Culturally available defences against anxiety and personhood in the recovery approach

In Victorian mental health, the recovery approach is held up as the ideal (Department of Human Services 2009:22). A fundamental aspect of this approach is that service consumers or clients defining their own notion of what it is to be ‘recovered’, which may have very little to do with how they were before experiencing mental illness. The orthodoxy of recovery is one of process rather than outcomes (Jacobson & Curtis 2000:3), however, on another level, there are clearly outcomes that are advocated for. As the recovery approach is rolled out in mental health, consumers are no longer clients who can conceive of their identity as compared to workers. Lost is the ability for clients to engage in projections onto staff in the way that can provide ‘relief from the anxieties which can arise from trying to contain conflicting needs and conflicting emotions.’ (Halton 1994:14). This post is an abridged version of an essay I handed in for an honours seminar class. Here I discuss splitting and projecting resulting from externalisation, as a core element in the recovery approach.

In the recovery approach ‘externalising’ is often used. Externalising uses methods such as narrative therapy to enable people to ‘separate themselves from the problem’ and so to no longer see themselves as ‘the burdens and problems of society’ (Lit 2008:187). The human subject is therefore defined as the person who can actively participate in society and the ‘illness’ is defined as a separate entity. Externalisation is not a new or unusual way to deal with aspects of a person that are feared, hated or threatening. Exorcism is one example of this. Forensic mental health demonstrates the acceptance of externalisation when it comes to mental illness. Our legal system sees people who commit crimes as a result of ‘symptoms’ to not be guilty in the same way as people with any other motivation.

There are obvious parallels with the mechanism for the paranoid-schizoid framing of the illness as a separate object, as the Other. In Klein’s model the paranoid-schizoid is an earlier developmental stage and there is a higher level way of relating, the depressive position (Klein 1986). The depressive position is when the projections are re-owned, but there is always the risk that, especially when ‘survival or self-esteem are threatened’ there will be a return to the paranoid-schizoid mode (Halton 1994:18). A more thorough exploration of how the depressive position has and can be used within a mental health paradigm is a worthy project, but clearly the depressive mode is not drawn on in this example of externalisation of the mental illness.

It is not a coincidence that consumers involved in the recovery approach movement, such as Patricia Deegan in the USA (eg Deegan 1996) and Helen Glover in Australia (eg Glover 2005), have had diagnoses of schizophrenia. This is a diagnosis where symptoms, which the person experiences as not having control over, and behaviours, which are considered part of the person, can be separated. Externalisation is much more difficult to employ in the case of many other diagnoses, especially in the case of personality disorders. Consumers with a personality disorder diagnosis are, unsurprisingly, treated as particularly problematic for mental health services and in Victoria there is a specialised, state wide unit which not only works with consumers with personality disorder diagnoses but also provides secondary consult to staff in other agencies working with this consumer group (Spectrum 2009).

While the redefinition of the subject through externalisation is explained as stopping the consumer from being pathologised, perhaps it is not so much for the benefit of the consumer but rather other people that they are in relationship with. For many people, the experience of knowing somebody with mental illness results in a situation where they both love and hate the person with the mental illness – the object. While this can often happen in all relationships, here there is an opportunity for the anxiety generated by ‘loving and hating the same object’ to be dealt with in the ‘paranoid-schizoid mode’ described by Klein (Klein 1986). The hated facets are defined as the mental illness while the loved aspects are the person-minus -the-illness. By separating the facets it is possible for the person to ‘safely love the object, in a state of uncontaminated security, and safely hate without the fear of damaging the loved object.’ (Odgen 1989:19). It absolves workers, family and others from guilt when they feel frightened, repulsed or otherwise negative about any behaviours. These behaviours can be construed as not originating from the object that they love, but rather the object of hate from which they are actually seeking to protect their loved object.

In redefining mental illness as something which people fact the challenge of, rather than resulting in subjects who are actually defined as mentally ill, they are called to share the same goals and obligations as others in society. Here we have a situation where those who experience mental illness instead of being sidelined are told that they have special insights. They are not excluded from the order but become hyper consumers, who are expected to be extra reflexive about life and what it means to be ‘well’. We can only wonder what would have happened to Deegan if, instead of being told to take her medication and avoid stress (Deegan 1996), she was told that it is now your responsibility to achieve greatness. Instead of society being to blame for institutionalising people, it is a system where the individual is responsible for not succeeding. The recovery approach may have a lower human cost than other approaches, but it is still a tool used in a way that contributes to a Habermassian interpolation of subjects. Perhaps mental health services would do consumers a greater favour by being explicit about their ideological drives, but then again this may denaturalise the ideology rendering it ineffective.

List of references

Deegan, P. 1996. Recovery as a journey of the heart. Psychiatric Rehabilitation Journal 19:91.

Department of Human Services. 2009. Because mental health matters. Victorian Government.

Glover, H. 2005. Recovery based service delivery: Are we ready to transform the words into a paradigm shift? Australian e-Journal for the Advancement of Mental Health 4.

Halton, W. 1994. “Some unconscious aspects of organizational life,” in The Unconscious at work : Individual and organizational stress in the human services. Edited by V. Z. Roberts and A. Obholzer, pp. 11-18. London & New York: Routledge.

Jacobson, N., and L. Curtis. 2000. Recovery as policy in mental health services: Strategies emerging from the States. Psychosocial Rehabilitation Journal.

Klein, M. 1986. “Mourning and its relation to manic-depressive states,” in The selected Melanie Klein. Edited by J. Mitchell, pp. 146-174. Harmondsworth: Penguin.

Lit, S. 2008. “Alternative mental health project: The use of narrative approach in working with people with mental illness,” in Strengths based perspectives in working with clients with mental illness. Edited by K.-S. Yip. Hauppauge: Nova.

Ogden, T. H. 1989. The primitive edge of experience. London & Northvale: J. Aronson.

Spectrum. 2009. Spectrum: The personality disorder service for Victoria. http://www.spectrumbpd.com.au accessed 16/11/09.

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One Response to “Culturally available defences against anxiety and personhood in the recovery approach”

  1. Jason Says:

    This is fascinating reading. The paranoid-schizoid mode is something I’ve often found people I’ve been intimate with wanting me to adopt. In a sense they have split themselves down the middle labelling some of their behavior as good and other behaviors either as a mental illness or as something they are working on to dispose of.

    Such behaviour doesn’t make me feel comfortable partly because I secretly like my darker side and partly because the other person is pressuring me to think about them in a certain way that is deceptive.

    Interestingly people I know who behave in socially disapproved of ways yet when challenged say effectively, “that’s just who I am – accept the bad with the good,” also leave me feeling un comfortable.

    I guess I just prefer people being secretly bad like me and then airing their dirty washing with me later! (Again, in secret!)

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