Paper read by Alastair Kemp at AMM#11, 21 Jan 2015, Housmans Bookshop
Robert mentioned that one of the problems with regards mental health today is the usurpation of what is called the ‘Recovery Model’. The word ‘recovery’ has been around since around the days of alienists and asylums, even perhaps the earlier Private Madhouses that people such as Roy Porter saw as precursors to the larger Asylums. Peter Sedgwick’s own account of this history is reasonable and broad enough and with regards his criticism of Foucault, Sedgwick’s questioning of some of the specifics such as the existence of a great confinement, are pretty reasonably accepted within the discourse and are not particularly controversial. If one wants to read Foucault one has to take such things into consideration, there is no point denying them. Anyway, back to recovery, there probably is a split that Foucault points out (despite the historical finer details, let’s avoid the historical version of a fallacy fallacy and not assume a few points disprove the meta thesis, or at least its wider implications), between the forces of containment and the forces of ‘recovery’ in the history of mental health. It is the central dialectic in mental health (although there are others) and each of them has had the upper hand at differing historical times. That ‘recovery’ hasn’t usually had the upper hand suggests something about its historical relationship with the means of production, but let’s examine its nature more. Foucault’s arguments that Tuke or Pinel’s liberality may in some ways be more insidious than the chains and harsh treatment of the asylum does though have a relevance to this point, but I would argue for a more dialectical reason. As I said the word ‘recovery’ has been around since the time of the alienists and mad doctors and basically was due to the idea that people could, well, recover. We talk to day of revolving door mental health patients, but the work of scholars of mental health history in works such as Bartlett and Wright’s ‘Outside the Walls of the Asylum’ have shown that there have always been revolving doors throughout the history of the asylum, at least in the British sense, and although there were many cases of long term patients, mistreated and chained, there was alongside this a much more fluid movement in and out of these asylums.
These worst cases though did get to become the basis of the reformers campaigns, the symbols of their campaigns. And throughout the time of the asylums the number of long term cases did increase along with the increase in size of the asylum population. The links between this, changes in economy and political and social policies and attitudes to the mentally ill are vast numerous and much written about, but for time being I have to skip this and return to the existence of these revolving door and how they are associated with the belief in recovery. However with the burgeoning medicalisation of psychiatry which was part of a scramble for authority, in both the meaning of a knowledge base and one of governance and control, and the increase in population that led to more long term inmates there was a move away from the more therapeutic elements of recovery towards the containment elements of control. The priority of psychiatrists’ practice of containment over their practice and use of the term recovery was not all smooth running. The arrival of the theories of Freud and especially the effectiveness of the treatment of shell shock after WWI gave psychoanalysis a short between war boost, until behaviourism set up its stall as a ‘psychological science’ that bit closer to the medical encampment. The study of the behaviour of the mad became more important than their inner world, and created a position where the arrival of Chloropromazine could create docile clients, and the pharmacological industry could help tip psychiatry fully back into the bosom of medicine it had been so desperate to embrace for so long. It was at this time that the belief that the mentally ill could ‘recover’ reached a low where it would remain for another 30 to 50 years, depending on the stringency of your definitions. In this time, as discussed in Sedgwick, Scull and many others, questions about the costs of the asylums started arising again, well they never went away, but at this point, post WWII in the late 50’s, early 60’s they were intensifying again. There were as ever a vast array of forces, the recovery movement in the form of social reform was still here. Learning disabilities had been separated from the insane at this time and already had their spaces in the community, as were there spaces for puerperal insanity, based around a logic of women’s attachment to the home and the needs of child rearing. But the asylum was the bastion of the psychiatrist. However as there were moves to decentralise health, so there were moves afoot to do so with madness, and now that there was a medical basis, the social reformers had their own lever with which to force open the door. And due to a combination of economic cost cutting, the arrival of medication, and civil and medical reformist concern for the welfare of the insane the decarceration that led to care in the community came about. It was from the social movements born here that the new meaning of ‘recovery’ that was born of the struggle of service users, or survivors, in the community came about, and it is this that is now returning back as a form of containment after its 30 or 40 year emancipatory push.
I think here I have to talk about the place of Sedgwick’s critique of anti-psychiatry. There are three aspects of Psychopolitics. Sedgwick’s critique of those who he identifies as the four main theorists of anti-psychiatry; and then combined in the last chapter a review of the literature on decarceration; and the question of the formation of mental health social movements in this new sphere, of what I would argue, still through the use of medication, was still a sphere of containment. As Robert has argued, Sedgwick’s understanding of these social movements seems to be under-informed, naïve, outdated (we’ll excuse him given the date of publication) and very narrow, focusing on the need for the advocacy of professionals and relatives (I have to say right here, right now, this whole battle for advocacy is a wonderful central thread that weaves through Robert’s book. Go! Buy it now!). I would also like to say that there is supposed to be a forthcoming book on the history of the Survivor movement in the UK by Andrew Roberts and Pete Campbell of the Survivor History Group that I am really looking forward to, but I am not sure when it is out. But it will be well worth looking out for if you want to fill in the historical gaps that Sedgwick has left. However there is also from an academic point of view also Nick Crossley’s book Contesting Psychiatry available that is another invaluable work. Anyway, as Robert and I hope to show there has been plenty of survivor politicking in the last 40 years, but Sedgwick’s book is still invaluable in highlighting the need for it, even if ultimately he undermines the autonomy of those caught in the mental health system by denying their self-advocacy. But to appreciate this and to bring light to bear on what has happened to this newly forged term ‘recovery’ we have to look at Sedgwick’s critique of anti-psychiatry. The main thrust seems to start along the lines that the anti-psychiatrists were validly criticising the medical claims of psychiatry but in a way that left medical discourse as a purer, neutral discourse. I am happy to accept this (except with Foucault but Sedgwick seems to tacitly acknowledge that by not discussing it in the chapter on Foucault), and would say it is very true with regards Goffman and Szasz, less so Laing, but Laing’s dalliance and then subsequent withdrawal from the realms of social psychiatry is a valid criticism from Sedgwick. However I think this is a valid argument. And so I would like to pursue it.
If we now leap forward to today and take the term ‘recovery’ as you find it in contemporary mental health services, NHS and Government policy, as well as much survivor therapeutic support work and charitable campaigning. You will find that the ideal is seen as a personal journey that takes the person seeking relief from the distress that has most likely led them to seek help from mental health services towards personal autonomy and relief from their suffering. It is a very individualistic understanding of mental health recovery and has very strong elective affinities with spiritual practices that have their roots in the Protestant Reformation which in itself if you have any respect for Weber has its own affinities with Capital. I would love to lead you on another history here that takes us through the Dissenting traditions, Lollards, Ranters and Ravers as well as feminism, midwives and witchcraft trials. But that’s a whole other occult history that you will have to untangle from what I tell you today. However I hope to meet you at the end with references to the inheritors of these traditions; Situationists, Operaismo, and their relations to collective action at the end if I have time.
Anyway, this ideal of recovery, that seems to neglect any question of how autonomy is possible without a political relation to the autonomy of others, is a mirage, a Fata Morgana. With regards users of mental health services one could sing the song by the Specials “I’ve seen no sign of you, I‘ve only heard of you, you are putting the monkey on me”. It is most eloquently been described by Rachel Perkins and Julie Repper in the book ‘Social Inclusion and Recovery’ a book that set out to lay down the foundations of recovery and the rights of the service user, including parity of pay with regards the use of their lived experience by mental health services for teaching, therapy, professional training, peer research etc. But again whilst without it as a core text one cannot decipher public policy from Labour’s New Horizons through to the Conservative’s No Health Without Mental Health, it too is a mirage. It has had marched hand in hand with thousands of workers and service users towards recognition and respect in the world outside the mental health ghetto, it is as essential a text to the critique of recovery as an understanding of Hayek or Friedman is for a Marxist critiquing the economy since the 1970’s, but as Nancy Fraser claims in her critique of Axel Honneth’s thesis on Recognition this view of recovery is shackled without an acknowledgment of the need for wealth redistribution. And here lies the rub. These high ideals, these noble virtues. How can we sound almost as if we clamour against our own well-being, as we are frustrated in our desire to slake our thirst at an oasis that hasn’t seen a spring for centuries? How can we call out to be unrecovered?
According to a meta-analysis by John Read, you are 7 times more likely than the general population to be diagnosed with schizophrenia if you are born in a deprived economic background (as opposed to only 4 times the general population with regards non-schizotypal disorders) , more so if you are black. It is here, where recovery fails to tackle inequality specifically, and the class system and the economy in general, that Sedgwick’s critique of anti-psychiatry is relevant. The focus on individual libertarian therapy and ‘recovery’ is a market strategy. One that as Foucault argued can be as insidious as imprisonment. Although it is worth noting that under this coalition, and before but markedly more recently, there has been concern at the number of people with mental health conditions being diverted to prisons due to lacks of beds.
The ‘recovery model’ that arrived at a political definition in Perkins and Repper’s book after decades of agitation and antagonism, solidarity and mutual support by the mental health activist community draws its well spring not just from the experience in battle with the ‘system’ of mental health and its relation to economy and society but from the anti-psychiatrist movement before it. And it also inherited anti-psychiatry’s individualism. Not from lack of political conscience from its most battle hardened members without whom many of us would not be here to give them their due credit. But from the same need for identification and integration with these opposed systems that afflicts every identity movement as it reaches success. But it has come to a point where those battle worn members are just as vociferous in their Weltschmerz as the young bloods coming into the system. And in many ways the survivor movement was a victim of its own success.
As I said earlier there has been amongst other struggles a dialectical movement throughout mental health history between containment and cure, control and recovery. The two sides have never been clearly distinguished from each other but the tension is always there. One of the effects of decarceration towards care in the community was to shift the balance of power to the social work and psychology sector of the health and social care economic nexus. However as has been discussed in Sedgwick, Scull and others, whether the economic drivers were the prime drivers or not they were there, and when decarceration took pace the care infrastructure was not in place, all that was there was the infrastructure for learning disabilities and a few others, as well as a few communities set up by anti-psychiatrists and other social reformers. This led to two things that pulled in two directions; the arrival of a need for organisation amongst service users, that led to their emancipatory struggle adding to the recovery discourse as the communities and campaigning groups they forged meant ad hoc forms of mental health support had to be formed in the moment so to speak. And in the other direction the return of the ascendancy of the psychiatrist through CTOs and forced medication and involuntary incarceration due to the myth of the dangerous male. It was here that on this battle ground that the UK survivor movement had its birth pangs, youth and adolescence. But the struggle was reasonably successful and there was a significant amount of recognition achieved. And the rights, experience and autonomy of service users were taken up by the NHS, mental health services and government policy to a significant extent, in more than just token way. For a while anyway.
And then the brute reality of failing to take into account the economic and class aspects came into play. The implications of ignoring the need for wealth redistribution as an aspect of recovery became clear. Class distinctions became apparent amongst those who successfully recovered and started to work on changes on ‘the inside’. And then a combination of separate policies with regards the marketisation of public services combined with the crisis hit. It is here that the ‘recovery model’ started to lose its emancipatory veneer of autonomy and the mental health strategies and technologies became Procrustean as they had to be cost effective meeting the needs of audited services based on outcome measures, to which today we are left with a limited spread of CBT, WRAP groups, mindfulness, occasionally hearing voices groups for psychotics, although these are threatened as services are cut. If you don’t fit these it’s the dangers of readmission and forced medication under CTOs or a diagnosis of a personality disorder, the ASBO of mental health diagnoses. Navigate these and one then has to face the WRAG group and workfare, most likely before you are recovered enough, in this case more literally as soon as you are just about well enough to work, sending you scuttling around the edges of readmission and CTOs singularities. Unless you get a job as a peer worker where you have now lost the original parity of pay and are expected to offer these services containing your fellow sufferers at a wage that undercuts the professionals originally expected to fulfil these duties with greater training.
So what of resistance? Robert’s book has detailed the campaigns and fight for advocacy that he and others raged. These are as relevant as others, but these campaigns need to address once and for all the class base of these struggles and the need for a more equitable economic system whatever your particular flavour is. But it needs to go further, identity politics by their nature are forever co-opted by the forces that they reform and such reforms are forever turned against them, as such it is important to forge broader alliances. One example would be to use the skills learned from service user work to work with unions rather than directly with the NHS or mental health services. With regards unionisation of mental health it seems to me that Sedgwick’s observation that the mentally ill are segregated from the working population due to their conditions is correct, even if we fight for the right to work and improved employment rights, better welfare rights, that leaves a vast number of our cadre marginalised. For this reason I personally am drawn to more Workerist/ Operaismo strategies due to their respect for the position of the lumpenproletariat as necessary surplus labour under free market capitalist conditions. This would include survival strategies, because under the current attack on welfare a new battlefront has arrived absent in previous decades, a success as it were of the battle for the right to recover, and that is for the space to recover in an autonomous fashion (rather under the Procrustean demands of the Recovery model). As the need to process surplus labour faster, rather than a march to full employment, never on the free market agenda, intensifies, so this space has come under attack, so it I think it is fitting that we learn and share strategies with regards the production of autonomous space with other groups of activists on the various front lines in the fight against capital.
So to recap, we have had our right to autonomous recovery taken from us so now the immediate battle seems to be along campaign lines, solidarous connections with other groups and unions along Workerist type strategies, as well as mental health awareness education, and the development of survival strategies, whether Situationist, Lefebvrian or other method.
Bartlett, Peter, and David Wright, eds. Outside the Walls of the Asylum : On “Care and Community” in Modern Britain and Ireland. New Brunswick N.J.: Athlone Press, 1999.
Honneth, Axel. The Struggle for Recognition: The Moral Grammar of Social Conflicts. Cambridge, UK; Oxford; Cambridge, MA: Polity Press ; Blackwell, 1995.
Porter, Roy. Madness : A Brief History. Oxford ;;New York: Oxford University Press, 2002.
Read, John, Paul Jay Fink, Thom Rudegeair, Vincent Felitti, and Charles Whitfield L. “Child Maltreatment and Psychosis: A Return to a Genuinely Integrated Bio-Psycho-Social Model.” Clinical Schizophrenia & Related Psychoses, no. October (2008).
Repper, Julie, and Rachel Perkins. Social Inclusion and Recovery : A Model for Mental Health Practice. Edinburgh ;;New York: Baillière Tindall, 2003.
Scull, Andrew. Decarceration : Community Treatment and the Deviant : A Radical View. 2nd ed. Cambridge: Polity, 1984.
Sedgwick, Peter. Psycho Politics. The Politics of Health. London: Pluto Press, 1982.
 Porter, Madness : A Brief History.
 Sedgwick, Psycho Politics.
 Bartlett and Wright, Outside the Walls of the Asylum : On “Care and Community” in Modern Britain and Ireland.
 Scull, Decarceration : Community Treatment and the Deviant : A Radical View.
 Crossley, Contesting Psychiatry.
 Repper and Perkins, Social Inclusion and Recovery : A Model for Mental Health Practice.
 Honneth, The Struggle for Recognition.
 Read et al., “Child Maltreatment and Psychosis: A Return to a Genuinely Integrated Bio-Psycho-Social Model.”