Austerity and identity formation: How welfare cutbacks condition narratives of sickness

Cooperation in Return-to-work Interventions for Common Mental Disorders: An Ideal Theory Analysis of Actors, Goals, and Ethical Obstacles

The rise in the number of people on sick leave for common mental disorders is a growing concern, both from a societal and individual perspective. One common suggestion to improve the return-to-work process is increased cooperation between the relevant parties, including at least the employer, the social insurance agency and health care. This suggestion is often made on the presumption that all parties share the common goal of reintegrating the patient-employee back into the workplace. In this paper we investigate this presumption by mapping out the ethical frameworks of these three key actors in any return-to-work process. We show that although the goals of these actors often, and to a large extent, overlap there are potential differences and tensions between their respective goals. Further, we emphasise that there may be other limitations to an actor's participation in the process. In particular the health care system is required to respect patient autonomy and confidentiality. There is also an inherent tension in the dual roles of health care professionals as therapists and expert witnesses in work ability assessment. In conclusion, there are potential tensions between the key actors in the return-to-work process. These tensions need to be addressed in order to enable an increased cooperation between actors and to facilitate the development of a feasible plan of action for all parties, including the employee.

"Nothing's changed, baby": How the mental health narratives of people with multiple and complex needs disrupt the recovery framework

The dominant narrative in mental health policy and practice has shifted in the 21st century from one of chronic ill health to a 'recovery' orientation. Knowledge of recovery is based on narratives of people with lived experience of mental distress. However the narratives of people experiencing structural inequalities are under-represented in recovery research. Meanwhile, uses of recovery narratives have been critiqued by survivor-researchers as a co-option of lived experience to serve neoliberal agendas. To address these twin concerns, we undertook a performative narrative analysis of two 'recovery narratives' of people with multiple and complex needs, analysing their co-construction at immediate/micro and structural/macro levels. We found two contrasting responses to the invitation to tell a recovery story: a narrative of personal lack and a narrative of resistance. We demonstrate through reflexive worked examples how the genre of recovery narrative, focused on personal transformation, may function to occlude structural causes of mental distress and reinforce personal responsibility in the face of unchanging living conditions. We conclude that unacknowledged epistemological assumptions may contribute to co-constructing individualist accounts of recovery. A critical, reflexive approach, together with transparent researcher positionality, is imperative to avoid the epistemic injustice of a decontextualised form of recovery narrative.