Beyond Paradigms: Promoting a Recovery Agenda in Mental Health
Prof Pat Bracken
Institute for Philosophy, Diversity and Mental Health
Centre for Ethnicity and Health
University of Central Lancashire
In recent years, the concept of recovery has increasingly been used to signal a growing demand for alternatives in the field of mental health. Allot et al[i] argue that the move to a recovery framework represents a ‘paradigm shift’ in our understanding of mental health problems. In this paper, I will argue for a more radical interpretation and suggest the recovery movement is not about shifting from one paradigm to another but about moving beyond paradigm thinking altogether. First I will look at what is meant by the term paradigm and suggest that it is essentially a feature of what Kuhn calls ‘normal science’. I will outline what I see as the main features of the currently dominant paradigm in mental health and indicate the ways in which recovery presents a challenge to this. I will then use some ideas from Heidegger to help us think about how we might get beyond thinking through paradigms.
Thomas Kuhn introduced the concept of ‘paradigms’ in his 1962 book The Structure of Scientific Revolutions[ii]. Kuhn argued that all scientific work takes place on the basis of an accepted background framework. This essentially involves agreed examples of what sort of experiments are appropriate and accepted in the science but also involves shared assumptions and values that allow the scientists to communicate with one another, to challenge one another and to design new experiments and theories. Kuhn uses the word paradigm to suggest ‘that some accepted examples of actual scientific practice - examples which include law, theory, application, and instrumentation together- provide models from which spring particular coherent traditions of scientific research’[iii] .
While the word paradigm is now used outside the field of science, it still refers to a situation where there is a framework that guides developments in a particular field of enquiry or discourse. Such frameworks allow individuals, objects and relationships to ‘show up’, or present themselves, in particular ways. They set out the area of concern in a way that permits interventions of one sort or another. They allow for discussion, disagreement and development to take place. Thus, while the word ‘paradigm’ can be used to signal something that stands outside of science, it still connotes a discourse where there are accepted models at work. Paradigms are about how we know the world around us. They are part of a discourse that has an epistemological orientation, a discourse which is ultimately all about possibilities of knowledge and expertise.
My argument is that currently the world of mental health is orientated by a particular paradigm, a dominant framework that involves certain assumptions, values and priorities. This paradigm determines what is accepted as a ‘fact’ and what counts as ‘evidence’. Furthermore, I will argue that what is genuinely radical about the recovery movement is that it involves, essentially, a call to get beyond paradigms altogether, rather than replace this with a different paradigm.
For Kuhn, paradigms lie at the heart of what he called ‘normal science’. They provide the scientist with set ideas about what counts as a fact, about what are appropriate methods of investigation and ultimately about how interpretations of experiments should be made. The recovery movement does not seek to replace one set of assumptions, examples and styles of judgments with another. Rather, the user/survivor recovery literature points to a situation where there is an acceptance of diversity and where a new normal science is unable to take hold. In fact, I believe that in this interpretation, the recovery movement is a quest to find a way of engaging with mental health problems that doesn’t start from an epistemological orientation at all.
The dominant paradigm
While we often talk about the currently dominant orientation in mental health in terms of the ‘medical model’, Phil Thomas and I have been arguing for some time that the governing paradigm is something that goes deeper than the medical vocabulary used within psychiatry itself. We refer to it as the ‘technical’ paradigm: the idea that mental health problems are primarily challenges of a technical nature. In this paradigm, questions to do with values and ethics, meanings and contexts, relationships and power are not ignored but they are secondary.
The operation of the technical paradigm is probably best demonstrated in two recent developments. First is the preoccupation with classification that has so absorbed psychiatry in the past 25 years. Huge efforts have been expended on developing the various versions of the DSM. The DSM is promoted as being ‘empirical and value-free’. It has been exported around the world and works on the basic assumption that by using a set of operationalised criteria, mental disorders can be diagnosed independently of culture, history and context.
The technical paradigm is also seen to underscore debates in the area of treatment and, in particular, in the operation of the ‘evidence based’ approach to mental health. This works with the assumption that there are a set of mental health interventions that can be applied and studied independent of context and relationships and that are essentially value-neutral in themselves. Just as it is possible (and important) in the field of oncology to study the benefits and side-effects of different modalities of intervention (surgery, radiotherapy, chemotherapy) in as detached a manner as possible, the same is put forward as being the case in mental health.
That the technological understanding of mental health is dominant, and (almost always) accepted as common-sense, is evidenced by the contents of journals of psychiatry across the world. Over 90% of the articles in the major journals concern technical aspects of mental health. As I said before, values, relationships and meanings are not ignored altogether but they are marginalized as secondary.
It is important to note that when Phil and I speak about the technical paradigm we are talking about something that is much deeper and more prevalent than biological frameworks and drug treatments. The ‘evidenced based’ practice approach does not just involve drug trials. Proponents of various different forms of psychotherapy also make the case for their interventions on the basis that they can be studied in a detached, context-independent manner. In fact, the technical way of thinking orientates most of the schools of psychotherapy. For example, CBT (cognitive behavioural therapy) is promoted as an evidence-based set of techniques that can be studied in isolation from questions to do with relationships, values and setting. On the other side, psychoanalysis can be just as technical with a complex specialized vocabulary that sets it apart from ordinary daily discourse.
This focus on the technical is also seen in service frameworks. While there is usually a statement somewhere in all our policy documents about values and respect for cultures, the central element is technical, to do with team organization, structures, protocols and service models. To a large extent, the promotion of the current National Service Framework (NSF) in the UK has become a matter of managers ticking boxes when they have certain elements of the service plan in place. While this was certainly not the intention of many of those who developed and promoted the NSF in the UK, the fact that this has happened is the product of the powerful operation of the underlying technical paradigm at work. In the day-to day reality of the world of mental health services, this paradigm works to determine what the priorities are, where energy should be focused and how the whole NSF development will be judged. With regard to the latter, this has largely become a question of identifying ‘performance indicators’, and working out how these can be operationalized and assessed.
Why does this paradigm hold sway?
Thinking about mental health problems as technical difficulties is attractive for a number of reasons. It is initially attractive to many patients who are often happy for someone to put a name and a model on what they are going through. Sometimes it is a relief to regard this as a ‘thing’, something almost separate from the self. As such it is something that can be passed over to an expert to deal with. It also allows the sufferer to give up some responsibility and to move into the ‘sick role’ for a period of time. This is sometimes needed and helpful.
The technical paradigm has obvious advantages for the practitioner. It allows him/her to adopt the position of expert. In a paradigm - orientated approach, the person who is trained in the logic and workings of the paradigm will always be the most powerful. Knowing the model and how to apply it becomes the essence of professional training. The practitioner learns the vocabulary, incorporates the assumptions and shares a frame of reference with his/her colleagues who work within the same model. This all brings an income and prestige to the professional. In many ways, the technological paradigm underscores the workings of the entire ‘psych industry’. It provides the logic and justification for university departments, research institutes, conferences, seminars and journals.
One of the major supports for this paradigm is the enormous wealth of the pharmaceutical industry. The medicalization and technicalization of life that Western (and increasingly non-Western) societies have witnessed in the second half of the 20th century has opened new markets for this industry; in particular, anti-depressant drugs have been very big earners. These drugs are now prescribed for a range of ‘syndromes’ from social anxiety to posttraumatic stress disorder. The industry has worked to extend a technicalized way of thinking about problems to areas of life that previously would not be the concern of doctors, therapists and other professionals.
While in the technological paradigm there is a role for service users, this is advisory only, and works at the level of consultation. Just as patient groups can be allies in the field of cardiology or endocrinology, they do not change the assumptions or science of the discipline. They are there in an adjunctive role. They may help with getting certain messages to the patients involved and can be used to identify people for research projects. They can even campaign for research funds and for new services. But they rarely set the research, service or training agendas.
The emergence of an alternative paradigm
In recent years the dominance of this paradigm has been challenged. While some of this challenge has come from professionals, the momentum and political force of this has been from the service user/suvivor movement. Now it is important to be clear: many service users are happy with the technical paradigm, they seek a diagnosis and a treatment and are happy to understand their problems in a medical or psychotherapeutic idiom. As stated above, the ‘medical model’ has clear advantages for many people who are distressed or suffering emotionally. Many service users and their organizations place a priority on efficiency when it comes to service delivery and if they have a criticism of the ‘system’ it is about a need for more services.
However, a growing number of users are struggling not for more but for different ways of thinking about, and working with, mental health problems. This is evidenced in the emergence of groups such as The Hearing Voices Network, The Paranoia Network, the Evolving Minds group in Yorkshire, Mad Pride, Mind Freedom International and the Icarus Project in the US. These groups don’t seek more interventions from psychiatry, more psychotherapy or even more efficient services. They don’t want more research into classification, genetics and cognitions. In their different ways, what they seek is not knowledge or technology but empowerment.
In different ways, this movement has become associated with the idea of recovery.
While the term ‘recovery’ is not without its problems, it looks as though it is here to stay! While a bit vague, and thus easily co-opted and neutralized, it has been used by service users themselves to identify a move to a different and alternative way of approaching the whole question of mental illness. Against the technological paradigm, recovery puts as centre stage a discourse centered on questions to do with values and ethics, meanings and contexts, relationships and power. Questions to do with classification and interventions are not dismissed but they are rendered secondary. Their orientation and significance only emerges from the more primary focus on values, meanings and relationships.
The recovery approach has a wide range of implications: how we understand and frame states of distress, alienation and madness; how we think about the appropriateness of various interventions; what we prioritise in terms of the development of services; what sorts of research are a priority; how we do training and who should be involved; how we see the relevance of disciplines such as philosophy and anthropology in understanding the world of mental health; how we see the relevance of discourses that move between creativity, spirituality and mental health.
Most importantly, the voices of service users and their organizations are central in the recovery approach: they are the experts when it comes to the fundamentals of what is at stake in mental health and illness. This is the theoretical grounding of user empowerment. Without such a move away from the technical paradigm, the user voice will always be secondary to that of the doctor, the therapist or the researcher: the expert.
I believe that there are philosophical, historical, ethical and empirical reasons in favour of a move to this orientation but I will not dwell on these here. I will simply take it for granted that overcoming the technical paradigm is to be welcomed. Remember, we are not talking about demonizing drugs or biological psychiatry. This is about reorganizing our thinking in a way that finds a more authentic role for these interventions; one that positions them in relation to a more democratic discourse about mental health; a discourse that actively seeks to put the needs and priorities of users and survivors above professional and corporate interests. This is a move to understanding the relevance of endeavours like psychopharmacology in a different light.
Now the question arises: how are we to effect this fundamental shift in priorities? How are we to free ourselves from a technical idiom? How can we get outside a discourse that thinks about mental health in terms of paradigms and models?
This is indeed a pressing problem. Everywhere we see examples of well meaning initiatives to improve mental health services turning into ‘projects’ that then become wrapped up in a technicalized language and orientation and become something other than that as which they started. If we are not aware of how deep this form of thinking affects our experience of the world and our understanding of problems and solutions, our best efforts to initiate progressive developments will continue to become infected with a form of thinking that neutralises efforts towards radical change. In the next section, I will look at some ideas put forward by the philosopher, Martin Heidegger, which may help us to get some sense of direction.
Heidegger and the history of being.
Throughout all his work, Heidegger was concerned with the question of Being.
I am minded to follow the American philosopher, Hubert Dreyfus, in my understanding of Heidegger on this point. Dreyfus points out that what Heidegger has in mind when he raises the ‘question of Being’ is an attempt ‘to make sense of our ability to make sense of things’[iv].
Heidegger wants us to think about the fact that (for the most part) things show up for us as connected, meaningful and as somehow coherent. He wants us to dwell on the simple fact that a world shows up for us, a world where things are connected and positioned and somehow ordered. We take this for granted most of the time, Heidegger wants to highlight it and make it an object of wonder.
It might help to use an analogy. I ask the reader to think of a game of chess. We are familiar with all the different pieces and their different characteristics, powers, levels of significance etc. But a game of chess would be impossible without the chequered board on top of which and according to which all these pieces are related. Very crudely, Being is like the chessboard; it is the background matrix against which things in our lives are meaningful and connected. Without the board in the game of chess, the pieces are all present but their relationships become arbitrary and purposeless. Exploring the question of Being is about exploring the way in which a world shows up as meaningful for us.
Now a key element of Heidegger’s philosophy as worked out in Being and Time[v] is that Being is not generated primarily by thinking. Instead, for Heidegger, background meaning derives from our practical engagement in the world. It is given to us by the social practices through which we emerge as human beings with an understanding of ourselves and our worlds. These practices are not conscious in the main but they do involve the transmission of values, assumptions and expectations. They produce a background against which particular things - objects, relationships, ideas, goals - make sense.
Dreyfus says: ‘One might say that a culture’s understanding of being is its style of life manifest in the way its everyday practices are coordinated. A culture’s understanding of being allows people and things to show up as something’[vi] . What is important is that this background is not itself a ‘thing’, it cannot be grasped in the same way that we would grasp individual things. In philosophy, the study of Being is known as ontology. Heidegger sometimes uses the notion of the ‘ontological difference’ to describe the difference between Being and beings (or things). Richard Polt says: ‘It is not an easy matter to grasp. But roughly, when we ask about Being we are not asking about any particular thing, nor even about the totality of things in the universe; we are asking why all these things count as beings in the first place. This makes our question unusual indeed. We are asking about a ‘thing’ that is no thing at all. We must never make the mistake of confusing Being with a particular entity: not ourselves, not the universe, not even God’[vii].
Now the ontological difference is important because we start to see that while we can investigate entities in the world through science and other sorts of analytic enquiry, investigation of the background - ontological enquiry - has to be something very different.
In the Zollikon Seminars, Heidegger says: ‘The prevailing opinion nowadays is [that it is] as if science could provide objective truth. Science is the new religion. Compared to it, any attempt to think of being appears arbitrary and “mystical”. Being cannot be glimpsed by science. Being demands a unique demonstration, which does not lie in the human being’s discretion and which cannot be undertaken by science, As human beings, we can only exist on the basis of this difference[between being and beings]. The only thing that helps us catch a glimpse of being is a unique readiness for receiving-perceiving’[viii].
In Being and Time, Heidegger is still working within the shadow of Husserl and is attempting to do what he calls ‘fundamental ontology’ ie work out an approach to the study of Being that is universal. In his later works, Heidegger became increasingly sceptical about any such enterprise.[ix] In fact, he moves to speak about the history of Being. This involves the idea that Being is not something fixed but something that changes across time and, I would add, across cultures.
In the modern Western world, our understanding of Being has become technological. Heidegger sees technology not just as a means to an end. Rather it has, in our culture, become the end in itself. In our age, the world (including the natural world and the world of human beings) shows up primarily as a resource. In the modern age, ‘to be’ means primarily to be available for exploitation and manipulation. We routinely refer to a country’s ‘natural resources’ and companies and institutions have departments of ‘human resources’. The essence of technology for Heidegger involve efforts to order everything according to a logic of efficiency and flexibility.
Conclusion: towards a recovery orientation
We don’t have to agree with everything Heidegger says on this, but clearly he is correct when he maintains that the technical attitude goes deep in the modern West. It is not just about a preoccupation with machines and gadgets but about an orientation to life itself, to our worlds and their problems. In effect, the technical approach to life has become the essence of our culture. What exists, what is a fact, what is to be believed, what is counted as evidence, what is to be valued and what is to be prioritized emerge from this underlying and fundamental attitude. As Dreyfus says: ‘ultimate goals like serving God, society, our fellows, or even ourselves no longer make sense to us. Human beings, on this view, become a resource to be used –but more important, to be enhanced –like any other’[x].
This is where Heidegger’s position connects with our discussion about recovery as an alternative to the ‘technological paradigm’. It is worth considering this paradigm (which I have described above in relation to mental health) to be a manifestation of an even deeper cultural orientation. If we allow this, it is worth contemplating Heidegger’s remarks about how we might think about change.
Heidegger maintains that not only are we intimately wrapped up in technology but that our attempts to manipulate and even restrict technology are also ‘technological’ and thus self-defeating. Technology essentially involves an effort to control and order the world. Trying to control technology is only to extend the technological attitude further.
He argues that we will not change our cultural assumptions, attitudes and outlook by manipulating them through policies, laws, decrees, initiatives, projects and other controlling interventions. All of these words stem from the technological attitude itself. For Heidegger, what we are facing is not a problem demanding a solution but ‘an ontological condition that requires a transformation of our understanding of Being’[xi]. We need first to overcome our will to calculate and order. We need a very different style of thinking. Heidegger argues that modernity is associated with a particular style of calculative thinking. He says this kind of thinking is: ‘… the mark of all thinking that plans and investigates. Such thinking remains calculation even if it neither works with numbers nor uses an adding machine or computer. Calculative thinking computes … Calculative thinking is not meditative thinking, not thinking which contemplates the meaning which reigns in everything that is’[xii]. Against this, he wants to promote an alternative style of thought. He used the German word Gelassenheit in a 1959 book with this title[xiii]. While the English translation of the book is called Discourse on Thinking, the word Gelassenheit is usually translated as ‘releasement’. This is a sort of meditative thought that engages with the world without trying to analyze, order or control it. Heidegger wants to engage with technology not by fighting it or controlling it but by encouraging a way of being, a way of thinking that allows us to live in the midst of technology without being in its grasp.
Ultimately, Heidegger argues for an ‘acceptance’ of technology. Attempts to control it and order it are seen simply to push us further into difficulties.
Many attempts to initiate cultural change have become something other than that as which they have started out, becoming instead part of the problem they sought to change in the first place. If we genuinely wish to change the way in which we encounter mental health problems; if we wish to move our understanding from a technological to a recovery orientation, we will need to develop ways of thinking about mental health that, while not rejecting science and technology, promote a primary discourse that is not calculative. This is not about opposing a new paradigm to the medical model but about nurturing a mental health discourse that is not technological.
For myself, the recovery approach does not involve an alternative model or paradigm. It is not about a new way of knowing about mental health. It is not about the development of a new ‘normal’ science. Instead, it comes from a different staring point and has a different orientation with different goals and priorities. Ultimately it involves a very different way of thinking about mental health, a different way of encountering states of madness, distress and alienation. While this might not be exactly what Heidegger had in mind with his notion of ‘releasement’, there are similarities. This will be a discourse that involves philosophy, creativity, reflection on identity and spirituality but most importantly one that is related to the practical struggles of peoples’ lives. It will be a discourse that is user/survivor centred. It is the sort of discourse that the new Institute for Philosophy, Diversity and Mental Health is ideally positioned to promote.
[i] Allot, P., Loganathan, L. and Fulford, K.W.M. (2003) Discovering hope for recovery from a British perspective. In International Innovations in Community Mental Health (Special Issue) (eds S. Lurie, M.McCubbin aand B. Dallaire). Canadian Journal of Community Mental Health, 21, [need full reference]
[ii] Kuhn, T. (1962) The Structure of Scientific Revolutions. Chicago: University of Chicago Press.
[iii] Kuhn, T. (1962) p. 10.
[iv] Dreyfus, H. (1991) Being-in-the-World: A Commentary on Heidegger’s Being and Time. Cambridge: MIT Press, p. 10.
[v] Heidegger, M. (1962) Being and Time (trans. J Macquarrie, E Robinson). Oxford: Blackwell.
[vi] Dreyfus, H. (2003) Being and Power revisted. In: Foucault and Heidegger: Critical Encounters, (edited by Alan Milchman and Alan Rosenberg). Minneapolis: University of Minnesota Press, Pages 30-54. Page 31.
[vii] Polt, R. (1999) Heidegger: An Introduction. London: UCL Press, p. 28.
[viii] Heidegger, M. (2001) Zollikon Seminars. Protocols, Conversations, Letters. (Edited by Medard Boss, translated by Franz Mayr and Richard Askay). Evanston Illinois: Northwestern University Press, p. 18.
[ix] Frede, D. (1993) The question of being: Heidegger’s project. In: The Cambridge Companion to Heidegger (edited by Charles Guignon). Cambridge: Cambridge University Press, Pages 42-69. Page 65.
[x] Dreyfus, H. (1993) Heidegger on the connection between nihilism, art, technology, and politics. In: The Cambridge Companion to Heidegger (edited by Charles Guignon). Cambridge: Cambridge University Press, Pages 289-316. Page 306.
[xi] Dreyfus, H. (1993), Page 305.
[xii] Heidegger, M (1966) Discourse on Thinking. (Translated by JM Anderson and EH Freund). New York: Harper and Row, page 46.
[xiii] Heidegger, M. (1966).