So what is Democratic Psychiatry? by @validconsent

One of our readers who came along to Asylum’s conference ‘ASYLUM: Action and Reaction’ reflects on what democratic psychiatric might actually mean. We welcome more reflections on this theme.

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The word psychiatry comes from the Greek roots ‘psykhe’, meaning mind, and ‘iatreia’, meaning healing, suggesting that literally ‘psychiatry’ is ‘healing the mind’.  That meaning of the word does not seem to have captured us as a society, as has the idea of psychiatry being ‘the study and treatment of mental illness, emotional disturbance, and abnormal behaviour’.  That definition plunges us directly into judgements of normality, questions of who has the power to make those judgements and what end those judgements serve, as well as the use of power to enforce those judgements. The way psychiatry currently operates in our society might be a product of a form of democracy — because it has arisen from the way a majority might like to treat a minority — but it does not seem to me to be one that is democratic in its relationship to those who might be on the receiving end of its services.

Looking back to last year, I think I decided to go to the conference to see what it was all about because the word ‘democratic’ alongside the word ‘psychiatry’ was so intriguing. I also remember that I was concerned about coming to the conference as psychiatry in our society is surrounded in silencing and bitter conflict: those who believe their lives were saved by diagnosis and those who feel diagnosis is a form of oppression that caused them profound harm; those who believe the evidence for medication is deeply flawed and misleading, alongside those who feel that the drugs worked for them; those who believe that psychiatry has committed (and continues to commit) serious human rights abuses, and those who feel that those very same restrictions of rights saved their lives; those who can only feel safe if some things are not spoken about and those who feel that their way to healing is through learning how to speak about their experiences; those who believe that when people are in an altered state they are not responsible for their actions, and those who believe that this position confuses our approach to healthcare with our approach to criminal behaviour in a way that is hopelessly muddled.

The dangers for those participating in conversations about psychiatry seem to be immense — the dichotomies are so profound that it so often seems that one person’s needs can only be met at the expense of another’s. It seems that as one person reaches towards increased safety for themselves, another person is pushed towards experiencing terror and threat. Yet the opportunities for making valuable connections which could potentially create something that might work better are also tremendous. These are fraught and painful tensions to hold. The tensions are so unbearable that — even in a more democratic space, away from the mental health system, where there are more voices to be heard and more opportunities to speak — I wondered if a group of people could possibly bear them.

I do think that the people organising the conference, who were volunteers, put in their personal effort and time because they believe in the project of democratic psychiatry. I do think that the people speaking said things that may have very little forum in mainstream mental health discourse. I did get to hear people who were articulate, brave and interesting. I do think the conference was well organised, well thought-through and enabled many different speakers to present their ideas. I do think that the ideas available at the conference were ones that might otherwise never be heard. The presentations included Soteria, the way the diagnostic manual is structured and community networks. There were opportunities to learn about creative responses to confusion and distress which seem squashed out of existence in our current top-down, power-over Mental Health system. Any place which exists and allows this exchange of information is essential and important. This needs recognition and celebration.

I don’t think we managed to make gentle space.

These impressions meant that after the conference I was left thinking: Why did I feel we did not quite manage to develop a space for Democratic Psychiatry? Democracy is a deeply valued term, but it also seems to be one of the vaguest political terms in our current social world.

In my reflections I considered that perhaps it was the arrangement of the conference that felt restrictive: a format of people presenting and giving information while others listened did not give much room for the exchange of perspectives which are the deeply difficult heart of a democratic process. The format of upfront presentation and information-led workshops with little time for talk and reflecting felt like the structures of university teaching. Places of learning have rules of engagement which are deeply learnt; you don’t disturb others, you don’t leave early or arrive late and, of course, more subtly, your views are not important if you are not presenting. Even more insidiously, in a university setting, there might be a less obvious message that if you are not even a student or have never been a student you do not belong there. Perhaps we are all so steeped in the ‘power-over’ structures of our society that we take them with us when we try and find out what a ‘power-with’ approach might be like. In our culture where can we learn about what a truly participatory democratic experience might look and feel like? Considering my experience — of learning institutions, of religious institutions, of political institutions, of the media, of popular culture — I cannot see how any one of us has very much opportunity to learn about how to have a more egalitarian approach.  All our systems are set up so that only certain authorities — such as established members of a group, academics or professionals — provide the information and get the chance to express their views. This means that many people do not get the opportunity to learn how important what they have to say can be. I like the ideas that come from academics and professionals very much, at times. However, new and interesting ideas do not always come from them and without other voices the conversation becomes depleted. The ways power really operates in our society is more like an oligarchy where, while some are heard, other perspectives are lost.  

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My unease made more sense to me when I read articles in Asylum magazine which explored the difficulties some other people had faced during one of the presentations. The understanding I took from the letters was that being asked to bear witness to a threatening, hostile and derogatory Voice being presented in a context where it felt difficult to leave might be democratic, but it certainly did not feel safe. For me, it does not feel democratic for a person who has found a way to present their experience to have to hide or remove some aspect of that experience. That feels like censorship. However, one right in a democracy is to choose not to participate.  Either way, when there are people who are not able to join in, the conversation is less rich and varied. In our current ‘Mental Health’ system, we have lost too many important opportunities for learning and lost too many irreplaceable voices.

It struck me then that most of our Democratic systems only work by silencing or marginalising some voices. Even in a participatory democracy the majority can also be a tyranny; having the power to wield cruel, unreasonable, or arbitrary forms of control over a minority. It seems to me that the tensions in discussion around mental health already fall into agonising forced dichotomies. This means that any collective of people involved in those discussions may always only be a step away from the anarchy of collapse or animosity. How do we make spaces where we can somehow hold the intolerable tension of needing to listen, but it being unbearable to hear?

I don’t think we can continue to hope that we can reach a form of safety by excluding everything that is potentially threatening. If we cannot directly hear messages that are unwelcome — the voices of terror, distrust, panic, blame, hostility, loathing and criticism — what happens to the communication that we do not receive? If some messages are rejected, there is the possibility some individuals who are part of the group feel rejected too.

Perhaps we need to reconsider the concept of Democracy as a model for social organising, with its inherent risks of oligarchy, tyranny or anarchy. Perhaps democracy has its limits when we are dealing in discussions about being human.  Perhaps we can only develop new ways forward by creating something I do not think that anyone of us has ever really experienced: spaces which seek ways to be together that are based on power-with, not power-over.

Perhaps what we need is a form of inclusion: where we start from the assertion that we all have the right to feel safe all the time.

So I propose some questions, from this different perspective, as we need to talk about intense and devastating experiences, as well as uplifting and transformative ones:

  • How do we promote an egalitarian approach so everyone can be heard and no voices are rejected?
  • How do we set
  • up spaces where everyone knows what it means to feel safe?
  • How can we design a space where we all feel safe all the time?
  • How do we create the possibility of feeling safe, even as we might feel terrified by what we are hearing

@validconsent

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  • reply cally starforth hill ,

    Like you say, we have already got ‘democratic psychiatry’. People vote for politicians who endorse psychiatry. Therefore psychiatry is given a mandate to do what it wants. Not surprising as we live in a very sick capitalist greedy economy. My guess is that minds can only really heal themselves. Some will not manage to heal but can perhaps find positive ways to make life a bit more bearable. Being courageous enough to stand up for a world in which that is allowed to happen, where death is seen as part of the cycle and not automatically a bad thing, would be a start.

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