This jointly authored blog is a slight departure in that it explores a recent conceptual discussion paper, rather than a research study. However, as us elves have a duty to keep you posted on the latest ideas in mental health too, we thought it well worth covering.
In this paper, Spandler and McKeown (2017) outline the case for and against holding a Truth and Reconciliation process (T and R) in psychiatry and mental health services between ‘service users, survivors and refusers’ alongside mental health staff.
The proposal is to address a long history of enforced treatment in psychiatry and mental health services, as well as the more recent manifestation of ‘psychiatric neglect’ (Spandler, 2016). Psychiatric neglect comes in the wake of austerity politics, a recovery agenda that now individualises and makes patients reponsible for their own mental health care, and the promotion of a rolling back of State and communal responsibility for those of us who experience mental distress (Harper and Speed, 2015).
The article considers T and R processes in the context of increasing interest in trauma informed approaches in mental health (TIAs), which Sarah explored in a previous blog summarising emerging evidence that many people who access mental health services are presenting with attempts to manage previous trauma, interpersonal harm and relational injuries.
Danny has argued that in these cases psychiatric diagnoses are primarily ‘discursive fig leaves’ that mask underlying abuse and so for these service users there is a risk of mental health services retraumatising people through patterns of coercion and control that are similar to the nature of the originally abusive relationships (Taggart, 2017). The risk of iatrogenesis (or the treatment being as bad as the disease) means that the relational process of mental health care needs to be as closely attended to as the content or form of treatment whether psychiatric, psychological or psychosocial.
A T and R process can be considered as instrumental for not only addressing the damage that mental health services and treatment have caused in the past, (and possibly offering space for acknowledgment, apology and reparation), but also pointing the way to more democratically accountable, consensual and participatory forms of mental health service and support in the future.
The authors use a ‘conceptual review approach’ to explore T and R processes and set out a case for their potential application to mental health services and psychiatry.
They specifically cite the example of T and R in Post-Apartheid South Africa as an approach to inform a healing process in the wake of institutional abuse and neglect in psychiatric services in the UK. They also acknowledge the ideas and work of the service user and survivor movement, most notably that of pioneering UK survivor activist Jan Wallcraft (2010).
In order to test their position, they respond to four objections to T and R in mental health systems:
- What if psychiatry would not accept any wrongdoing and apologise?
- Surely psychiatric harm is not equivalent to other human rights abuses?
- Would not calls for T and R alienate mental health professionals and workers?
- Should not inadequate mental health services be challenged through political activism?
The case is made for context-specific ‘grassroots T and R processes to begin the task of peace-building in the context of mental health services.’
The authors argue that any process will require the new spaces for collective dialogue and listening outside the mental health or psychiatric system and suggest ‘healing circles’ used in community-based restorative justice programmes and ‘polyphonic dialogic communication’, as used in Open Dialogue. Any approach should not be imposed or influenced by a ‘clinical mindset.’
Rather than waiting for a public apology, a process can start with multiple survivor testimonies that should be heard ‘without judgement, argument or contestation’ and build on grassroots community activism. Spandler and McKeown recognise that ‘ultimately psychiatry remains contested and contestable’, and that there is evidence that mental health services can be retraumatising, with the risk of ‘epistemic violence’. Therefore the abuses are not historical and still continue.
They posit the argument that ‘perhaps healing or restitution cannot take place until the full extent of survivor grievances has been acknowledged.’ T and R processes should explore the full complexities of psychiatric system harm to survivors and by or to staff: ‘we cannot realize genuine solidarity without the precondition of acknowledging harms…and significant power imbalances.’
Strengths and limitations
A particular strength of the piece is the emphasis upon the nature of T and R processes as being forms of restorative and transformational rather than retributive justice. Restorative justice emphasises the need for processes of non-blaming dialogue.
Spandler and McKeown deftly manage to avoid many of the typical polarities that can bedevil this debate. Calls for recognition of the harm caused by mental health services is often dismissed as empty, nihilistic critical psychology or anti-psychiatry posturing. However, here the authors have assessed a range of sources (academic and professional as well as service user and survivor) to make the case for a moderate, inclusive and appreciative form of T and R that can acknowledge both the harm to service users and survivors and staff. It would perhaps have been beneficial to have a survivor co-author, to balance the analysis and strengthen the proposition of the mental health social work and nursing academic authors.
The authors question the absolute distinction between staff and patients, recognising the worrying increase in stress-related illness and absence among mental health staff, and collapsing these categorical distinctions to offer the possibility of more open, humanistic discussion of relative harm that avoids victim – perpetrator dichotomies.
However, while this is to be welcomed, the partial emphasis on staff ‘victimhood’ reveals a key difficulty with the proposed T and R approach. Power in psychiatry and mental health services is structural as well as interpersonal. Although operating in the same harmful system, staff nonetheless remained in a position of power within those structures. They had a choice to work where they did, were not subject to containment and compulsion, and could leave the hospital at the end of the working day. They also had a professional (and human) duty to speak out and act if they witnessed abuse within services, as the best staff did and still do.
South Africa undertook a process of T and R that in some ways at least led to tangible social and political change, the quest to follow a similar process in post-Troubles in Northern Ireland was less successful. The Northern Irish example floundered in part because of the contested nature of ‘victimhood’ during the Troubles with both Nationalists and Unionists having some claim to being wronged. Arguably this lack of willingness to acknowledge the broader and structural harms caused from within their own community was one reason why the process did not get off the ground.
Similar pitfalls need to be avoided in this case by staff being fully open and willing to listen to survivors’ stories without feeling personally attacked. These are primarily systemic problems, not individual ones. Although staff have been hurt by the system and what they have been expected to do, many survivors would argue that the psychiatric harm they have experienced is highly complex and ontological.
Conclusions and implications
The authors conclude that:
In the absence of an officially sanctioned T and R process a grassroots reparative initiative in mental health services may be an innovative bottom-up approach to transitional justice. This would bring together service users, survivors and refusers, with staff who work/ed in them, to begin the work of healing the hurtful effects of experiences in the system.
In accomplishing effective truth-telling, reparation and reconciliation, new forms of dialogic communication and horizontal democracy might emerge that would sustain future alliances and prefigure the social relations necessary for more humane mental health services.
While the comparison between a State system of institutionalised racism that lasted 43 years, and the treatment of the ‘mentally ill’ under a outwardly benign if paternalistic psychiatric system in the UK might seem to stretch credulity and even risk insult to the plight of millions of black South Africans, there are some respects in which there are concerning parallels.
Successive Apartheid governments utilised the rhetoric of security as a means to justify human rights abuses including detention without trial in a way that is similar to the rhetoric of public safety whereby many thousands of psychiatric patients are annually detained under the Mental Health Act against their will and in the absence of any crime being committed.
In addition, a form of what can now be called ‘epistemic injustice’ (Fricker, 2007) was deployed in Apartheid South Africa to suppress black South African voices in explicit ways such as the shutting down of newspapers and printing presses, but also in more subtle ways such as revisionism of South African history to emphasise the importance of the Dutch colonies thereby erasing centuries of pre-colonial history.
This process of structural and covert silencing can be seen in the ways that knowledge about madness and mental distress have been colonised and controlled by those working within mental health and psychiatric services, often leading to the silencing of users and survivors of services. The research agenda in mental health has been dominated by forms of categorisation and treatment (both psychiatric and psychological), often commodified and costed, to the exclusion of examination of the sorts of human rights abuses and other social injustices that many service user and survivor groups identify as unacceptable within current services.
The tricky balance to strike is to make T and R processes for psychiatry and mental health services consensual and non-blaming enough to convince mental health professionals to participate, while having enough space for psychiatric survivors to air long standing and legitimate grievances about coercion and control, and more recently, in the wake of austerity politics and NHS cuts, ‘psychiatric neglect.’ If this can be achieved the authors suggest a new, more progressive and less harmful form of mental health services can be built collaboratively.
Spandler H, McKeown M. (2017) Exploring the case for truth and reconciliation in mental health services. Mental Health Review Journal 22 (2) pp.83-94, https://doi.org/10.1108/MHRJ-01-2017-0011
Fricker M. (2007) Epistemic injustice: Power and the ethics of knowing (PDF). Oxford University Press
Harper D, Speed E. (2015) Uncovering recovery: The resistible rise of recovery and resilience. Demedicalising misery. Palgrave Macmillian, UK. [Abstract]
Spandler H. (2016) “From psychiatric abuse to psychiatric neglect?”, Asylum Magazine, Vol. 23 No. 2, p. 7-8.
Taggart D. (2017) Anatomised. Asylum Magazine, Vol 24 No.1, pp 29-31.
Wallcraft J. (2010) “Truth and reconciliation in psychiatry”, available at: www.ipetitions.com/petition/truth_and_reconciliation_in_psychiatry/
Excellent discussion – but will be hard job getting anyone at RCPsych to admit psychiatrists harm anyone – former President Simon Wessely described ME/CFS patients who spoke out against abuses as ‘militants’ who were ‘anti-psychiatry’. Recently, I published a paper on Epistemic Injustice in ME/CFS with Dr Blease on this topic (in JME) using Frickers framework.
To have any kind of reconciliation there needs to be truth – then action; I don’t see UK psychiatry admitting any of their errors of iatrogenesis in ME/CFS for example, so I imagine it might be the same in other illness domains.
RCPsych and partners are quick to rebut any criticism – eg recent response to BBC panorama programme on SSRIs and violent acts – you won’t see any response or engagement with ME/CFS patient groups.
Hopefully discussions of this kind and papers in this area will raise the need for T&R – which can only lead to better psychiatry and mental health.
I am afraid that a few legal cases claiming compensation under human rights law will be needed for RCPsych to take this issue seriously. Latest I heard is that College politics are stifling use of co-produced suicide protection plans. (see Alys Cole-King)
Yes, but I am pleased to hear that the RCP has recently formally apologised for the harm cased to gay men who were ‘treated’ with aversion therapy in UK state mental hospitals. No compensation and long overdue but still progress.
Truth and reconciliation processes in South Africa and Northern Ireland took place after notable gains in power and status by formerly oppressed and low status groups. These gains were achieved in some measure as a consequence of effective and radical independent action on the part of these groups. A truth and reconciliation process of this nature is not possible in psychiatry because there has been no significant shift in power and status between mental health professionals, particularly psychiatrists, and survivors, and any gains made by survivors over the years have been carefully managed by a largely stable high status group consisting of mental health professionals, service commissioners and providers and supposedly independent funding agencies who shape the market in accordance with the status quo.
I think you are quite right about this Patrick. In the paper we try and address this and draw on a more ‘grassroots’ bottom-up truth and reconciliation process, modelled on examples in the US where the powerful organisations refuse to accept responsibility for harm. This can help us build a case for a more formal process and also raise consciousness. See for example, http://blogs.lse.ac.uk/usappblog/2016/06/17/how-grassroots-truth-and-reconciliation-commissions-can-help-activists-to-reclaim-their-communities-and-advance-social-justice/ This approach has been used in a mental health context in the States by organisations like the Icarus Project and Rethinking Psychiatry. For example https://kboo.fm/media/50002-truth-reconciliation-mental-health. We find these examples inspiring and would like to see something similar in the UK.
Here in Canada a few cases of shrinks admitting there is no such disease as “mental illness’ are on the books. SEE the Sutherland who has made ALL his legal documents available for others to duplicate. https://www.madinamerica.com/2018/02/seeking-justice/
Because the NIMH withdrew all funding for the DSM5 owing to a lack of scientific credibility forcing the APA to fund it themselves, it legally should have been forced into a junk science litigation on the basis that misdiagnosis is both medical malpractice and insurance fraud. The “chemical imbalance theory that mental illness is a brain disease” requiring dangerous “treatment” let alone that there is even a ‘disease” to treat is specious at best. Informed consent requires practitioners provide the risks, benefits and alternatives to would be users of any “treatment” as well as the fact that there is no evidence that they have a “disease” to treat in the first place. The science shows that most of what ails people experiencing what is being misdiagnosed via “mental health” as depression is poor gut health from inadequate diet and prolonged stress resulting in inflammation that can be cured with proper diet and lifestyle. No one requires neurotoxic drugs, therapy or a lifelong label as a “mental patient” because they and those “treating: then lack basic facts about health.
Interesting piece. I doubt that truth and reconciliation processes will actually “work” in terms of restorative justice, speaking as a whistleblower about human rights abuses in psychiatric setting, Fife, Scotland, 2012.
I “won” an Ombudsman case and received an apology for “unreasonable treatment” in late 2014, it took me 30mths to get this brief letter. Meanwhile the health board received £4.4m to build a new unit and they had stopped using the locked seclusion room with no toilet, light or water, after the “successful” Ombudsman decision. I got financially poorer as an unwaged Carer and my son, who lives with me, got targeted by DWP to justify his mental illness and I advocated for him at meetings.
I’ve had to get over the fact that there is no real justice after psychiatric abuse, being a survivor myself of 3 psychiatric inpatient stays and coercive, abusive treatment. My 2 older sons have also survived psychiatric treatment, and I supported them also in and out of MH settings. In fact I’ve done this for family members since 1970, a lifetime.
I’m just glad to have survived this far, aged 67 this year, and hope that I may have another career that isn’t mental health, which is what I’m living for, having got off all the neurotoxins myself back in 2005, under my own steam.