“Democratic” Psychiatry

When I hear the phrase “democratic psychiatry” I immediately think of the rhetoric of “service user involvement” and the ideology of empowerment. These aren’t the directions psychiatry should take simply because this is the direction psychiatry is already taking and which it is already perfectly able to assimilate. I am opposed to this rhetoric and ideology not because I think they will be the ruin of psychiatry as it exists, but because I am convinced that they will not.

Where democracy is meant in terms of a process of democratisation of existing institutions, we are caught in a problem that resembles Zeno’s Paradox of Achilles and the Tortoise: the infinite divisibility of stages of democratisation that renders the process essentially illusory. In the paradox, Achilles and the tortoise are set against each other in a race where the former is pursuing the latter. The idea is that in order to reach the tortoise, Achilles has to traverse the space from where he begins running to where the tortoise began. In the time it takes him to do this the tortoise has moved further ahead and so he must now race to that point, and so on to infinity where Achilles must bridge ever diminishing intervals of space. The upshot is that Achilles never catches the Tortoise, and all the spectators go home entirely bored by the never-ending logical nonsense.

This paradox is a logical problem that doesn’t match our experience: of course a hero like Achilles would catch the tortoise. The point is that it also serves as a fable of democratisation. Conceptually, it is uncertain where we could draw the limit-point, the transgression of which would mark psychiatry as being truly democratic. Against traditional readings, democratisation is not a transition from pre-democracy to democracy but is in fact the bad infinite of adding “a little more democracy”. This is how I understand the democratisation of psychiatry: the attempt to increase participation in psychiatric service design and review by those who receive psychiatric treatment and their significant others and families. All very well and good, but conceptually such increases in participation can be infinitely divided into ever more vanishing gestures. This is played out in practical terms in the tokenism that many psychiatric survivors see in the way that psychiatry has appropriated the democratisation agenda.

In practice, democratisation has come to mean increased involvement in a system that is necessarily founded upon the cognitive authority of medicine, despite its scientific stature being almost entirely spurious. When a system of governance mimics and grounds itself in the cognitive authority of experts, and when it advances its own “expert” opinions as unassailable necessities, then such cognitive authority becomes the scaffolding for a form of authoritarianism. The democratisation of psychiatry isn’t a transition to a democratic regime, but the increased embedding of dissent within psychiatry so as better to neutralise it. When authoritarianisms can no longer neglect, exclude, or otherwise destroy those in their grip they move onto become adepts of management, negotiation, and, therefore, containment and pacification.

While there has undoubtedly been a radical improvement in the conditions people find themselves in and the way they are treated by “services” (a term that implies a consumer-commodity relation that is entirely lacking) since the early days of psychiatry, this is not evidence of a transformation of psychiatry itself. Without a fundamental reorientation of psychiatry, democratisation is simply the attempt to create a space within psychiatry, and therefore outside of the political, that resembles an agonistic play of voices. This chorus is tolerated and even encouraged but also within limits. Those limits are defined by the contours of psychiatry itself: just like with democratic political regimes, you are free to choose whatever you like as long as you choose what has already been chosen.

I am an advocate of the position that those who are affected by a decision should also be those who are making those decisions. In psychiatry this is a difficult position to maintain; we can’t really allow floridly psychotic people to make decisions about their own care, nor can we allow violent people the last word on whether or not restraint is ever to be used on their bodies. These are sensible objections but they also miss the point insofar as they remain wedded to the “empowerment” ideology that is, in reality, only the application of an atomising individualism to the people who are already feeling the most acute consequences of that ideology.

So how can this principle – arguably the principle of democracy – be applied? It can only be applied by considering that the people making the decisions aren’t only psychiatric subjects, but are capable of such decision-making (even if they aren’t capable of understanding the nuances of psychiatry as it conceives itself today.) Do you have to be a psychiatrist to make a decision about what’s best for a person? I think not. It is the experience of non-expertise that is required by psychiatry today.

We hear a lot about the idea of the “expert by experience”. Some people champion this as a way of saying that only the person who experiences mental distress is able to understand it and that the professional must listen and be receptive. This is an attempt to equalise the power relationship within psychiatry by disrupting the distribution of roles of expertise through the affirmation of personal and collective counter-knowledge. And yet, this has been integrated into psychiatric and nursing training programmes without having made much of a difference. Distress is still pathologised, voices that escape the democratic regime are still “behavioural” or “unstable” etc., and spurious treatment regimes continue to destroy the capacity of people to engage in the processes of their own care – with the full legal backing of the state.

I don’t find this surprising at all –  the argument of expertise is not liberatory or emancipatory but caught within the democratic management of positions. The patient is an expert and the professional is an expert – their mutual expertise is complementary and reciprocal. In clinical practice this expertise is often that of the individual, whether it is the psychiatrist, nurse, or patient/client/service user/survivor, while in terms of policymaking it is too often the privilege of select pressure groups. The discursive horizon of expertise is naturally the horizon of the expert-as-expert who recognises the expert-from-experience as possessing an expertise that is announced as “different” from her own, but where this “difference” really means subordinate or a mere point of interest. The expertise of sufferers is usually only really regarded as such when it comes wrapped up in the expert’s own expertise: An unquiet mind will always be recognised as the real deal. By attempting to disrupt the discourse of the expert, the discourse of the sufferer is consumed by the structures of expertise as if by phagocytosis.

An emancipatory psychiatry should involve a genuinely democratic move by asserting that in terms of mental health there is no expertise and no expert. Psychiatrists, nurses, pharmacologists, people in distress, their friends and their families (none of these categories are exclusive): none of us know what is going on and none of us know what to do about it. But, psychiatry operates by pretending, by acting as if it knew even when it is repeatedly shown that its theories, evidences, and treatments are wrong, do not work, and cause more harm than they do healing.

I am not arguing that reforms are unimportant or that all mental health activists withdraw any involvement in the structures of psychiatric power. I am not suggesting a manichean binary wherein professionals are bad and people in distress are good. Rather, I am suggesting that democratic psychiatry can’t even be realised outside of its own ideal image while it remains allied to a practice of the self-management of psychiatric subjects within psychiatry.

When I think about democratic psychiatry I think about the ambiguity between democratisation of the same, and the radical possibility of a dictatorship of psychiatric survivors informed by the knowledges of psychiatric workers that are no longer considered as structural experts. This would resemble a kind of self-managed vision of mental health services where democracy was a material precondition, rather than an outcome, for emancipation from psychiatric oppression. There are already nascent examples of this throughout the world in the forms of self-help groups, peer-support, the Hearing Voices Network, the Soteria Project and others. Rather than being a democratic psychiatry these movements are something else entirely. These groups already implement a praxis that assumes an implicit demand: the supersession of psychiatry itself.

By Arran James | @dronemodule

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