Book Review: Recovery’s Edge: An Ethnography of Mental Health Care and Moral Agency

Recovery’s Edge: An Ethnography of Mental Health Care and Moral Agency. Neely Laurenzo Myers, Nashville: Vanderbilt University Press, 2015, 191 pp.

One of the challenges in studying and discussing “the recovery movement” in mental health care is how profoundly mundane it can sound to the person who is unfamiliar with it. It is about empowerment, it is about fostering hope, it is about disrupting the “paternalistic” crimes of the medical model of care, it is about designing care for people to ensure that the goal of treatment is not merely symptom reduction but to assist people suffering with a mental illness in the achievement of a better life—of the life that they would have had had they not been derailed by mental illness.

I have spent many hours trying to explain to people what is so different about a recovery orientation compared to what came before. These conversations have often followed a certain script when I have had them with mental health care providers—psychiatrists, clinical social workers, clinical psychologist, psychiatric nurses—with them nodding in bemusement and then responding: “We have already been doing that” or “Oh, that just sounds like our wellness program” or “Yes, we have a peer volunteer at our clinic.” I have found that it is the ease with which many care providers conflate organizational change with a transition to a recovery orientation that is most troubling.

On rare occasions, though, there is a mental health provider to whom I feel I can confide and speak directly without a layer of false acknowledgment and sagely sympathy about how hard it is to provide recovery-oriented services. To those people, when they ask me what the recovery movement is about, I take a deep breath, look directly into their eyes, and tell them: “The recovery movement is about YOU changing who YOU are and what YOU do.” This can be profoundly threatening to many mental health providers because the challenge goes beyond a simple questioning of the science of mental health care and specific care practices to which they might feel invested; most pointedly, it challenges their own sense of efficacy, their own sense of themselves as a moral person, their own sense of agency, and their own assessment of whether they are a good person.

Neely Myers’s 2015 book Recovery’s Edge captures the contradictions and realities—as well as those moments of promise—through her masterful, well-reasoned, balanced, and eminently readable prose. Myers conducted years of ethnographic research in and around “Horizon” —an urban mental health outpatient care clinic that seeks to provide recovery-oriented care. Her project is to understand what (if anything) is so different about recovery-oriented care. The subjects of her book are multiple: conceptual (What is different about the new recovery orientation?); institutional/organizational (What does a clinic look like, from the operational standpoint, if it seeks to add recovery-oriented care?); clinical (What clinical practices change or stay the same when adding a recovery orientation?); experiential (What does it feel like to experience the process of recovery?); and structural (What political and economic structures are in place to support—or, more commonly, derail—the goals of recovery-oriented care?).

A less skilled writer might organize his or her book along these lines, but, Myers eschews such conventions and integrates her analysis of these subjects in a running engagement throughout the book, with stories of the struggles of the members of Horizon framing stories of the struggles that clinicians and peer care providers faced in providing services or nurturing recovery in the members; those human snapshots are in constant conversation with the structural realities (e.g., how the details of Medicaid/Medicare/SSI/SSDI distinctions can shape recovery by disincentivizing one of the cornerstones of recovery—self-actualization and independence through employment) and structures of violence (the ever-present risks of rape, murder, and theft faced by most of the abjectly poor, homeless population who suffer from mental illness) that posed challenges to recovery.

Throughout this book, Myers shows a powerful capacity to sympathize (and, at times, empathize) with the struggles faced by members and care providers alike. Though the recovery movement was, at least in part, created out of an adversarial critique of the traditional medical model of care—and, though there are certainly tensions between the person who manages the peer-run, recovery-oriented treatment center (PEP, Peer Empowerment Program) and those traditional care providers (Riverside Program)—Myers is able to show the basic humanity of all the people who populate her book. She avoids reducing them to stereotypes, even when those stereotypes are present in her narrative (even when some peer advocates insist that personal agency and recovery means allowing members to eat wherever they want in the center, leading to pest infestation; even when some clinicians insist that too much freedom to make personal decisions for themselves can harm the members). Instead, Myers provides a truly balanced and evocative account of how the troubling question of self-determinacy and the privileged primacy of medical authority clash in seeking to help people with profound mental illness.

Myers conducts the kind of clinical ethnography that should be familiar to anthropologists—she spent time in the clinic, went to staff meetings, mingled with members (the organization’s preferred term for patients, clients, consumers, or any number of other terms that are used in clinical settings) within the clinic walls, during smoke breaks outside, over coffee beyond the confines of the clinic, and on the street. This commitment to deep ethnography is reflected in her writing style, which is accessible and straight-forward and relies more heavily on the words or her interviewees and stories of moments from the field to convey her ideas than on labored, theory-heavy analysis. Her closeness to the world of mental illness and all of the acts of violence, death, heartbreaking loss, and profound frustration over a convoluted system of services and an uncaring world that has victimized or neglected people with severe mental illnesses leaves Myers scarred—she does not hesitate to recount the troubling feelings of guilt and impotence in the face of all that she see (without over-dwelling on her own experiences).

The combination of convincing ethnographic methods, her accounts of her own subjective experiences with this fieldwork, and her evocative writing style make for a powerful one-two punch that will serve students better than many of the more esoteric works in clinical ethnography or the medical anthropology of mental health care/mental illness. Indeed, in thinking about teaching, I cannot think of a more essential and accessible book to assign to students to teach them about medical anthropology, clinical ethnography, the culture of mental health care, and what it feels like to be a person in America struggling with mental illness and poverty.

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