Psychological, sociological and psychiatric research on recovery and mental illness

                                       -         A review of main approaches 1960-2005

In this review I outline some of the main approaches of research and user perspectives that have inspired and “triggered” focus on recovery from mental illness since 1960. This is done in order to identify how a sociologic approach to the area of recovery from mental illness differs from the existing approaches and provides the potential of new insight.

During the 1960s, 1970s and into the 1980s manifold critics of the use of force, diagnosis and medical treatment in the practices of psychiatry arose. Psychiatrists like R.D. Laing (1957) and Thomas Szazs (1961) challenged the legitimacy of psychiatric treatment. The former approached schizophrenia as a division in the self caused by the inhumane treatment of psychiatry (Laing 2001:14-22, 188f). The latter asserted that mental illness was a myth constructed through the biological and psychoanalytical conceptions of psychiatry which give meaning to specific roles and patterns of communication, and thereby structure and construct what is conceived as mental illness (Szazs 1961:12). The Canadian born sociologist, Erving Goffman (1961, 1963) examined less normative although critically with the approach of symbolic interactionism, how inmates in psychiatric institutions managed the in-hospitalization in terms of identity and stigmatization (Goffman 1971:268). Thus, these critics directed a humanist critique of the damaging impact of psychiatry on the self, behavior and identity of the individual.

In the same period of time Michel Foucault (1961, 1963) analyzed how madness was separated as an individual category in the Enlightenment period. Foucault conceived humanist enlightenment ideals as the basis of modern psychological and psychiatric treatment of madness as a mental illness (Foucault 2003:54). Foucault’s perspectives were carried on in analyses of the new decentralized local- and social psychiatric services in the US conducted by Robert Castel (Castel 1982:xii). Furthermore, inspired by Foucault the English professor of sociology Nikolas Rose (1986, 1993) conducted analyses of psychology and psychiatry as productive forms of knowledge and technologies of power in modern societies (Rose 1999:ix, Miller & Rose red. 1986:14).

These new approaches to psychiatry served as inspiration for the users’ movements. On an international basis the anti-psychiatric movement (founded by Laing) suggested the abolishment of psychiatric treatment (Clausen red. 1970:45), and in Denmark especially Galebevægelsen demanded changes in psychiatric treatment (Hagens et al. 1986:105). Furthermore, during the 1970s the humanist and scientific perspectives of force and inhumanity in psychiatry gave inspiration to criticism of the so-called chronic, biological conception of mental illness and tendency to exaggerate psycho-pharmaceutical treatment (Mosher & Burti 1996:14-17). In 1985 the American professor of psychiatry Richard Warner conducted materialistic inspired statistical research in the variation of the prevalence of schizophrenia and recovery from schizophrenia with specific conditions of culture and production (Warner 1985:70 & 170f). Warner distinguished and created the concepts of social and complete recovery (Ibid). This division is frequently used in the literature of recovery (e.g. Jensen et al. 2004:24). Throughout the 1980s and 1990s the Italian psychiatrists Luc Ciompi developed a systemic approach to schizophrenia as a multidimensional and changeable phenomenon (Ciompi 1984:636). The American psychologist John Strauss elaborated a person-dynamic conception of recovery and the course of schizophrenia, focusing on how persons interact with mental illness (Strauss 1989:182). In the 1980s and 90s the users’ movements first of all focused on existential, phenomenological and experienced approaches to mental illness, focusing on recovery, self-help, free choice of treatment, users’ influence and self-determination (Copeland 2004:7, Deegan 1988:11, Deegan 1996:91-91, Ralph & Corrigan 2005:3f, 35).

In the 1970s and 80s the research at Boston Center of Psychiatric Rehabilitation mainly focused on the development and evaluation of psychiatric rehabilitation programs (Anthony et al. 1972:447ff). Influenced and inspired by the users’ movements’ quest for alternative mental health services supportive of their individual coping-strategies and hopes, the research increasingly began to focus on recovery in the 1990s (Anthony 1993a:11-24, Anthony 1993b:1, Anthony 2003:2). Towards the end of the 1980s and into the 1990s the Dutch professor of social-psychiatry Marius Romme conducted narrative research into voice-hearing. Romme conceived voice-hearing as meaningful in the perspective of the individual life-story, and asserted the possibility of coping with voices through dialogue (Romme & Escher 1989:215). Around the millennium the Swedish psychologist Alain Topor conducted research based on a cognitive and narrative approach on recovery as a process, through which mentally ill persons experience their self as negatively influenced by the illness and learn to cope with the problems and a complex self-notion (Topor 2001:318, Topor 2003:111). Next, a Norwegian/Swedish group of scientists conducted a research-project, examining what kinds of factors mentally ill persons regard as important in order to recover. This research was based on Grounded Theory and a narrative and cognitive approach (Topor et al. 2002:12f).

Furthermore, using a social constructionist approach, the Finnish psychologist Jaakko Seikkula has done research on recovery as a new social and verbal understanding between the mentally ill person and the personal network (Seikkula 2002:155f). These approaches of research place themselves near the mainly grounded and phenomenological perspectives of the users’ experiences. However, they tend to relate more to social constructionism by stressing the importance of language for recovery as a subjective or inter-subjective phenomenon created through narrations or interpersonal relations.

Although the users’ movement, humanist and social science research are main sources of inspiration for the current quest of recovery-oriented mental health services, also quantitative psychological and psychiatric research into the long-term course of psychotic illnesses is used in order to constitute arguments of recovery-orientation. From 1972 to 2001 some follow-up studies have shown that the long-term course of schizophrenia does not in all cases end up in a state of chronic illness. Based on diagnostic concepts of symptoms, treatment and psychosocial functioning, these studies conclude that up till 2/3s of persons diagnosed with schizophrenia recover completely or socially for longer or shorter periods of time (Bleuler 1978:414, Huber et al. 1980:595-601, Ciompi 1984:637f, Harding et al. 1987a:722, Harding et al. 1987b:730, Harrison et al. 2001:512). These studies show that the possibility of recovery from mental illness is not only argued for through the experiences of users, but also through the use of diagnostic, objective approaches.

In Denmark humanist and social science research into the living conditions of mentally ill persons and the psychiatric services is frequently conducted (Jensen 1996:18, Høgsbro red. 2004:15). However, only two scientific examinations have been made into recovery in Denmark. These investigations follow the line of experienced and phenomenological research, on the one hand by conducting participant based research, open theoretical approach, and on the other hand by using measures of experiences (Jensen & Projekt Recovery-orientering 2004:105, Center for Evaluering 2004:41ff, Evermann 2004). Danish non-medical research are quested, both into the wider area of recovery and specifically into the area of illness understandings and use of the formal psychiatric system vs. alternative services (Jensen et al. 2004:252).

To summarize, research into local psychiatry as new technologies of power and knowledge has been done with inspiration from Michel Foucault and Nikolas Rose (Abildtrup & Neidel 2003, Christensen & Hansen 2004). Next, research has examined recovery and mental illness as impacts in self-notion through interactionist, constructionist, cognitive and grounded approaches. Finally, research has both quantitatively and qualitatively examined course of illness and recovery by using standardized psychological and psychological measures of experiences and objective parameters. To contribute to these approaches of science and user experiences, I have chosen to conduct a study of the development of recovery-orientation in mental health services in Denmark based on the sociological theories of Pierre Bourdieu. The potential of a study inspired by Bourdieu, is like the Foucauldian types of analysis to show that forms of knowledge and power (e.g. in central, local or voluntary mental health services) are not natural, but arbitrary, that is – historically created and changeable. Unlike Foucault, Bourdieu attempted to create a scientific research-program based on a theoretical account of how subjective experiences tend to correlate with social structures and function as incorporated social structures. The goal of this program was to reveal how mechanisms of transformation and reproduction function (not always conscious) in different areas of society through the patterns of perception of participants themselves (Bourdieu & Waqcuant 2002:194). Thus, the potential of choosing this research-program is not only to show the social and arbitrary of the development of recovery-orientation, but also to conduct a critical, scientific research into how mechanisms of reproduction, transformation and symbolic power function when recovery-orientation is attempted in mental health services. A study inspired by Bourdieu differs from grounded and interactionist approaches by questioning subjective experiences and attempting to show, how they are related to objective social conditions and reproduces and transforms them. Thus the potential is to show how the ideas, perceptions and understandings of professionals and users in psychiatry are related to their objective positions in psychiatry. Finally a study inspired by Bourdieu does not take psychological and psychiatric approaches for granted; it examines them in order to show how they function as instruments of symbolic power (the invisible power to create and shape the world through legitimate understandings).

 Although not perfect, and perhaps tending to be satisfied with own techniques of objectivation, I have chosen this research-program inspired by Bourdieu, to analyze how relations of symbolic power are transformed and/or reproduced when professionals and users work with recovery in various mental health and psychiatric services in Denmark. The research-program of Bourdieu, is regularly used to analyse welfare-programs, politics and practices in Denmark (Mathiesen & Højbjerg 2004:257, Arnzholt Hansen 2004:16). An area of research has been somatic health services (Petersen 1999:183). Hitherto now, I know of two studies (MA-thesis) from Denmark conducting analysis of psychiatry with inspiration from Bourdieu (Arnfjord & Hauge 2002, Hardy-Hansen, Wahlgren & Mortensen 2001). These studies concluded that a dominance of medical practices relying on diagnosis and psycho-pharmaceutical treatment, can be conceived as the main cause of the continued criticism of psychiatry. In my MA-thesis I focus on how new forms of practices function and become integrated in psychiatric practices, not to question the use of force or the medical dominance in psychiatry, but in order to examine the possibilities of change of reproduction by introducing new ideas. The potential is to produce insight into how new ideas functioning along with and integrated in, traditional concepts and practices of mental health services/ psychiatry. 

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