jurnal - An anthropological exploration of moral agency in stories of mental health recovery

Transcultural Psychiatry 2016, Vol. 53(4) 427–444 ! The Author(s) 2016
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DOI: 10.1177/1363461516663124 tps.sagepub.com
Article
Recovery stories: An anthropological
exploration of moral agency in stories
of mental health recovery
Neely Anne Laurenzo Myers
Southern Methodist University
Abstract
Moral agency has been loosely defined as the freedom to aspire to a ‘‘good life’’ that
makes possible intimate relationships with others. This article uses ethnographic
research to further the discussion of the role of moral agency in mental health recovery.
This article attends to the ebb and flow of moral agency in the life stories of three
people diagnosed with a serious psychiatric disability at different stages in their individual recoveries to illustrate particular aspects of moral agency relevant for recovery.
From these, a more complex notion of moral agency emerges as the freedom not only
to aspire to a ‘‘good life,’’ but also to achieve a ‘‘good’’ life through having both the
intention to aspire and access to resources that help bring one’s life plans to fruition.
Each storyteller describes an initial Aristotelian peripeteia, or ‘‘breach’’ of life plan,
followed by an erosion of moral agency and sense of connection to others. The stories
then diverge: some have the resources needed to preserve moral agency, and others
attempt to replenish moral agency that has been eroded. In these stories, the resources
for preserving and nourishing moral agency include the ability to cultivate the social
bases of self-respect, autobiographical power, and peopled opportunities. These stories
cumulatively suggest that without such resources one’s attempts to preserve or nourish
the moral agency needed for recovery after the peripeteia, which is often perpetuated
by the onset and experience of serious mental illness, may fall short.
Keywords
moral agency, recovery, serious mental illness, storytelling, United States
Corresponding author:
Neely Myers, Department of Anthropology, Southern Methodist University, PO Box 750336, Dallas,
TX 75275-0336.
Email: [email protected]
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Introduction
In the past 40 years, increasing numbers of people have described themselves as
‘‘in recovery’’ from serious psychiatric disabilities. Many people use the term
‘‘recovery’’ to repudiate the biomedical focus on diagnoses, symptoms, and functioning (Myers, 2015). Instead of full, unmarked return from some discrete clinical
event, they invoke a narrative of ‘‘transformation’’ and ‘‘healing’’ from ‘‘serious
emotional distress’’ (e.g., Deegan, 2002; Fisher, 1993). In this view, a person in
recovery cultivates their capacity to live the kind of life they may have expected to
live (or perhaps even a better life) prior to their entry into mental health care
(Nudel, 2009; Saks, 2007). The ways recovery can be brought to fruition, however,
are complicated (Hopper, 2007; Jacobson, 2004; Liberman, Kopelowicz, Ventura,
& Gutkind, 2002). Despite scholarly efforts to operationalize recovery outcomes
and identify ways to promote it, how best to encourage people in their recovery
process remains a pressing social and clinical question.
Thinking through the potential role of moral agency in the recovery process may
provide some anwers. Like all forms of agency, moral agency is intersubjective.
Mattingly (2014) argues that interactive social spaces are ‘‘moral laboratories’’—spaces of possibility and critique—where experience is experiment and ‘‘with
action, humans are able to create something new—to begin something unexpected’’
(Mattingly, 2014, p. 16, paraphrasing Arendt, 1958). To make possible intimacy
with others in such social spaces, a person’s actions must also be recognized by
others as ‘‘moral.’’
Kleinman (1999) has long discussed the intersubjective importance of being
recognized by others as ‘‘moral’’ or ‘‘good’’ in a ‘‘local moral world’’ for mental
health and healing. Garcia’s (2010) work among heroin-addicted families similarly
ponders the role of intimacy in the process of being recognized as ‘‘good’’ in one
local moral world, and how the complex entanglements of human desire and the
constraints and enablements of local moral worlds build and erode relationships
between her interlocutors. Blacksher (2002) has used the term ‘‘moral agency’’ in the
context of health and chronic socioeconomic deprivation to describe the freedom to
aspire to a ‘‘good life’’ in a way that leads to intimate relationships with others.
Larry Davidson and colleagues (Davidson, Rowe, Tondora, O’Connell, &
Lawless, 2008) also identified the process of connecting with others and finding
one’s niche in the community as important for recovery from serious psychiatric
disability. Recovery requires taking back control of one’s life—in private life, and
in public life, as well. Ware and colleagues (Ware, Hopper, Tugenberg, Dickey, &
Fisher, 2007) argue that people seeking recovery need access to citizenship.
Recovery advocates often describe recovery from serious psychiatric disabilities
in similar terms: the ability to live, love, and work in a community that values
one’s contribution (Anthony, 2000)—a community within which one can build
intimate connections.
Descriptions of the phenomenology of psychosis reflect how one’s ability
to create intimate connections may be compromised with the onset of psychotic
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symptoms, and the significance this loss has for one’s capacity for both agency
and recovery. ‘‘People with [a psychotic disorder] are filled with an essential longing,’’ writes one clinician–patient pair, ‘‘for connection, for some relationship that
will give them a pathway back to the world they have lost’’ (Schiller & Bennett,
2008, p. 238). Sass (1992) describes how the assumptions of everyday life become
altered so that one has,
[T]he sense of living one’s perceptions, thoughts, and actions, as if from within, with
an implicit or semiconscious sense of intention and control . . . [assumptions] can no
longer be relied upon—and, in the wake of their collapse, the nearly unimaginable
holds sway. (p. 214)
These works indicate that the ability to be recognized as a locally ‘‘good’’ person
and find intimacy is likely a critical part of mental health and well-being, perhaps
especially for people who have experienced psychosis. This article asks what people
in recovery from serious psychiatric disabilities need in order to become a moral
agent, or a person who can bring their life projects to fruition and connect in
intimate and meaningful ways to others who see them as a ‘‘good’’ person.
Anthropology, recently called the ‘‘science of intimacy’’ (Saez, Kelly, & Brown,
2014), has much to offer in advancing our understanding of moral agency.
Background
A person’s ability to cultivate the intentions and resources needed for moral agency
is fundamentally shaped and constrained by culture. For the past decade, public
mental health services users in the United States have been treated under a new
‘‘recovery’’ paradigm in mental health care that asks them to generate life projects
that will make them a valued, reintegrated citizen ‘‘in recovery’’ (Jacobson, 2004;
Myers, 2010). Here, recovery is used to describe an attempt to cultivate in people
the desire and intention to aspire to the ‘‘good life’’ in a very North American way
(Myers, 2015). Prescriptions for recovery often include finding gainful employment
to attain ‘‘a house, a car, and a girlfriend’’—all signals of valued adulthood in this
context. Even if one has the intention to aspire to such material benchmarks of
recovery, people seeking recovery do not necessarily have the resources and relationships needed to see such projects brought to fruition (Myers, 2010). For example, Hopper (2007) has dubbed the American recovery paradigm a ‘‘gospel of
hope’’ with no teeth due to the lack of government funding or any clear explication
of what would constitute genuinely transformative and doable recovery-oriented
mental health services within the existing public mental health system.
In the US, older ‘‘clubhouse models’’ were designed to connect their ‘‘members’’
with the broader community, and seemed to help people feel ‘‘less lonely’’ (Stein,
Barry, van Dien, Hollingsworth, & Sweeney, 1999), but offered little in terms of the
employment, education, housing, spirituality, social relations, and recreational
activities service users find essential for recovery (Slade, 2010). Researchers have
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further observed that older clubhouse models provided refuge rather than rehabilitation (Whitley, Harris, & Anglin, 2008), and that in the long term, they can
become ‘‘isolated havens’’ that foster a ‘‘service-dependent lifestyle’’ (Whitley,
Strickler, & Drake, 2012).
Most American public mental health care programs for people with serious
psychiatric disabilities today use a case management model of ‘‘care,’’ which has
been heavily critiqued for discrediting the agency and identity of service users who
are often subjected to intense surveillance, control, and intrusion (Brodwin, 2012;
Estroff, 1981; Floersch, 2002; Stefan, 2002). Case managers often assume that clients who resist control are irrational and irresponsible (Wright, 2012). While case
management may reduce rehospitalizations, it seems to erode one’s ability to flourish (Angell & Mahoney, 2007).
The life stories of people using this system of care, systematically silenced in the
past, can help us disentangle how to move forward. Life stories focus on agency
(Brettell, 2002, p. 439). Storytelling is one of the ways in which people ‘‘reflect,
exercise agency, contest interpretations of things, make meaning, feel sorrow and
hope, and live their lives’’ (Brettell, 2002 cited in Lamb, 2001, p. 28; Ralph, 2014).
This article explores how three people describe moving from intention to recoveryoriented action after being diagnosed with a psychotic disorder and how that
makes possible intimate connections with others (or does not). The driving questions are how do people recover from self-eroding experiences to find mental health
recovery, and what role might moral agency play in that work?
Each storyteller describes an initial Aristotelian peripeteia, or ‘‘breach’’ of life
plan, followed by a subsequent erosion of moral agency and sense of connection to
others. In these stories, the resources for preserving and nourishing moral agency
include: the ability to cultivate the social bases of self-respect, autobiographical
power, and peopled opportunities. These are explained further in the discussion,
but briefly, cultivating the social bases of self-respect entails meeting local definitions
of what a person should do to be respected; autobiographical power is the ability to
be the editor of one’s own life; and peopled opportunities are social circumstances
that enable one to be recognized as a good, accountable person by others in a way
that makes possible intimate relationships. These stories cumulatively suggest that
without such resources one’s attempts to develop the moral agency needed for
recovery after the peripeteia of a serious psychiatric disability may fall short.
Methods
Four years of ethnographic fieldwork in two psychiatric rehabilitation settings in
two regions of the US inform this account, including the participants’ points of
view and my efforts to bear witness to their everyday experiences (Farmer, 2003;
Ortner, 1995). This work aimed to understand the perspective of a service user
through research methods which included interviews, participant observation, and
hours of informal conversation. Interviews were audiotaped and transcribed verbatim. Ethnographic fieldnotes and interview transcripts were written into
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Microsoft Word documents that could be searched for keywords and coded for
themes. I then used qualitative data analysis and grounded theory methods, including theoretical saturation (when no new themes appear in interviews and notes) and
triangulation (cross-checking findings with at least three sources, such as fieldnotes,
an interview with a staff member, and an interview with a service user) to distill a
detailed sense of moral agency in these settings (Charmaz, 2006; Glaser & Strauss,
2009). After a pause in the research, findings were ‘‘member-checked’’ with participants and other stakeholders (Emerson & Pollner, 1988).
The first ethnographic project that this paper draws from involved 3 years of
engagement with staff and clients at a psychosocial rehabilitation organization
attempting to become ‘‘more recovery-oriented.’’ The sample was primarily over
the age of 30 and Caucasian, and all had a diagnosis of a serious psychiatric
disability, most often schizophrenia. Methods and sample are more fully described
in Myers (2015). All participants gave informed consent under the supervision of
the University of Chicago IRB.
I then used these findings to further explore the theory of moral agency at a
second fieldsite. This second 9-month mixed-methods study (ethnography, semistructured interviews, surveys), inspired by the findings of the first study, took place
in a different urban area of the US at a program attempting to replicate an exemplary, grassroots, peer-run organization. At this site, most participants were
African American males between the ages of 18 and 60 with a diagnosis of a serious
psychiatric disability, most often schizophrenia. All participants signed consent
forms confirming their participation in this study under the supervision of the
Nathan Kline Institute for Psychiatric Research IRB.
While using data from different studies is unorthodox outside of the social sciences, these studies use the classic ‘‘comparative method’’ of anthropology
(Radcliffe-Brown, 1951) to represent knowledge about the everyday experiences
of people with serious psychiatric disabilities using North American public
mental health services at different fieldsites. Case studies of similar clinical populations are also widely used in the psychiatric literature. These three storytellers
offer insights into their own experiences of recovery, which we can use to better
understand the experiences of others.
The absence of moral agency: The philosopher
After 12 years of treatment in a psychosocial day program, the staff thought of
Moe as a ‘‘regular’’ (for more on this program and its participants, see Myers,
2010, 2015). One afternoon, Moe presented me with a résumé. It began with
glimpses of an innovative young adult: ‘‘President of the Young Democrats’’; an
author for major national publications like American Scholar and the Boston Globe;
the owner of an independent bookstore. A subsequent 20-year gap in his work
history ended with this: ‘‘Applying sales labels to plumbing fixtures.’’
As a young man, Moe and his girlfriend left a small town to ‘‘tune in and drop
out.’’ They became politically active, opened an independent bookstore in a large
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city, and planned to marry. But then, she was murdered in front of their
bookstore. Moe claimed that this event triggered his ‘‘voices.’’ This was Moe’s
peripeteia—the moment in a story when there is a sudden reversal in circumstances,
a breach in the narrative that the rest of the narrator’s story seeks to repair (Bruner,
2003, p. 17).
Moe tried medications, but they did not completely halt the voices. He struggled
with side effects such as weight gain and smacking lips. Care providers told him
that he could not work, although he eventually (20 years later) had access to
invisible, minimum wage jobs, which he accepted, such as off-the-books accounting
work.
One evening, I gave Moe a ride to a coffee shop. He had used a free local paper
to advertise for others to join him in a community philosophy group. About 10
people had come to the first meeting, and Moe was elated. They were mostly
‘‘young and normal,’’ he explained, but they had had a good conversation, and
he felt he had a lot to teach them. He probably did. Through his treatment center,
Moe had co-led a ‘‘happiness group’’ at a smoky diner for other service users,
which I had attended. Many of the users seemed to enjoy Moe’s teachings on
Western philosophy.
A few weeks later, I asked Moe how the community-wide meeting at the coffee
shop went. ‘‘No one came,’’ he said sadly. As far as we knew, no one came again.
Many of Moe’s fellow mental health service users thought of him as a philosopher,
but when he tried to translate that success into starting a community philosophy
group with people he thought of as ‘‘normal,’’ they only came once.
It is impossible to say why the entire group failed to return, but this is a scenario
I have seen play out repeatedly in the lives of people seeking recovery. Moe built up
the intention and then tried to publicly craft himself as a quirky philosopher on a
quest for happiness, but people outside of his treatment setting did not recognize
him as such. Maybe it had nothing to do with him, but Moe interpreted this
experience as a rejection. It harmed his sense of self-respect. He could not recast
his life narrative as that of a philosopher on a difficult journey on his own. Under
these constraints, Moe’s efforts at recovery failed. He was unable to build relationships with people outside of the mental health system, and continued to rely on the
day program for ‘‘social support’’ by coming in for coffee most days, sitting in the
cafeteria, and hoping to find someone willing to talk to him. Quite often, he sat
alone.
Recovering moral agency: The psychotherapist
Around the same time that Moe was running an independent bookstore, Jeremy
flung himself from his seventh-story balcony to protect his pregnant wife from the
FBI (for more on the clinic where Jeremy worked and the people in attendance, see
Myers, 2012, 2016; Myers & Ziv, in press). A tree broke his seven-story fall. This
was Jeremy’s peripeteia—the psychotic break, the broken fall, followed by a long
story of repair.
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After being taken to the local emergency room, Jeremy told me that he had been
released to their inpatient unit, which he described as ‘‘very chaotic, very loud, very
condescending.’’ He felt this setting eroded his self-respect. ‘‘I was terribly, terribly
depressed, and feeling lousy about myself, totally out of it, with at times delusions.
I was basically cared for and supported by people who didn’t understand.’’ As
Goffman (1961) has argued, Jeremy felt that his sense of self was eroded by the
experience. The people around him saw his diagnosis as a ‘‘death sentence.’’ He was
told to anticipate unemployment and a chronic, deteriorating course of illness. His
treatment team did not even encourage him to have the intention to aspire; they
told him that this would only lead to false hopes and eventual disappointment.
Jeremy also struggled with his diagnosis and the challenge it posed to his own
autobiographical power, or ability to be at least the editor of his own life narrative.
‘‘‘Chronic paranoid schizophrenic’ was a big word. They were using it a lot. I was
devastated.’’ He said he would have preferred more of an explanation, such as
‘‘delusions are perceptual problems and they go away . . . emphasize the positive
part.’’
Jeremy’s wife proved a crucial ally. She refused to believe that he was permanently disabled, and actively tried to preserve and cultivate Jeremy’s potential for
taking charge of his own life. She ‘‘scoured the city for the best hospital.’’ After 2
weeks, she moved him to the best possible private hospital, one that was interested
in helping him foster his intention to take on new life projects and that asked him
to share his autobiographical narrative in intensive psychotherapy-based treatment. He stayed there as an inpatient for 2 years.
He described this time as ‘‘very positive. I was feeling terribly lousy, but I got a
lot of support.’’ Jeremy decided to stay in the hospital where he and his doctors
worked together to ‘‘basically put me back together again.’’ A 2-year stay in a
private hospital is not available to most people, but this peopled opportunity to
be recognized as a good and valued person nourished Jeremy’s sense of self. He
began to cultivate resources to bring his life projects to fruition. After 2 years,
Jeremy left the hospital for graduate school and earned a PhD in clinical
psychology.
After several decades of clinical practice and formal retirement, Jeremy decided
he wanted to work part-time in a peer setting—a new opportunity for him. ‘‘It’s a
warmer, more understanding, less condescending, less scary environment,’’ he
explained. ‘‘A peer can lend that whole experience—deliver it better—to an individual who is going through what the peer therapist has gone through.’’ He
thought peer services helped users cultivate both their intention to aspire and the
resources they would need to see their aspirations come to fruition early in the care
process.
As Jeremy explained,
A 16 year old who has psychiatric involvement . . . [is] looking for someone to help
them because they must be very terrified. I think a peer at any age, of any race, I don’t
think it has to be matched exactly. That’s [the assumption that peers need to be
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matched by age and race to be effective] exactly the type of naı̈veté that blocks these
kinds of things . . . this definition of what’s good and what’s not good rather than this
feeling about relating to someone, shared humanity.
Jeremy also thought peers offered users counterevidence of autobiographical
breaches mended, which fed hope and subtly piqued damaged self-respect: ‘‘if
[mental health service users] know that they are not so different, and not so bad,
then I think that will be very helpful to them.’’ These kinds of moral agencybuilding resources seemed to have helped Jeremy in his own recovery story.
Preserving moral agency: The pillar
Irene was an African American woman in her early 50s that I met at the same clinic
where I met Jeremy. Her peripeteia was her first suicide attempt at age 18, when, as
she explained: ‘‘I was fighting two wars . . . at school I was trying to be the best and
then at home I was trying to be strong.’’ She told me, ‘‘my mom made me a
confidante, which is why I grew this persona of being a strong pillar even
though I was the youngest.’’ Irene continued to keep her mother’s secrets, but
she also told me that,
[I]t was hard . . . keeping her secrets, so I became a strong brick tower that nothing
could get through and penetrate. I took it as an honor that she was confiding in me at
first, but it was detrimental later on because I couldn’t let nobody get in to help me.
Her home life was continuing to generate a lot of pain. ‘‘My sisters were IV drug
users, and mom gave them money, but it was never enough. They prostituted
anyways.’’ One of her older sisters was ‘‘a brainiac and I felt so sad that she
would waste what God had given to her. I strived to be like her academically
and I surpassed her education and everything and it hurt to see them.’’ Two of
her sisters eventually died of AIDS after she took care of them for several years.
Irene had the intention to aspire early on, and had the ability to secure the social
bases of self-respect that she valued: being reliable, caring for others, and performing well in school. Around the age of 15, Irene also began experiencing ‘‘hallucinations and delusions, command voices, telling me to kill myself.’’
After the suicide attempt, she said, she was ‘‘good for a while. I married and had
two children, and then several more suicide attempts, at 21, then 23. I would go a
long period of time with no medications, no nothing, and then [she slaps the table],
it would happen again.’’ She added, ‘‘my marriage wasn’t good at all . . . I left him
with a little boy in my belly, another in my arms, and a black eye.’’ Irene’s autobiographical power may have been withered by circumstance; however, she worked
hard to preserve her moral agency.
Irene spoke to a psychiatrist. ‘‘It was just all right,’’ she said. ‘‘I still withheld
stuff because I did not want to seem weak.’’ Irene knew that she needed to preserve
her social bases of self-respect, and she used peopled opportunities to do so.
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She and her children lived with her mother until a friend of her parents got her an
apartment. A landlord watched the children, which enabled her to attend college.
However, she continued to cycle on and off of her medications, and experienced
multiple relapses and rehospitalizations. ‘‘I’ve been on every medication you can
name,’’ she said, laughing. She explained that a new peer psychiatrist at the clinic
had finally helped her get some of her auditory verbal hallucinations under control.
Before that, the voices had often driven her to a suicide attempt:
You are having a fight, but it’s real, but you’re fighting. You gotta talk to ‘em, too,
you gotta tell ‘em to get away from you . . . and you’re trying to hold it together
but you got these voices sayin’: ‘‘you’re no good, jump in front of that car, take
those pills, don’t ever wake up.’’
Irene asserted her autobiographical power to try and stay alive in spite of exceptional circumstances.
During the time I spent with Irene, she was accepting medications at the new
peer service center and felt a reduction in her voices: ‘‘as strong as those voices are,
my will is getting even stronger to resist them.’’ Her children need her, she said.
This is a peopled opportunity, because ‘‘they respect me as mom.’’ She added, ‘‘see,
I believe in God, and if you put God first, he’ll carry you through . . . weeping may
come in the night, but joy comes in the morning.’’
In addition, at the peer service center, Irene had developed more interest in work,
I appreciate the opportunity to facilitate a couple of groups. Peers is a good piece.
You feel more comfortable and open up more instead of just a doctor with his glasses
looking over his nose and you are a case study.
Discussion
Moral agency means having the wherewithal to aspire, and the intentions and
necessary resources to achieve what one understands to be a ‘‘good life.’’ This
means having the opportunity to be held accountable, which makes possible stronger connections to others (Blacksher, 2002). This careful analysis of stories about
life after the peripeteia of a psychotic disorder explores the importance of moral
agency in mental health recovery.
The ability to reintegrate and become recovered is a matter of ‘‘moral agency’’
because definitions of ‘‘the good’’ vary according to the local context, depending on
local knowledges about what it means to live a ‘‘good’’ and meaningful life
(Kleinman, 1999). The recovery process can be difficult in rehabilitation settings
that put patients ‘‘out of sight and out of mind’’ in terms of the community and try
to ‘‘enable empowerment while fostering dependence’’ (Townsend, 1998, p. 166).
Brodwin (2012) also eloquently describes the ethical dilemmas of frontline case
managers who have little power or resources to promote aspects of moral agency
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in the lives of the people they serve. In the stories presented here, replenishing
moral agency included actively pursuing or protecting three key ingredients: the
social bases of self-respect, autobiographical power, and peopled opportunities for
intimacy.
The social bases of self-respect
People seeking recovery need the ‘‘social bases of self-respect’’ discussed by Rawls
(1971, p. 440) in order to thrive, a basic need that is easily diminished and hard to
replace without flexible means. Moe and Jeremy described the corrosive experiences that diminished their self-respect early in their mental health treatment.
Jeremy spent some time as a ‘‘chronic schizophrenic’’ advised to have no hope
for the future. Moe, despite his success, intelligence, and drive, became an
unemployable mental patient. When he attempted to recast his social status to
that of a quirky philosopher, he had no secure social bases from which to build
respect outside of the day program. Jeremy, on the other hand, had his social status
as a married person, a growth-oriented treatment setting, school, and then work, as
secure social bases for self-respect. Jeremy’s marriage seemed to protect him from
being persistently discredited early on. His wife advocated for better care. In contrast, Moe had lost the love of his life.
Irene used others’ perceptions that she was ‘‘strong’’ and intelligent to shore up
her own social bases of self-respect over time, which seemed to help her reorient
toward recovery after each round of relapse. She used this credibility to help her
find housing after leaving a husband she described as abusive, and to find childcare
and financing to return to college as a single mother. She preserved it by providing
care for relatives and children when she was well, which was valued in her community. The social bases of self-respect are clearly also one of the key resources for
mental health recovery and moral agency in Irene’s stories.
Autobiographical power
In the presence of a chronic illness or disability, one narrative can ‘‘colonize’’ the
self-narrative, and crowd out other possible versions (Weingarten, 2013). Many
people with psychiatric disabilities have described feeling that their narratives have
been colonized by the biomedical approach (Brodwin, 2012; Luhrmann, 2001),
which often ignores existential crises and ontological insecurities (Jenkins, 2010;
Kirmayer & Gold, 2012; B. Lewis, 2014; Myers & Ziv, in press). This is unfortunate, as autobiographical power, or power over the self-narrative, may be of key
importance for mental health recovery (Padgett, 2007). Bury (1982) also argued
that healing despite the continuing presence of a chronic illness required a dramatic
reevaluation of one’s self-concept.
We can see this at work in Irene’s story. She continued to write her story,
through all that she endured, as that of a ‘‘strong’’ woman needed by others.
She views her experience of voices as a ‘‘fight,’’ but trusts that she is ‘‘as strong
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as these voices are, I am strong enough to resist them.’’ Part of this strength, she
told me, was her reliance on God and spirituality to help her persevere.
Autobiographical renderings can help people overcome demoralization and
achieve healing—including in early psychosis (Judge, Estroff, Perkins, & Penn,
2008; Larsen, 2004; Myers & Ziv, in press; Weingarten, 2013). B. Lewis (2014)
and Halliburton (2009) have written that multiple explanations—biomedical, spiritual, developmental—are useful for psychiatric patients in the healing process. S.
E. Lewis and Whitley (2012) have suggested that people with psychiatric disabilities
seeking ‘‘moral agency’’ want the right to author their own lives. Frank (1995)
claimed that all people with chronic conditions should have the right to at least be
the editor of their own lives. All point to the importance of autobiographical power
for moral agency and recovery.
Autobiographical power was also evident in Jeremy’s recovery story. He resisted
the colonization of his self-narrative by subverting his initial diagnostic story of
‘‘chronic paranoid schizophrenia.’’ His wife found him another treatment setting
that allowed him to work toward a softer diagnosis (such as depression with psychotic symptoms). He refused to become unemployed and earned his PhD in psychology. He then transformed his illness narrative into a motivational autobiography
for others in his work with peers. Jeremy’s story also indicates the importance of
autobiographical power for recovery—the ability to produce alternative narratives
of a psychotic disorder and share them with others. Tranulis, Park, Delano, and
Good (2009) provided an example of this as well in a discussion of an Indian couple
living in Canada who resisted biomedical narratives of the wife’s early symptoms of
a new psychotic disorder, which was highly stigmatized in their culture, and then
eventually found a way to manage her symptoms of psychosis on their own terms.
Among peers who share psychotic experiences, the sharing of stories is a manifestation of the ‘‘horizontal recognition’’ and affirmation that Solomon (2012)
claims is valuable among marginalized groups. Davidson and colleagues (2008)
suggest that peers offer each other ‘‘hope.’’ I would add that the editorial skills
required to confront the injustice and inequity often experienced by people with
psychiatric disabilities, as Sayer (2011. p. 209) suggested, may best emerge when
marginalized people compare themselves to each other, monitor inequalities, and
decide what is and is not acceptable for them.
Peopled opportunities
Finally, all three stories demonstrate an initial dearth of access to peopled opportunities to practice moral agency outside of mental health treatment settings after
the initial peripeteia. The term ‘‘peopled opportunities’’ is distinct from classic
notions of ‘‘social support.’’ Peopled opportunities means that a person has a
sincere opportunity to be recognized as a good, accountable person by others in
a way that makes possible lasting, two-way intimate relationships. Inviting someone for Sunday dinner, allowing someone to borrow a car to take a girlfriend on a
date, referring them to a colleague for a job, and inviting someone to join a
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community drumming group are all examples. This is more complicated than social
support; it is a holistic vetting and recognition by the person or people offering the
opportunity that makes possible further connections.
Often, one cannot flourish if one lacks a peopled opportunity to even practice
being the kind of person one desires to be (Sayer, 2011). For example, Moe wanted
the young community philosophers to look up to him, but his students gave him
little opportunity to practice building that relationship with them—practice he
needed for his plans to come to fruition. People need the opportunity to practice
this and do well (perhaps first with peers as S. E. Lewis, Hopper, and Healion
[2012] have suggested).
Irene’s life also included several peopled opportunities that helped her preserve
the social bases of self-respect. She was her mother’s pillar, her sisters’ keeper and
caregiver, her children’s rock, and someone so respected that people paid for her
schooling. The strength of her reputation was enough to carry her past her suicide
attempts—a seeming sign of weakness in a woman otherwise highly regarded.
Jeremy’s road was different. Jeremy’s wife created the initial peopled opportunities for him. She helped him find a hospital where people did not see him as
chronically deteriorating. He then returned to a life plan on his own terms, leaving
the hospital after 2 years for graduate school. Reintegrating into a setting of higher
education offered him peopled opportunities to interact with likeminded others.
Slowly, Jeremy rebuilt his capacity for moral agency as those around him recognized his potential to be a good person and afforded him the peopled opportunity
to practice being one—and, ultimately, succeed as a psychotherapist.
Moral agency may best be fostered, as Rawls (1971, p. 67) first argued, in a community of shared interests where one’s associates can confirm (or help edit) one’s
aspirations. With peopled opportunities, moral agency can be developed through
‘‘the ordinary sentiments, reflexivity, behavior and interactions of people, constrained
and enabled by their physical and psychological capacities and susceptibilities, and by
social structures and cultural discourses’’ (Sayer, 2011, p. 186). As Sayer (2011, p. 187)
has argued, such a ‘‘mundane morality,’’ must be learned, developed, nourished in
social context and practiced; it requires peopled opportunities.
Readers familiar with the situations faced by people who are trying to manage a
serious psychiatric disability in North American culture may recognize many elements
of these stories, and hopefully can now see how these stories relate to the recovery
literature through some aspects of moral agency. More research is needed to further
investigate what exactly moral agency is in mental health recovery, how it operates,
and how we can best encourage its preservation and nourishment in settings of care.
Replenishing moral agency
This paper has accentuated the ways that moral agency is often eroded and not
refreshed in treatment settings for people with psychiatric disabilities, but could
instead be nurtured if settings of care focused on building one’s intention to flourish
and helped people develop or claim the resources needed to do so—namely, the social
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bases of self-respect, autobiographical power, and peopled opportunities. These three
resources for nourishing moral agency, coupled with the freedom and intention to
become a moral agent, seem to be key drivers of mental health recovery.
Peer-provided services have the potential to provide such resources. Several peer
models have been shown to be successful in providing effective case managementstyle services, reducing stigma, and increasing hope in the users of those services,
but more research is needed to build the evidence base (Lloyd-Evans et al., 2014;
Chinman et al., 2014; Clay, Schell, & Corrigan, 2005), especially in low-resource
settings (Fuhr et al., 2014; Pitt et al., 2013). Peer providers, like other lay health
workers, may help people find treatment more quickly, reduce stigma, encourage
help-seeking, and protect a person’s existing moral agency (Balaji et al., 2012;
Chatterjee et al., 2011).
Another underexplored setting is that of spiritual or religious communities.
Ninety percent of the world considers itself to live in a religion-oriented culture,
and religious leaders are often a first stop for mental health care (Koenig, 2009).
Irene mentions this resource, as do recent publications (Luhrmann, 2013; Whitley,
2012). Many people with psychiatric disabilities report that religion helps them in
their process of mental health recovery (Borras et al., 2010; Gearing et al., 2011;
Mohr, Brandt, Borras, Gilliéron, & Huguelet, 2006). With supportive congregations, opportunities to testify, alternative ways to ‘‘make sense’’ of an initial
break, and so forth, religious settings likely offer the social bases of self-respect,
autobiographical power, and peopled opportunities that are essential for developing
moral agency.
Conclusions
Jacobson (2004) has shown how rehabilitation organizations become quagmires for
reform. Traditional, institution-driven psychosocial rehabilitation programs may
not be the best venue for promoting recovery. Strong alternative venues for replenishing lost moral agency (or preserving it in the first place), this article suggests,
may include: peer networks, family-based interventions (especially in the context of
marriage, it seems), employment settings, education-based interventions (perhaps
especially in higher education), and religious settings. By promoting care for early
psychosis in settings that build and preserve moral agency, we may help divert
chronic disability and better empower people to take charge of their own lives.
Acknowledgements
I am grateful to Kim Hopper and Rebecca Lester for their insightful comments on this
paper. Thank you also to those who shared their time and stories with me.
Declaration of Conflicting Interests
The author declared no potential conflicts of interest with respect to the research, authorship, and/or publication of this article.
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Funding
The author disclosed receipt of the following financial support for the research, authorship,
and/or publication of this article: This study was funded by the National Institute of Mental
Health Center for the Study of Recovery in Social Contexts, Grant No. P20MH078188.
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Neely A. L. Myers, PhD, is an Assistant Professor of Anthropology at Southern
Methodist University (SMU). She has been engaged in ethnographic research on
the everyday experience of serious emotional distress and mental health recovery in
the US since 2003, and in Tanzania since 2013. In 2014, she also began a project on
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youth engagement in care for early psychosis in the US. Her research has been
funded by the National Center for Complementary and Alternative Medicine, the
Elliott School of International Affairs, the National Institute of Mental Health,
and the Hogg Foundation for Mental Health. Her most recent book is Recovery’s
Edge: An Ethnography of Mental Health Care and Moral Agency (Vanderbilt
University Press, 2015).
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