A Relationship Approach to Recovery In Mental Health: A Qualitative Analysis

Background and Purpose: In recent years ‘recovery' has become the single most important conceptual development in mental health service delivery. And while recovery is not a technique, method, or model of practice (i.e., motivational interviewing, cognitive-behavioral therapy, or assertive community treatment), it does purport to describe and prescribe desired and valued outcomes for clients, parents, providers, researchers, and policymakers. In research and scholarship, memoirs and personal accounts, recovery makes reference to the roles of formal and informal relationships in producing and sustaining recovery from serious mental illnesses. The aim of this study was to identify the ‘practical knowledge' deployed in problem solving interactions among mental health providers (principally case managers) and clients. Methods: Single and comparative case study methods were used to study three clients (one with major depression and two with schizophrenia) and three case managers over 24 months. Participant observation of case manager and client-initiated interactions were audio recorded or notated and a three-stage analytic strategy (thematic, grounded theory, and narrative) was conducted using two coders who independently coded problem-solving events for type of relational activity. Coders could not agree on 33 events (i.e., the thematic relational code); these were discarded and the remaining 628 events were used in a grounded theory and narrative analysis.

Results: Four categories of practical and relational knowledge were identified: doing for, doing with, standing by for support, and letting go. A narrative matrix of provider and client interactions identified the practical and relational actions (e.g., doing for and doing with) associated with specific life domains (i.e., cognitive, emotional, and behavioral). These findings demonstrated that the activities of case management were not only practical. They were also value driven. For example, when case managers respected client dignity and independence, they acted with values that guided them in making judgments about both the type and use of the relational activities (e.g., doing for and doing with activities) within specific time and spatial dimensions. Conclusions and Implications: Foucault and Bourdieu inspired an enormous and diverse literature on practice and its relationship to theory. In this paper we argue that this scholarship tends to elide how knowledge works in the ethical dimension, that is, in the inevitable and necessary tension between fact and value. Doing for and doing with, for example, emerge from practical knowledge and in the particulars of caring relationships, and their effects cannot be explained or prescribed by technique. And these practitioner reflections on value require our taking seriously ‘values' as knowable and actionable. Indeed, these data show how practical knowledge in provider/client relationships produce particular ‘valued' effects and how relational aspects of treatment are often overlooked because the fact/value separation in social work research consigns these to the subjective (i.e., value) and emotional (i.e., interference), thus unknowable dimensions of practice.