Elsevier

Social Science & Medicine

Volume 65, Issue 5, September 2007, Pages 868-879
Social Science & Medicine

Rethinking social recovery in schizophrenia: What a capabilities approach might offer

https://doi.org/10.1016/j.socscimed.2007.04.012Get rights and content

Abstract

Resurgent hopes for recovery from schizophrenia in the late 1980s had less to do with fresh empirical evidence than with focused political agitation. Recovery's promise was transformative: reworking traditional power relationships, conferring distinctive expertise on service users, rewriting the mandate of public mental health systems. Its institutional imprint has been considerably weaker. This article takes sympathetic measure of that outcome and provides an alternative framework for what recovery might mean, one drawn from disability studies and Sen's capabilities approach. By re-enfranchising agency, redressing material and symbolic disadvantage, raising the bar on fundamental entitlements and claiming institutional support for complex competencies, a capabilities approach could convert flaccid doctrine into useful guidelines and tools for public mental health.

Introduction

Ambiguity about core values, operational principles, and organizational goals has its strategic uses, among them the formation of unlikely coalitions in pursuit of structural change. Such amalgams have figured critically in the annals of mental health reform, though the roles of specific groups or external constraints remain disputed and the verdict of history mixed (compare Scull, 1976, with Grob, 1991). Institutional reform inevitably involves a reckoning, a sorting out of competing versions of allegedly shared assumptions, and their selective translation into practice and policy. “Working misunderstandings” can carry a merry band of reformers only so far before political realities step in to call the question and tally the bill.

This article takes stock of the institutional imprint of “recovery” from severe psychiatric disability in US public mental health, and does so from an applied anthropological stance. This may surprise some. Anthropologists are best known for bringing a spoiler's sensibility to their reading of psychiatric procedure, dusting for cultural fingerprints on the suspect premises of clinical practice—like discerning traces of “governmentality” where others see therapy or empowerment (Joseph, 2002; Rose, 1999). A second, lesser-known tradition claims the same ancestry but applies a rather different sensibility. Its proponents (initially Estroff, 1981) tend to portray contemporary community psychiatry as unusually hard repair work in socially suspect precincts (Hopper, 2006; Luhrmann, 2000; Rhodes (1991), Rhodes (2004); Robins, 2001; Ware, Lachicotte, Kirschner, Cortes, & Good, 2000), work that has pointedly moral overtones. This inquiry hails from that latter school. It accepts the reality of schizophrenia as ethnographic fact—local, consequential, contested—and asks how its social fortunes may have shifted in response to what looked like an ideological uprising.

Section snippets

The empirical record

The enigma of recovery in schizophrenia is partly a confusion of tongues. From the earliest days of clinical tracking, the orthodox view of progressive deterioration was harried by reports (sometimes bewildered) of apparent recovery. Its chief proponent, Emil Kraepelin, was widely cited as documenting a “real improvement” rate of 26%, half of whom showed complete recovery (Hinsie, 1931). Early in 20th century, Eugen Blueler cautioned that most “end-states” escaped clinical inspection; still, he

Paradigm lost? Recovery's institutional career to date

It is not too much to say that in the late 1980s and early 1990s, a nascent social insurrection seemed in the works. Its manifesto—that something resembling a full life after severe mental illness was possible and that public mental health systems should be held accountable to that high standard—fired the imagination of discontented and excluded users (and once-were-users) of public mental health systems. Retribution and reformation seemed credibly in the offing. Those were giddy times, as the

Taking agency seriously: the capabilities approach

An unavoidably moral enterprise, distrustful of experts, concerned with human flourishing, invested in choice but suspicious of plainly self-limiting ones, deeply social in outlook, political by default: these same concerns have driven a parallel movement in global development studies—the capabilities approach. This approach not only ratifies the idea that impairment's standing and impact are socially brokered, but also heeds advocates’ calls for respect.

Capabilities emerged as an alternative

Towards a capabilities-informed agenda

Capabilities rework recovery not from within (where it remains hostage to a rhetoric of suffering), but from without (informed by an idiom of opportunity). Not healing but equality becomes the operant trope. This has both participatory and substantive meaning. How essential goods and services are distributed can be as consequential as their approximation of equity (Anderson, 1999; Hopper, 2006). This arms us to address both immediate grievances—experiences of humiliation and shame that are

Conclusion

Seriously espoused, CA could reclaim recovery's checkered clinical history, reopen old puzzles, and milk their implications for contemporary practice. This means taking on the orphaned “work of specification” and transforming what is now a co-opted, near-toothless gospel of hope into workable guidelines and tools. Affirming human flourishing as the orienting aim of public mental health is foremost. Our metric of progress should be those locally valued commitments people are actually able to

Acknowledgments

For critical comments on earlier drafts, I would like to thank Mary Jane Alexander, Barbara Dickey, Dan Fisher, Kris Jones, Sophie Mitra, Beth Shinn, Carole Siegel, Susanna Sussman, Toni Tugenberg, and Norma Ware. This work was supported by NIMH grants MH51359 and MH065247. In memory of Rob Barrett: psychiatrist, anthropologist, stalwart.

References (71)

  • G.L. Albrecht et al.

    Handbook of disabilities studies

    (2001)
  • S. Alkire

    Valuing freedoms

    (2002)
  • M. Amering et al.

    Psychiatric advance directives: Qualitative study of informed deliberations by mental health service users

    British Journal of Psychiatry

    (2005)
  • E.S. Anderson

    What is the point of equality?

    Ethics

    (1999)
  • W.A. Anthony

    Recovery from mental illness: The guiding vision of the mental health system in the 1990s

    Psychosocial Rehabilitation Journal

    (1993)
  • A.K. Blanch et al.

    Consumer-practitioners and psychiatrists share insights about recovery and coping

    Disability Studies Quarterly

    (1993)
  • E. Bleuler

    Dementia praecox, oder Gruppe der Schizophrenien

    (1911)
  • M. Bleuler

    The long-term course of the schizophrenic psychoses

    Psychosocial Medicine

    (1974)
  • T. Burchardt

    Capabilities and disability: The capabilities framework and the social model of disability

    Disability and Society

    (2004)
  • J. Chamberlin

    On our own

    (1979)
  • Clay, S. (1994). Conference presentation: The work of recovery: Implications for psychiatry and research, 17–18 October...
  • P.W. Corrigan et al.

    Demonstrating translational research for mental health services: An example from stigma research

    Mental Health Services Research

    (2003)
  • G. Deegan

    Discovering recovery

    Psychiatric Rehabilitation Journal

    (2003)
  • P.E. Deegan

    Recovery: The lived experience of rehabilitation

    Psychosocial Rehabilitation Journal

    (1988)
  • S. Estroff

    Making it crazy

    (1981)
  • D.B. Fisher

    Towards a positive culture of healing, in The DMH core curriculum: Consumer empowerment and recovery, part I

    (1993)
  • J.E. Floersch

    Meds, money, and manners

    (2002)
  • G.G. Grob

    From asylum to community

    (1991)
  • J. Hamann et al.

    Shared decision-making in psychiatry

    Acta Psychiatrica Scandinavica

    (2003)
  • M. Hammer et al.

    Source material on the epidemiology of illness

  • C.M. Harding et al.

    The Vermont longitudinal study of persons with severe mental illness, I: Methodology, study sample, and overall status 32 years later

    American Journal of Psychiatry

    (1987)
  • C.M. Harding et al.

    The Vermont longitudinal study of persons with severe mental illness, II: Long-term outcome of subjects who retrospectively met DSM-III criteria for schizophrenia

    American Journal of Psychiatry

    (1987)
  • C.M. Harding et al.

    Chronicity in schizophrenia: Revisited

    British Journal of Psychiatry

    (1992)
  • L.E. Hinsie

    Criticism of treatment and recovery in schizophrenia

  • Hogan, M. F. (2002). Transmittal letter to the President. Interim report of the President's New Freedom Commission on...
  • K. Hopper

    Some old questions for the new cross-cultural psychiatry

    Medical Anthropology Quarterly

    (1991)
  • K. Hopper

    Interrogating culture in the WHO studies of schizophrenia

  • K. Hopper

    Redistribution and its discontents

    Human Organization

    (2006)
  • N. Jacobson

    In recovery: The making of mental health policy

    (2004)
  • N. Jacobson et al.

    Recovery as policy in mental health services: Strategies, emerging from the States

    Psychiatric Rehabilitation Journal

    (2000)
  • M. Joseph

    Against the romance of community

    (2002)
  • A. Kleinman

    Rethinking psychiatry

    (1988)
  • D. Lewis et al.

    Policies of inclusion and the mentally ill: Long-term care in a new environment

    Journal of Social Issues

    (1989)
  • T.M. Luhrmann

    Of two minds

    (2000)
  • S. Mitra

    The capability approach and disability

    Journal of Disability Policy Studies

    (2006)
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