The Roots of the Recovery Movement in Psychiatry: Lessons Learned
Writing a book “by committee,” with more than two authors, is quite difficult. Perhaps that is why The Roots of the Recovery Movement in Psychiatry, by Davidson, Rakfeldt, and Strauss, is somewhat confusing. The volume contains excellent information, yet is laced with misinformation about the past, misrepresentation of the present, and misguided conjecture about the future. I was fascinated by the subject the authors took on—the historical underpinnings of the contemporary American psychiatric recovery movement—but was disappointed by this book. I found it distressing, even disheartening sometimes.
In making one's way through the book, one must decipher sentences such as, “Within the constraints of whatever substantive unfreedoms they may be subjected to based on historical legacies and current circumstances (e.g., stigma, discrimination), they are always already making choices in their day-to-day lives based on which capabilities they value and what choices may be available to them (based also on available resources, social structure, etc.).”
The authors attempt to root the recovery movement in the work of such individuals as Philippe Pinel, Jean-Baptiste Pussin, Dorothea Dix, Jane Addams, Erving Goffman, Franco Basaglia, Lev Vygotsky, and others. The authors take the reader from the early 18th century to the present, but when authors base their argument in historical precedents, they must do their homework about that history. Unfortunately, these authors, perhaps relying too heavily on secondary sources, provide misinformation about the history of psychiatry. For example, they state that Massachusetts funded and built Worcester State Hospital after Dorothea Dix's investigation and report to the legislature on conditions of the insane in Massachusetts. The first Worcester State Hospital, however, was funded and built in 1833, before Dix's first excursion in 1841 into the East Cambridge jail to see the plight of the insane therein.
The authors state that S. Weir Mitchell was a psychiatrist who served a term as president of the American Psychiatric Association (APA). In fact, S. Weir Mitchell was a neurologist who in an invited address attacked the organization that later became APA. The authors extol the work of Adolf Meyer and his “psychobiology” but completely ignore his work in eugenics. They report that Meyer was recruited to Worcester State Hospital to manage the facility when in fact he was a junior member of the staff brought there to be the hospital pathologist. They take us back to a statement Meyer made about himself without finding out whether his self-attributions were accurate. For example, they quote Meyer accruing to himself credit for appointing the first psychiatric social worker but ignore the founder of psychiatric social work, Mary Jarrett.
The authors' purpose is to inform the reader how psychiatry has slipped from being recovery focused and to teach the reader how the field can get back on track. The problem appears to be that the authors started with a thesis and then used information and misinformation to support and extend their thesis. In other words, they did not examine history or even contemporary practice to inform us about recovery but instead took their beliefs about recovery as the starting point and molded history and contemporary practice to fit their beliefs. For example, they attribute “reducing substantive unfreedoms and expanding opportunities and supports” to “what people in recovery have advocated since the 1980s.” However, one can find such expositions in the work of the 19th century American alienists (see, for example, the Galts' work at what is now Eastern State Hospital in Williamsburg, Virginia) or in the 1950s (see the articles in Hospital and Community Psychiatry from this decade). The authors talk about institutionalism as described in the work of Goffman and others in the 1960s but ignore the subsequent work on the young adult chronic patient and negative symptoms of schizophrenia. They report that in the United States today “tens of thousands of people continue to live significant portions of their adulthood, in many cases the remainder of their adult lives, within the locked confines of state institutions.” That's not what the data would show.
The book is structured such that each chapter ends with a “summary of lessons learned.” Often the lessons are not derivative of the chapter and are quite repetitive. The book's final chapter is a fabricated discussion among the historical figures and John Strauss, modeled on Steve Allen's television show Meeting of Minds. There is no dispute that the last statement of this dialogue and therefore the last statement of the book is true. It is spoken through Vygotsky, who says, “The focus should be on activity and on how to assist people in participating, and being successful, in the activities they want to participate in. What else is there?”
The dispute I have with this book is the authors' belief that there are very few in psychiatry who subscribe to this principle and that a focus on recovery is new and unique, with the exception of stellar thinkers of the 19th and 20th centuries. What the authors report as new is actually a repeating principle throughout American psychiatry; they state, “The core focus of the system will be on facilitating the process of development in which each person with a psychiatric disability actively engages, ensuring that a historically oppressive and presently vulnerable population has the resources, opportunities, and ongoing supports it needs in order to function well in the environments and roles of its choice, with the eventual goal being that of its achieving the capability to live a dignified and fulfilling life despite the enduring presence of a disability.” The challenge in the 21st century is the same as the challenge in the 20th and the 19th centuries: given whatever resources are directed toward this population, how best does psychiatry accomplish this end?
The reviewer reports no competing interests.
