Mike Slade, Cambridge University Press, 2009
This is an informative, stimulating and brave overview of the Recovery movement in mental health and wellbeing. Despite its subtitle, this book will be of interest to everyone involved in recovery. This is especially true for people who use mental health services or support family members or friends, although they do need to be willing to grapple with some challenging philosophical and social ideas and language.
The book was written following Mike Slade’s sabbatical year visiting a wide variety of recovery oriented services across the English speaking world. As might be expected, it has a wealth of suggestions for ways that recovery oriented services can be implemented. But there are many other places where similar suggestions can be found, not least his own paper, “100 Ways To Support Recovery”, an excellent (free) summary of many of the main points made in this book.
But the book’s importance is that it also provides a coherent overview of the historical roots of the recovery movement and a philosophical framework for recovery oriented services. It shows clearly why recovery has the potential to lead to revolutionary changes in the mental health system, with many practical examples, taken from Mike’s travels, being provided to illustrate the themes. One of these is Recovery Devon (Case Study 25, p. 231).
Mike says (p. 136):
‘What are the guiding values of a recovery-focussed mental health service? They don’t have to be complex. Bill Anthony has proposed the transcendent principle of personhood – “People with severe mental illness are people”. This provides a fundamental orientation for mental health services. People with mental illness want to work, love, play, make choices, be citizens – all the normal entitlements, roles and responsibilities of being a person. The task of mental health services is to support progress towards these goals.’
He firmly places the recovery movement within a context of challenge to previous mental health system orthodoxy. In the first chapter (p. 1) he points out that as well as people who benefit from mental health services, and others for whom the services promise much but do not fully deliver, there is ‘a group of people for whom the mental health system, with its current preoccupations, imperatives and values, is harmful’. And he is unafraid to state his own opinions (p. 7), ‘e.g. that recovery is at its heart an issue of social justice’.
He then proceeds to describe in detail just why that is so. He goes back to first principles, asking the question, ‘What is mental illness?’. He looks at the various clinical models that have been used, including the current biopsychosocial model, and points out numerous ways in which these fall short. He points out that the current model, with its emphasis on diagnosis, actually gives primacy to the ‘bio-’ part of the model and is an inadequate, if not often actually wrong, description of mental illness. As he puts it, diagnosis does not ‘cut nature at its joints’. And even if it did, it would still be a deficit-based, partial analysis of the person, which fails to look to people’s strengths, hopes and ambitions, and is intrinsically stigmatising.
He then considers two other kinds of model – disability models and diversity models – and shows how they both offer numerous advantages. The latter are of particular interest, as they seek to explicitly challenge the view that differing mental states, such as psychotic experiences, are necessarily psychopathological. Indeed, one of the current manifestations of this view that he mentions is the Mad Pride movement. He shows that such models (p. 30) ‘align with other liberation movements, and focus on emancipatory changes needed in society, rather than either treatment of, or adaptation by, the individual’. It is a measure of this book that these differing views of mental illness and health are described and compared fairly.
Mike then looks at the two meanings of recovery – clinical recovery and personal recovery – and discusses the ways in which they interact with each other.
The next section of the book considers this in detail, giving five rationales for the importance of personal recovery – epistemological, ethical, effectiveness, empowerment and policy based. Each of these has a chapter devoted to it. These chapters are essential to the book, providing a philosophical foundation for the recovery movement. They stress above all the importance of personal experience and the meanings and stories we attach to this, the hopes, desires and ambitions which flow from it, as the basis for recovery. He states the obvious but easily forgotten fact (p. 46) that, ‘mental illness is, before all else, a subjective experience’ and ‘if the essence of mental illness is the inner subjective world, then only the person themselves can access this stratum’ – which should make us all pause before we apply labels of any sort to another person’s experience.
This is in stark contrast to the impersonal and statistical methods of evidence based medicine. As Mike puts it (p. 49), ‘In the human sciences reductionism is a problem, not an asset. It objectifies the person by squeezing all the meaning out of their experiences’. While careful to give EBM its due weight, he suggests that it should be just one tool among many that we can use to support recovery, rather than the main guide to practice.
Mike covers many issues in these chapters and is not afraid to ruffle some feathers – for instance in a short ‘Effectiveness’ chapter he gives short shrift to many of the claims of the pharmaceuticals industry. Similarly, his chapter on ‘Empowerment’ has a searing indictment of the historical abuses perpetrated in the name of psychiatry. It raises the question whether an apology is now owed to those who suffered from them and advises caution in pronouncing on what is in the person’s best interests.
He then provides a longer section on recovery-focused mental health services. He first provides a Personal Recovery Framework and then considers its implications for many different aspects of the mental health system. At its heart is the person, their sense of identity and the relationships that support and flow from this. He describes the job of mental health professionals as having four tasks: supporting hope, identity, meaning and personal responsibility. The rest of the book is a guide to doing just that, with many case studies taken from his recent journeys in this and other countries.
Once again, these chapters are wide ranging, as in the chapter on ‘Promoting Well-being’. This looks beyond the usual disciplines of the mental health service, to positive psychology and the work of Martin Seligman, Corey Keyes, C. Rick Snyder and Mihaly Csikszentmihalyi on Authentic Happiness, the Complete State Model of Mental Health, Hope Theory and Flow respectively.
And near the end of the book, a chapter on ‘Improving Social Inclusion’ states (p. 198), ‘A central transition is to enlarge the focus of the clinician’s role, to being about more than treating individual patients. Treatment is, of course, part of the job, but so too is supporting people to exercise their full citizenship rights’.
The book ends with a quote from the Brazilian activist Paulo Freire:
”This then is the great humanistic and historical task of the oppressed: to liberate themselves and their oppressors as well ….. Only power that stems from weakness of the oppressed will be sufficiently strong to free both”.
Mike Slade comments, ‘The recovery agenda will be complete when there are simply groups and communities and networks in which there is no caseload because there is no service user – there are only people’.
All in all, this is a book that will challenge, inform and stimulate in equal measures and I heartily recommend it.