Recovery and Citizenship

25th October 2017

Having an overly individualistic interpretation of recovery can mean we risk losing sight of all the other things that need to be in place for people to get their lives back. In this article Dr Larry Davidson of Yale University explores why ‘citizenship’ can counterbalance this.

In English-speaking societies, the concept of “recovery” in relation to serious mental illnesses has often been defined as a unique or deeply personal journey. Such definitions were initially intended to relieve people of the pressure of conformity to the set of expectations that constitute a given society’s ideal of “normalcy,” under the assumption that persons with such conditions were already “normal.” Recovery, that is, is not about living up to someone else’s assumptions about a good life, but is rather about living up to one’s own aspirations, or finding a personally gratifying sense of meaning and purpose in one’s own life. In addition, this view has been effective in shifting the locus of our concern, and the locus of agency, of decision-making, from the practitioner to the person him or herself. As such, it has been tremendously empowering and has given people hope that there are things they can do on their own behalf, that they have a central role to play in their own lives.

At the same time, however, this highly individualistic sense of recovery has led to an unintended and unfortunate misunderstanding that is beginning to have deleterious effects in policy and practice. Briefly stated, viewing recovery as the individual’s own, unique journey has led to mistakenly placing the entirety of the work of recovery on the shoulders of each person him or herself. What was being emphasized as a central role for the person to play has become understood as being only  the individual’s role, as something that the person does him or herself in a kind of vacuum, a pulling oneself up by one’s own bootstraps. This has led policy makers, managers, and staff to do questionable things for and to people in the name of this version of “recovery.” In England, for example, this version of recovery has been used as a justification for cutting funding for care—if people recover then they should need less support from others. If this doesn’t happen, then it must be that people aren’t working “hard enough” on their recovery so that they can become less dependent on the government. That same thing has begun to happen in the U.S. too, of course.

But if we only think of recovery as a deeply personal journey of reclaiming a new sense of self and purpose, then we risk losing sight of all the other things that need to be in place for people to get their lives back. Things like a safe, stable, and affordable home in a supportive environment; transportation; a job or school; a family; some friends; and a sense of belonging to a community or cause greater than oneself. All of these factors are known to our colleagues in public health as “social determinants of health.” None of us achieve or acquire all of these different essentials in life solely or entirely by ourselves as individuals, that is why they are called social determinants of health. We are born into a community, we are raised in a community, we play valued roles in our community like parent, homeowner, tenant, employer, employee, student, sibling, caretaker, and voter. This is where the concept of “citizenship” comes into the picture to counterbalance an overly individualistic interpretation of recovery.

In the future, with early intervention, we hope that persons developing a serious mental illness and/or an addiction will not have to lose all of these valued roles—these ways of engaging and participating actively and meaningfully in all aspects of community life—as a result of becoming ill. We hope young people early in the course of a behavioral health disorder will be able to stay in school, will be able to keep their friends, and will be able to go on to learn how to drive, how to date, and, eventually, how to be a contributing citizen … just like most everyone else. But we know the history of our field, and we know that this has tragically not been the case for many, many people. Through a combination of the stigma that accrues to these conditions, the discrimination those who experience these conditions face as a result, the lack of material resources that also results from the lack of social and political will to reverse this long-standing discrimination, and the traditional, narrow view of our health care system on the management of symptoms, many people have lost these various indicators, benefits, and, as it turns out, basic requirements for exercising their citizenship. They have stopped being a student or employee, they may have lost their friends, forgotten how to drive, and may find it hard to believe that anyone would want to date them. And this has been a tragic loss, not only for the person and his or her loved ones, but for all of us and our society as a whole.

So recovery understood as a person reclaiming his or her life in the face of mental illness involves more than the person reclaiming a sense of meaning and purpose. It involves society and its various institutions, mediating structures, and communities and sub-communities no longer turning their collective backs on people with various disabilities, including behavioral health disabilities. It involves society and its various institutions, mediating structures, communities and sub-communities—and its various agents—identifying, acknowledging, appreciating, and affording value to the contributions persons with behavioral health conditions make to our lives. With the introduction of recovery about 30 years ago, we realized that no one is “just” an addict or a mental patient. With the introduction of the concept of citizenship today we add, importantly, that what more that person is, is a citizen of our community. Every person has the right to belong somewhere, to be a contributing member of some community. For as Esso Leete, one of the early leaders of the consumer/survivor/service user movement in mental health in the U.S., has said:

“What makes life valuable for those of us with mental illness? … Exactly what is necessary for other people. We need to feel wanted, accepted, and loved … We need support from friends and family … We need to feel a part of the human race, to have friends. We need to give and receive love.”

That is the vision of a citizenship-oriented system of care, in which personal recovery is promoted not only at the individual level, but at the program, system, and societal levels as well.