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Davidson et al's book on the recovery movement in psychiatry denies that it is a history, but that is how it is classified by the publisher, and it is also what is suggested by the title. It is a history, of sorts, and it draws on a diverse range of historical sources to build its central thesis: that what we read about today as "recovery" in mental health care has continuities with past developments in mental health care and social activism. It is something of a moot point whether all theses sources really are roots of the recovery movement in modern psychiatry, and that may be why the authors are rather coy about claiming to have produced a history. But a central problem for psychiatry is that it is often practised in a silo and theorized in a vacuum from related disciplines, not to mention its own history. So it is refreshing to have a book that takes a wider view, and attempts to locate psychiatry within a wider context.
The roots identified in this book are many and varied. They include Pinel, Dorothea Dix, Jane Addams, Martin Luther King, Goffman, Basaglia and Deleuze. Numerous other theorists are cited as well, so recovery is seen as consistent with many psychiatric and social theorists. Such and eclectic cast means the roots traced are both conceptual and historical. In some cases the fit seems somewhat forced, but in others the authors have drawn on insights from earlier periods to show that notions such as hope, agency and choice are not new. The idea of recurrence has been explored in previous literature, such as Patricia Allderidge's 1979 paper "Cycles in the care of the insane" and others pointing out that many "new" ideas are not so new at all. And as Peter Sedgwick noted in 1981, psychiatry, or mental health care, has a history of new movements that promise much at their inception, but which are quickly forgotten. Davidson and his colleagues are attempting a different narrative, one that posits "recovery" as new, but with significant historical antecedents.
The book comprises seven chapters, beginning with an overview of the idea of recovery, and a synopsis of the history of psychiatry, beginning in the late 18th century. The introduction also previews the scope of the book and discusses concepts central to the modern view of recovery, those of agency and citizenship. There is a chapter on Phillipe Pinel, in which Pinel's work and ideas are favorably compared to those of his English contemporary Tuke. This is followed by a chapter on Dorothea Dix and Jane Addams, providing a broader social context for recovery than the more individualist model of Pinel. The next chapter draws on the work of Adolph Meyer to cast mental illness as a problem in living. Deinstitutionalization is given a chapter of its own, with reference to Goffman and Basaglia. The focus moves in the following chapter to citizenship, which is informed by discussion of Deleuze and Martin Luther King. The final substantial chapter draws on Amartya Sen's capabilities approach, and the work of psychologist Lev Vygotsky. An imaginary scenario closes the book, with several theorists (and author Strauss) engaged in conversation in the manner of Steve Allen's 1979s television program Meeting of the Minds. Each chapter concludes with a bullet pointed section entitled "Lessons Learned".
I felt the authors rather over reached themselves in attempting to create such a wide narrative. While there is no denying that each of the theorists cited have something to teach us, I felt that the connections to the current recovery movement in psychiatry were somewhat thin in places. This was particularly so in the case of Martin Luther King and Jane Addams. While there are parallels to be drawn, that is all they are, and those social reformers did not directly address issues of mental health as addressed by modern psychiatry. I also found the valorization of Pinel over Tuke rather forced. Tuke, it seems to me, proposed a non-medical model of madness, and whatever its limitations it had in its favor that it resisted the dominance of medicine. It may have been strongly moralistic, but nineteenth century medicine had no compunction about appropriating "moral treatment" into the emergent discipline of psychiatry. I also found the sections on "lessons learned" and "lessons to avoid repeating" rather didactic, although perhaps they have value as a teaching tool.
The strongest section of the book is the chapter on agency as the basis for transformation, especially its opening sections on the need for a new conceptual framework and "beyond deinstitutionalization". So much space in journals is given to deinstitutionalization that it is something of a relief to read of a model that is forward-looking, rather than wringing its hands about a (supposed) lost golden age. I'm not sure that an argument for human agency for people with mental illness needs to be underpinned by historical precedents. Of course where they are found they are of interest. But since the "discovery" of madness there has been no unproblematic social response, and in that sense our own time is no different to any other. "Recovery" definitely has promise, not to mention limitations (an issue not addressed in this book), but my sense is that its promise is more to do with what is new about recovery than what can be read into the past. Just as Tuke and the late 18th century reformers were bold in their vision of moral treatment, we need to be bold about recovery. Davidson et al. provide some of the conceptual and political framework for that vision, and it is these aspects of their book that will help practitioners build recovery focused mental health services.
© 2011 Tony O'Brien
Tony O'Brien RN, MPhil, Senior Lecturer, Mental Health Nursing, University of Auckland , [email protected]