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