‘I Don’t Think It Should Make a Huge Difference if You Haven’t Got the “R” Word in It’: Practitioner Accounts of Mental Health Recovery

‘I Don’t Think It Should Make a Huge Difference if You Haven’t Got the “R” Word in... Abstract Rhetorically contextualised against a history of poor outcomes and negative attitudes, New Labour’s mental health policy introduced recovery as a turn towards optimism, control and choice for those who provide and use mental health services. Recovery continues to occupy a key role within contemporary policy and practice. Despite such privilege, recovery remains a contested concept, not least because it means different things to different people. This article reports empirical work conducted during 2010–11 and explores two interpretive repertoires (traditional and responsibilised-progressive) that mental health practitioners draw upon in their accounts of recovery. Grounded in constructionist theory, the findings suggest that practitioner accounts of recovery are diverse and produce many different subject positions from which recovery may be experienced. Developing Webber and Joubert’s (2016) editorial comments on the challenge for social work, it is argued that professional social work must practise in a manner compatible with its own value base and any model of recovery must be held up for scrutiny. A knowledgeable position for the practitioner is advocated—one that is capable of working multiple paradigms in order to better understand and meet service user need. Mental health, recovery, subjectivity, discourse, interpretive repertoires Background As a concept distinct from clinical recovery or cure, personal recovery (Slade, 2013) emerged as a policy theme at the beginning of the New Millennium (Department of Health, 2001). Authored by the 2010–15 coalition government, current UK mental health policy continues to advocate recovery as one of six specific objectives (Department of Health, 2011) and is clearly visible as an ‘ethos’ within the recent mental health social work strategy (Allen et al., 2016, p. 9). Recovery has a particular meaning within policy and explicitly draws upon a North American definition (Anthony, 1993). Policy commitment is set out in Objective 2: ‘ … more people with mental health problems will recover’ (Department of Health, 2011, p. 21), which is rhetorically explained as: More people who develop mental health problems will have a good quality of life—greater ability to manage their own lives, stronger social relationships, a greater sense of purpose, the skills they need for living and working, improved chances in education, better employment rates and a suitable and stable place to live (Department of Health, 2011, p. 21).Assuming there is agreement with the above, then Objective 2 can be achieved, at least in principle. If, however, recovery is ‘deeply personal’ (Anthony, 1993), then a question emerges about the alternative ways in which recovery can be experienced and accounted for. Thus, recovery can quickly come to mean ‘whatever different interests groups want it to mean’ (Pilgrim, 2008, p. 302). However, what counts as valid meaning and who decides what is legitimate will, in part, depend upon the unchallenged orthodoxy of the dominant (recovery) discourse. For example, in their analysis of women’s talk about depression and recovery, Fullagar and O’Brien (2012, p. 1069) point out that alternative meanings of recovery will be closed down by ‘the authority invested in clinical knowledge and biomedical discourses that rely on specified treatment-regimes and normalised availabilities of recovery pathways’. In other words, recovery will become colonised (Beresford, 2015) and its meaning restricted to a narrow range of politically expedient options. MacCulloch (2011, p. 188) argues that recovery is a political attempt to reframe the lived experience of mental distress as something that is uncomplicatedly amenable to positive approaches, and advocates the need to develop professional awareness of ‘dishonest spin’ and the reassertion of professional honesty when working with people. Tilley and Cowen (2011, p. 95) go further and suggest that, within Scottish mental health policy, recovery amounts to ‘bad rhetoric’ due to it obstructing progress and debate. It has become an idea that paradoxically both openly contests and uncritically celebrates its own concept. Left unchallenged, Holloway’s (2013, p. 12) claim ‘what’s not to like about recovery?’ exemplifies the potential for a new orthodoxy, forming around the irresistible feel-good factor that accompanies recovery. Developing professional awareness of what recovery might mean is crucial in order to challenge orthodox accounts. For example, Young and Ensing (1999) found that service users often spoke about routine activities such as self-care in relation to recovery. Yet there is little mention of this topic in the broader recovery literature, with such matters deemed out of step with the progressive, strengths-based ideology that underpins recovery (Young and Ensing, 1999; Harper and Speed, 2012). Making informed choices about what any recovery service can, or claims to, offer demands that both practitioner and agency are explicit about what recovery means (Fox and Ramon, 2012). Without such transparency, informed decision making becomes undermined, and ethical practice compromised. Webber and Joubert (2016) make an important point when they argue that practitioners need to challenge the orthodoxy of clinical recovery and work towards asserting a user-centred version of personal recovery. Whilst this is a laudable rallying call, the wider issue must also recognise that both clinical and personal aspects of mental health recovery can mean different things to different people and can mean different things at different times. The challenge therefore is to appreciate that privileging any given perspective will, in principle, work to rule in and rule out certain practices. Thus, the social work task concerns empowering service user accounts of recovery (if recovery means anything at all), whilst holding up to scrutiny whatever the state, or those in positions of power, say it is. This requires a level of professional practice that is not only well versed in a range of perspectives, but also able to offer a synthesis in order to promote better health and well-being (Appleby, 2016). This approach necessitates rethinking the nature of paradigm shifts. Recovery represents a new paradigm within mental health care (Glover, 2012) and necessitates a ‘radical shift’ (Adams et al., 2009, p. 43) or a ‘radical transformation’ (Braslow, 2013, p. 785), from one way of talking about and doing mental health recovery to another: from the ‘clinical’ to the ‘personal’ (Slade, 2009). The recovery literature consistently draws upon Kuhn’s (1970) notion of paradigm shifts to explain how knowledge about recovery can challenge established orthodoxies surrounding mental health treatment and services (Allot and Loganathan, no date). Yet, the Kuhnian account is but one version. Wendel (2008) evokes Halloun’s (2004) explanation in which paradigms are considered as personal ways of making sense of the world. Thus, there is not one single paradigm that is shared by mental health practitioners (as the Kuhnian version would imply), but many personal paradigms that intersect the personal paradigms of other practitioners. Halloun’s (2004) version is useful because it not only allows critical re-examination of the radical-shift imperative; it also supports the reflective practitioner—one with the capacity and capability to work the moment and draw upon a range of knowledge in order to make sense of the task at hand. This article reports a section of empirical work undertaken as part of the author’s economic and social research council (ESRC)-funded Ph.D. The aim of the wider study was to explore the context-specific use of language that mental health practitioners and service users draw upon to make sense of recovery. The author is a qualified social worker and has a background in community mental health work. Methodology Underscored by constructionist theory, a relativist epistemology argues that we can best know about recovery through language. Discursive psychology explores what people do with their talk in particular contexts (Potter and Wetherell, 1987). This is held to be contingent upon the social and cultural availability of a range of discursive resources which people draw upon to construct various accounts. Discursive resources are central to the endeavour and include rhetorical devices and interpretive repertoires. Rhetorical devices can be explained in terms of the strategies that people use in their day-to-day language in order to persuade, justify and make authoritative truth claims. Interpretive repertoires refer to ‘broadly discernible clusters of terms, descriptions and figures of speech often assembled around metaphors, or vivid images’ (Wetherell and Potter, 1992, p. 90). Whilst drawing upon a range of discursive resources, particular subject positions (Davies and Harré, 1990) are opened up and others closed down. Subject positions offer a particular outlook from which certain aspects of the social world may be experienced. Accounting for recovery in specific ways will therefore not only elucidate particular meanings, but will also construct subject positions for how recovery can be experienced. Between July 2010 and January 2011, and due to its visible recovery orientation, the author was granted permission to undertake qualitative research within a community-based mental health social inclusion and recovery team jointly run by the National Health Service (NHS) and local authority (LA). A naturalistic approach was engaged, embracing the philosophical tradition of the Geisteswissenschaften and its concern with interpretive and constructivist aspects of social life (McAllister, 2008). Ethical approval was granted by the National Research Ethics Service (Ref: 10/H1015/33) and written consent obtained from participants. All quotations were anonymised and pseudonyms used throughout. In addition to fieldnotes, team meeting recordings (n = 16) and the collation of local documents, eighteen semi-structured interviews were recorded with mental health practitioners (n = 9) and service users (n = 9). Following Webber and Joubert’s (2016) commentary introduced earlier, this article only reports upon the analyses of data relating to mental health practitioners. Both professionally qualified practitioners (from nursing, occupational therapy (OT) and social work) and non-professionally qualified practitioners (support, time and recovery workers; Department of Health, 2003) participated in the study. The sampling strategy was opportunistic and interviewee recruitment was careful not to introduce categorical bias into the research process. Although representativeness was not an explicit aspect of the research, the greater issue was to avoid unrepresentativeness. Interviews were conversational in character and, whilst flexibility was an organising feature, a two-part strategy focused upon first asking practitioners ‘how have things been in your professional life recently?’ This was followed by asking about the day-to-day importance of the emergent topics in the person’s professional life. This approach created space for participants to draw upon a broad range of experiences, including possibilities of recovery talk. The second part of the strategy allowed the direct introduction of the word ‘recovery’. Analysis Grounded in a version of discourse analysis outlined by Potter and Wetherell (1987), interview recordings were transcribed and subjected to a process of iterative reading. Transcribed material was initially coded by open reference to recovery, which then progressed to include all instances with possible connection to recovery. This procedure generated a number of extracts, which were categorised under a common descriptor. For example, instances of recovery that associated with relapse or cure were given the category of medical or clinical. Instances that were more aligned with self-management or optimism were located under the category of responsibilised-progressive and so on. Each category or repertoire containing one or more extracts then became the basis for analysis. Analysis proceeded by exploring the patterns within the data, looking for ways in which differences and similarities demonstrated ‘variability’ (Potter and Wetherell, 1987, p. 168). Scrutiny continued by attending to the orientation of the text and its effects upon how recovery could be experienced. Data analysis was only a particular reading at a given point in time and, as with the construction of various repertoires, alternative readings are possible. Findings and discussion Four distinct interpretive repertoires are identified: traditional, responsibilised-progressive, getting on in the world and connectedness. Whilst all four repertoires support previous conceptual and empirical work, the findings indicate that repertoires are messy and subject to a range of social and cultural influence. Focusing upon Webber and Joubert’s (2016) comments discussed earlier, this paper only reports upon the first two repertoires. Traditional repertoire The traditional repertoire is closely related to clinical explanations of recovery and captures a constellation of terms that practitioners draw upon to make sense of recovery. This repertoire is the most frequently deployed linguistic resource and the most diverse. Whilst practitioner accounts do agency work, construct eligibility criteria and gate-keeping functions, they also produce versions of recovery. They accomplish this in several ways, and I introduce these below. Mechanical In the following extract, Sara challenges the appropriateness of the word ‘recovery’ and uses the analogy of mending a broken truck to evoke a mechanical sense of recovery: Recovery is like you could take a truck in and you can get that sorted out, and that’s recovered. I see it as a mechanical thing. I don’t see it as something that’s normal, that word recovery. I don’t see it as a normal word (Sara, support, time and recovery (STR) worker, interview extract).Sara’s argument rejects the word ‘recovery’, implying that service users are not mechanical objects and therefore recovery is not a normal word to be routinely uttered in connection with people. Although Sara’s talk of sorting trucks is quintessentially a Cartesian (mind–body) argument, sorting trucks resonates with a medical model of mental illness; where the body (machine) experiences illness (breakdown) requiring a doctor (mechanic) to provide the repair (recovery) (Mender, 1994). Sounding ill and being ill Although Sara makes the claim that recovery is not a normal word, her argument suggests that both recovery and the mechanical are unsatisfactory ways of accounting for mental distress. Unlike Sara, Kym (STR worker) explicitly uses the word ‘ill’. In the following extract, I ask Kym whether she would rather be asked about her hopes and aspirations instead of recovery goals: I would prefer to be, because if you said to me ‘What are your hopes and your aspirations?’ That is about my dreams. What am I looking forward to in the future, yeah? And it doesn’t sound like I’m ill. If you were asking me ‘What are your recovery goals?’ To me, ‘Oh, you’re ill. What’s your goal to get better?’ (Kym, STR worker, interview extract).Kym uses active voicing to bolster her account. This is a rhetorical strategy designed to justify and give factual status to her claim. It also works to minimise any challenge (Hutchby and Wooffitt, 1998). Kym does not actually speak of being ill, but about sounding ill. Kym draws upon a sense of embodied optimism in which the recovery–illness nexus somehow jeopardises a sense of future and wellness. Sounding ill is problematised, and there are both private and public consequences of this. For example, a consequence of sounding mentally ill can evoke a sense of marginalisation and stigma: I think because of the stigma around mental health, a lot of people seem to think that ‘Oh my God we’re going to be killed’. There’s a massive negative stigma and a lot of people we come across have maybe just got off track and just need a bit of support to get back on track (Kym, STR worker, interview extract).Not talking about recovery can be viewed as a strategy to avoid talking about mental illness, and not talking of either undermines earlier government rhetoric that ‘services of the future will talk as much about recovery as they do about symptoms and illness’ (Department of Health, 2001, p. 24). This can be seen as running counter to the treating of mental illness as any other illness approach (Read et al., 2006) and current discourse around parity of esteem (Bell, 2013). Evoking biological causality as a strategy to minimise public perception of the service user as morally culpable neatly side-steps structural inequalities and the complexity of social problems, and works to entrench mental health within a dominant biological discourse (Malla et al., 2015). I ask Kirk (STR worker) whether recovery is a useful way of making sense of experience. Kirk draws upon a traditional repertoire to make sense of recovery and constructs an argument to claim that talk of illness and recovery is unhelpful: Kirk: You see I don’t do illness. I don’t allow a person to talk about their pills and their potions and how they’re feeling and stuff because I think sometime it feeds … so I actively disapprove of that and I’ll say ‘If you want to talk about your illness, go somewhere else’. AS: So … recovery isn’t something that you would use on a day-to-day basis because it does have clinical … health related connotations? Kirk: It dwells too much on their illness, rather than ‘get on with it’ sort of thing and do stuff … and then perhaps think about why do I feel better than I did yesterday? (Kirk, STR worker, interview extract).Kirk’s argument privileges a sense of doing as opposed to thinking and his talk implies that doing things somehow promotes a sense of feeling better. Kirk’s construction of the doing service user is promoted over the thinking service user. However, Kirk’s argument is contradictory because he later attempts to reclaim thinking as a necessary tool to assess whether doing stuff has been productive. Kirk’s talk is important because it introduces a sense of social and cultural contingency surrounding the work that language does. Kirk has an extensive background working within the OT profession. Diversional activity is a notable therapeutic intervention within OT practice (McColl, 2002). The range of discursive resources that are available to Kirk would include possibilities for articulating an account that would draw sympathy with McColl’s (2002) writing. For example, secondary socialisation (professional training) works to construct a ‘sub-world’ (Berger and Luckmann, 1966, p. 158) in which role-specific vocabularies are developed in order to facilitate professional sense making. It is pertinent to point out that psychiatric rehabilitation assumes a dominant position within the recovery literature (underwriting Anthony’s 1993 definition) and, as Pilgrim (2008) succinctly points out, much recovery research is derived from work undertaken with people labelled with severe and enduring mental health problems. Thus, the language of a particular sub-world (social work, psychiatry, OT and psychology, for example) not only works to produce differing accounts of recovery, but the weighting of those accounts will vary according to what counts as legitimate knowledge. Cure and relapse Michael is a mental health practitioner. Here he makes sense of recovery by accounting for mental health problems as something that will last the duration of someone’s life: I think this word recovery, to people with mental health problems, is that there is an assumption that it’s going to go away one day and they’ll recover. But to me if you’ve got a significant mental health problem it’s going to be your pal for life … and it might be down here sometimes and it might be up there some other times. So to me I would never think ‘I have never known anyone recover from this’, but I wouldn’t want that to be a depressive sort of thought, that I was going to be like this forever. I’m just going to think ‘Well, it’s like this wart on my back’, or ‘It’s going to be there and sometimes it’s going to bother me’, so if you help people to kind of view recovery in those terms rather than ‘You will be recovered and this will all go away and it will be a thing of the past and you’ll be normal’, because who is normal anyway, and who won’t suffer from some emotional distress? (Michael, mental health practitioner, interview extract).Michael draws upon expert knowledge to demark his reasonable-through-experience position from the unreasonable-assumptive position of the ‘other’ (MacCallum, 2002). A traditional repertoire is evident and Michael minimises the possibilities for distress by introducing contrasting discourses (Smith, 1978)—for example, present/not present, up here/down there, sometimes it will/sometimes it won’t. Drawing upon vague descriptions (Potter, 1996), Michael advances his argument and claims personal, expert knowledge to testify that people never recover. However, Michael dismisses the curative illusion and offers the service user normative membership of society. The possibility of distress emerging at varying times through the life course, as with Michael’s account, draws upon a traditional repertoire that constructs mental illness as chronic or persistent. I ask Sara whether, if one can recover from chicken pox, one can also recover from depression or schizophrenia: There’s always a relapse isn’t there? There’s always a chance of relapse, so you can’t always recover. So this is why I don’t think that word recovery is appropriate, because you might recover from depression for three years but something else might happen in your life and then you might start with depression again (Sara, STR worker, interview extract).I am critical of my question to Sara because it is plausible that I unintentionally set up a mind–body dualism to which Sara’s response may simply reflect the duality inherent in the question. However, Sara’s talk is consistent with her talk elsewhere in the interview and, drawing upon extreme case formulations (Pomerantz, 1986), she produces an unstable version of recovery. At first, Sara argues that relapse (which is itself unstable) will make recovery impossible. Then, Sara rhetorically uses an example to make her account more credible and suggests that people do recover, only to become ill again due to life experiences. Being better and living a normal life Jane is a qualified mental health practitioner. We have previously been talking about hopes and aspirations, and I enquire how useful it would be to ask about recovery goals: Well, it depends what the word recovery meant to that person didn’t it? If they saw it as in terms of their mental health, their recovery, they’d see it as being better and not having … a mental health problem, not being on medication, being kind of back in normal society, living a normal life (Jane, mental health practitioner, interview extract).Jane’s account of recovery is conflicting because she initially produces a version that is contingent upon personal meaning. Then, Jane discursively circumscribes this meaning to a much narrower range of (mental) health-related categorical identities. These are presented in terms of the positive side of the binary, but necessarily invite the opposite—for example, normal/abnormal, well/unwell and on medication/not on medication. Accounted for in this way, service users are offered subject positions of the included and the normative society member. However, there is always the availability of opposing subjectivities such as the ‘other’ (MacCallum, 2002), who live non-normal lives and inhabit non-normal societies. The gateway to normal society and a normal life is founded upon the amelioration of their mental health problem. Harper and Speed (2012) write about binary categories and suggest that the strengths-based rhetoric that accompanies recovery must, by default, imply weakness. However, dallying with binary categories not only assumes a measure of temporal stability, but speaks little to the complexity of the lived experience and the potential for diversity. Responsibilised-progressive repertoire The responsibilised-progressive repertoire captures a sense in which talk of dreams, hopes and aspirations are assembled as personal goals, founded upon a sense of optimism and neo-liberal sensibilities of responsibilised, self-managed health care. This repertoire is more aligned to personal recovery (Slade, 2009) which is, for many commentators, a neo-liberal response to mental ill health (Beresford, 2015). As with the traditional repertoire, there is much complexity and contradiction in the various ways that practitioners construct accounts of recovery. Dreams Practitioners talk about identifying and working with service users’ dreams. Having dreams is the expectation for both mental health practitioners and service users (NSIP, 2008) and listening to service users’ dreams is an attribute of capable mental health teams (CSIP/NIMHE, 2007). Talk of dreams is evident in the research literature (Leamy et al., 2011) and in the recovery literature more generally (Watkins, 2007). I ask Kym whether she would prefer to be asked about her hopes and aspirations rather than recovery goals. My question is prompted by the introduction of a new initial assessment pro forma. Whereas the original form asked about recovery goals, the new version asks about hopes and aspirations: Yeah, I think I would rather be asked that question because I’d say it is more focussed on my dreams. Things that I’ve always wanted to do, and I think you are giving people that opportunity (Kym, STR worker, interview extract).Although my talk assumes that there is a difference between hopes, aspirations and dreams, Kym readily accepts that there is and produces a response which claims that dreams are long-held wants, positioning herself as a benevolent practitioner. However, such benevolence has limitations. Working with service user dreams is problematic. Not only do dreams have to be within the boundaries of professional ethics and the law; their fulfilment is problematised by structural inequality and the lived experience of mental distress. The benevolent practitioner position can only privilege specific dreams that are located in the practical realm of doing, effectively subjugating dreams that are intangible, messy and related to being, such as dreams of belonging, acceptance or simply of being happy or loved. Kym’s account of dreams as ‘things I’ve always wanted to do’ suggests that only temporally stable and coherent dreams are valid dreams. However, much rests upon the assumption that service users have dreams in the first place and can actually articulate them. Hopes, aspirations and goals Mental health practitioners talk of hopes and aspirations, although offer little explanation as to what these terms actually mean. Nevertheless, the situated context of their use offers an insight into how recovery gets done. In the following interview excerpt, I have just asked Elle about how asking service users about their hopes and aspirations helps to advise mental health work and I suggested to her that privileging the service user represents some departure from traditional practices: I think that [the] reason this service is different in many ways is because it is about what the service users want to do, and their hopes and their aspirations … not the other way around. I think it is more about ‘What do you want to do?’ and ‘What are your hopes and aspirations?’ and ‘Is it achievable?’ and ‘Can we help you to do it?’ (Elle, STR worker, interview extract).Elle’s talk accounts for the service as qualitatively distinct from previous arrangements, and is grounded in the hopes and aspirations of service users rather than a restricted menu of predetermined options. Whilst Elle’s account ostensibly works to distance the present from the past, the extent to which this is successful is debatable. Although the service user is rhetorically positioned as central, practitioners are positioned as umpires or adjudicators, making judgements and taking measure about what is and what is not achievable. Possibilities for recovery are therefore ultimately decided by the service. I agree in principle about putting the service user first and Elle continues: That’s the way I kind of look at it. But it is about realistic … you know, what is achievable … you know like you used to get ‘Right ok, you can come here and you can sit and play scrabble all morning’ (laughs) ‘and you can go on a walk this afternoon’. We’re not doing it. We are changing the focus and fitting the service more to what the service user’s hopes and aspirations are, to help them to recover … . It is a different way of looking at it isn’t it? We don’t kind of sit there and just put people in boxes (Elle, STR worker, interview extract).Elle returns to her talk of achievability and reframes this in terms of the service deciding what is realistic. According to Elle’s account, playing Scrabble and going for walks are not acceptable manifestations of service user hope and aspiration. They are discounted. As before, Elle’s talk is contradictory because, on the one hand, it advocates a version of service provision that is founded upon service user hopes and aspirations, but then asserts that what is realistic and achievable will be at the discretion of the service. Elle’s talk of realistic contrasts with Kirk’s version in which he recounts a training course: She said ‘You’ve got to look for the golden nugget’. We all laughed, and then she told us this tale about somebody who wanted to play for [football club ] … and a lot of people in that meeting was ‘Well that’s ridiculous. You’ve got to be realistic’. She hated the word realistic. She said ‘There’s no such word as realistic’, you can’t say that to a person, ‘Be realistic’ because you should not take away that person’s dream. And then she went on about how you can work with that person to achieve the goal … and … they ended up … cleaning up in a football ground. But that … was his first step to be playing for [football club]. And she never ever took the goal away, because that was where he was going … even though he was on the first rung of it … sweeping-up at a football ground. He might end up working behind a counter selling pies at the football ground, or he might go even high[er] … but the goal is still, ‘I want to play’ (Kirk, STR worker, interview extract).In Kirk’s version, what counts as realistic is unbounded and a tension arises in the practitioner’s collusion in advocating a specific activity whilst cognisant that the activity itself falls short of what the service user’s hopes and aspirations actually are. In other words, it is at best naïve and at worse unethical to condone that a service user cleans up or sells pies at a football ground, whilst being aware that their hopes and aspirations are to play professional football. This potential is acknowledged by Shepherd et al. (2008) when they suggest that ‘While it is true that recovery approaches do generally believe that the individual’s hopes and dreams are often more important than professional judgements about what is “realistic”, they do not encourage naïve unrealism’ (Shepherd et al., 2008, p. 3). The following exchange is set in context of a discussion about the change of language in the new assessment form. Elle indicates that, although there may not be perfect agreement between recovery, hopes and aspirations, they are nevertheless collectively used as a metaphor for moving on: AS: Previously it actually asked service users what their recovery goals were. Do you think that’s different than asking about someone’s hopes and aspirations? Elle: I don’t think it should make a huge difference if you haven’t got the ‘R’ word in it, because you should still be asking the same thing. AS: Which is? Elle: What are your hopes and aspirations? What are your goals, where do you want to move on to, you know? I think that’s a valid question (Elle, STR worker, interview extract).Constructing recovery, along with hopes and aspirations, as metaphors for moving on works to produce a particular subject position for Elle. A moral-authoritative position is afforded that carries the potential to seek out specific responses from service users. The moral-authoritative position is further supported by Elle’s assertion of validity, which of course makes claims to know about valid and invalid questions. Elle’s talk of moving on draws equity with accounts of self-development which can be found in Anthony’s (1993) definition of recovery. The service user is positioned as someone with responsibility to exist in a perpetually fluid and dynamically progressive state. It is implicit that the service user holds a future sense of self in order to engage the metaphor of moving on and have the capacity to (privately/publically) articulate their responsibilised self. For the practitioner and for the state more generally, moving on implies a stable trajectory where the individual makes incremental growth over time. However, recovery is not necessarily a linear process. It is hallmarked with twists, turns and periods of maintaining the status quo. Service users are able to resist Elle’s moral authority, but resistance could easily suggest non-engagement with services, and documented as such ‘in the case notes of the incorrigible’ (Pilgrim, 2008, p. 298). A clear sense of moving on is captured in the following extract: Kenny and Kirk were locked in discussion. Later Kirk contacted a service user to rearrange a meeting. ‘I can only carry on working with you if you show progression’ said Kirk. Failure to progress therefore appears to be a condition of the service. I wondered whether people in general ‘show progression’ and if they do, how is it evidenced? Moreover, what if one feels that one is progressing but services do not agree? (Fieldnotes, 1 November 2010). The independent self Promoting independence is an ethical principle of social work practice (BASW, 2014) and of importance to personal recovery. However, personal independence and independence from the state are two areas that are blurry. Indeed, the importance of personal independence within the wider recovery project often goes assumed and cultural norms are seldom evoked when accounting for diversity (Glynn et al., 2006; Ng et al., 2008). Even in terms of Western culture, the concept of individualism does not translate very easily, and the ‘rugged’ individualism of North America upon which recovery is clearly rooted stands accused of being excessive (Roberts and Wolfson, 2004). I ask Elle about how the notion of independence fits with recovery: I think it is because we are saying to people ‘You are coming here as a member of a group, you are not coming here are as a service user’ and we are trying to make that distinction and it’s about leaving that at the door if you like, if people are able to … it’s leaving that bit at the door and having an understanding of it so that you know if somebody comes and they are very quiet or whatever, that you’ve got the understanding of why it might be happening. But not bringing all the baggage that comes with it and dealing with it all in the group (Elle, STR worker, interview extract).Elle’s reply constructs and contrasts two categories of person: the service user and the group member. This evokes a particular arrangement whereby service users are associated with recovery, and members are associated with independence. Importantly, service users not only carry baggage, but this is liable to be unpacked within the group. Following Elle’s argumentation, the independent person is a responsible person—one who attends groups and neither brings nor unpacks their baggage within the group. The independent self also constructs the dependent self with all the oppositional qualities to those outlined above. Speaking in this way, Elle constructs the rules about what counts as acceptable and unacceptable criteria for group membership. Jane offers an opposing view of independence to that of Elle. Here, she is speaking in response to my question about her understanding of recovery teams: Well, from my understanding it’s kind of when people have got to that point where they’re ready to basically leave mental health services, back to the care of the GP. They’re at that stage where they can manage independently (Jane, mental health practitioner, interview extract).Jane evokes a sense of recovery (as indicated by her account of what recovery teams do) that is premised upon the individual’s linear progression through mental health services culminating in an ability to manage independently. Thus, independence becomes a euphemism for self-management—the leading of a life away from mental health services. Limitations Local and national socio-cultural trends, the very people I encountered and my relationships with them undoubtedly contributed to the substance of this study. In terms of limitations, therefore, it must be noted that the findings are but one representation of the data corpus gathered in one geographic area in a specific period of time. Conclusion As evidenced by the two interpretive repertoires presented in this article, practitioner accounts of recovery are variable and contradictory, and offer a number of subject positions from which recovery can be experienced. Although exploration of what recovery means for mental health practitioners is not commonplace within the research literature (Jacob et al., 2015), the findings add weight to the notion that recovery is a contested concept, whose meaning is ‘polyvalent’ (Pilgrim, 2008, p. 295). In terms of applying the findings to social work practice, it is important that such debate is not summarily side-stepped, and the practitioner left to get on with agency-led versions of ‘doing recovery’. Rather, the issue is to nestle multiple accounts of what recovery may mean within routine practice in order to develop a richer understanding of language, the work that it does and the consequences that it has for subjective experience. In practice, this involves orienting to service user accounts of recovery whilst appreciating that other fields, such as professional training, agency context, theory and research, work to rule in and rule out other versions. Thus, understanding the ways in which our personal and professional ‘worldview’ both shapes and is shaped by the lived experience becomes an important leaning point for social work. Webber and Joubert (2016) are correct to encourage challenges to the dominant medical model. Yet, there is an obligation for social work to work across all paradigms and hold up all models for scrutiny, including recovery. In this way, a knowledgeable position for the practitioner is advocated—one that is pluralistic in the privileging of any model to better understand and meet service user need. References Adams N., Daniels A., Compagni A. ( 2009) ‘ International pathways to mental health transformation’, International Journal of Mental Health , 38( 1), pp. 30– 45. Google Scholar CrossRef Search ADS   Allen R., Carr S., Linde K., Sewell H. ( 2016) Social Work for Better Mental Health: A Strategic Statement , London, Department of Health. Allott P., Loganathan L. (no date) Discovering Hope for Recovery from a British Perspective: A Review of a Sample of Recovery Literature, Implications for Practice and Systems Change, West Midlands Partnerships for Mental Health, available online at http://www.critpsynet.freeuk.com/LITERATUREREVIEWFinal.htm (accessed 3 October 2017). Anthony W. A. 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( 2016) ‘Editorial: Social work and recovery’, British Journal of Social Work , 45(Suppl 1), pp. i1– 8. Wendel P. J. ( 2008) ‘ Models and paradigms in Kuhn and Halloun’, Science and Education , 17( 1), pp. 131– 41. Google Scholar CrossRef Search ADS   Wetherell M., Potter J. ( 1992) Mapping the Language of Racism: Discourse and the Legitimation of Exploitation , London, Harvester Wheatsheaf. Young S. L., Ensing D. S. ( 1999) ‘ Exploring recovery from the perspective of people with psychiatric disabilities’, Psychiatric Rehabilitation Journal , 22( 3), pp. 219– 31. Google Scholar CrossRef Search ADS   © The Author 2017. Published by Oxford University Press on behalf of The British Association of Social Workers. All rights reserved. http://www.deepdyve.com/assets/images/DeepDyve-Logo-lg.png The British Journal of Social Work Oxford University Press

‘I Don’t Think It Should Make a Huge Difference if You Haven’t Got the “R” Word in It’: Practitioner Accounts of Mental Health Recovery

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© The Author 2017. Published by Oxford University Press on behalf of The British Association of Social Workers. All rights reserved.
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0045-3102
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Abstract

Abstract Rhetorically contextualised against a history of poor outcomes and negative attitudes, New Labour’s mental health policy introduced recovery as a turn towards optimism, control and choice for those who provide and use mental health services. Recovery continues to occupy a key role within contemporary policy and practice. Despite such privilege, recovery remains a contested concept, not least because it means different things to different people. This article reports empirical work conducted during 2010–11 and explores two interpretive repertoires (traditional and responsibilised-progressive) that mental health practitioners draw upon in their accounts of recovery. Grounded in constructionist theory, the findings suggest that practitioner accounts of recovery are diverse and produce many different subject positions from which recovery may be experienced. Developing Webber and Joubert’s (2016) editorial comments on the challenge for social work, it is argued that professional social work must practise in a manner compatible with its own value base and any model of recovery must be held up for scrutiny. A knowledgeable position for the practitioner is advocated—one that is capable of working multiple paradigms in order to better understand and meet service user need. Mental health, recovery, subjectivity, discourse, interpretive repertoires Background As a concept distinct from clinical recovery or cure, personal recovery (Slade, 2013) emerged as a policy theme at the beginning of the New Millennium (Department of Health, 2001). Authored by the 2010–15 coalition government, current UK mental health policy continues to advocate recovery as one of six specific objectives (Department of Health, 2011) and is clearly visible as an ‘ethos’ within the recent mental health social work strategy (Allen et al., 2016, p. 9). Recovery has a particular meaning within policy and explicitly draws upon a North American definition (Anthony, 1993). Policy commitment is set out in Objective 2: ‘ … more people with mental health problems will recover’ (Department of Health, 2011, p. 21), which is rhetorically explained as: More people who develop mental health problems will have a good quality of life—greater ability to manage their own lives, stronger social relationships, a greater sense of purpose, the skills they need for living and working, improved chances in education, better employment rates and a suitable and stable place to live (Department of Health, 2011, p. 21).Assuming there is agreement with the above, then Objective 2 can be achieved, at least in principle. If, however, recovery is ‘deeply personal’ (Anthony, 1993), then a question emerges about the alternative ways in which recovery can be experienced and accounted for. Thus, recovery can quickly come to mean ‘whatever different interests groups want it to mean’ (Pilgrim, 2008, p. 302). However, what counts as valid meaning and who decides what is legitimate will, in part, depend upon the unchallenged orthodoxy of the dominant (recovery) discourse. For example, in their analysis of women’s talk about depression and recovery, Fullagar and O’Brien (2012, p. 1069) point out that alternative meanings of recovery will be closed down by ‘the authority invested in clinical knowledge and biomedical discourses that rely on specified treatment-regimes and normalised availabilities of recovery pathways’. In other words, recovery will become colonised (Beresford, 2015) and its meaning restricted to a narrow range of politically expedient options. MacCulloch (2011, p. 188) argues that recovery is a political attempt to reframe the lived experience of mental distress as something that is uncomplicatedly amenable to positive approaches, and advocates the need to develop professional awareness of ‘dishonest spin’ and the reassertion of professional honesty when working with people. Tilley and Cowen (2011, p. 95) go further and suggest that, within Scottish mental health policy, recovery amounts to ‘bad rhetoric’ due to it obstructing progress and debate. It has become an idea that paradoxically both openly contests and uncritically celebrates its own concept. Left unchallenged, Holloway’s (2013, p. 12) claim ‘what’s not to like about recovery?’ exemplifies the potential for a new orthodoxy, forming around the irresistible feel-good factor that accompanies recovery. Developing professional awareness of what recovery might mean is crucial in order to challenge orthodox accounts. For example, Young and Ensing (1999) found that service users often spoke about routine activities such as self-care in relation to recovery. Yet there is little mention of this topic in the broader recovery literature, with such matters deemed out of step with the progressive, strengths-based ideology that underpins recovery (Young and Ensing, 1999; Harper and Speed, 2012). Making informed choices about what any recovery service can, or claims to, offer demands that both practitioner and agency are explicit about what recovery means (Fox and Ramon, 2012). Without such transparency, informed decision making becomes undermined, and ethical practice compromised. Webber and Joubert (2016) make an important point when they argue that practitioners need to challenge the orthodoxy of clinical recovery and work towards asserting a user-centred version of personal recovery. Whilst this is a laudable rallying call, the wider issue must also recognise that both clinical and personal aspects of mental health recovery can mean different things to different people and can mean different things at different times. The challenge therefore is to appreciate that privileging any given perspective will, in principle, work to rule in and rule out certain practices. Thus, the social work task concerns empowering service user accounts of recovery (if recovery means anything at all), whilst holding up to scrutiny whatever the state, or those in positions of power, say it is. This requires a level of professional practice that is not only well versed in a range of perspectives, but also able to offer a synthesis in order to promote better health and well-being (Appleby, 2016). This approach necessitates rethinking the nature of paradigm shifts. Recovery represents a new paradigm within mental health care (Glover, 2012) and necessitates a ‘radical shift’ (Adams et al., 2009, p. 43) or a ‘radical transformation’ (Braslow, 2013, p. 785), from one way of talking about and doing mental health recovery to another: from the ‘clinical’ to the ‘personal’ (Slade, 2009). The recovery literature consistently draws upon Kuhn’s (1970) notion of paradigm shifts to explain how knowledge about recovery can challenge established orthodoxies surrounding mental health treatment and services (Allot and Loganathan, no date). Yet, the Kuhnian account is but one version. Wendel (2008) evokes Halloun’s (2004) explanation in which paradigms are considered as personal ways of making sense of the world. Thus, there is not one single paradigm that is shared by mental health practitioners (as the Kuhnian version would imply), but many personal paradigms that intersect the personal paradigms of other practitioners. Halloun’s (2004) version is useful because it not only allows critical re-examination of the radical-shift imperative; it also supports the reflective practitioner—one with the capacity and capability to work the moment and draw upon a range of knowledge in order to make sense of the task at hand. This article reports a section of empirical work undertaken as part of the author’s economic and social research council (ESRC)-funded Ph.D. The aim of the wider study was to explore the context-specific use of language that mental health practitioners and service users draw upon to make sense of recovery. The author is a qualified social worker and has a background in community mental health work. Methodology Underscored by constructionist theory, a relativist epistemology argues that we can best know about recovery through language. Discursive psychology explores what people do with their talk in particular contexts (Potter and Wetherell, 1987). This is held to be contingent upon the social and cultural availability of a range of discursive resources which people draw upon to construct various accounts. Discursive resources are central to the endeavour and include rhetorical devices and interpretive repertoires. Rhetorical devices can be explained in terms of the strategies that people use in their day-to-day language in order to persuade, justify and make authoritative truth claims. Interpretive repertoires refer to ‘broadly discernible clusters of terms, descriptions and figures of speech often assembled around metaphors, or vivid images’ (Wetherell and Potter, 1992, p. 90). Whilst drawing upon a range of discursive resources, particular subject positions (Davies and Harré, 1990) are opened up and others closed down. Subject positions offer a particular outlook from which certain aspects of the social world may be experienced. Accounting for recovery in specific ways will therefore not only elucidate particular meanings, but will also construct subject positions for how recovery can be experienced. Between July 2010 and January 2011, and due to its visible recovery orientation, the author was granted permission to undertake qualitative research within a community-based mental health social inclusion and recovery team jointly run by the National Health Service (NHS) and local authority (LA). A naturalistic approach was engaged, embracing the philosophical tradition of the Geisteswissenschaften and its concern with interpretive and constructivist aspects of social life (McAllister, 2008). Ethical approval was granted by the National Research Ethics Service (Ref: 10/H1015/33) and written consent obtained from participants. All quotations were anonymised and pseudonyms used throughout. In addition to fieldnotes, team meeting recordings (n = 16) and the collation of local documents, eighteen semi-structured interviews were recorded with mental health practitioners (n = 9) and service users (n = 9). Following Webber and Joubert’s (2016) commentary introduced earlier, this article only reports upon the analyses of data relating to mental health practitioners. Both professionally qualified practitioners (from nursing, occupational therapy (OT) and social work) and non-professionally qualified practitioners (support, time and recovery workers; Department of Health, 2003) participated in the study. The sampling strategy was opportunistic and interviewee recruitment was careful not to introduce categorical bias into the research process. Although representativeness was not an explicit aspect of the research, the greater issue was to avoid unrepresentativeness. Interviews were conversational in character and, whilst flexibility was an organising feature, a two-part strategy focused upon first asking practitioners ‘how have things been in your professional life recently?’ This was followed by asking about the day-to-day importance of the emergent topics in the person’s professional life. This approach created space for participants to draw upon a broad range of experiences, including possibilities of recovery talk. The second part of the strategy allowed the direct introduction of the word ‘recovery’. Analysis Grounded in a version of discourse analysis outlined by Potter and Wetherell (1987), interview recordings were transcribed and subjected to a process of iterative reading. Transcribed material was initially coded by open reference to recovery, which then progressed to include all instances with possible connection to recovery. This procedure generated a number of extracts, which were categorised under a common descriptor. For example, instances of recovery that associated with relapse or cure were given the category of medical or clinical. Instances that were more aligned with self-management or optimism were located under the category of responsibilised-progressive and so on. Each category or repertoire containing one or more extracts then became the basis for analysis. Analysis proceeded by exploring the patterns within the data, looking for ways in which differences and similarities demonstrated ‘variability’ (Potter and Wetherell, 1987, p. 168). Scrutiny continued by attending to the orientation of the text and its effects upon how recovery could be experienced. Data analysis was only a particular reading at a given point in time and, as with the construction of various repertoires, alternative readings are possible. Findings and discussion Four distinct interpretive repertoires are identified: traditional, responsibilised-progressive, getting on in the world and connectedness. Whilst all four repertoires support previous conceptual and empirical work, the findings indicate that repertoires are messy and subject to a range of social and cultural influence. Focusing upon Webber and Joubert’s (2016) comments discussed earlier, this paper only reports upon the first two repertoires. Traditional repertoire The traditional repertoire is closely related to clinical explanations of recovery and captures a constellation of terms that practitioners draw upon to make sense of recovery. This repertoire is the most frequently deployed linguistic resource and the most diverse. Whilst practitioner accounts do agency work, construct eligibility criteria and gate-keeping functions, they also produce versions of recovery. They accomplish this in several ways, and I introduce these below. Mechanical In the following extract, Sara challenges the appropriateness of the word ‘recovery’ and uses the analogy of mending a broken truck to evoke a mechanical sense of recovery: Recovery is like you could take a truck in and you can get that sorted out, and that’s recovered. I see it as a mechanical thing. I don’t see it as something that’s normal, that word recovery. I don’t see it as a normal word (Sara, support, time and recovery (STR) worker, interview extract).Sara’s argument rejects the word ‘recovery’, implying that service users are not mechanical objects and therefore recovery is not a normal word to be routinely uttered in connection with people. Although Sara’s talk of sorting trucks is quintessentially a Cartesian (mind–body) argument, sorting trucks resonates with a medical model of mental illness; where the body (machine) experiences illness (breakdown) requiring a doctor (mechanic) to provide the repair (recovery) (Mender, 1994). Sounding ill and being ill Although Sara makes the claim that recovery is not a normal word, her argument suggests that both recovery and the mechanical are unsatisfactory ways of accounting for mental distress. Unlike Sara, Kym (STR worker) explicitly uses the word ‘ill’. In the following extract, I ask Kym whether she would rather be asked about her hopes and aspirations instead of recovery goals: I would prefer to be, because if you said to me ‘What are your hopes and your aspirations?’ That is about my dreams. What am I looking forward to in the future, yeah? And it doesn’t sound like I’m ill. If you were asking me ‘What are your recovery goals?’ To me, ‘Oh, you’re ill. What’s your goal to get better?’ (Kym, STR worker, interview extract).Kym uses active voicing to bolster her account. This is a rhetorical strategy designed to justify and give factual status to her claim. It also works to minimise any challenge (Hutchby and Wooffitt, 1998). Kym does not actually speak of being ill, but about sounding ill. Kym draws upon a sense of embodied optimism in which the recovery–illness nexus somehow jeopardises a sense of future and wellness. Sounding ill is problematised, and there are both private and public consequences of this. For example, a consequence of sounding mentally ill can evoke a sense of marginalisation and stigma: I think because of the stigma around mental health, a lot of people seem to think that ‘Oh my God we’re going to be killed’. There’s a massive negative stigma and a lot of people we come across have maybe just got off track and just need a bit of support to get back on track (Kym, STR worker, interview extract).Not talking about recovery can be viewed as a strategy to avoid talking about mental illness, and not talking of either undermines earlier government rhetoric that ‘services of the future will talk as much about recovery as they do about symptoms and illness’ (Department of Health, 2001, p. 24). This can be seen as running counter to the treating of mental illness as any other illness approach (Read et al., 2006) and current discourse around parity of esteem (Bell, 2013). Evoking biological causality as a strategy to minimise public perception of the service user as morally culpable neatly side-steps structural inequalities and the complexity of social problems, and works to entrench mental health within a dominant biological discourse (Malla et al., 2015). I ask Kirk (STR worker) whether recovery is a useful way of making sense of experience. Kirk draws upon a traditional repertoire to make sense of recovery and constructs an argument to claim that talk of illness and recovery is unhelpful: Kirk: You see I don’t do illness. I don’t allow a person to talk about their pills and their potions and how they’re feeling and stuff because I think sometime it feeds … so I actively disapprove of that and I’ll say ‘If you want to talk about your illness, go somewhere else’. AS: So … recovery isn’t something that you would use on a day-to-day basis because it does have clinical … health related connotations? Kirk: It dwells too much on their illness, rather than ‘get on with it’ sort of thing and do stuff … and then perhaps think about why do I feel better than I did yesterday? (Kirk, STR worker, interview extract).Kirk’s argument privileges a sense of doing as opposed to thinking and his talk implies that doing things somehow promotes a sense of feeling better. Kirk’s construction of the doing service user is promoted over the thinking service user. However, Kirk’s argument is contradictory because he later attempts to reclaim thinking as a necessary tool to assess whether doing stuff has been productive. Kirk’s talk is important because it introduces a sense of social and cultural contingency surrounding the work that language does. Kirk has an extensive background working within the OT profession. Diversional activity is a notable therapeutic intervention within OT practice (McColl, 2002). The range of discursive resources that are available to Kirk would include possibilities for articulating an account that would draw sympathy with McColl’s (2002) writing. For example, secondary socialisation (professional training) works to construct a ‘sub-world’ (Berger and Luckmann, 1966, p. 158) in which role-specific vocabularies are developed in order to facilitate professional sense making. It is pertinent to point out that psychiatric rehabilitation assumes a dominant position within the recovery literature (underwriting Anthony’s 1993 definition) and, as Pilgrim (2008) succinctly points out, much recovery research is derived from work undertaken with people labelled with severe and enduring mental health problems. Thus, the language of a particular sub-world (social work, psychiatry, OT and psychology, for example) not only works to produce differing accounts of recovery, but the weighting of those accounts will vary according to what counts as legitimate knowledge. Cure and relapse Michael is a mental health practitioner. Here he makes sense of recovery by accounting for mental health problems as something that will last the duration of someone’s life: I think this word recovery, to people with mental health problems, is that there is an assumption that it’s going to go away one day and they’ll recover. But to me if you’ve got a significant mental health problem it’s going to be your pal for life … and it might be down here sometimes and it might be up there some other times. So to me I would never think ‘I have never known anyone recover from this’, but I wouldn’t want that to be a depressive sort of thought, that I was going to be like this forever. I’m just going to think ‘Well, it’s like this wart on my back’, or ‘It’s going to be there and sometimes it’s going to bother me’, so if you help people to kind of view recovery in those terms rather than ‘You will be recovered and this will all go away and it will be a thing of the past and you’ll be normal’, because who is normal anyway, and who won’t suffer from some emotional distress? (Michael, mental health practitioner, interview extract).Michael draws upon expert knowledge to demark his reasonable-through-experience position from the unreasonable-assumptive position of the ‘other’ (MacCallum, 2002). A traditional repertoire is evident and Michael minimises the possibilities for distress by introducing contrasting discourses (Smith, 1978)—for example, present/not present, up here/down there, sometimes it will/sometimes it won’t. Drawing upon vague descriptions (Potter, 1996), Michael advances his argument and claims personal, expert knowledge to testify that people never recover. However, Michael dismisses the curative illusion and offers the service user normative membership of society. The possibility of distress emerging at varying times through the life course, as with Michael’s account, draws upon a traditional repertoire that constructs mental illness as chronic or persistent. I ask Sara whether, if one can recover from chicken pox, one can also recover from depression or schizophrenia: There’s always a relapse isn’t there? There’s always a chance of relapse, so you can’t always recover. So this is why I don’t think that word recovery is appropriate, because you might recover from depression for three years but something else might happen in your life and then you might start with depression again (Sara, STR worker, interview extract).I am critical of my question to Sara because it is plausible that I unintentionally set up a mind–body dualism to which Sara’s response may simply reflect the duality inherent in the question. However, Sara’s talk is consistent with her talk elsewhere in the interview and, drawing upon extreme case formulations (Pomerantz, 1986), she produces an unstable version of recovery. At first, Sara argues that relapse (which is itself unstable) will make recovery impossible. Then, Sara rhetorically uses an example to make her account more credible and suggests that people do recover, only to become ill again due to life experiences. Being better and living a normal life Jane is a qualified mental health practitioner. We have previously been talking about hopes and aspirations, and I enquire how useful it would be to ask about recovery goals: Well, it depends what the word recovery meant to that person didn’t it? If they saw it as in terms of their mental health, their recovery, they’d see it as being better and not having … a mental health problem, not being on medication, being kind of back in normal society, living a normal life (Jane, mental health practitioner, interview extract).Jane’s account of recovery is conflicting because she initially produces a version that is contingent upon personal meaning. Then, Jane discursively circumscribes this meaning to a much narrower range of (mental) health-related categorical identities. These are presented in terms of the positive side of the binary, but necessarily invite the opposite—for example, normal/abnormal, well/unwell and on medication/not on medication. Accounted for in this way, service users are offered subject positions of the included and the normative society member. However, there is always the availability of opposing subjectivities such as the ‘other’ (MacCallum, 2002), who live non-normal lives and inhabit non-normal societies. The gateway to normal society and a normal life is founded upon the amelioration of their mental health problem. Harper and Speed (2012) write about binary categories and suggest that the strengths-based rhetoric that accompanies recovery must, by default, imply weakness. However, dallying with binary categories not only assumes a measure of temporal stability, but speaks little to the complexity of the lived experience and the potential for diversity. Responsibilised-progressive repertoire The responsibilised-progressive repertoire captures a sense in which talk of dreams, hopes and aspirations are assembled as personal goals, founded upon a sense of optimism and neo-liberal sensibilities of responsibilised, self-managed health care. This repertoire is more aligned to personal recovery (Slade, 2009) which is, for many commentators, a neo-liberal response to mental ill health (Beresford, 2015). As with the traditional repertoire, there is much complexity and contradiction in the various ways that practitioners construct accounts of recovery. Dreams Practitioners talk about identifying and working with service users’ dreams. Having dreams is the expectation for both mental health practitioners and service users (NSIP, 2008) and listening to service users’ dreams is an attribute of capable mental health teams (CSIP/NIMHE, 2007). Talk of dreams is evident in the research literature (Leamy et al., 2011) and in the recovery literature more generally (Watkins, 2007). I ask Kym whether she would prefer to be asked about her hopes and aspirations rather than recovery goals. My question is prompted by the introduction of a new initial assessment pro forma. Whereas the original form asked about recovery goals, the new version asks about hopes and aspirations: Yeah, I think I would rather be asked that question because I’d say it is more focussed on my dreams. Things that I’ve always wanted to do, and I think you are giving people that opportunity (Kym, STR worker, interview extract).Although my talk assumes that there is a difference between hopes, aspirations and dreams, Kym readily accepts that there is and produces a response which claims that dreams are long-held wants, positioning herself as a benevolent practitioner. However, such benevolence has limitations. Working with service user dreams is problematic. Not only do dreams have to be within the boundaries of professional ethics and the law; their fulfilment is problematised by structural inequality and the lived experience of mental distress. The benevolent practitioner position can only privilege specific dreams that are located in the practical realm of doing, effectively subjugating dreams that are intangible, messy and related to being, such as dreams of belonging, acceptance or simply of being happy or loved. Kym’s account of dreams as ‘things I’ve always wanted to do’ suggests that only temporally stable and coherent dreams are valid dreams. However, much rests upon the assumption that service users have dreams in the first place and can actually articulate them. Hopes, aspirations and goals Mental health practitioners talk of hopes and aspirations, although offer little explanation as to what these terms actually mean. Nevertheless, the situated context of their use offers an insight into how recovery gets done. In the following interview excerpt, I have just asked Elle about how asking service users about their hopes and aspirations helps to advise mental health work and I suggested to her that privileging the service user represents some departure from traditional practices: I think that [the] reason this service is different in many ways is because it is about what the service users want to do, and their hopes and their aspirations … not the other way around. I think it is more about ‘What do you want to do?’ and ‘What are your hopes and aspirations?’ and ‘Is it achievable?’ and ‘Can we help you to do it?’ (Elle, STR worker, interview extract).Elle’s talk accounts for the service as qualitatively distinct from previous arrangements, and is grounded in the hopes and aspirations of service users rather than a restricted menu of predetermined options. Whilst Elle’s account ostensibly works to distance the present from the past, the extent to which this is successful is debatable. Although the service user is rhetorically positioned as central, practitioners are positioned as umpires or adjudicators, making judgements and taking measure about what is and what is not achievable. Possibilities for recovery are therefore ultimately decided by the service. I agree in principle about putting the service user first and Elle continues: That’s the way I kind of look at it. But it is about realistic … you know, what is achievable … you know like you used to get ‘Right ok, you can come here and you can sit and play scrabble all morning’ (laughs) ‘and you can go on a walk this afternoon’. We’re not doing it. We are changing the focus and fitting the service more to what the service user’s hopes and aspirations are, to help them to recover … . It is a different way of looking at it isn’t it? We don’t kind of sit there and just put people in boxes (Elle, STR worker, interview extract).Elle returns to her talk of achievability and reframes this in terms of the service deciding what is realistic. According to Elle’s account, playing Scrabble and going for walks are not acceptable manifestations of service user hope and aspiration. They are discounted. As before, Elle’s talk is contradictory because, on the one hand, it advocates a version of service provision that is founded upon service user hopes and aspirations, but then asserts that what is realistic and achievable will be at the discretion of the service. Elle’s talk of realistic contrasts with Kirk’s version in which he recounts a training course: She said ‘You’ve got to look for the golden nugget’. We all laughed, and then she told us this tale about somebody who wanted to play for [football club ] … and a lot of people in that meeting was ‘Well that’s ridiculous. You’ve got to be realistic’. She hated the word realistic. She said ‘There’s no such word as realistic’, you can’t say that to a person, ‘Be realistic’ because you should not take away that person’s dream. And then she went on about how you can work with that person to achieve the goal … and … they ended up … cleaning up in a football ground. But that … was his first step to be playing for [football club]. And she never ever took the goal away, because that was where he was going … even though he was on the first rung of it … sweeping-up at a football ground. He might end up working behind a counter selling pies at the football ground, or he might go even high[er] … but the goal is still, ‘I want to play’ (Kirk, STR worker, interview extract).In Kirk’s version, what counts as realistic is unbounded and a tension arises in the practitioner’s collusion in advocating a specific activity whilst cognisant that the activity itself falls short of what the service user’s hopes and aspirations actually are. In other words, it is at best naïve and at worse unethical to condone that a service user cleans up or sells pies at a football ground, whilst being aware that their hopes and aspirations are to play professional football. This potential is acknowledged by Shepherd et al. (2008) when they suggest that ‘While it is true that recovery approaches do generally believe that the individual’s hopes and dreams are often more important than professional judgements about what is “realistic”, they do not encourage naïve unrealism’ (Shepherd et al., 2008, p. 3). The following exchange is set in context of a discussion about the change of language in the new assessment form. Elle indicates that, although there may not be perfect agreement between recovery, hopes and aspirations, they are nevertheless collectively used as a metaphor for moving on: AS: Previously it actually asked service users what their recovery goals were. Do you think that’s different than asking about someone’s hopes and aspirations? Elle: I don’t think it should make a huge difference if you haven’t got the ‘R’ word in it, because you should still be asking the same thing. AS: Which is? Elle: What are your hopes and aspirations? What are your goals, where do you want to move on to, you know? I think that’s a valid question (Elle, STR worker, interview extract).Constructing recovery, along with hopes and aspirations, as metaphors for moving on works to produce a particular subject position for Elle. A moral-authoritative position is afforded that carries the potential to seek out specific responses from service users. The moral-authoritative position is further supported by Elle’s assertion of validity, which of course makes claims to know about valid and invalid questions. Elle’s talk of moving on draws equity with accounts of self-development which can be found in Anthony’s (1993) definition of recovery. The service user is positioned as someone with responsibility to exist in a perpetually fluid and dynamically progressive state. It is implicit that the service user holds a future sense of self in order to engage the metaphor of moving on and have the capacity to (privately/publically) articulate their responsibilised self. For the practitioner and for the state more generally, moving on implies a stable trajectory where the individual makes incremental growth over time. However, recovery is not necessarily a linear process. It is hallmarked with twists, turns and periods of maintaining the status quo. Service users are able to resist Elle’s moral authority, but resistance could easily suggest non-engagement with services, and documented as such ‘in the case notes of the incorrigible’ (Pilgrim, 2008, p. 298). A clear sense of moving on is captured in the following extract: Kenny and Kirk were locked in discussion. Later Kirk contacted a service user to rearrange a meeting. ‘I can only carry on working with you if you show progression’ said Kirk. Failure to progress therefore appears to be a condition of the service. I wondered whether people in general ‘show progression’ and if they do, how is it evidenced? Moreover, what if one feels that one is progressing but services do not agree? (Fieldnotes, 1 November 2010). The independent self Promoting independence is an ethical principle of social work practice (BASW, 2014) and of importance to personal recovery. However, personal independence and independence from the state are two areas that are blurry. Indeed, the importance of personal independence within the wider recovery project often goes assumed and cultural norms are seldom evoked when accounting for diversity (Glynn et al., 2006; Ng et al., 2008). Even in terms of Western culture, the concept of individualism does not translate very easily, and the ‘rugged’ individualism of North America upon which recovery is clearly rooted stands accused of being excessive (Roberts and Wolfson, 2004). I ask Elle about how the notion of independence fits with recovery: I think it is because we are saying to people ‘You are coming here as a member of a group, you are not coming here are as a service user’ and we are trying to make that distinction and it’s about leaving that at the door if you like, if people are able to … it’s leaving that bit at the door and having an understanding of it so that you know if somebody comes and they are very quiet or whatever, that you’ve got the understanding of why it might be happening. But not bringing all the baggage that comes with it and dealing with it all in the group (Elle, STR worker, interview extract).Elle’s reply constructs and contrasts two categories of person: the service user and the group member. This evokes a particular arrangement whereby service users are associated with recovery, and members are associated with independence. Importantly, service users not only carry baggage, but this is liable to be unpacked within the group. Following Elle’s argumentation, the independent person is a responsible person—one who attends groups and neither brings nor unpacks their baggage within the group. The independent self also constructs the dependent self with all the oppositional qualities to those outlined above. Speaking in this way, Elle constructs the rules about what counts as acceptable and unacceptable criteria for group membership. Jane offers an opposing view of independence to that of Elle. Here, she is speaking in response to my question about her understanding of recovery teams: Well, from my understanding it’s kind of when people have got to that point where they’re ready to basically leave mental health services, back to the care of the GP. They’re at that stage where they can manage independently (Jane, mental health practitioner, interview extract).Jane evokes a sense of recovery (as indicated by her account of what recovery teams do) that is premised upon the individual’s linear progression through mental health services culminating in an ability to manage independently. Thus, independence becomes a euphemism for self-management—the leading of a life away from mental health services. Limitations Local and national socio-cultural trends, the very people I encountered and my relationships with them undoubtedly contributed to the substance of this study. In terms of limitations, therefore, it must be noted that the findings are but one representation of the data corpus gathered in one geographic area in a specific period of time. Conclusion As evidenced by the two interpretive repertoires presented in this article, practitioner accounts of recovery are variable and contradictory, and offer a number of subject positions from which recovery can be experienced. Although exploration of what recovery means for mental health practitioners is not commonplace within the research literature (Jacob et al., 2015), the findings add weight to the notion that recovery is a contested concept, whose meaning is ‘polyvalent’ (Pilgrim, 2008, p. 295). In terms of applying the findings to social work practice, it is important that such debate is not summarily side-stepped, and the practitioner left to get on with agency-led versions of ‘doing recovery’. Rather, the issue is to nestle multiple accounts of what recovery may mean within routine practice in order to develop a richer understanding of language, the work that it does and the consequences that it has for subjective experience. In practice, this involves orienting to service user accounts of recovery whilst appreciating that other fields, such as professional training, agency context, theory and research, work to rule in and rule out other versions. Thus, understanding the ways in which our personal and professional ‘worldview’ both shapes and is shaped by the lived experience becomes an important leaning point for social work. Webber and Joubert (2016) are correct to encourage challenges to the dominant medical model. Yet, there is an obligation for social work to work across all paradigms and hold up all models for scrutiny, including recovery. 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Published: Oct 17, 2017

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