Recovery, Hope and Agency: The Meaning of Hope amongst Chinese Users of Mental Health Services in the UK

Recovery, Hope and Agency: The Meaning of Hope amongst Chinese Users of Mental Health Services in... Abstract Hope is considered crucial to mental health recovery. However, the manner in which social inequalities shape individuals’ meaning of hope has received little attention. Based on a close analysis of the recovery journeys of six Chinese service users in the UK, this paper explores the diverse meanings of hope among service users from non-dominant cultures. Illustrative stories are selected from in-depth life history interviews conducted with twenty-two participants. Based on the capabilities approach and intersectionality analysis, the findings reveal a paradox of hope and show how hope can be embraced, cautiously pursued or held at bay by individuals. Whilst hope is one expression of human agency, service users with reservations about hope maintain agency in other ways, despite their diminished life chances. This paper argues for an increased focus on individuals’ agency development to support recovery and advocates for the challenging of inequalities to achieve this. Mental health, inequalities, hope, recovery, Chinese, ethnic minorities Introduction The recovery movement advocates for a cultural change in mental health services that moves away from perpetuating pessimistic diagnoses and towards full citizenship (Davidson et al., 2010). Recovery is seen as living a meaningful life with or without the limitations caused by distress and mental ill-health (Anthony, 1993). Advocating for power and control for service users aligns with the social work value of respecting self-determination (Webber and Joubert, 2015). This implies human agency: service users are considered to be autonomous actors who actively pursue their recovery journey and personal growth despite setbacks (Davidson et al., 2010). Hope is often considered an essential motivational resource for countering pessimism and activating personal growth and has been discussed as a universally applied concept (Webber and Joubert, 2015). However, wider research on the meaning of hope has brought to light its diverse meanings and the risks it can bring in association with the difficult social conditions in which service users may live (e.g. Simpson, 2004; Corbett et al., 2007). What hope means for individuals from non-dominant cultures has also rarely been investigated. Based on the findings from a study of the recovery journeys of Chinese people in the UK, this paper aims to fill this gap by exploring how social inequalities shape the meaning of hope (Tang, 2017). First, the literature on hope is reviewed. The need to view research on Chinese people in the UK through a recovery lens is explained, and the use of the capabilities approach (CA) (Sen, 1999) and intersectionality analysis (Anthias, 2006) as theoretical frameworks is elaborated. After the methods section, a close analysis of the stories of six service users illustrates how intersecting inequalities shape the paradox of hope. The paper ends with a discussion that argues for the need to support agency development and challenge inequalities that constrain hope. Recovery and the hope of Chinese service users in the UK Recovery, hope and social context Studies on hope and recovery have considered the ways that mental health practitioners can instil hope to engender a sense of agency (e.g. Schrank et al., 2012; Heller, 2015; Matsuoka, 2015). Research in this area typically draws upon positive psychology, in which hope is understood as an emotion and/or cognition to achieve goals (Snyder, 1994). The literature focuses on techniques that practitioners can use to instil hope in individuals through, for example, developing self-management strategies (Schrank et al., 2012), building inter-personal relationships (Heller, 2015) and promoting positive thinking (Matsuoka, 2015). However, focusing on techniques to induce hope may have limitations in promoting recovery. Simpson (2004) argues that hope can bring vulnerability. It opens an individual to the possibility of disappointment and being hurt by circumstances if what is hoped for does not come to pass. For some, such vulnerability is linked to fluctuating symptoms. Yet, as Simpson (2004) suggests, vulnerability is also closely linked to the social context in which hope is experienced. For example, inter-personal relationships with family and friends can deny one’s hope. Life chance is another dimension that may bring vulnerability. Social and economic forces can give rise to a sense of hopelessness when these forces limit job opportunities and other life chances (Corbett et al., 2007). This echoes the critique made by Slade et al. on mental health recovery that ‘hope, without opportunity, dies’ (2012, p. 101). Thus, for service users, a paradox of hope may arise in the face of limited chances to achieve a life they value (Mattingly, 2010). Hope is closely linked to despair, resulting in an individual gauging how much she may allow herself to hope for to reduce disappointment. A ‘back and forth’ spiralling movement towards and away from hope may result, and this movement may be shaped by the social environment of service users. Holloway and Moss (2010) suggest that, in the face of a social reality that may extinguish one’s spirit, the social worker’s role is to maintain service users’ spirit by enabling them to explore their own conception or meaning of hope centred on their own frame of reference/worldview. Because worldview can be influenced by one’s social network and life chances, there is a need to explore how social contexts shape the meaning of hope and how this may facilitate or hinder recovery. Exploring how particular social contexts shape hope also allows us to understand the experiences of different groups. Whilst research on hope in service users from non-dominant cultures is limited, a few studies that focus on ethnic minorities show that hope is linked to the particular oppression and social inequalities they experience. Matsuoka (2015) finds that, for Japanese-Canadian older adults, hope and recovery are closely related to the systemic oppression they encounter in everyday life, such as ageism. Gendered ideology in Japanese culture, which emphasises humility, also inhibits positivity about oneself. Mattingly (2010) observes that, for chronically ill African American patients and their families, hope is ‘an existential problem [that] takes cultural and structural root as it is shaped by poverty, racism, and bodily suffering’ (p. 3). Hope becomes a moral project to summon strength against oppression and pain. Both studies show that the experiences of ethnic groups are not just ‘cultural’. The social contexts that shape their hope are underpinned by structural inequalities such as socio-economic deprivation, gender relations, ageism and mental health stigma. Chinese people in the UK Chinese people in the UK were chosen for this study because they are largely invisible in mainstream mental health recovery studies. However, previous research about them has identified a range of risk factors related to poor mental health. Members of this group, especially those with limited English-language skills, face language and cultural barriers in their host country (Lee et al., 2002; Huang and Spurgeon, 2006; Lane et al., 2011). Many are employed in Chinese catering businesses where poor working conditions are a source of stress (Huang and Spurgeon, 2006). Additional factors include marital breakdown, ageing and inter-generational conflict (Lee et al., 2002; Lane et al., 2011). Drawing on the surveys by the Information Centre (2006) and the Care Quality Commission’s report (2010), Yeung et al. (2013) report that Chinese people in the UK are less likely to seek help from primary care services for psychological distress but are more likely to face compulsory admission (67 per cent) than the national average (47 per cent). After acute crisis, structural barriers exist when they seek community participation and employment (Tang, 2018). Their recovery needs are clearly not met. Before explaining how this study explores inequalities that shape the hope of UK Chinese service users, a note on the cultural correspondence of the concepts is necessary. Research in Chinese societies has shown that recovery is a relevant but relatively new concept to Chinese people (Tse, 2004; Siu et al., 2012; Tse et al., 2012). Elements of a recovery ethos, such as hope and having meaning in life, are highly regarded by psychiatric inpatients in Hong Kong (Siu et al., 2012). However, Tse et al. (2012) note that some dimensions of recovery, such as recovery aspirations, may be differently defined in Chinese culture due to its collectivist orientation. Also, hope(lessness) is related to fatalism in Chinese culture. For some, it may imply powerless and pessimism but, for others, it may mean being at peace with one’s conditions (Tse, 2004). However, it is necessary to avoid dichotomous ‘East versus West’ thinking when understanding an individual’s recovery because this may mask heterogeneity within a cultural group. For example, some practices in the West, such as the asset-based approach, emphasise the collective strength of communities and the potential of community networks to support their members’ recovery (Boyd et al., 2008). For Chinese service users in the UK, a framework is needed to account for their multiple identities and diverse diasporic experiences, which may be underpinned by different dimensions of social inequality. Theoretical frameworks The CA and intersectionality analysis are adopted to explore the interplay of agency and social inequalities. This choice is underpinned by a critical realist approach that accommodates a constructivist argument (in this case, how the meaning of hope is constructed) and an exploration of social structures (probable social inequalities that give rise to these meanings) (Pilgrim, 2014). These frameworks also resonate with social work literature that makes a normative claim on the expression of agency as essential against oppression (Parsell et al., 2017). CA, originally developed from human development studies (Sen, 1999), has been applied in studies of mental health (e.g. Hopper, 2007; Davidson et al., 2010). Capability is understood as ‘substantive freedom to be and do’ (Sen, 1999), in which the process of exercising choice—agency—is one dimension. For freedom to be substantive, it is necessary to consider the life chances or ‘exercisable opportunities’ that are available to an individual (Daniels, 2010), which are constituted by structural inequalities. Hopper (2007) has explicitly critiqued the insufficient attention given to structural inequalities in the recovery movement and argues for the use of CA in understanding the social context of recovery. In this research, recovery is understood as capability (re)development. CA is used here to heuristically explore the social context that facilitates or hinders recovery. It is not concerned with what the individual ultimately chooses to do or, for the purpose of this paper, the particular life and recovery goals chosen by the individual. What is illuminated is the scope of opportunities or valued options and life choices available and socially sanctioned for service users (Hopper, 2007). Intersectionality analysis supplements CA by facilitating an understanding of the exercisable opportunities of Chinese service users: the myriad ways in which structural inequalities, such as ethnicity, class, gender and mental health discrimination, mutually shape their social conditions (Collins, 1998; Anthias, 2006). For social work, intersectionality as a tool enables practitioners to develop a culturally sensitive anti-oppression practice: a deep understanding of how dynamic power relations intersect and constitute oppressions both within and among ethnic groups (Mattsson, 2014). Anthias’s (2006) concept of ‘translocational positionality’ is useful here. Many Chinese immigrants maintain close contact with social networks in their country of origin. These social networks, along with the transnational migration experience, mean that the intersecting inequalities that UK Chinese people experience can be translocational. Anthias argues that different power relationships based on class, gender and ethnicity intersect to constitute hierarchies that exist within and cut across the boundaries of cultures and nation states. Positioning within these translocational hierarchies gives rise to different experiences of belonging and oppression, which influence individuals’ capability development. It also illuminates people’s agency: service users draw upon cultural and social resources according to their position in the hierarchy to inform their practices and multiple identities. Of particular relevance to the discussion of hope is the concept in CA of adaptive preference (Nussbaum, 2000). The concept of adaptive preference sensitises us to the adaptation and lowering of aspirations in the face of inequalities. Along the recovery journey, service users face changing life circumstances and the gain or loss of certain capabilities. Their worldview, perception of opportunities available to them and hence their recovery/life goals may change accordingly. Discussing why service users with a schizophrenia diagnosis reported subjective quality-of-life measures that minimised their loss of capabilities, despite reduced quality of life according to objective measures, Wallcraft and Hopper (2015) argue that deprivation leads an individual to ‘adapt’ to what she ‘allows’ herself to hope for. This echoes the vulnerability that hope may bring, as discussed above. In this study, attention is paid to whether one’s outlook is compromised by barriers experienced along the recovery journey. In sum, service users’ articulations of hope are analysed in relation to their social contexts, which are marked by intersecting inequalities, and their subjective assessment of their life chances to see in what way hope is capability-enhancing (or not). Method In-depth life history interviews were used due to their strength in exploring the interaction of biography and social structure (Elder et al., 2003) and their ability to generate narrative data for interpreting the participants’ social context and how they make sense of their recovery journeys. To allow narratives to emerge, the interviews included broad, open-ended questions through which the participants were invited to recount what happened before, during and after their mental health crisis. Particular attention was paid to the participants’ decision-making processes, to prompt discussion on how they made sense of mental health events, available resources and social networks, the strategies they used, the barriers they encountered and the opportunities that were available. Just as recovery is a polyvalent concept in the English-speaking world (Pilgrim, 2008), individual members of Chinese societies can also have different understandings of recovery and what it entails (Tse et al., 2012). Thus, during the interview, the researcher did not force a definition of recovery upon the participants, but allowed them to articulate how they understand recovery and hope. Two recruitment criteria were applied: self-identification as Chinese and having received a psychiatric diagnosis. To capture the heterogeneity of Chinese communities, purposive sampling was used. Interviews were conducted between 2009 and 2010. In total, twenty-two participants between twenty-five and eighty-five years of age were recruited (thirteen women and nine men). Places of birth included mainland China, Hong Kong, Vietnam and the UK. The years in which immigrants settled in the UK ranged from the mid-1960s to 2010. Diagnoses received included, but were not limited to, depression, bipolar disorder and schizophrenia. Twelve participants had been hospitalised in the UK, mainland China or Hong Kong. As recounting one’s recovery journey can be distressing and cathartic (Dickson-Swift et al., 2007), participants were recruited through Chinese community centres so that they could obtain support from the staff when necessary. They were recruited across three major cities in the UK (London, Manchester and Birmingham), after the study passed the university research ethics approval procedure. Consent forms were signed after explanation of the research aided by a bilingual information sheet. The researcher speaks fluent Cantonese, Mandarin and English. Interviews were carried out in these languages, in line with the preference of participants, who could choose to be interviewed wherever they felt comfortable. Verbatim transcriptions were carried out in the language of the interviews, and substantive coding was completed after the first interview to discern the participants’ social context, as well as the themes central to individual narratives on capability development/deprivation and those common to groups of participants. Follow-up interviews were then carried out to verify the identified themes and further explore them in relation to the intersection of inequalities. Data generation ended when no new themes were observed (Guest et al., 2006). Thematic analysis was conducted using the constant comparative method to identify key themes across the participants’ stories and the variations within each theme (Glaser and Strauss, 1967). Three caveats should be noted about the methodology. First, this research relied on participants’ personal accounts, but they could only report what they remembered of their experiences and may not have been aware of the structural forces at play. Thus, there is no claim to prove causation between inequalities and the meaning of hope. Rather, this study illuminates useful pointers to the wider social forces within which meaning-making takes place. Second, the sample size is small. Thus, the research is exploratory and does not provide a comprehensive account of the social inequalities Chinese people face in the UK. Third, selected verbatim quotes were translated by the researcher. To ensure the meaning was retained, the quotes were checked by another bilingual researcher from the Chinese community in the UK. Findings: a paradox of hope Close analysis of the data reveals the existence of a paradox of hope (Mattingly, 2010). In some cases, hope was found to hinder agency and capability development. Participants who resisted the concept of hope did so to avoid vulnerability. Yet they were not resistant to the possibility of positive change. Confirming Wallcraft and Hopper (2015), this paradox was closely related to service users’ adaptations to changing life chances along their recovery journeys. The participants’ relationships with hope were shaped by their evaluation of their life chances. This paradox of hope is further explored in the context of three themes: (i) a strong articulation of hope, (ii) the cautious pursuit of hope and (iii) a distancing from hope. The stories of two participants illustrate each theme. These stories were deliberately selected to best exemplify the similarities and contrasts among the three themes (Maxwell, 1997). A strong articulation of hope Hope was articulated strongly by five participants. However, this does not mean that they were optimistic about their future. Hins (female, early thirties) and Yung (female, mid-forties) expressed a concrete articulation of hope. However, this hope affected their capabilities in very different ways. Hins worked as a professional before migration. Having been hospitalised once for schizophrenia as a young teenager in mainland China, she had since been well. When asked whether she ever worried about relapse, she was certain that she would not relapse and gave religious faith as her reason: ‘In the Bible, it talks about heaven …. When you have God in your heart, your life will be like in heaven. It’s not something empty. You have hope. It really helps me solve a lot of things.’ For Hins, the content of Christian teachings was a source of strength against setbacks. More importantly, religion provided her with a new identity. She recalled feeling trapped by the way her close-knit family kept defining her in relation to her hospitalisation: ‘But I really didn’t like to hear about it. Because I believe in God now. I am a new person. I don’t want to look back.’ Her strong identity as a Christian enabled her to put her mental health history behind her and to narrate her new life. In contrast, Yung explicitly linked watching television programmes about fashion and glamour to hope when recounting her daily life: ‘The fashion is pretty. The models are pretty on the catwalk. I like to watch them. I feel that there is some hope in life watching them.’ Yung migrated from mainland China to get married, hoping for a better life. When she arrived, she found that her fiancé was in fact already married to another woman. She left him and moved into her own home, but then lost all her possessions in a burglary. Her new partner cheated on her, as her ex-husband had done. After these setbacks, she compared herself with other Chinese immigrants and British people whom she perceived as living a well-off life. She started buying brand-name clothes she could not afford, in her words, to ‘feel more balanced’. She became caught in a vicious cycle of spending and debt that was hard to break. When invited to elaborate on how these television programmes make her happy, Yung said it ignited her spirit: ‘I want to wear those clothes that I see on television. I want to fight for myself.’ Yet, when reflecting on her current life, the ideal body often perpetuated by these fashion shows upset her: ‘Sometimes I think I’ve got nothing in my life apart from the fat on my body.’ Yung’s words are a reminder of Cushman’s (1990) critique that consumerism gives rise to an ‘empty self’ and that people experience no real satisfaction from it. The way Yung clung onto this hope reflects an adaptive preference that seemed to hinder her rather than foster her flourishing—she ran into debt and felt bad about herself. Her meaning of hope reflects the dominant gendered ideology: a good life attainable through the consumerist culture of fashion. The formation of such adaptive preference and the vulnerability it brings are also linked to the ‘evaluation anxiety’ typical of modern unequal societies (Wilkinson and Pickett, 2011). Yung compared herself to British shoppers on the street, Chinese migrants who had come to the UK and built successful businesses, and reality stars on television programmes. These programmes instil hope in ordinary people that they too can be a star, whilst at the same time producing evaluation anxiety in terms of the ‘haves’ and the ‘have-nots’. The promises of consumer culture fuelled Yung’s evaluation anxiety as a lower-class Chinese woman migrant. Her attachment to this hope hindered her recovery: the more she hoped, the more upset she was, as she was more aware of what she did not have. Cautious expression and pursuit of hope Half of the participants expressed a cautious pursuit of hope. Their caution was a way to avoid despair. Carol (female, late thirties) had been struggling with panic attacks and crying spells since she was hospitalised for post-natal depression. After a bad day of ‘relapse’, as she called it, she could not recall what had happened. As a full-time housewife, ‘relapse’ felt like an added pressure, critically undermining her self-identity as a homemaker and carer, as often she was unable to perform domestic work during relapse. For Carol, recovery meant total cure—a state in which she would be symptom-free and medication-free. Asked what she would like to do if one day she did recover, she expressed two wishes: to be able to drive without worrying she would have a panic attack and to return to Hong Kong, as she had never got used to living in the UK. Whilst Carol seemed to have a clear sense of what she wanted to do for herself, she seemed to feel caught in a conflict between hope and what she termed ‘not daring to hope’. After expressing what she wanted to do, she said: I dare not to hope for such a perfect outcome … or such a concrete plan … because even if you just try to come up with a weekly plan, you may have a week of relapse. You never know. So, I really do not dare to hope. It seems that, to Carol, the notion of hope was a heavy weight to bear. This can be understood from her account of her gruelling recovery journey: I am wretched … the torture. You know, these medications have a lot of side effects. My body has changed. My husband really wanted me to be cured. But I told him to give up, that I can’t be cured. The doctor gave up on me too. He only gives me pills. He just told me to try different pills. ‘Not daring to hope’ was thus a strategy to avoid further disappointment through hardening her heart. Nonetheless, she used the concept of ‘good relapses’ to gauge and validate her recovery progress when revealing how she coped day after day: ‘I would ask my husband, “Did I have a ‘good relapse’ yesterday? Did I shout at you two?” … He might say, “‘No problem!’ This time you handled it very well”.’ Thus, this notion of the ‘good relapse’ was a strategy through which Carol maintained her agency over the recovery process. Lai (male, mid-sixties), suffering from long-term mental ill-health since his early twenties, also cautiously pursued his hope and recovery goal. He attributed his breakdown to gruelling working conditions and bullying in Chinese restaurants. Since the breakdown, he had been unable to secure a permanent job. Yet he kept pursuing his goal to find a paid job. He had started to study to improve his employability, but quit because he found it difficult to concentrate. Reflecting on his decision not to carry on his study, he said: ‘I thought: I’d better not give myself too much stress; it’s not good to break down again. It’s not a good time to break down.’ For Lai, negotiating between attempts to expand his life and efforts to avoid relapse is a balancing act. An adaptive preference has been formed from this balancing act. Such adaptations allow him to exercise agency amid fluctuating health and diminishing life chances to protect the recovery he has achieved so far. Nonetheless, he kept trying to engage with the labour market over the forty years since his breakdown, although most of the time he was thwarted. Having reached retirement age, with his chances of being employed further decreased by ageism, he continued to try and improve his employability in other ways, such as regular attendance at the Job Centre. To protect himself from the disappointment arising from the constant setbacks, he embraced a Chinese proverb: ‘No flowers can blossom forever.’ The proverb means that all good things come to an end and that life is beyond one’s control. He took a positive interpretation of this proverb to remind himself to be at peace with adversaries. This proverb, along with his cautious pursuit of hope, are his strategies to manage his expectations but keep persevering. Distancing from hope Six participants did not engage with the researcher’s questions about hope. Some of them were those who faced the most oppressive inequalities and limited life chances. Nevertheless, their stories and worldviews revealed their hidden aspirations and a wish to take control of life decisions. Young (male, early thirties) was born in Hong Kong and grew up in the UK. When asked what he wanted to do in the future, he said: ‘I cannot think about it.’ He described his confidence as a ‘thing’ that did not belong to him anymore: Young: In the past I could make decisions. But now, when working, I try to make decisions but it doesn’t work … I had self-confidence in the past. I didn’t think I would ever be ill. I had a lot of confidence before. When I started to get ill, the confidence disappeared. Researcher: Over the years, do you think your self-confidence came back, or further diminished? Young: I think my self-confidence is not up to me …. It’s like I have to let other people make the decision for me. Maybe they [his parents] don’t believe in me. Not many people accept this illness. Young’s continuing absence of confidence arose not only from his symptoms or his family’s reaction to his conditions, but also from the mistreatment he experienced at work. He reported being blamed for being slow at work and feeling that he was being picked on by colleagues. He was fired, being told that it was related not to illness, but to the fact that he was ‘lazy’. He said he could not assert himself in the workplace. A period of prolonged unemployment followed, and his family lost faith in his ability to make his own choices regarding study and work: Young: If I put the family pressure aside, I don’t know what I am doing. Because every time I do things, it’s my family’s suggestion. I usually listen to them. Researcher: Maybe you need to find out what you really want? Young: Yes. That’s exactly what I lost. Researcher: Maybe you can’t find it in family. Young: I have to find myself. Young’s story shows that the loss from which he felt he needed to ‘recover’ was an accumulated diminishment of agency. In this regard, the desire to regain a sense of human agency seemed to be his driving force in recovery. Feng (male, late twenties) migrated to the UK illegally and was later hospitalised for delusion. He did not articulate any concrete hope about his future and gave the impression that he chose not to think about it. Lacking English-language skills, he could only find jobs in Chinese catering businesses. He felt a sense of entrapment because he thought the harsh working conditions caused his mental illness. Aware of the stigma around mental illness in his workplace, he said he avoided chatting with his colleagues to avoid revealing his illness. However, his worldview revealed that he strove for a life with meaning. Feng migrated to the UK in search of a better life, which, to him, is more than economic advancement. Originally a fisherman from a small village, he felt that the UK had broadened his horizons and he wanted to carry on his exploration. When reflecting on his migration history, he said: I learnt that the world is very big. There are a lot of things I haven’t learnt, because I had been staying in my own space … . If I have to live like this forever, my life will be a void. Although Feng had not yet determined precisely what a meaningful life was to him, he knew he wanted change. This desire for change can be seen as a reaction to his current entrapment, which was linked to his marginalised positions within and outside Chinese communities in the UK. His desire for a meaningful life propelled his recovery and life journey. Discussion Contrary to the assumption that hope is essential to agency development and positive personal change (e.g. Schrank et al., 2012; Webber and Joubert, 2015), this study’s analysis reveals that the relationship between hope and agency development is not a straightforward one. Several observations about hope, agency and inequalities can be made in terms of recovery in general and Chinese people in particular. Implications for social work practices are discussed below. First, echoing Simpson (2004), some participants did not embrace hope because it can bring vulnerability. In addition to fluctuating symptoms, social inequalities are shown to be a major culprit in making one feel vulnerable. As shown by the analysis, diminished exercisable opportunities and oppression due to mental health discrimination, ageism, gender ideology, restricted opportunities in the labour market and harsh working conditions can dampen hope. Thus, for service users to feel hopeful, it is necessary to change a social environment that is harmful to well-being and recovery. Second, in some cases, hope can diminish individuals’ agency and hinder their development of capability to live a life they desire. This is also linked to inequalities. In Yung’s story, the hope promised by consumerist culture actually reinforces dispiriting feelings of ‘otherness’ and social distance. Under neo-liberalism, the popularisation of such hope paradoxically promotes self-blame for perceived individual failure (Ehrenreich, 2010). Hope, in this sense, keeps service users in a cycle of disappointment, rather than offering real opportunities for agency development. Third, the concept of hope may not be sufficient for understanding what propels recovery. Those participants who were cautious in expressing hope or were distanced from hope did persevere in attempting to maintain control in their recovery process (e.g. Carol’s concept of a ‘good relapse’ or Young’s realisation of ‘finding oneself’). Thus, the concept of agency could be useful for understanding the various identities and strategies service users use to keep going in the face of life constraints (e.g. Carol’s identity as a homemaker and Lai’s use of a Chinese proverb). What, then, hinders or enables the development of human agency for Chinese service users in the UK? The analysis shows that supporting their recovery requires tackling their multiple disadvantages, which are underpinned by inequalities based on class, gender, ethnicity, age and mental health discrimination (Tang, 2018). The use of intersectionality analysis illuminates diverse experiences. Hins’ story illustrates the pressure from transnational family networks. Yung’s story shows how class inequality, consumerism and gender ideology can induce evaluation anxiety and limit agency. The stories of Lai, Young and Feng are testimonies to how alienating working conditions and discriminating job markets limit working-class Chinese people’s chances of employment. These structural constraints shape their hope and recovery goals in different ways. The participants used strategies drawn from cultural resources and their positioning in the social hierarchies as sources of resilience. Hins’s religious faith provided a new identity for her to unleash a new life. Carol’s self-identity as a homemaker allowed her to focus on day-to-day coping to gradually regain confidence in recovery. Lai reminded himself of a Chinese proverb to stay at peace with constant setbacks in life. Contrary to Tse’s (2004) observation that Chinese culture emphasises dependence on family and harmonious relationship, both Hins and Young desire to keep family pressure at bay. This may be linked to their higher educational level or being more Europeanised in their behaviours and independent attitudes. Implications for social work practice Putting agency and inequalities into focus, this paper argues for empowering service users and challenging inequalities to engender hope. This requires recontextualising the life of service users when supporting them and advocating for them (Karban, 2017). Several pointers relevant to social work training, practice and policy implications in the UK are discussed below. Implications for training Collins (2015) observed that social work education pays insufficient attention to the different ways hope is conceptualised, such as faith-based hope, hope with specific goals or existential hope that solicits one’s meaning of life. Understanding the different ways hope is conceptualised and experienced would enable social workers to explore their own and service users’ concepts of hope. Such reflection can help avoid injecting hope that is not appropriate for service users. For mental health training, because hope is recognised as a core component of recovery, it is especially important to caution that, in some contexts, hope can be disempowering, rather than emancipatory. When supporting ethnic minorities, this requires social work training beyond ideas of cultural sensitivity that focus on cultural differences among groups (Matsuoka, 2015). Intersectionality can be taught as a tool to better understand the various social contexts of ethnic minorities (Mattsson, 2014). Implications for practice A strength-based approach could empower Chinese people and facilitate their agency development (Tse, 2004). Matsuoka, (2015) applied a strengths-based critical social work approach in her delivery of a ‘wellness recovery action plan’ (WRAP) with Japanese-Canadian older adults. A similar approach may be applicable to Chinese people in the UK, because both groups share a heritage of Eastern collectivist culture and reside in a Western country. Developed by Copeland (2002), the WRAP programme helps service users to reflect on their own meaning of recovery and available personal, familial and community resources to develop a self-management plan. Social workers who use a strengths-based critical approach empathise with service users’ vulnerability, but also validate their strengths in the face of various structural barriers that may be difficult to change. With this approach, service users may be able to realise their own strategies and resilience and develop a sense of agency to enable them to persevere (Matsuoka, 2015). Implications for policy This paper argues for the importance of tackling inequalities to engender hope. Yet, as Karban (2017) notes, current policies on mental health focus on interventions with individuals rather than tackling deep-rooted socio-economic conditions. In addition, social workers often find themselves working within an organisational context that links recovery to discharge rate and employment rate, rather than supporting individuals’ valued goals. Services have been cut in the name of ‘austerity’, which makes the far-reaching developmental work necessary for tackling inequalities difficult. This paper supports Karban’s (2017) call for community work and alliance across different service-user groups to campaign against common problems such as cuts in public spending. Limited references to tackling ethnic inequalities can be found within UK mental health policy since the coalition government came to power in 2010. Yet some progress may be found in the public health agenda to tackle the social determinants of health, including ethnic inequalities, by proposing changes at a local level (British Academy, 2014). The ‘Social Work for Better Mental Health’ initiative promoting co-production with service users provides another opportunity for social workers to consider working with Chinese communities with a community development approach (Department of Health, 2016; Tang, 2018). In sum, based on the experiences of Chinese people in the UK, this paper contributes to the understanding of recovery by arguing for the importance of challenging inequalities to engender real hope for meaningful recovery. Inequalities specific to this ethnic group are discussed, and individual sources of strength to maintain agency are identified. Social workers can facilitate the agency development of service users and challenge inequalities at both micro and macro levels. Acknowledgement The author would like to thank the participants for sharing their life stories, as well as Chinese Community Centre Birmingham, Wai Yin Chinese Women Society and Chinese Mental Health Association for their help in recruiting and supporting the participants. Thanks are also extended to Jill Anderson, Mick Carpenter, Ann Davis, Peter Ratcliffe and Daniel Wong for their comments on the research and the draft manuscript. 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Published by Oxford University Press on behalf of The British Association of Social Workers. All rights reserved. This article is published and distributed under the terms of the Oxford University Press, Standard Journals Publication Model (https://academic.oup.com/journals/pages/about_us/legal/notices) http://www.deepdyve.com/assets/images/DeepDyve-Logo-lg.png The British Journal of Social Work Oxford University Press

Recovery, Hope and Agency: The Meaning of Hope amongst Chinese Users of Mental Health Services in the UK

The British Journal of Social Work , Volume Advance Article – May 24, 2018

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© The Author(s) 2018. 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 Hope is considered crucial to mental health recovery. However, the manner in which social inequalities shape individuals’ meaning of hope has received little attention. Based on a close analysis of the recovery journeys of six Chinese service users in the UK, this paper explores the diverse meanings of hope among service users from non-dominant cultures. Illustrative stories are selected from in-depth life history interviews conducted with twenty-two participants. Based on the capabilities approach and intersectionality analysis, the findings reveal a paradox of hope and show how hope can be embraced, cautiously pursued or held at bay by individuals. Whilst hope is one expression of human agency, service users with reservations about hope maintain agency in other ways, despite their diminished life chances. This paper argues for an increased focus on individuals’ agency development to support recovery and advocates for the challenging of inequalities to achieve this. Mental health, inequalities, hope, recovery, Chinese, ethnic minorities Introduction The recovery movement advocates for a cultural change in mental health services that moves away from perpetuating pessimistic diagnoses and towards full citizenship (Davidson et al., 2010). Recovery is seen as living a meaningful life with or without the limitations caused by distress and mental ill-health (Anthony, 1993). Advocating for power and control for service users aligns with the social work value of respecting self-determination (Webber and Joubert, 2015). This implies human agency: service users are considered to be autonomous actors who actively pursue their recovery journey and personal growth despite setbacks (Davidson et al., 2010). Hope is often considered an essential motivational resource for countering pessimism and activating personal growth and has been discussed as a universally applied concept (Webber and Joubert, 2015). However, wider research on the meaning of hope has brought to light its diverse meanings and the risks it can bring in association with the difficult social conditions in which service users may live (e.g. Simpson, 2004; Corbett et al., 2007). What hope means for individuals from non-dominant cultures has also rarely been investigated. Based on the findings from a study of the recovery journeys of Chinese people in the UK, this paper aims to fill this gap by exploring how social inequalities shape the meaning of hope (Tang, 2017). First, the literature on hope is reviewed. The need to view research on Chinese people in the UK through a recovery lens is explained, and the use of the capabilities approach (CA) (Sen, 1999) and intersectionality analysis (Anthias, 2006) as theoretical frameworks is elaborated. After the methods section, a close analysis of the stories of six service users illustrates how intersecting inequalities shape the paradox of hope. The paper ends with a discussion that argues for the need to support agency development and challenge inequalities that constrain hope. Recovery and the hope of Chinese service users in the UK Recovery, hope and social context Studies on hope and recovery have considered the ways that mental health practitioners can instil hope to engender a sense of agency (e.g. Schrank et al., 2012; Heller, 2015; Matsuoka, 2015). Research in this area typically draws upon positive psychology, in which hope is understood as an emotion and/or cognition to achieve goals (Snyder, 1994). The literature focuses on techniques that practitioners can use to instil hope in individuals through, for example, developing self-management strategies (Schrank et al., 2012), building inter-personal relationships (Heller, 2015) and promoting positive thinking (Matsuoka, 2015). However, focusing on techniques to induce hope may have limitations in promoting recovery. Simpson (2004) argues that hope can bring vulnerability. It opens an individual to the possibility of disappointment and being hurt by circumstances if what is hoped for does not come to pass. For some, such vulnerability is linked to fluctuating symptoms. Yet, as Simpson (2004) suggests, vulnerability is also closely linked to the social context in which hope is experienced. For example, inter-personal relationships with family and friends can deny one’s hope. Life chance is another dimension that may bring vulnerability. Social and economic forces can give rise to a sense of hopelessness when these forces limit job opportunities and other life chances (Corbett et al., 2007). This echoes the critique made by Slade et al. on mental health recovery that ‘hope, without opportunity, dies’ (2012, p. 101). Thus, for service users, a paradox of hope may arise in the face of limited chances to achieve a life they value (Mattingly, 2010). Hope is closely linked to despair, resulting in an individual gauging how much she may allow herself to hope for to reduce disappointment. A ‘back and forth’ spiralling movement towards and away from hope may result, and this movement may be shaped by the social environment of service users. Holloway and Moss (2010) suggest that, in the face of a social reality that may extinguish one’s spirit, the social worker’s role is to maintain service users’ spirit by enabling them to explore their own conception or meaning of hope centred on their own frame of reference/worldview. Because worldview can be influenced by one’s social network and life chances, there is a need to explore how social contexts shape the meaning of hope and how this may facilitate or hinder recovery. Exploring how particular social contexts shape hope also allows us to understand the experiences of different groups. Whilst research on hope in service users from non-dominant cultures is limited, a few studies that focus on ethnic minorities show that hope is linked to the particular oppression and social inequalities they experience. Matsuoka (2015) finds that, for Japanese-Canadian older adults, hope and recovery are closely related to the systemic oppression they encounter in everyday life, such as ageism. Gendered ideology in Japanese culture, which emphasises humility, also inhibits positivity about oneself. Mattingly (2010) observes that, for chronically ill African American patients and their families, hope is ‘an existential problem [that] takes cultural and structural root as it is shaped by poverty, racism, and bodily suffering’ (p. 3). Hope becomes a moral project to summon strength against oppression and pain. Both studies show that the experiences of ethnic groups are not just ‘cultural’. The social contexts that shape their hope are underpinned by structural inequalities such as socio-economic deprivation, gender relations, ageism and mental health stigma. Chinese people in the UK Chinese people in the UK were chosen for this study because they are largely invisible in mainstream mental health recovery studies. However, previous research about them has identified a range of risk factors related to poor mental health. Members of this group, especially those with limited English-language skills, face language and cultural barriers in their host country (Lee et al., 2002; Huang and Spurgeon, 2006; Lane et al., 2011). Many are employed in Chinese catering businesses where poor working conditions are a source of stress (Huang and Spurgeon, 2006). Additional factors include marital breakdown, ageing and inter-generational conflict (Lee et al., 2002; Lane et al., 2011). Drawing on the surveys by the Information Centre (2006) and the Care Quality Commission’s report (2010), Yeung et al. (2013) report that Chinese people in the UK are less likely to seek help from primary care services for psychological distress but are more likely to face compulsory admission (67 per cent) than the national average (47 per cent). After acute crisis, structural barriers exist when they seek community participation and employment (Tang, 2018). Their recovery needs are clearly not met. Before explaining how this study explores inequalities that shape the hope of UK Chinese service users, a note on the cultural correspondence of the concepts is necessary. Research in Chinese societies has shown that recovery is a relevant but relatively new concept to Chinese people (Tse, 2004; Siu et al., 2012; Tse et al., 2012). Elements of a recovery ethos, such as hope and having meaning in life, are highly regarded by psychiatric inpatients in Hong Kong (Siu et al., 2012). However, Tse et al. (2012) note that some dimensions of recovery, such as recovery aspirations, may be differently defined in Chinese culture due to its collectivist orientation. Also, hope(lessness) is related to fatalism in Chinese culture. For some, it may imply powerless and pessimism but, for others, it may mean being at peace with one’s conditions (Tse, 2004). However, it is necessary to avoid dichotomous ‘East versus West’ thinking when understanding an individual’s recovery because this may mask heterogeneity within a cultural group. For example, some practices in the West, such as the asset-based approach, emphasise the collective strength of communities and the potential of community networks to support their members’ recovery (Boyd et al., 2008). For Chinese service users in the UK, a framework is needed to account for their multiple identities and diverse diasporic experiences, which may be underpinned by different dimensions of social inequality. Theoretical frameworks The CA and intersectionality analysis are adopted to explore the interplay of agency and social inequalities. This choice is underpinned by a critical realist approach that accommodates a constructivist argument (in this case, how the meaning of hope is constructed) and an exploration of social structures (probable social inequalities that give rise to these meanings) (Pilgrim, 2014). These frameworks also resonate with social work literature that makes a normative claim on the expression of agency as essential against oppression (Parsell et al., 2017). CA, originally developed from human development studies (Sen, 1999), has been applied in studies of mental health (e.g. Hopper, 2007; Davidson et al., 2010). Capability is understood as ‘substantive freedom to be and do’ (Sen, 1999), in which the process of exercising choice—agency—is one dimension. For freedom to be substantive, it is necessary to consider the life chances or ‘exercisable opportunities’ that are available to an individual (Daniels, 2010), which are constituted by structural inequalities. Hopper (2007) has explicitly critiqued the insufficient attention given to structural inequalities in the recovery movement and argues for the use of CA in understanding the social context of recovery. In this research, recovery is understood as capability (re)development. CA is used here to heuristically explore the social context that facilitates or hinders recovery. It is not concerned with what the individual ultimately chooses to do or, for the purpose of this paper, the particular life and recovery goals chosen by the individual. What is illuminated is the scope of opportunities or valued options and life choices available and socially sanctioned for service users (Hopper, 2007). Intersectionality analysis supplements CA by facilitating an understanding of the exercisable opportunities of Chinese service users: the myriad ways in which structural inequalities, such as ethnicity, class, gender and mental health discrimination, mutually shape their social conditions (Collins, 1998; Anthias, 2006). For social work, intersectionality as a tool enables practitioners to develop a culturally sensitive anti-oppression practice: a deep understanding of how dynamic power relations intersect and constitute oppressions both within and among ethnic groups (Mattsson, 2014). Anthias’s (2006) concept of ‘translocational positionality’ is useful here. Many Chinese immigrants maintain close contact with social networks in their country of origin. These social networks, along with the transnational migration experience, mean that the intersecting inequalities that UK Chinese people experience can be translocational. Anthias argues that different power relationships based on class, gender and ethnicity intersect to constitute hierarchies that exist within and cut across the boundaries of cultures and nation states. Positioning within these translocational hierarchies gives rise to different experiences of belonging and oppression, which influence individuals’ capability development. It also illuminates people’s agency: service users draw upon cultural and social resources according to their position in the hierarchy to inform their practices and multiple identities. Of particular relevance to the discussion of hope is the concept in CA of adaptive preference (Nussbaum, 2000). The concept of adaptive preference sensitises us to the adaptation and lowering of aspirations in the face of inequalities. Along the recovery journey, service users face changing life circumstances and the gain or loss of certain capabilities. Their worldview, perception of opportunities available to them and hence their recovery/life goals may change accordingly. Discussing why service users with a schizophrenia diagnosis reported subjective quality-of-life measures that minimised their loss of capabilities, despite reduced quality of life according to objective measures, Wallcraft and Hopper (2015) argue that deprivation leads an individual to ‘adapt’ to what she ‘allows’ herself to hope for. This echoes the vulnerability that hope may bring, as discussed above. In this study, attention is paid to whether one’s outlook is compromised by barriers experienced along the recovery journey. In sum, service users’ articulations of hope are analysed in relation to their social contexts, which are marked by intersecting inequalities, and their subjective assessment of their life chances to see in what way hope is capability-enhancing (or not). Method In-depth life history interviews were used due to their strength in exploring the interaction of biography and social structure (Elder et al., 2003) and their ability to generate narrative data for interpreting the participants’ social context and how they make sense of their recovery journeys. To allow narratives to emerge, the interviews included broad, open-ended questions through which the participants were invited to recount what happened before, during and after their mental health crisis. Particular attention was paid to the participants’ decision-making processes, to prompt discussion on how they made sense of mental health events, available resources and social networks, the strategies they used, the barriers they encountered and the opportunities that were available. Just as recovery is a polyvalent concept in the English-speaking world (Pilgrim, 2008), individual members of Chinese societies can also have different understandings of recovery and what it entails (Tse et al., 2012). Thus, during the interview, the researcher did not force a definition of recovery upon the participants, but allowed them to articulate how they understand recovery and hope. Two recruitment criteria were applied: self-identification as Chinese and having received a psychiatric diagnosis. To capture the heterogeneity of Chinese communities, purposive sampling was used. Interviews were conducted between 2009 and 2010. In total, twenty-two participants between twenty-five and eighty-five years of age were recruited (thirteen women and nine men). Places of birth included mainland China, Hong Kong, Vietnam and the UK. The years in which immigrants settled in the UK ranged from the mid-1960s to 2010. Diagnoses received included, but were not limited to, depression, bipolar disorder and schizophrenia. Twelve participants had been hospitalised in the UK, mainland China or Hong Kong. As recounting one’s recovery journey can be distressing and cathartic (Dickson-Swift et al., 2007), participants were recruited through Chinese community centres so that they could obtain support from the staff when necessary. They were recruited across three major cities in the UK (London, Manchester and Birmingham), after the study passed the university research ethics approval procedure. Consent forms were signed after explanation of the research aided by a bilingual information sheet. The researcher speaks fluent Cantonese, Mandarin and English. Interviews were carried out in these languages, in line with the preference of participants, who could choose to be interviewed wherever they felt comfortable. Verbatim transcriptions were carried out in the language of the interviews, and substantive coding was completed after the first interview to discern the participants’ social context, as well as the themes central to individual narratives on capability development/deprivation and those common to groups of participants. Follow-up interviews were then carried out to verify the identified themes and further explore them in relation to the intersection of inequalities. Data generation ended when no new themes were observed (Guest et al., 2006). Thematic analysis was conducted using the constant comparative method to identify key themes across the participants’ stories and the variations within each theme (Glaser and Strauss, 1967). Three caveats should be noted about the methodology. First, this research relied on participants’ personal accounts, but they could only report what they remembered of their experiences and may not have been aware of the structural forces at play. Thus, there is no claim to prove causation between inequalities and the meaning of hope. Rather, this study illuminates useful pointers to the wider social forces within which meaning-making takes place. Second, the sample size is small. Thus, the research is exploratory and does not provide a comprehensive account of the social inequalities Chinese people face in the UK. Third, selected verbatim quotes were translated by the researcher. To ensure the meaning was retained, the quotes were checked by another bilingual researcher from the Chinese community in the UK. Findings: a paradox of hope Close analysis of the data reveals the existence of a paradox of hope (Mattingly, 2010). In some cases, hope was found to hinder agency and capability development. Participants who resisted the concept of hope did so to avoid vulnerability. Yet they were not resistant to the possibility of positive change. Confirming Wallcraft and Hopper (2015), this paradox was closely related to service users’ adaptations to changing life chances along their recovery journeys. The participants’ relationships with hope were shaped by their evaluation of their life chances. This paradox of hope is further explored in the context of three themes: (i) a strong articulation of hope, (ii) the cautious pursuit of hope and (iii) a distancing from hope. The stories of two participants illustrate each theme. These stories were deliberately selected to best exemplify the similarities and contrasts among the three themes (Maxwell, 1997). A strong articulation of hope Hope was articulated strongly by five participants. However, this does not mean that they were optimistic about their future. Hins (female, early thirties) and Yung (female, mid-forties) expressed a concrete articulation of hope. However, this hope affected their capabilities in very different ways. Hins worked as a professional before migration. Having been hospitalised once for schizophrenia as a young teenager in mainland China, she had since been well. When asked whether she ever worried about relapse, she was certain that she would not relapse and gave religious faith as her reason: ‘In the Bible, it talks about heaven …. When you have God in your heart, your life will be like in heaven. It’s not something empty. You have hope. It really helps me solve a lot of things.’ For Hins, the content of Christian teachings was a source of strength against setbacks. More importantly, religion provided her with a new identity. She recalled feeling trapped by the way her close-knit family kept defining her in relation to her hospitalisation: ‘But I really didn’t like to hear about it. Because I believe in God now. I am a new person. I don’t want to look back.’ Her strong identity as a Christian enabled her to put her mental health history behind her and to narrate her new life. In contrast, Yung explicitly linked watching television programmes about fashion and glamour to hope when recounting her daily life: ‘The fashion is pretty. The models are pretty on the catwalk. I like to watch them. I feel that there is some hope in life watching them.’ Yung migrated from mainland China to get married, hoping for a better life. When she arrived, she found that her fiancé was in fact already married to another woman. She left him and moved into her own home, but then lost all her possessions in a burglary. Her new partner cheated on her, as her ex-husband had done. After these setbacks, she compared herself with other Chinese immigrants and British people whom she perceived as living a well-off life. She started buying brand-name clothes she could not afford, in her words, to ‘feel more balanced’. She became caught in a vicious cycle of spending and debt that was hard to break. When invited to elaborate on how these television programmes make her happy, Yung said it ignited her spirit: ‘I want to wear those clothes that I see on television. I want to fight for myself.’ Yet, when reflecting on her current life, the ideal body often perpetuated by these fashion shows upset her: ‘Sometimes I think I’ve got nothing in my life apart from the fat on my body.’ Yung’s words are a reminder of Cushman’s (1990) critique that consumerism gives rise to an ‘empty self’ and that people experience no real satisfaction from it. The way Yung clung onto this hope reflects an adaptive preference that seemed to hinder her rather than foster her flourishing—she ran into debt and felt bad about herself. Her meaning of hope reflects the dominant gendered ideology: a good life attainable through the consumerist culture of fashion. The formation of such adaptive preference and the vulnerability it brings are also linked to the ‘evaluation anxiety’ typical of modern unequal societies (Wilkinson and Pickett, 2011). Yung compared herself to British shoppers on the street, Chinese migrants who had come to the UK and built successful businesses, and reality stars on television programmes. These programmes instil hope in ordinary people that they too can be a star, whilst at the same time producing evaluation anxiety in terms of the ‘haves’ and the ‘have-nots’. The promises of consumer culture fuelled Yung’s evaluation anxiety as a lower-class Chinese woman migrant. Her attachment to this hope hindered her recovery: the more she hoped, the more upset she was, as she was more aware of what she did not have. Cautious expression and pursuit of hope Half of the participants expressed a cautious pursuit of hope. Their caution was a way to avoid despair. Carol (female, late thirties) had been struggling with panic attacks and crying spells since she was hospitalised for post-natal depression. After a bad day of ‘relapse’, as she called it, she could not recall what had happened. As a full-time housewife, ‘relapse’ felt like an added pressure, critically undermining her self-identity as a homemaker and carer, as often she was unable to perform domestic work during relapse. For Carol, recovery meant total cure—a state in which she would be symptom-free and medication-free. Asked what she would like to do if one day she did recover, she expressed two wishes: to be able to drive without worrying she would have a panic attack and to return to Hong Kong, as she had never got used to living in the UK. Whilst Carol seemed to have a clear sense of what she wanted to do for herself, she seemed to feel caught in a conflict between hope and what she termed ‘not daring to hope’. After expressing what she wanted to do, she said: I dare not to hope for such a perfect outcome … or such a concrete plan … because even if you just try to come up with a weekly plan, you may have a week of relapse. You never know. So, I really do not dare to hope. It seems that, to Carol, the notion of hope was a heavy weight to bear. This can be understood from her account of her gruelling recovery journey: I am wretched … the torture. You know, these medications have a lot of side effects. My body has changed. My husband really wanted me to be cured. But I told him to give up, that I can’t be cured. The doctor gave up on me too. He only gives me pills. He just told me to try different pills. ‘Not daring to hope’ was thus a strategy to avoid further disappointment through hardening her heart. Nonetheless, she used the concept of ‘good relapses’ to gauge and validate her recovery progress when revealing how she coped day after day: ‘I would ask my husband, “Did I have a ‘good relapse’ yesterday? Did I shout at you two?” … He might say, “‘No problem!’ This time you handled it very well”.’ Thus, this notion of the ‘good relapse’ was a strategy through which Carol maintained her agency over the recovery process. Lai (male, mid-sixties), suffering from long-term mental ill-health since his early twenties, also cautiously pursued his hope and recovery goal. He attributed his breakdown to gruelling working conditions and bullying in Chinese restaurants. Since the breakdown, he had been unable to secure a permanent job. Yet he kept pursuing his goal to find a paid job. He had started to study to improve his employability, but quit because he found it difficult to concentrate. Reflecting on his decision not to carry on his study, he said: ‘I thought: I’d better not give myself too much stress; it’s not good to break down again. It’s not a good time to break down.’ For Lai, negotiating between attempts to expand his life and efforts to avoid relapse is a balancing act. An adaptive preference has been formed from this balancing act. Such adaptations allow him to exercise agency amid fluctuating health and diminishing life chances to protect the recovery he has achieved so far. Nonetheless, he kept trying to engage with the labour market over the forty years since his breakdown, although most of the time he was thwarted. Having reached retirement age, with his chances of being employed further decreased by ageism, he continued to try and improve his employability in other ways, such as regular attendance at the Job Centre. To protect himself from the disappointment arising from the constant setbacks, he embraced a Chinese proverb: ‘No flowers can blossom forever.’ The proverb means that all good things come to an end and that life is beyond one’s control. He took a positive interpretation of this proverb to remind himself to be at peace with adversaries. This proverb, along with his cautious pursuit of hope, are his strategies to manage his expectations but keep persevering. Distancing from hope Six participants did not engage with the researcher’s questions about hope. Some of them were those who faced the most oppressive inequalities and limited life chances. Nevertheless, their stories and worldviews revealed their hidden aspirations and a wish to take control of life decisions. Young (male, early thirties) was born in Hong Kong and grew up in the UK. When asked what he wanted to do in the future, he said: ‘I cannot think about it.’ He described his confidence as a ‘thing’ that did not belong to him anymore: Young: In the past I could make decisions. But now, when working, I try to make decisions but it doesn’t work … I had self-confidence in the past. I didn’t think I would ever be ill. I had a lot of confidence before. When I started to get ill, the confidence disappeared. Researcher: Over the years, do you think your self-confidence came back, or further diminished? Young: I think my self-confidence is not up to me …. It’s like I have to let other people make the decision for me. Maybe they [his parents] don’t believe in me. Not many people accept this illness. Young’s continuing absence of confidence arose not only from his symptoms or his family’s reaction to his conditions, but also from the mistreatment he experienced at work. He reported being blamed for being slow at work and feeling that he was being picked on by colleagues. He was fired, being told that it was related not to illness, but to the fact that he was ‘lazy’. He said he could not assert himself in the workplace. A period of prolonged unemployment followed, and his family lost faith in his ability to make his own choices regarding study and work: Young: If I put the family pressure aside, I don’t know what I am doing. Because every time I do things, it’s my family’s suggestion. I usually listen to them. Researcher: Maybe you need to find out what you really want? Young: Yes. That’s exactly what I lost. Researcher: Maybe you can’t find it in family. Young: I have to find myself. Young’s story shows that the loss from which he felt he needed to ‘recover’ was an accumulated diminishment of agency. In this regard, the desire to regain a sense of human agency seemed to be his driving force in recovery. Feng (male, late twenties) migrated to the UK illegally and was later hospitalised for delusion. He did not articulate any concrete hope about his future and gave the impression that he chose not to think about it. Lacking English-language skills, he could only find jobs in Chinese catering businesses. He felt a sense of entrapment because he thought the harsh working conditions caused his mental illness. Aware of the stigma around mental illness in his workplace, he said he avoided chatting with his colleagues to avoid revealing his illness. However, his worldview revealed that he strove for a life with meaning. Feng migrated to the UK in search of a better life, which, to him, is more than economic advancement. Originally a fisherman from a small village, he felt that the UK had broadened his horizons and he wanted to carry on his exploration. When reflecting on his migration history, he said: I learnt that the world is very big. There are a lot of things I haven’t learnt, because I had been staying in my own space … . If I have to live like this forever, my life will be a void. Although Feng had not yet determined precisely what a meaningful life was to him, he knew he wanted change. This desire for change can be seen as a reaction to his current entrapment, which was linked to his marginalised positions within and outside Chinese communities in the UK. His desire for a meaningful life propelled his recovery and life journey. Discussion Contrary to the assumption that hope is essential to agency development and positive personal change (e.g. Schrank et al., 2012; Webber and Joubert, 2015), this study’s analysis reveals that the relationship between hope and agency development is not a straightforward one. Several observations about hope, agency and inequalities can be made in terms of recovery in general and Chinese people in particular. Implications for social work practices are discussed below. First, echoing Simpson (2004), some participants did not embrace hope because it can bring vulnerability. In addition to fluctuating symptoms, social inequalities are shown to be a major culprit in making one feel vulnerable. As shown by the analysis, diminished exercisable opportunities and oppression due to mental health discrimination, ageism, gender ideology, restricted opportunities in the labour market and harsh working conditions can dampen hope. Thus, for service users to feel hopeful, it is necessary to change a social environment that is harmful to well-being and recovery. Second, in some cases, hope can diminish individuals’ agency and hinder their development of capability to live a life they desire. This is also linked to inequalities. In Yung’s story, the hope promised by consumerist culture actually reinforces dispiriting feelings of ‘otherness’ and social distance. Under neo-liberalism, the popularisation of such hope paradoxically promotes self-blame for perceived individual failure (Ehrenreich, 2010). Hope, in this sense, keeps service users in a cycle of disappointment, rather than offering real opportunities for agency development. Third, the concept of hope may not be sufficient for understanding what propels recovery. Those participants who were cautious in expressing hope or were distanced from hope did persevere in attempting to maintain control in their recovery process (e.g. Carol’s concept of a ‘good relapse’ or Young’s realisation of ‘finding oneself’). Thus, the concept of agency could be useful for understanding the various identities and strategies service users use to keep going in the face of life constraints (e.g. Carol’s identity as a homemaker and Lai’s use of a Chinese proverb). What, then, hinders or enables the development of human agency for Chinese service users in the UK? The analysis shows that supporting their recovery requires tackling their multiple disadvantages, which are underpinned by inequalities based on class, gender, ethnicity, age and mental health discrimination (Tang, 2018). The use of intersectionality analysis illuminates diverse experiences. Hins’ story illustrates the pressure from transnational family networks. Yung’s story shows how class inequality, consumerism and gender ideology can induce evaluation anxiety and limit agency. The stories of Lai, Young and Feng are testimonies to how alienating working conditions and discriminating job markets limit working-class Chinese people’s chances of employment. These structural constraints shape their hope and recovery goals in different ways. The participants used strategies drawn from cultural resources and their positioning in the social hierarchies as sources of resilience. Hins’s religious faith provided a new identity for her to unleash a new life. Carol’s self-identity as a homemaker allowed her to focus on day-to-day coping to gradually regain confidence in recovery. Lai reminded himself of a Chinese proverb to stay at peace with constant setbacks in life. Contrary to Tse’s (2004) observation that Chinese culture emphasises dependence on family and harmonious relationship, both Hins and Young desire to keep family pressure at bay. This may be linked to their higher educational level or being more Europeanised in their behaviours and independent attitudes. Implications for social work practice Putting agency and inequalities into focus, this paper argues for empowering service users and challenging inequalities to engender hope. This requires recontextualising the life of service users when supporting them and advocating for them (Karban, 2017). Several pointers relevant to social work training, practice and policy implications in the UK are discussed below. Implications for training Collins (2015) observed that social work education pays insufficient attention to the different ways hope is conceptualised, such as faith-based hope, hope with specific goals or existential hope that solicits one’s meaning of life. Understanding the different ways hope is conceptualised and experienced would enable social workers to explore their own and service users’ concepts of hope. Such reflection can help avoid injecting hope that is not appropriate for service users. For mental health training, because hope is recognised as a core component of recovery, it is especially important to caution that, in some contexts, hope can be disempowering, rather than emancipatory. When supporting ethnic minorities, this requires social work training beyond ideas of cultural sensitivity that focus on cultural differences among groups (Matsuoka, 2015). Intersectionality can be taught as a tool to better understand the various social contexts of ethnic minorities (Mattsson, 2014). Implications for practice A strength-based approach could empower Chinese people and facilitate their agency development (Tse, 2004). Matsuoka, (2015) applied a strengths-based critical social work approach in her delivery of a ‘wellness recovery action plan’ (WRAP) with Japanese-Canadian older adults. A similar approach may be applicable to Chinese people in the UK, because both groups share a heritage of Eastern collectivist culture and reside in a Western country. Developed by Copeland (2002), the WRAP programme helps service users to reflect on their own meaning of recovery and available personal, familial and community resources to develop a self-management plan. Social workers who use a strengths-based critical approach empathise with service users’ vulnerability, but also validate their strengths in the face of various structural barriers that may be difficult to change. With this approach, service users may be able to realise their own strategies and resilience and develop a sense of agency to enable them to persevere (Matsuoka, 2015). Implications for policy This paper argues for the importance of tackling inequalities to engender hope. Yet, as Karban (2017) notes, current policies on mental health focus on interventions with individuals rather than tackling deep-rooted socio-economic conditions. In addition, social workers often find themselves working within an organisational context that links recovery to discharge rate and employment rate, rather than supporting individuals’ valued goals. Services have been cut in the name of ‘austerity’, which makes the far-reaching developmental work necessary for tackling inequalities difficult. This paper supports Karban’s (2017) call for community work and alliance across different service-user groups to campaign against common problems such as cuts in public spending. Limited references to tackling ethnic inequalities can be found within UK mental health policy since the coalition government came to power in 2010. Yet some progress may be found in the public health agenda to tackle the social determinants of health, including ethnic inequalities, by proposing changes at a local level (British Academy, 2014). The ‘Social Work for Better Mental Health’ initiative promoting co-production with service users provides another opportunity for social workers to consider working with Chinese communities with a community development approach (Department of Health, 2016; Tang, 2018). In sum, based on the experiences of Chinese people in the UK, this paper contributes to the understanding of recovery by arguing for the importance of challenging inequalities to engender real hope for meaningful recovery. Inequalities specific to this ethnic group are discussed, and individual sources of strength to maintain agency are identified. Social workers can facilitate the agency development of service users and challenge inequalities at both micro and macro levels. Acknowledgement The author would like to thank the participants for sharing their life stories, as well as Chinese Community Centre Birmingham, Wai Yin Chinese Women Society and Chinese Mental Health Association for their help in recruiting and supporting the participants. Thanks are also extended to Jill Anderson, Mick Carpenter, Ann Davis, Peter Ratcliffe and Daniel Wong for their comments on the research and the draft manuscript. 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Published by Oxford University Press on behalf of The British Association of Social Workers. All rights reserved. This article is published and distributed under the terms of the Oxford University Press, Standard Journals Publication Model (https://academic.oup.com/journals/pages/about_us/legal/notices)

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The British Journal of Social WorkOxford University Press

Published: May 24, 2018

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