The Recovery Model: Discourse Ethics and the Retrieval of the Self

Abstract

The recovery model, as applied in mental health, is significant because it intends to foster a critical retrieval by the subject of herself as a self-determining agent of change. This paper will show that the recovery model represents an approach to caring for the self that is congruent with critical themes inherent in some forms of contemporary philosophy, particularly that of Michel Foucault and Jurgen Habermas. The paper will also consider the contribution that Habermas’ discourse ethics could make towards the non-coercive, dialogical resolution of differences between clients and professionals.

The reform of some mental health practices is influenced by an emerging expression of self-care called the recovery model. Historically, mental health reforms have tended to be influenced by professional and organizational needs. The recovery model is different from these earlier reforms, as it originated in the liberating experiences of individuals who struggle with symptoms of mental illness. While coming to terms with the personal and social challenges of living with both the symptoms and stigma of mental illness, proponents of the recovery model strive for a renewed sense of self-determination and respect. This re-appropriation or recovery of self-initiative and self-regard occurs sometimes independently of mental health professionals, sometimes in collaboration with them, and sometimes despite their involvement. Consequently, as it is articulated by individuals living with mental health challenges, the recovery movement promotes a practice of self-care which emphasizes the ethical and therapeutic necessity of including individual/client participation in the process of both defining and actualizing the conditions most conducive for recovery. At the same time, unlike some earlier reform movements, this model of care recognizes the rights and responsibilities that both clients and professionals have to work collaboratively towards mutually acceptable plans of care.

In this paper, I will identify the connections between the recovery model and philosophical discourse by showing how some proponents of the recovery model utilize Foucault’s philosophy to challenge professional discourse that they believe limits the possibilities for client-self expression. I will also discuss how the recovery model represents an approach to caring for the self that is congruent with critical themes inherent in some forms of contemporary philosophy, particularly those of Michel Foucault and Jurgen Habermas.¹ I will argue that professionals, who choose to support the meaningful retrieval of the self, as represented by the recovery model, are required to move beyond the explanatory methodologies employed by the natural and social sciences towards the inclusion of self-reflective methodologies from the humanities. Such methodologies, particularly forms of philosophical thinking, provide language which compliments the critical understanding and appreciative retrieval of the self in relation to, and independent from, psychiatric symptoms. This philosophical language also provides an ethical framework for more egalitarian and inclusive clinical collaboration between clients and professionals. Finally, I will show that the philosophical perspective of Habermas provides an ethical framework that may be useful to recovery oriented professionals as they begin to consider and integrate such principles into their practice.

The paper is structured as follows. Beginning with a brief description of the historical context and influence of ethical ideas in early mental health reforms, the analysis will address early European and Canadian reforms and their continuity with those currently under consideration at a psychiatric institution in Kingston, Ontario, Canada. I will then consider the emergence and meaning of the recovery model as interpreted by people who have had or are experiencing psychiatric symptoms as well as the views of recovery put forward by mental health professionals who are supportive of the model. Particular attention will be given to interpretations of recovery which emphasize the relevance of egalitarian concerns regarding the relationship of professional power to client self-determination. I will also consider the influence that Foucault’s philosophy has had on the perception by clients of the relationship between professional discourse and power and the possibilities for clinical collaboration. Finally, I will recommend that the individual emphasis on self-care and the co-operative potential of the recovery model would be enhanced by the attentive inclusion of Habermas’ discourse ethics and its contribution towards promoting and protecting the non-coercive, dialogical resolution of differences between clients and professionals.

The emergence of the recovery model

During the middle of the nineteenth century, some individuals who lived in the southeastern region of Ontario and exhibited psychiatric symptoms were confined in the underground cells of the Kingston Federal Penitentiary. It was not until 1839 that the government of Ontario determined that better and more protected housing, in the form of asylums, should be offered to these vulnerable individuals who were then characterized as “lunatics and idiots.” As a result, Rockwood Asylum in Kingston accepted its first male patients, transferred from the Kingston Penitentiary, in 1865. By 1868, female patients, who were initially housed in refurbished stables, were also transferred to the Asylum. This early Canadian approach towards the mentally ill reflected a Victorian moral perspective, emphasizing both a benevolent and segregationist approach to their care. There was a belief that patients needed protection from the exploitative and intolerant attitudes exhibited by many members of the larger community, as illustrated in a 1893 report by the Inspector of Prisons and Public Charities on the Lunatic and Idiot Asylums of the Province of Ontario:

Under the civilizations of past ages no provision was made for the care or treatment of the insane. In many cases they were more inhumanely treated than the brute creation would be, and at best they were exposed to all the destructive agencies by which they were surrounded, which, according to the inevitable law of “the survival of the fittest” soon terminated their existence….²

Staff were encouraged to live with their families on the grounds of the Rockwood Asylum, segregating them and the patients from the larger community. It would appear that both staff and patients became more attuned to the natural and communal rhythms of life. Besides experiencing life events such as births and deaths and sharing in the operation of agricultural pursuits, patients and staff also shared in a variety of recreational activities. Hospital records from the 1880’s show the existence of weekly dances, baseball games, steam yacht outings and a brass band, composed of patients.³

The models for nineteenth century North American reforms in the care of the mentally ill originated primarily with the religious humanism of William Tuke and the rational humanism of Dr. Philippe Pinel. According to historian Roy Porter, Tuke, a Quaker and lay person (he was a tea merchant), initiated a therapeutic community in England called the York Retreat. Emphasizing a moral rather than a medical approach towards the care and treatment of psychiatric patients, the York Retreat:

…was modelled on the ideal of the bourgeois family life, and restraint was minimized. Patients and staff lived, worked, and dined together in an environment where recovery was encouraged through praise and blame, rewards and punishment, the goal being the restoration of self-control.⁴

At around the same time, but in relation to the humanistic and egalitarian ideals of the French Revolution, Dr. Philippe Pinel began emphasizing the role of reason in the treatment of mental illness. According to Porter, Pinel viewed insanity as a mental illness which could be alleviated through cognitive or rational approaches to treatment. The application of reason to the understanding of insanity would increase the capacity of patients for self control and eliminate the need for coercion or confinement in the care of mental patients:

Inspired by the Revolutionary ideals of liberty, equality, and fraternity, in 1793 Pinel figuratively (and perhaps literally) struck off the chains from his charges…Pinel embraced the progressive thinking of the Enlightenment.⁵

Historical analyses highlights how the understanding and approach to the care of the mentally ill reflects larger cultural, social and political norms. For instance, over the past 100 years the response of society to the mentally ill has changed from an emphasis on paternalistic care and control to an emphasis on more rational approaches to treatment and the importance of patient autonomy. In addition, the influence of science in the treatment of patients has seen the application of electric convulsive treatment, insulin shock therapy, and the administration of a range of psychotropic medications. The success of psychiatric medication in treating severe forms of mental illness, in conjunction with larger modern and postmodern concerns for individual rights, suspicions of professional power and an increased emphasis on the value of autonomy, have contributed to a renewed process of mental health reform. This process has produced changes in both organizational names and functions. What was known in the 19th century as Rockwood Asylum is, in the twenty-first century, Providence Care, Mental Health Services.

The name change also reflects the organization’s interest in providing both institutional and community support. Another example of the contemporary restructuring of mental health is the organization’s sponsorship of a 2004 conference entitled, “Changing Attitudes, Changing Cultures,”⁶ which represented the recognition of an emerging approach to patient care called the “recovery model.” This understanding of recovery continues the early emphasis by Tuke and Pinel on ethical and rational care and the linking of such care with mental health reforms—particularly reforms, which expand the possibilities for clients to recover a sense of themselves as both members of a community and self-governing agents of choice. Consequently, while acknowledging the importance of medical technology in improving the lives of patients, the recovery model stresses the representational importance of patients understanding themselves apart from their symptoms. Therefore, the mediating role of language in the self-formation of identity is recognized and promoted. For example, rather than viewing an individual hospitalized with psychiatric symptoms as a “patient,” with its passive associations, the recovery model favours the more interactive term of “client.” In this way, the recovery model, as applied in mental health, is significant because it intends to facilitate a reflective retrieval by the subject of herself as a self-determining agent of change. Furthermore, the recovery model also recognizes the influence of internal and external circumstances towards supporting or impeding the client’s possibilities for self-directed forms of change. The internal conditions include the individual’s ability to reflect on personal ideas, values, and attitudes, which may inhibit or promote transformative change. The external conditions include policies, professional practices and systems, which may enhance or hinder the clients possibilities for self-expression or growth. In this way, the recovery model encourages the client to engage in an ongoing conversation with self and with others, concerning those individual and social conditions most conducive to her ongoing recovery and care of the self. As such, the client must be mindful of the ways in which she may have internalized concepts or expectations which hamper her possibilities for positive growth. At the same time, professionals who support the recovery model must continue to ask themselves (and their clients) whether their practice represents a collaborative approach to care and whether their approaches to treatment invite clients to greater freedom or mask a misuse of power.

In addition to its concern for collaboration between client and professional, the recovery model is significant because it reflects the self-determined efforts by individuals who suffer from mental illness to re-appropriate a healthier sense of self. This re-appropriation of self may occur in conjunction with the efforts of mental health professionals or may occur despite their classifications and interventions. In this way, participants in the recovery model reflect the “anti-reductionist” concerns of post modern thought. As such, recovery oriented clients and practitioners are alert to the ways that diagnostic classifications can limit the possibilities of client (and professional) growth and development. Consequently, the individual who re-constructs her sense of self within the recovery model represents an existential perspective which recognizes that the human condition embodies more than psychiatric symptoms. As such, the philosophy of the recovery model encourages all participants to avoid simplified forms of understanding mental illness which constrain the potential of clients for human development. Moreover, the recovery model urges professionals to be mindful that the “client” is always more than the sum of her symptoms and that the recovery of self always involves more than adherence to medical protocols of care. Sometimes this will mean that the professional encourages clients to move beyond their internalized beliefs that their symptoms place certain limitations on their possibilities for growth; sometimes it will require clients to remind the professional that they have a human right to exercise a degree of risky behaviour in the interests of increasing their scope for responsible self-determination. As Alan Lunt, a peer advocate, states:

Despite their best efforts, professionals cannot save consumers from having to face the dilemma of self. Consumers are no less human than any of the rest of us. The dilemma of self is universal. While the burden of mental illness exists in addition to the dilemma of self, it is not apart from that dilemma. Consumers must address self in mental illness, as well as mental illness in self. It is the self that mental illness affects (and effects).⁷

The recovery model is different from other mental health reform movements in that it directly reflects the views of individuals who have, or continue to experience, the symptoms of mental illness. However, in addition to reflecting the emerging voice of previously “subjugated” or ignored individuals, the recovery model also represents a conjuncture of larger ethical, political and emancipatory interests. Just as the paternalistic and segregationist mental health reforms of the nineteenth century reflected traditional Victorian moral concerns and the development of twentieth century technical and professional interventions represented the dominance of scientific method and expert culture, so too does the recovery model reflect the larger challenges to “modernity” embodied in critical forms of postmodern thought, particularly those of Foucault.

The influence of Michel Foucault and other philosophical perspectives

Some proponents of the recovery model utilize the philosophy of Michel Foucault (1926–1984) to identify the use and abuse of power in the interactions between clients and professionals. At the same time, proponents of the recovery model emphasize the importance of reflective dialogue, both in relation to understanding the “lived experience” of a client’s recovery and the cooperative negotiation and application of professional practice to the process of recovery. Foucault’s philosophy reflects a postmodern concern with the relationship and circulation of power and systems of power, particularly with respect to the formation and care of the self. His critique emphasizes the power of language in the definition of individual identity and the determination of social roles. As such, Foucault identifies the controlling effects of technical language in its deployment by professionals to define objectively the truth of mental illness for those living with its symptoms. By so doing, Foucault fosters the self-determining possibilities for subjects, as “patients,” to distance themselves linguistically from diagnostic classifications that may unduly restrict their human potential for growth. For example, when professionals refer to clients as patients, or as a diagnostic category, such as “schizophrenic” or “borderline personality,” they may limit the possibilities for appreciating the person’s strengths and transformative potential independent from her psychiatric symptoms. In this way, Foucault’s deconstructivist perspective offers a critique of the links between knowledge and expert power that opens up discursive space within which reductionist forms of professional practice/language may be identified and resisted by individuals moving towards a recovery of their mental health. As Dan Goodley, a recovering individual and mental health activist, states:

Foucault’s main thrust of analysis was in challenging those discourses and practices which masquerade as “truths” emerging from the human sciences and related practices such as psychiatry and psychology. Foucault argued that a whole host of discursive practices—technologies of normalization and bio-power—have emerged under the banner of modernist progression with the same single focus of understanding and intervention: the human subject.⁸

Through Foucault, the recovery model shares an intellectual and political lineage with the “anti-psychiatry” movement of the 1960s and 1970s. However, unlike the earlier movement, which was shaped primarily by critical psychiatrists such as R.D. Laing, David Cooper, Thomas S. Szasz and others, the recovery model originated from the pragmatic experience of recovery by, and as articulated through, the voices of individuals with mental health symptoms. Also, unlike the earlier “anti-psychiatry” movement, those who identify with the recovery process are themselves more open to collaboration with others, including mental health professionals. The recovery model rejects positivistic expressions of psychiatry which reduce the definition of and coping with mental illness to biological diagnosis and treatment of symptoms; however, it welcomes psychiatric care that recognizes the self-understanding of the subject in determining the meaning of recovery. As one “ex-patient,” Patricia Deegan, asserts:

The goal of the recovery process is not to become normal. The goal is to embrace our human vocation of becoming more deeply, more fully human. The goal is not normalization. The goal is to become the unique, awesome, never to be repeated human being that we are called to be. Martin Heidegger said that to be human means to be a question in search of an answer. Those of us who have been labelled with mental illness are not de facto excused from this most fundamental task of becoming human.⁹

An increasing number of mental health practitioners, including psychiatrists, are accepting the philosophical and practical challenge of the recovery model in reassessing the role and meaning of professional knowledge, power, and accountability. There is a growing belief that modernist concepts concerning the understanding and treatment of mental illness misinterpret both the meaning of subjectivity and its relationship to the larger environment. Psychiatrists such as Patrick Bracken and Philip Thomas, who are supportive of recovery model values and postmodern perspectives, believe that modernist psychiatry has uncritically assimilated an overly abstract and environmentally detached concept of the self. As such, Bracken and Thomas recognize the role that philosophy has played in shaping contemporary views of self-formation, believing that the emphasis of Descartes, Husserl, and Jaspers on individual thinking, independent of context, has contributed to a reified understanding of the subject, independent of the complex cultural contexts, which contribute towards self-development. Consequently, for postmodern psychiatry, this modernist, scientific approach has led to an emphasis on “neutral” and “objective” assessments and treatments of mental illness, which exclude or diminish the positive and negative effects of the larger environment on the formation of the subject. As such, Bracken and Thomas argue that even psychiatrist and existential philosopher Karl Jaspers, author of General Psycho-Pathology, overemphasizes an internal or “privatized” view of the self. Although they consider Jaspers’ book to be the most influential European psychiatric text of the 20th century, they are concerned that:

Jaspers worked within the framework of phenomenological psychology developed by the philosopher Edmund Husserl, who promoted phenomenology as a “rigorous science” of human experience. His method involved “bracketing out” contextual issues and an intense self-examination with strong echoes of Descartes’ Meditations. In this theoretical tradition the mind is understood as internal and separate from the world around it.¹⁰

Most proponents of the recovery model do not reject the benefits of medical and/or professional interventions. However, from the perspective of the recovery model, medical/professional interventions in the field of mental health, even when necessary, do not represent a sufficient condition for the healthy retrieval by the subject of herself. This is because explicit to the recovery model is the belief that intentional acts of a self-determining subject are necessary for the authentic retrieval of a healthy self. For the recovery model, the subject must consciously recognize herself as an agent of choice; she must realize her potential in the reflective process of freely choosing goals that increase her prospects for human growth and development. Although acknowledging that the symptoms of mental illness may severely limit an individual’s possibilities for human well being and growth, the recovery model nonetheless emphasizes the importance of affirming the person’s capabilities and strengths. Richard Barton, a recovery model advocate, defines recovery as:

…a mode of being that is entered into, an act of conscious volition, not something imposed from without. The process may begin with a person’s recognition that he or she is more than the illness, followed by efforts to further restore the capacity for self-recognition and self-regulation. In the view of many recovered consumers, symptom reduction is secondary to improving competencies, and both must be subservient to the recovery of being.¹¹

At the same time as the recovery model promotes a reflective process of personal growth and recovery, it also encourages clients to make morally responsible decisions concerning the ways that they identify, evaluate and act upon self-actualizing choices. As such, the recovery model encourages the subject to develop an ethical self, a self that attempts to understand and realize her possibilities for recovery in relation to the “other’s” point of view or situation. In this way, the recovery model includes an ethic of shared care, which attempts to give attention to the views of those people, whether professionals, family members, or friends who may support or oppose the recovery oriented choices made by the client. Consequently, the recovery model promotes ethical relations in which the subject attempts to define her process of recovery in collaboration with other interested and potentially affected parties. In this way, the recovery model is congruent with the ethical perspective advocated by postmodern psychiatry, articulated by Bradley Lewis:

Postmodern psychiatry, owing to Michel Foucault (1980), would understand knowledge as always also power/knowledge—what is accepted as knowledge is always bound up with the interests of who gets to speak. As such, any psychiatric knowledge base that excluded patients’ perspectives would be suspect, and postmodern psychiatric knowledge would be created as much by patients as it was by clinicians.¹²

As previously mentioned, the recovery model represents a variety of themes that are congruent with postmodernist thinking, particularly those of Foucault. Participants in the recovery model, including both clients and professionals, share a suspicion of the relationship between power and knowledge, and there is a mutual concern that scientific/technical knowledge can overemphasize and validate as natural, what are normative representations of truth or “regimes” of truth. As a result, professional mental health workers may develop treatment plans which privilege expert knowledge at the expense of practical wisdom, which originates from the client’s lived experience of coping with mental illness. In this way, mental health workers may dominate the language protocols of assessment, diagnosis and treatment. By unilaterally creating the linguistic field (regime of truth) within which individuals are defined as clients, professionals may be well meaning but naive participants in social control. Paraphrasing Foucault, nurses Elizabeth Manias and Annette Street state that:

…dominant discourses may be considered as regimes of truth that determine what counts as important, relevant and “true” knowledge. Hence, regimes of truth cannot be understood in absolute terms that exist outside the knowledge and power relations of discourse but, rather, they must be understood in relational terms.¹³

Historically, power has been used coercively to intimidate, and thus, promote and ensure, personal compliance to social norms through public displays of violence. An example of such intimidating displays of power would include public punishments and executions. In contrast, from a Foucauldian perspective, the postmodern interpretation and expression of power does not depend upon the explicit use of violence but requires that subjects experience themselves as relatively autonomous and therefore, capable of being persuaded and/or deciding for themselves, whether or not to comply with a given set of social norms. In this way, the dispersion of power is always interactive; all parties in an interaction need to have at least a minimal degree of freedom, which allows them to accept or reject recommendations made by the other person. When social interactions become monocratic, then freedom and power cease to circulate and relations of domination prevail. Thus, according to Foucault, power and freedom are intrinsically forces of self-expression:

It should be noted that power relations are possible only insofar as the subjects are free. If one of them were completely at the other’s disposal and became his thing, an object on which he could wreak boundless and limitless violence, there wouldn’t be any relations of power. Thus, in order for power relations to come into play, there must be at least a certain degree of freedom on both sides.¹⁴

Most mental health workers and clients recognize the moral or legal requirement for rare but intrusive interventions by professionals in the lives of clients. These interventions are socially sanctioned for the purpose of preventing serious harm to clients or members of the community. In addition, some mental health workers may view benevolent but prescriptive interventions as representing the most efficient, and therefore, preferred means for alleviating the plight of a client. For example, in the process of discharge planning, a professional may determine that a safer, but highly structured environment is preferable to the less structured but riskier living conditions preferred by the client. Rather than taking the time to work with the client and allowing her to actualize her capacity to live in a more autonomous environment, the professional may conclude that it is more efficient and safer to impose the more restrictive environment. However, according to proponents of the recovery model, this apparently well meaning but authoritarian approach to care often masks and furthers the dominant interests of a norm determining professional “status quo.” In this way, the medical institutional ecology, which gives professionals permission to use a monological approach to care, also shapes the context within which the individual is encouraged to interpret her identity as a patient, client or consumer. As such, mental health professionals may promote diagnostic assessments that encourage individuals to assume roles which reflect a self-limiting sense of their potential for growth. In describing the negative clinical effects of diagnostic approaches which shape and reduce the individual to the “sum of her symptoms,” recovery model advocate, Larry Davidson, argues:

Not only does a person experience psychological and emotional symptoms, social consequences, and stigma, but also he or she may be socialized into assuming the role and identity of a “mental patient.” This role is reinforced by a system that has historically valued and rewarded compliance and passivity and been skeptical (at best) of signs of autonomy and independence.¹⁵

Therefore, mental health practitioners who live in and work within a modernist perspective may incorrectly conclude that a particular institution’s framework is one which can be applied across all clinical situations. As a result of this process, mental health practitioners may combine scientific/medical knowledge with professional power to categorize and subordinate the individual as patient. Consequently, the modern subject, as client, is invited to participate in a professionally mediated process of self-formation, which may discursively contribute to their own subordination. Laura Epstein, a Foucauldian social worker, writes:

Our disciplinary power works not so much by overpowering and coercing, but more subtly, through discursive practices which infiltrate and colonize from within, recruiting our clients into roles and practices, and discourses complementary to our own so that they can become willing participants in our technologies and passive beneficiaries of our expertise.¹⁶

Consequently, this discursive form of therapeutic colonization is a disciplinary process, which both client and professional may experience within the clinical relationship.

For the recovery model, the process of dialogue is central to the care and self-determination of the client as subject. In clinical circumstances where the application of professional expertise excludes client input, the possibilities for a patient-oriented retrieval of the self are diminished. When recommendations become unquestionable prescriptions or commands, then both freedom of choice and power disappear and the self becomes subjugated to the will of the other. At the same time, the more willing the agent (mental health professional) is to assert culturally sanctioned forms of power and the more willing the subject (client) is to submit unreflectively to such recommendations, the more likely is the predominance of professional power/knowledge in the clinical relationship. For these reasons, advocates of the recovery model encourage both professionals and clients to give priority to the importance of personal autonomy, self-determination and dialogue and consider them intrinsic to the process of a collaborative and healthy recovery of the self. However, for collaboration to occur, professionals need to practice a discourse ethics, which encourages an open conversation between themselves and their clients concerning the relevance and congruence of proposed clinical interventions to the perceived life needs of their clients. For proponents of the recovery model, clinical interests would expand from technical priorities to the recognition that quality of life concerns are intrinsic to the human flourishing of clients. Such collaboration would require professionals to engage in a more transparent, tentative, open-ended and inclusive approach to practice. However, as noted by social workers Margaret McKee Sellick, Roger Delaney, and Keith Brownlee:

Few of us have been trained to reflect out loud with our clients on the sources of our knowing, to articulate how we know what we know, or reveal the areas of our own uncertainty and the dilemmas we experience in constructing our practice world.¹⁷

As previously indicated, the recovery model emphasizes the importance of professional/patient collaboration in the assessment, diagnosis and treatment of mental health symptoms. For the recovery model, the reduction of symptoms appears less important than recognizing the autonomy and self-determinative potential of the client towards a broader definition of her identity despite her psychiatric symptoms. The recovery model insists that clients be understood and assisted to understand themselves in a meaningful relation to the larger contexts of the social ecology within which they live their lives. Consequently, the process of recovery may give expression to a multitude of ethically responsible choices, which reflect a healthy concern by the individual for herself and the larger community within which she lives. According to psychologist and recovery model advocate, Larry Davidson, these choices may include an acceptance of one’s illness in conjunction with an interest in collaborating with professionals around different forms of symptom management, the assumption of an active civic role in advocating for improved social conditions for people with mental health symptoms and the challenging of different forms of stigma. At the same time for Davidson, the foundational theme, which most animates the process of recovery, is a sense of re-generation and pragmatic hope in the possibilities of personal renewal. Thus, according to Davidson, the essence of recovery is “…a renewed sense of self as a whole person, despite or incorporating one’s illness, along with a redefinition of one’s illness as only one aspect of a multidimensional self.”¹⁸

The recovery model emphasizes the transformative potential of clients to engage in an ongoing process of individual and interpersonal growth in relation to and in spite of the limitations, real or imagined, of mental health symptoms and social conditions. It recognizes that internal conditions, such as the individual’s ability to reflect on personal ideas, values, and attitudes, which may inhibit or promote transformative change, are necessary for a healthy retrieval of the self. It also appreciates the influence of external circumstances such as mental health policies, professional practices, and social systems, which may enhance or impede the client’s possibilities for self-expression or growth. Finally, it realizes that client recovery occurs within a dialectical process of self-determination in relation to the transformative possibilities inherent to internal and external circumstances of their lived experience. For the recovery model, these transformative possibilities are fluid and interconnected, meaning that change at the personal level can generalize to social and political actions, which favourably alter structural conditions affecting a client’s life chances. In turn, the reform of policies and systems can influence the allocation of resources necessary for the enhancement of individuals’ capacities for self-determined change. Recovery advocate, Nora Jacobson, asserts:

Together, internal and external conditions produce the process called recovery. These conditions have a reciprocal effect, and the process of recovery, once realized, can itself become a factor that further transforms both internal and external conditions.¹⁹

The contribution of Jurgen Habermas

Jurgen Habermas is a contemporary German philosopher who considers the ethical and rational criteria which are necessary for the dialogical resolution of differences between individuals. For Habermas, this collaborative process of critically assessing the validity/meaning of controversial normative claims is best achieved within the conceptual framework of what he calls discourse ethics. According to Habermas, discourse ethics both represent and presume the existence of performative criteria which are necessary for the rational resolution of differences. In this regard, Habermas believes that the discursive process of achieving inter-subjective consensus presupposes the existence of what he refers to as an “ideal speech situation.” In this way, the ideal speech situation represents the individual and social criteria that are necessary for the discursive determination of agreed upon norms. For Habermas, individuals committed towards the discursive resolution of differences need to be sincere in their efforts, motivated to find the truth and free from internal constraints, i.e., not so neurotic or ideologically conditioned that they could not see the truth of a situation. They also need to be free from external constraints, and therefore, not coerced by any authority into accepting a particular position and consequently, remain open to the “force of the better argument.” According to Habermas:

Whoever enters into discussion with the serious intention of becoming convinced of something through dialogue with others has to presume performatively that the participants allow their “yes” or “no” to be determined solely by the force of the better argument. However, with this they assume—normally in a counterfactual way—a speech situation that satisfies improbable conditions: openness to the public, inclusiveness, equal rights to participation, immunization against external or inherent compulsion, as well as the participants’ orientation toward reaching understanding (that is, the sincere expression of utterances).²⁰

The discourse ethics promoted by Habermas recognizes that human development occurs within the inter-subjective context of a life-world that is historically and socially situated. For Habermas, human communication (or communicative action) is expressive of a shared life world, and such linguistic interactions generally occur in an uncontroversial fashion. That is, people have conversations about a variety of topics for which the validity claims are assumed or taken for granted. However, when individuals or groups of people experience a difference of opinion or misunderstanding, then the previously assumed background consensus or agreement is called into question and the process of communicative action is suspended. At this point, the communicative participants have to choose the best means for resolving their dispute or disagreement. According to Habermas, participants have the options of moving towards strategic forms of action, that is behaviour which is oriented towards the achievement of self-interested goals, independent of the effect that such actions may have on the well-being of others; of terminating any further discussion and perhaps resorting to force; or of attempting to resolve differences through a process of further reflection or argumentation. For Habermas, the latter course of action assumes a cooperative effort, which intends to achieve a higher level of consensus based upon mutual understanding. However, this higher level of understanding must occur through a process of argumentative dialogue. In this communicative process, participants are attempting to arrive at a rational agreement about an issue or a course of action:

The tasks of mutual interpretation, then, are to achieve a new definition of the situation that all participants can share. If this attempt fails, one is basically confronted with the alternatives of switching to strategic action, breaking off communication altogether, or recommencing action oriented toward reaching understanding at a different level, the level of argumentative speech...²¹

Given that the recovery model is concerned about client self-determination and the ways that clients are included in meaningful discussions about their care, the integration of Habermas’ discourse ethics with the recovery model would make explicit some of the moral and cognitive attributes that are practically required by participants in the recovery model’s collaborative approach to care. The inclusion of Habermasian discourse ethics would provide the recovery model with conceptual performative criteria for the assessment and development by the subject of her transformative capacities in relationship to both herself and others. As such, discourse ethics could provide a critical and collaborative perspective from which the participant (client) could assess the transformative value/potential of her internal and external circumstances towards a healthy and meaningful retrieval of the self. At the same time, discourse ethics would remind the recovery oriented professional to ask to what extent her dialogical interaction with the client assumed and affirmed that client’s right and responsibility for self-care and human development.

The application of Habermasian discourse ethics to recovery oriented conversations between professionals and clients provides a procedural criteria for assessing the degree to which a collaborative understanding or agreement has developed, or is immediately possible, concerning the mutual acceptability of any proposed assessments or treatments. At the same time, while the performative criteria inherent in the ideal speech situation (sincerity, truthfulness, freedom from internal/external constraints) attempts to maximize the symmetrical conditions necessary for rational consensus, the recovery model recognizes that asymmetrical performative conditions are inherent to the professional/client relationship, especially during the early stages of the client’s symptoms. Therefore, from a therapeutic perspective, clinicians need to exercise a timely form of judgement concerning whether to challenge or support normative claims made by clients. Thus, in the early stages of the recovery process, Gorry and Deegan, advise clinicians to “…avoid adding insight to injury, for denial of illness, especially early on, may have a self-protective function.”²²

The integration of discourse ethics with the recovery model, as a co-operative approach to care, has ethical and therapeutic relevance even for clients who are emerging from the most serious and restrictive stages of their illness. The client, no matter how dependent her symptoms may have rendered her upon the structures of institutional or professional care, is invited to express her views and aspirations from the interpretive perspective she currently holds. The fact that professionals are protecting and facilitating a dialogical space within which clients are recognized as having a point of view worthy of being listened to (no matter how irrational this perspective may appear to the clinician) may in itself foster a therapeutic recovery by the client of her self-respect. In this way, the inter-subjective and self-determining potential of the client, at even the earliest stages of her recovery, is recognized and encouraged. Psychiatrists Glenn Roberts and Paul Wolfson report:

It is sometimes claimed that recovery is often further delayed by a state of learned helplessness encouraged by the low expectations of mental health professionals, especially when they remove the individual’s responsibility. However, even in circumstances that begin with compulsory admission, there is the possibility of progressively handing back of power and control to the patient, so that choice and self-direction are supported at the earliest opportunity.²³

It is also interesting to consider the challenge that the recovery model and discourse ethics pose to the professional culture of psychiatric care, particularly as organized in mental health institutions. It is traditionally the case that such institutions reflect an epistemological hierarchy of authority based on the degree of empirical expertise exhibited by any particular profession. The more skilled the profession is perceived to be in predicting and measuring outcomes, the more control that profession is given in determining the administrative and clinical protocols of the institution. As such, the culture of psychiatric care structures the “role opportunities” for both staff and patients. With regard to the latter, this can result in roles reflecting a dispersion of power, which according to Weaver Randal and Salem:

…include the organization of relationships (e.g.; opportunities to be both the provider and recipient of help), and opportunities to be involved in organizational decision-making. The roles and opportunities available to mental health consumers communicate a great deal about how individuals with mental illness are valued and what contributions they can make to their own recovery and the recovery of others.²⁴

In order for mental health professionals and mental health organizations to adapt this recovery oriented approach to care, their own process of decision-making must represent a more inclusive and egalitarian understanding of decision making and its relevance to recovery. Currently, there would appear to be a performative contradiction inherent in the traditional hierarchical approach to decision-making, prevalent in many mental health settings, and the inclusive, empowering values explicit in the recovery model. For example, sometimes the professional authority of a discipline is extended to areas of decision-making where expertise is insufficient or inappropriate for the resolution of a particular problem. Just as professionals can sympathetically impose a solution on clients, so also can hierarchical organizations benignly impose administrative and clinical protocols which adversely affect the decision-making and treatment procedures of professionals. Thus, a clinical team may be exploring more collaborative ways for sharing decision-making around treatment and discharge planning. In order to be consistent with the principles of the recovery model and discourse ethics, members of the team should openly discuss their reasons for retaining or altering a particular protocol not only with each other but also with representatives from the client population. The clinical team should also include relevant managers concerning the organizational value of any revised decision-making protocol and its perceived relationship to patient care and fiscal efficiencies. Ideally, this conversation would not be internally impeded by any participant’s ambitions for unwarranted power or control or dogmatic commitment to a particular approach to treatment or unduly influenced by the perception by the team of externally generated expectations favouring a particular outcome. Thus, even if an authority external to the team (or the client) has the “correct” solution to a particular problem, it would not be imposed. From the perspective of the recovery model, and discourse ethics, the value is as much in the reflective process of co-operatively resolving a difference, as in the validity of the outcome. According to Habermas:

What is needed is a ‘real’ process of argumentation in which the individuals concerned cooperate. Only an inter-subjective process of reaching understanding can produce an agreement that is reflexive in nature; only it can give the participants the knowledge that they have collectively become convinced of something.²⁵

Conclusion

The mental health reforms of the mid-nineteenth century led to the release of psychiatric patients from the confines of prisons as well as the removal of other forms of physical restraint. Although not initiated by professionals, the recovery model reflects a similar emphasis on extending freedom to psychiatric clients by working to lessen cultural, professional and institutional constraints on the self-expression of people with psychiatric symptoms. However, the recovery model is different from earlier reform movements in that it is a narrative process, originating in clients, which respects the practical wisdom gained by individuals who have experienced a healthier retrieval of the self within and despite the experience of psychiatric symptoms. At the same time, it represents a moral point of view concerning the normative and material conditions most conducive to the process of recovery and embodies an inclusive principle of social justice which ensures that clients’ stories and descriptions of what provides them with an experience of meaningful living and independence be heard. In this way, it represents a broad range of personal aspirations and social ideals, including an emphasis on the role of meaning, self-determination and equality as intrinsic to the process of restoring a healthy sense of self.

The recovery model has received increased recognition from reform minded mental health professionals and institutions. Many of these practitioners also identify with the critical philosophy of Foucault, particularly as it is used to specify the use and abuse of power in professional/client relations. They recognize that Foucault’s concern with the circulation of power reduces the influence of professional knowledge, while enhancing the expertise and wisdom that clients have with regard to their lives.

As a result of Foucault’s influence on clients and professionals, there is a growing awareness that clinical decisions need to include the client’s point of view. This is also true with regard to clients’ concerns relating to types of treatment and discharge planning. However, neither Foucault nor proponents of the recovery model provide criteria for assessing the collaborative efforts between professionals and clients, but discourse ethics provides the recovery model and professional practice with moral criteria for collaborative discourse concerning the meaning and acceptability of proposed clinical actions. As such, discourse ethics represents a participatory form of social justice congruent with the recovery model’s concern for clients’ involvement and self-realization in the process of treatment. It reminds professionals that their clinical expectations are always (relative to harmful consequences) negotiable as they apply to life goals and aspirations identified by clients as worthy of pursuit. As well, discourse ethics increase awareness that internal beliefs and external resources influence the potential of both professionals and clients to engage realistically in recovery oriented conversations. In situations where participants disagree, discourse ethics asks that participants be as sincerely oriented towards a collaborative and consensual resolution of differences as conditions allow and be mindful of the ways that the outcome of their deliberations may affect the autonomy and well-being of all parties to the conversation, as well as members of the larger community. In this way, discourse ethics provides advocates of the recovery model with a regulative ideal for its fair consideration and application to practice.

As such, professionals and institutions which facilitate the values of the recovery model and discourse ethics promote a cooperative approach to health care which encourages a reflective retrieval by the client of herself as a self-determining agent of change. In this way, proponents of the recovery model represent a critically reflective approach to recovery which is congruent with some themes in contemporary philosophical thinking, particularly those of Foucault and Habermas. To end, I have argued that the philosophies of Foucault and Habermas provide moral and conceptual categories that can assist the collaborative efforts of clients and professionals as they critically assess the extent to which agreed-upon interventions promote non-coercive forms of recovery.