From Maintenance to “Recovery”: Mental Health Care and “Necessity” in the Age of Assessment

Community mental health in the US is apparently marked by perpetual revolutions. Case management, evidence-based medicine, neuroscience and more have all been identified as transformative forces that promise to change institutional logics, practices, and outcomes in major ways as they are deployed. The latest to emerge in this context is Recovery. This dissertation critically explores how a mental health program in Chicago called “Hemsworth” has attempted to implement the new treatment philosophy of Recovery. While numerous scholars, policy-makers, and consumers still recognize Recovery as a system-transforming force, I argue that Recovery itself has become a method to advance the knowledge, practices, and priorities of biopsychiatry and audit culture. To highlight this creative repurposing (and domestication) of Recovery I use Jacques Lacan’s discourse theory as a critical lens to ethnographically investigate program life. I begin by examining what is changing in the name of Recovery at Hemsworth, and discover that many of the services created in the name of recovery-oriented care advance a pedagogical-parental relationship that renders madness a problem of knowledge that is to be better accounted for by the consumer-qua-self-manager. I then closely consider other initiatives within public mental health that intersect with Recovery, namely medical necessity and audit-based practices. I demonstrate how these initiatives creatively appropriate the discursive resources of Recovery in order to further advance both neoliberal and biopsychiatric norms, values, and priorities – thus, ensuring that substantive changes to organizational culture do not occur. Perhaps the biggest revolution that Recovery is said to inaugurate is a subjective revolution, an imagining of a new human outfitted with previously unseen forms of agency and insight. At Hemsworth, however, I found a familiar subject that was guided to relate to oneself and others in rather predictable neoliberal and biomedical ways. I conclude with a discussion of anthropology’s interest in finding alternatives to hegemonic biopsychiatric care in the US, and go on to explore a novel mental health treatment program in Canada based on psychoanalytical theory.