharma in the area of psychotropics and has challenged the ways in which corporate interests have shaped the agenda of university departments of psychiatry. Furthermore it has examined how this alliance between academic psychiatry and Big Pharma has worked to shape the very models and classification systems that are used in psychiatry.

In my opinion, we should judge how much the recovery agenda is being accepted by looking at how much prominence is afforded this user/survivor discourse in the training of professionals and academics. The most radical implication of the recovery agenda, with its reversal of what is of primary and secondary significance, is the fact that when it comes to issues to do with values, meanings and relationships, it is users/survivors themselves who are the most knowledgable and informed. When it comes to the recovery agenda they are the real ‘experts’.