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Exploring the case for truth and reconciliation in mental health services



Purpose The purpose of this paper is to explore the case for a truth and reconciliation (T&R) process in the context of mental health services. Design/methodology/approach The approach is a conceptual review of T&R approaches; a consideration of why they are important; and how they might be applied in the context of mental health services and psychiatry. First, the paper sets out a case for T&R in psychiatry, giving some recent examples of how this might work in practice. Then it outlines potential objections which complicate any simplistic adoption of T&R in this context. Findings In the absence of an officially sanctioned T&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 of services, with staff who work/ed in them, to begin the work of healing the hurtful effects of experiences in the system. Originality/value This is the first paper in a peer-reviewed journal to explore the case for T&R in mental health services. The authors describe an innovative T&R process as an important transitional step towards accomplishing reparation and justice by acknowledging the breadth and depth of service user and survivor grievances. This may be a precondition for effective alliances between workers and service users/survivors. As a result, new forms of dialogic communication and horizontal democracy might emerge that could sustain future alliances and prefigure the social relations necessary for more humane mental health services.
Exploring the Case for Truth and Reconciliation in Mental Health Services
Helen Spandler and Mick Mckeown
Mental Health Review Journal (Accepted April 2017; Published 2017: 22(2)
Purpose - to explore the case for a Truth and Reconciliation process in the context of
mental health services.
Approach - a conceptual review of truth and reconciliation approaches, a
consideration of why they are important, and how they might be applied in the
context of mental health services and psychiatry. First, the paper sets out a case for
truth and reconciliation in psychiatry, giving some recent examples of how this might
work in practice. Then we outline potential objections which complicate any
simplistic adoption of T&R in this context.
Findings - In the absence of an officially sanctioned Truth and Reconciliation (T&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 of services, with staff who work/ed in them, to
begin the work of healing the hurtful effects of experiences in the system.
Originality/value - This paper is the first peer-reviewed journal article to explore the
case for truth and reconciliation in mental health services. It describes an innovative
truth and reconciliation process as an important transitional step towards
accomplishing reparation and justice by acknowledging the breadth and depth of
service user and survivor grievances. This may be a precondition for effective
alliances between workers and service users/survivors. As a result, new forms of
dialogic communication and horizontal democracy might emerge that could sustain
future alliances and prefigure the social relations necessary for more humane mental
health services.
This paper explores the case for organising a reparative truth and reconciliation
(T&R) process in mental health services and systems. For the purposes of this
paper, we refer to 'psychiatry' and 'mental health services' interchangeably as a
whole set of related practices in which mental health professionals are involved. This
includes the medical speciality of psychiatry which is the dominant perspective in
mental health services and frames statutory mental health systems. T&R would
involve bringing together service users, survivors and refusers of services, with the
staff who work/ed in them, to begin the work of healing the hurtful effects of
experiences in the system (Slade 2009; Wallcraft and Shulkes 2012; Spandler
2016b; Mckeown 2016). We see this as part of a wider project concerned with
challenging, reforming and transforming mental health care. In the absence of any
officially sanctioned Truth and Reconciliation (T&R) process, we outline a grassroots
initiative which could bridge towards constructive alliances between workers, service
users and survivors.
We have been involved in various mental health movements, predominantly as allies
of psychiatric survivors/service users, and have reflected upon the value of such
conjoint activism (e.g. Cresswell and Spandler 2013; McKeown et al. 2014).
However, we have been frustrated with tendencies for polarisation and splitting
which can derail progress by oversimplifying complexity, stifling debate, and
preventing further exploration and mutual understanding of different perspectives.
For alliances to embody genuine solidarity, rather than temporary instrumentality (for
example defending services, which may be inadequate, or even harmful), we need a
way to heal prior damage and provide restitution. It has recently been argued that
the neoliberal retreat from service provision has inadvertently opened up potential
spaces for grassroots activists to engage in reconciliation processes (Inwood et al.
2016). This doesn’t mean that neoliberalism (or, for that matter, psychiatry) shouldn’t
be contested, but that the possibility for its transformation may lie in opportunities to
articulate innovative strategies to achieve social justice. For example, by daring to
‘re-fashion and re-imagine’ possibilities for more just and peaceful social relations (or
support and services) (ibid: 59). In the process, this might expand our ideas of what
peaceful societies (or mental health services) might look like.
We recognise that our proposition for a T&R process in psychiatry is contestable.
On the one hand, some may see it as unnecessary, others as merely reforming a
harmful system that should be abolished. Ideally, the process would include people
who wish to defend or reform psychiatry as well as those who seek to abolish it, as
long as both are willing to listen to other’s experiences and perspectives. Ultimately,
we argue that if enacted with due care and sensitivity, the process could actually
prefigure the kinds of social relations required to frame better or alternative mental
health care.
What is Truth & Reconciliation?
Truth and reconciliation approaches have been enacted with varying degrees of
success in nations afflicted by human rights abuses or civil wars. The archetypal
South African Truth and Reconciliation Commission (TRC) was convened to address
national healing following the abuses of apartheid (Clark 2012; Rose 2015).
Democratic nation-building was to be supported by an explicit embrace of restorative
rather than retributive justice, providing amnesty for perpetrators and reparations for
victims. The architects of the TRC were animated by ‘the importance of bearing
witness to the past’, seeking reconciliation through public apologies, ‘truth-telling and
forgiveness’ (Stein et al 2008: 463).
In the absence of public apologies for psychiatric wrongdoing and the continuation of
a contested psychiatry in the present, grassroots T&R initiatives may be more
relevant to our purposes. For example, in recent years there have been a number of
‘bottom-up’ reconciliation initiatives in the US set up by community organisations
without local or national government endorsement (Androff 2010; Inwood et al.
2012). These constitute promising models for other communities seeking processes
of reconciliation (Androff 2010) and, as we shall see, have begun to be adopted in
the psychiatric context.
T&R processes are a form of ‘transitional’ justice aimed at forging newly respectful
relations and restitution for harm and wrongdoing. These are based on an optimistic
view of human relationships and belief that social change is possible (Seidel & Abu-
Nimer 2015). They differ from victim-offender restorative interventions as they
operate at a community level (Androff 2010). T&R involves, but is not confined to,
the public expression and acknowledgement of the testimony of previously silenced
and oppressed groups. This can promote greater compassion and community, raise
collective consciousness, provide accountability and promote healing (Rose 2015).
For example, the public expression of private pain can ‘transform the personal
experiences of victims info a far deeper statement of collective suffering and
injustice’ (Rose 2015: 71).
There are limitations to T&R which we explore, with specific reference to psychiatry
and mental health services in a later section. More generally, participating in T&R
isn't always immediately helpful and the inherent therapeutic value of revealing
traumatic experiences has been questioned (Rose 2015). For example, revisiting
these can amplify distress and further expose or violate victims (Stein et al 2008). In
addition, there may be pressure on survivors to ‘forgive’ and disappointment with
slow pace of change or lack of compensatory measures (Jeffery 2015). McEvoy and
McConnachie (2013) also highlight the centrality of attributing blame and victimhood,
which might not always be helpful. Positive benefits have often been distributed at
the community or nationhood levels, promoting collective reconciliation or
acceptance, largely amongst citizens witnessing the proceedings, rather than
through personal testimony (Stein 2008). Therefore reconciliation processes should
carefully and sensitively deal with matters of testimony, for example by not
necessarily requiring disclosure of victimhood or interpersonal forgiveness, but rather
work towards more peaceful relationships in the present and future (Rose 2015).
Moreover, T&R processes can move beyond testimony and truth-telling to involve a
reciprocal commitment to critical self-reflection, cognisant of the complexities of the
distribution of harms, both between and within groups. In effect, there is a
concomitant need to critically reflect upon all aspects of harm and possibilities that
victimhood may not always be a one-way street (McEvoy and McConnachie 2013).
As a result, one of the most significant achievements of the South African TRC was
in emphasising a common humanity and cultivating a deep sense of empathy,
helping to promote a more compassionate collective consciousness (Rose 2015)
and process of ‘re-humanization’ (Androff 2010: 274).
It is claimed that TRCs have ‘proven to be malleable enough interventions to be
adaptable to a range of unique contexts’ (Androff 2010: 272). Arguably, T&R
processes might help redeem health care organisations afflicted by catastrophic
system failures such as at Mid Staffs Hospital (Francis 2013) and Winterbourne View
(DoH 2012). Indeed, the ‘human factors’ movement urges the NHS to adopt no-
blame investigation of service failings, encouraging openness and disclosure rather
than evasion and reticence (Bromiley 2009). With this in mind, it seems reasonable
that T&R could be utilised in the psychiatric context. First, however, we need to
provide justification for this.
Psychiatric harm
The case for truth and reconciliation is most evidently grounded in a litany of harms
experienced by users or 'survivors' of mental health services. Obvious historical
examples include: “lobotomies, incarceration, seclusion, and restraint, harmful
drugging and electroshock, and stigmatising diagnoses meted out to people of
particular ‘race’, gender and sexuality” (Wallcaft & Shulkes: 2012: 12). As these
authors note, such practices continue within contemporary psychiatry in one form or
another. If anything, the relative dominance of a singular bio-psychiatry has been
consolidated, despite rhetorical commitments to biopsychosocial approaches (Read
2005). Arguably, this continues to allow for forms of psychosurgery and other
physical treatments experienced as harmful (Johnson 2009). In addition, the
propensity of psychiatry for colonising expansion, whilst neglecting survivor
perspectives, is evident in ongoing controversies surrounding psychiatric assertions
that conditions like Myalgic Encephalopathy/Chronic Fatigue Syndrome (ME/CFS)
constitute ‘false illness beliefs’ (Blease et al 2016; Spandler 2016b). Arguably,
systematic refusal to attend to users and survivors experiential knowledge -
‘epistemic injustice’ - might be a specific form of psychiatric harm (Crichton et al
2016: Liegghio 2013)
Mental health services can be traumatising and re-traumatising, even being referred
to as ‘trauma-organised systems’ (Bloom & Farragher, 2010; Sweeney et al 2016).
Widespread practices including physical restraint, seclusion and forced medication
are most obviously implicated (Freuh et al., 2005), but more subtle coercions occur
which inflict or revisit experiences of powerlessness, such as restrictions on liberties
or discursive pressure to comply with treatment (Bloom & Farragher, 2010). Indeed
service users and their allies have long criticised over-reliance on medication which
has a disputed evidence base and can cause serious, long-term detriments
(Whitaker 2002; Moncrieff 2013). These kinds of negative experiences have led
many critics to see psychiatric treatment as ‘iatrogenesis’ (Breggin 1991).
The harmful effects of mental health systems are especially concerning given the
increasing evidence of links between childhood abuse and mental health problems
(Varese et al. 2012). Moreover, there is evidence that patients have been sexually
and physically abused within services, especially in-patient settings (Henderson &
Reveley 1996); with patients reporting abuse disbelieved, pathologized and silenced
(Jennings 2016, Masson 1988). More than this, reactions to abuse are often
reframed as symptoms of mental illness, especially 'borderline personality disorder'
(Asylum magazine 2004). Even when disclosure occurs, and is believed,
proportionately low numbers of service users receive appropriately formulated or
compassionate care (Read et al 2016; Sweeney et al. 2016).
Hurting the workforce too
Once a case has begun to be made for truth and reconciliation within mental health
services we can also recognise that staff are damaged in the system. This can be
related to the stresses of working within inadequately resourced or managed public
services, anxieties over adverse outcomes for service users, threats of violence, and
the possibility of vicarious trauma within a caring role. In addition, staff who blow the
whistle on inadequate care or organisational wrongdoing have been victimised by
employers and colleagues (Jackson et al. 2014). Even if not a prime reason for
entering into T&R, acknowledgement of staff hurt opens up possibilities of also
attending to this and seeking common cause in addressing the complex distribution
of harms. Of course, many staff in mental health services also experience mental
health difficulties or use services themselves, problematising any simple
demarcations of identity. In other words, categories of 'service user' and 'mental
health professional' frequently overlap.
Rates of workplace stress and mental health problems are high in the mental health-
care workforce with consistently high sickness/absence rates (Rossler 2012; The UK
Health and Safety Executive 2016). In addition, research has noted the potential for
a distressing impact upon mental health professionals working with traumatised
individuals; indeed, the more empathic practitioners may be even more vulnerable
(Figley 1995; Sabin-Farrell and Turpin 2003). These deleterious effects are reflected
in the lexicon of compassion fatigue, vicarious trauma and secondary trauma and
are complicated and compounded by wider structural factors.
Given the legitimacy afforded to compulsion and coercion within psychiatry,
practitioners are inescapably complicit in interventions survivors might view as
harmful, even if they may object to them or be reluctant to use such measures like
physical restraint. Workers may bear responsibility for quite serious consequences
without necessarily having sufficient authority to alter systemic practices or
overarching power relations (McKeown and Foley 2015). Most members of the
mental health workforce would plausibly deny they entered into this work wishing to
abuse, harm or dominate.
Therefore, whilst conflictual relationships are highlighted as a major source of
workplace stress (Rossler 2012; Unison 2014) these are perhaps best viewed as
complex rather than simply oppositional. However, cycles of reciprocal
traumatisation can emerge as service users’ fear or powerlessness precipitate
aggression towards staff who, in turn, become suspicious and antagonistic, further
justifying coercive and containing organisational responses that escalate service
users’ safety concerns and provoke yet more aggression (McKeown et al. 2017).
T&R processes may justifiably help in careful consideration of the complexities of
relations between staff and service users to help explicate certain propensities for
mistrust, violence and coercion on all sides (Bloom 2006, Sweeney et al 2016).
Truth and reconciliation in the psychiatric context
We are by no means the first to suggest a truth and reconciliation process in the
context of mental health services. Previous calls for T&R have usually focused on
demanding public apologies. For example, Mike Slade (2009), a pioneer of the
recovery agenda, raised this possibility, followed by calls from the survivor
movement in the UK (Wallcraft 2010) and the US (Harris 2014). Slade (2009) locates
concerns over psychiatric harms within a broader socio-political frame, arguing the
first step towards genuine partnerships in mental health should be a public apology
for the wrongs done in the name of care and treatment. This, he argues, is justified
when any dominant group inflicts harm on a subordinate group over a sustained
‘Real reconciliation ... may only be possible once a line has been drawn,
through the symbolism of an apology, which explicitly recognises the need for
a new trajectory in the future’ (Slade 2009: 73).
Whilst psychiatrists have engaged in T&R processes, this has usually been as expert
witnesses in relation to the suffering experienced by indigenous populations under
various colonisation regimes, rather than addressing psychiatry itself (e.g. Cox
2005). Slade (2009: 73) notes ‘no general apology for maltreatment ... has ever been
made by a government or a mental health professional body’. The few extant
psychiatric apologies have focused strictly on narrow and clear-cut abuses of earlier
generations of professionals. Notable examples include the President of the German
Association for Psychiatry and Psychotherapy apologising for psychiatrists’
complicity during the Nazi regime’s forced sterilisation and murder of psychiatric
patients (Wallcraft & Shulkes: 2012: 12-13).
More recently, the New Zealand government specifically apologised for inappropriate
treatments such as ECT and injections being given to children and young people at
Lake Alice Hospital in the 1970’s. Following this, a series of further complaints were
made by former patients across the country, calling for a process of redress. This
resulted in the government setting up a Confidential Forum in 2005 to hear former in-
patients (as well as family members and staff) accounts of their experiences within
psychiatric institutions before 1992, when current mental health legislation came into
effect (Department of Internal Affairs 2007). Whilst a step towards recognising
harms, it was criticised by some patient groups for not resulting in a general public
apology and still being limited to historic cases of maltreatment (Kavanagh-Hall
2013). Entering the realms of satire, the celebrated antipodean survivor Mary
O’Hagan refers to a successful international truth and reconciliation commission for
psychiatry in a mock radio interview ‘taking place’ in 2031-2033, precipitating a
‘cascade of apologies’ and reforms
In the UK in 2010 Jan Wallcraft, psychiatric survivor, scholar and activist, started a
Truth and Reconciliation in Psychiatry petition with accompanying draft statement: Citing
Slade’s call, Wallcraft drew on the ratification of the UN Convention of the Rights of
Persons with Disabilities (CRPD) to demand apologies from government and
professional bodies. The Convention has been seen as a major step advancing the
rights of people with psychosocial disabilities, declaring enforced psychiatry a human
rights violation (Minkowitz 2015). The required apology, it was argued, should be
negotiated internationally and accompanied with the ‘right to reparation’. The latter
included specific demands for service user defined and non-coercive services, such
as the Soteria model and service user-led crisis houses, and repealing all
discriminatory forced treatment legislation, with due regard to the CRPD. Similarly, in
the Canadian context, the survivor magazine Our Voice/Notre Voix had a front page
feature calling for a long overdue public apology from psychiatry (LeBlanc 2016)
In addition, in the absence of formal public apologies, some grassroots organisations
have begun to explore ‘bottom-up’, transitional forms of justice, starting the process
of reconciliation themselves by exploring various ways of acknowledging harm and
discussing difficult and divisive issues in the present. The following section outlines a
recent notable example.
Communicative processes in reconciliation
One of the most important aspects of T&R is the creation of new spaces for
conversations, listening and dialogue, outside the parameters of the regime under
question (in this case psychiatry):
‘One of the first keys in justice activism is getting participants to sit down with
one another to engage fully in a process that can create the conditions
necessary to organising work to occur’ (Inwood et al 2016: 59)
In 2016, three grassroots mental health organizations in the US, The M.O.M.S.
Movement, Rethinking Psychiatry and The Icarus Project hosted a series of T&R
events. These events were initiated primarily in response to many users and
survivors experiences of dissatisfaction and harm within mental health systems
(Levy 2016a;b). They adopted the practice of ‘healing circles’ which have been used
in other community-based restorative justice initiatives (Androff 2010).
The healing circle approach involved creating inner and outer circles of participants
identifying with particular constituencies, e.g. staff or user/survivor, who take turns to
respectfully listen to each others’ narratives without interruption, before periods of
questioning for clarification and discussion. The space created is intended to enable
silenced voices, and stories of harm, that aren’t usually heard, to be aired,
acknowledged and attended to. Whilst it was set up because so many people feel
traumatised by the dominant psychiatric model, there was also room for people who
feel it had helped them. In addition, whilst the primary focus was of the experience of
people who felt harmed by mental health systems, it could also include people who
feel harmed by people with mental health problems, whose stories aren’t heard
either except as stories of the ‘dangerous mentally ill’. Participants seemed to
appreciate the opportunity to be heard and engage in genuine dialogue. For
example, staff who attended the first event reported it had already changed how they
practiced e.g. instead of giving the ‘party line’ about medication (“it’s like insulin for
diabetes”), they felt able to be more honest and offer balanced information. Whilst
these may be small steps, they point to possibilities for more significant shifts over
This initiative included someone who had been involved in the original South African
T&R process. Inspiration was gleaned from work with other politically divisive topics
where protagonists seemed to have little in common (e.g. abortion, LGBT rights).
The organisers were also inspired by features of the Open Dialogue approach to
mental health care (Seikkula & Arnkil 2013). One of the core principles of open
dialogue is commitment to speak honestly with the person’s self identified social
network present; in effect, mirroring the truth-telling of reconciliation processes.
Open Dialogue draws upon Mikhail Bakhtin’s theories of polyphonic dialogic
communication (Seikkula & Olson 2003). Bakhtin’s ideas offer a way into thinking
about the organisation of truth and reconciliation hearings and potential experiences
within them: the ‘understandings’ reached may not belong to any individuals, rather
being collectively constructed through concerted attention over the course of the
proceedings. Culturally, such respect and attention to the experiences and
viewpoints of others may be fairly untypical. To paraphrase Ptery Lieght (KBOO
2016), the inability to dialogue creates dis-ease.
Objections to T&R in mental health systems
A number of complicating factors problematise any simple adoption of T&R in the
psychiatric and mental health context. Therefore, in this section we respond to four
potential objections. We address them directly, in turn.
1. What if psychiatry won’t accept wrongdoing and apologise?
T&R processes are usually developed where wrongdoings are historical and there is
public acknowledgment of abuse and acceptance of the need for restitution. As we
have seen, there has been no general public acknowledgement or acceptance by
psychiatry of wrongdoing and critics argue that abuses are not ‘historical’ and
continue to this day (e.g. Virden 2016). Thus, some have argued that that any
psychiatric apologies for crimes and mistreatment in the past would be self serving
because ‘the legacy of previous abuses continues in the cruel and unacceptable
treatment of people all over the world (Wallcraft & Shulkes: 2012: 12-13 emphasis
added). Similarly, LeBlanc argues that states resist apologising lest it undermine the
‘flawed speciality of psychiatry’ (2016: 62). If the psy-professions are unwilling to
recognise wrongdoing and apologise this makes an official T&R process difficult to
However, T&R does not have to rely on public apologies, important though they are,
but can be an important first step towards the wider recognition of psychiatric harm.
Any T&R process involves gathering multiple testimonies from users/survivors which
have to be heard without judgment, argument or contestation. Robert Miller (2012)
who helped initiate an ongoing process of reconciliation following the New Zealand
Confidential Inquiry noted that understanding what went wrong, and publicly
acknowledging it, may be the biggest step to reconciliation, and the strongest
safeguard against its being repeated.
Moreover, it is often precisely the absence of formal apologies that has inspired
activists to utilise T&R in grassroots initiatives connected with demands for social
change (see Androff 2010; Inwood et al 2016). Indeed, such grassroots T&R usually
follow a period of community activism where it became increasingly clear that
relevant authorities were unwilling to take reparative action (Inwood et al, 2016). In
addition, there might be benefits to grassroots initiatives as they are not subject to
restrictions, limitations and parameters set by state-funded reparation schemes
(Rose 2015). On the other hand, grassroots initiatives may lack the ‘teeth’ to actually
provide restitution or compensatory measures (Inwood et al 2016).
2. Surely psychiatric harm isn’t equivalent to other human rights abuses?
The call for psychiatric T&R appears to rest on analogy with other human rights
abuses, such as genocide or apartheid. Critics may question whether such
comparison is appropriate. After all, psychiatry is complex and not ‘monolithic and
hegemonic’ and this complicates the case for a singular oppressive regime (Rose
2016: 434). Despite the efforts of radical survivor groups, it has not been universally
established or accepted that psychiatry is inherently abusive, wrong or blameworthy.
Ultimately, psychiatry remains contested and contestable. In addition, whilst many
mental health services are framed by psychiatry their practices may vary
considerably. It is not the case that all survivors reject all aspects of psychiatric
systems, including even compulsion and coercion, which some argue cannot be
simply reduced to human rights violations (Katsakou et al. 2012; Plumb 2015). For
example, some service users and their families argue, in hindsight, that despite the
oppressive nature of hospital wards and the lack of support offered, they might have
actually preferred more intervention, for example, to prevent absconsion when
severely depressed or suicidal (e.g. Poursanidou 2013). Indeed, even though
psychiatric abuse is still concerning, perhaps in the current context challenging
psychiatric neglect, rather than abuse, might be more appropriate (Spandler 2016a).
Whether or not psychiatric harm is ‘equivalent’ to other human rights abuses, a good
enough case has been made that mental health services can be harmful and
trauma-reinforcing, both historically and in the present (Sweeney et al. 2016). There
is also an argument for specific psychiatric ‘epistemic’ injustices or violence, where
mental health service users are systematically denied opportunities to have their own
experiential knowledge accepted and valued (Liegghio 2013). Indeed, one of the
criticisms of formal T&R processes is that it too narrowly focuses on particular
instances of gross human rights violations, and hasn’t addressed more subtle, yet
still damaging, systemic relations (Rose 2015). This recognition lies behind the
recent T&R movement in the US which seeks to address a wider range of issues
such as structural racism and inequality (Inwood 2012).
The time may come when there is widespread acceptance and condemnation of
psychiatric harm, perhaps with recourse to the UN Convention. In the meantime,
T&R processes can begin the work of demarcating boundaries between ‘conflicts’,
between different groups about how to respond to mental distress, and ‘abuse’,
involving systematic abuses of power (Shulman 2016). Perhaps healing or restitution
cannot take place until the full extent of survivor grievances have been
3. Won’t calls for Truth and Reconciliation alienate mental health professionals
and workers?
Partly as a result of these complications, many workers may be reluctant to take part
in a process which makes parallels between their professional role and perpetrators
of significant human rights abuses. Arguably, calls for T&R could alienate workers,
who might feel attacked and defensive, as well as some service users who don't
recognise their experiences as abusive. This is especially the case if the analysis of
harm depicts psychiatric services as a totalising ‘system’ and this becomes an ad
hominem argument when it further implies professionals are ‘actually nasty people’
(Rose 2016: 435). Whilst psy professionals may have certain powers they usually
exercise them with reluctance, caution and some cynicism (ibid).
We have previously made the case for greater alliances between relevant trade
unions and radical survivor movements. Yet trade union involvement in T&R is
potentially contentious because of their chequered history in prioritising defending
‘jobs and services’ over contesting practices and unequal power relationships within
services. It is notable that unions’ broader international positions, for instance
supporting T&R in South Africa, don’t necessarily translate into more reflexive
attention to their own members’ working practices in psychiatric services. For
example, unions and management have typically collaborated on ‘zero tolerance’
policies which minimise consideration of the various structural and systemic factors
that might precipitate violence. Furthermore, at least some of the violence in
psychiatric services is enacted by service users who wish to resist the implicit and
explicit coercive aspects of the system, including enforced treatment such as
intramuscular medication (McKeown et al 2017).
Clearly, addressing the violence of all parties, the implicit violence of the system, and
how this is legitimated, could be a key focus of any truth and reconciliation process.
T&R processes might help unpack complexities in the distribution of harms, taking
on board staff sensibilities and responsibilities. Amongst these concerns is the
potential to see mental health staff as damaged by the system they work in,
acknowledging their experiences too. Associated with this recognition is
consideration of the extent to which all individuals or elements of the workforce are
equally complicit, culpable or accountable for harms experienced by service users.
T&R processes could assist workers (and service users) to appreciate and
understand power imbalances in more nuanced ways. In turn, this may help staff
engage with radical survivor critiques without feeling personally or unfairly attacked,
and critically reflect on their own discomforts and responsibilities within the system
they work in (McKeown & White 2015). Whilst T&R processes might also help to
acknowledge staff, as well as user/survivor hurts, significant power imbalances
between users and staff must always be kept in mind.
4. Shouldn’t inadequate mental health services be challenged through political
Finally, some critics may argue that change will be achieved through social action
rather than the more ‘therapeutic’ focus of T&R. This objection is linked to various
‘structural critiques’ of transitional justice that suggest focusing on individual
testimonies doesn’t sufficiently address social inequalities and structural violence. In
other words, attempts at healing without changing the underlying socio-political
conditions is inadequate and ineffectual, it merely ‘pacifies’ or ‘placates’ rather than
delivers genuine justice (Nagy 2012). Indeed truth sharing alone does not bring
about transformation; it might equally be ‘helpful, harmful or irrelevant’, and other
factors or strategies need to be considered (Mendeloff 2004). Many radical survivors
might be reluctant to participate in T&R initiatives, mistrusting the sincerity of worker
participation or suspecting that a disliked biological psychiatry might emerge intact,
or even bolstered, after a superficial or insincere baring of its soul.
This kind of ‘structural critique’ relates to a broader false dichotomy between peace
and justice, or transitional and transformative justice (Rose 2015). It is true that
reconciliation is an ongoing process that cannot be achieved merely through T&R
processes, and ultimately depends on a range of other factors (Rose 2015). Its goals
may be ‘modest’ but they are still highly significant (ibid 68). T&R should not be a
replacement for wider social change and it is not a panacea. Arguably T&R should
be part of, and not separate from, a wider transformatory project. Moreover, the case
for grassroots T&R requires the active involvement of grassroots organisations and
the building of progressive coalitions (Inwood 2012). Therefore, they are not two
opposing or mutually exclusive strategies. Indeed, it might even be argued that wider
change cannot be achieved unless we pay attention to these more nuanced
discussions. In other words, T&R processes might actually help inform activist
strategies making them more effective in the long run.
Structural change necessitates and depends upon changes in our understanding
and ways of thinking. Therefore, the dialogical potential of a grassroots TRC
provides opportunities for bottom-up transformation grounded in the practical,
concrete and hard fought realities of struggle (Inwood et al. 2016). In order for
progressive change to happen, perhaps radical social movements, as well as mental
health services, need to be more open minded, reflexive and critical. There is no
point in making grand statements about what we want to achieve without paying
attention to the means of achieving this. If we don’t develop better ways of
discussing and debating together we may merely reproduce old problems in any new
mental health systems. That means being open to new ways of working together and
resolving conflict without personal attacks, insults and blame. In other words, it would
be hypocritical to criticise psychiatry for being coercive, abusive and non-consensual
if we can’t develop consensual, equal and respectful relationships with those we
disagree with.
Our case for deploying truth and reconciliation could be part of a broader agenda for
progressive change which acknowledges prevailing and historical harms are a
profound impediment to alliances between service users, survivors and the
workforce. Arguably, we cannot realise genuine solidarity without the precondition of
acknowledging harms. This is about inviting various actors, regardless of starting
positions, into a space where grievances can be aired, listened to, understood, and
restoratively acted upon. Rather than an end in itself, this could be a necessary first
step on a journey of continued dialogue and action.
Whilst these processes might be healing, it is important they are not imposed on
people, seen as part of ‘treatment’, or co-opted by professional groups. Activists
have made it clear reparation must not be subsumed under a clinical mindset,
avoiding temptations to pathologise user and survivor complaints. As Flick Grey
(2017) wryly notes “how quickly our mental health professional “colleagues” adopt a
clinical gaze when faced with challenging thinking or emotional distress from mad
folk!” Finally, any T&R process needs to be actively supported by those communities
most affected by the conflict, in this case survivor/service user groups.
If our case for T&R is accepted, the obvious question is: what next? The first thing to
say is that T&R processes must be adapted to context, not just taken ‘off the shelf’
(Seidel and Abu-Nimer 2015). Therefore, the form they take will differ according to
different local contexts, services and needs. We have been talking to various mental
health professional groups (such as nurses, Approved Mental Health Professionals
and trade unions) and mental health service users/survivors over the past couple of
years, generating debate and discussion about the possibility of T&R in the UK.
Obviously not everyone would agree to such a process, but we think it could start on
a small scale by some willing individuals, grassroots groups and organisations,
ideally initiated by user/survivors and their allies, including mental health workers.
In summary, we have made a case for grassroots truth and reconciliation processes
to begin the task of peace-building in the context of mental health services, reflecting
the concerns of more archetypal T&R commissions at the level of nation states.
Moreover, the process may also help expand the horizons of transitional justice,
beyond a focus on healing historical abuses, to maximize its transformative potential
in new and still-existing settings, like psychiatry. This could extend its reach to
include concerns with epistemic violence and injustice, a key feature of psychiatric
harm. 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. For example, the sort of dialogue made possible
might reveal paradoxical truths which, if accepted and worked with, might result in
new and creative ways of working with distress and conflict. As a result, attention
might be brought to bear on suicide prevention or crisis intervention, opening up
discussions about alternative, less oppressive, forms of support. Ultimately, these
processes might be necessary ‘to create the world we desperately seek, but which
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... A related approach that has been proposed to challenge and reform mental health care services is that of reparative truth and reconciliation. 46 These are complex processes that bring together survivors of services and mental health clinicians, and 'aim at forging newly respectful relations and restitution for [psychiatric] harm and wrongdoing'. 46 ...
... 46 These are complex processes that bring together survivors of services and mental health clinicians, and 'aim at forging newly respectful relations and restitution for [psychiatric] harm and wrongdoing'. 46 ...
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Background In many jurisdictions worldwide, individuals with a mental illness may be forced to receive care and treatment in the community. In Australia, legislation states that such care should be driven by a care plan that is recovery-focussed. Key components in the care planning process include engagement and decision-making about a person's support needs and care options, with trust being an essential component of care planning relationships. Objective This study examines how these components were enacted during service care contacts for individuals on community treatment orders. Methods The study was located at two community mental health teams in South Australia. Ethnographic observations of care planning discussions between consumers, their carers and clinicians, and interviews with individuals from these groups, were conducted over 18 months. Carspecken's critical ethnography provided a rigorous means for examining the data to identify underlying cultural themes that were informing day-to-day care interactions. Results Care planning was not occurring as it was intended, with service culture and structures impeding the development of trusting relationships. Clinicians striving to work collaboratively with consumers had to navigate a service bias and culture that emphasized a hierarchy of ‘knowing’, with consumers assumed to have less knowledge than clinicians. Conclusions Services and clinicians can challenge prejudicial ethical injustice and counter this through testimonial justice and implementation of tools and approaches that support genuine shared decision-making. Patient or Public Contribution This study included individuals with lived experience of mental illness, their carers and clinicians as participants and researchers.
... Trust is crucial for mental health care to be effective, and if inpatient facilities dismantle patients' trust the effects are likely to be most devastating amongst individuals most in need of support. To rebuild trust, researchers and practitioners must improve services by engaging with service user perspectives, rather than limit patients' feelings and beliefs to mere symptoms of mental illness as often occurs (29). In doing so, patients can play an active role in service development, allowing traumatic occurrences to be resolved and care to be more aligned with patients' needs for support. ...
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Inpatient psychiatric hospitalization is often negatively experienced, with previous studies indicating a high frequency of traumatic occurrences. This study aimed to expand upon such research, by obtaining service user perspectives on how inpatient psychiatric hospitalization may constitute an experience of trauma. Relevant posts and comments on the Reddit community r/PsychWardChronicles were collected that described potentially traumatic experiences associated with hospitalization. Reflexive thematic analysis of the data led to the development of 3 themes: neglect and abuse, coercion and obedience, as well as dehumanization and fear. Overall, hospitalization was found to induce significant fear, which eventually acted as a deterrent to seeking future mental healthcare services. Many traumatic occurrences were found to arise from care providers’ behaviors. As hospitalization was experienced to be harmful, many patients reported complying in the hopes of being discharged. Increased fear and traumatic stress due to inpatient stays coupled with the subsequent avoidance of mental health services may contribute to a significant public health problem as many previous patients may then avoid needed mental health support.
... 9 Finally, professionals who treated homosexuality were not only lauded at the time, but also remained in prominent positions in institutions around the world and continued to receive awards for their contributions to the discipline (King and Bartlett, 1999). Elsewhere we have argued for a Truth and Reconciliation approach to psychiatric harm (Spandler and McKeown, 2017). This process would start by acknowledging the mistakes of the past and involve carefully and truthfully documenting this history. ...
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This article presents the findings of a study about the history of aversion therapy as a treatment technique in the English mental health system to convert lesbians and bisexual women into heterosexual women. We explored published psychiatric and psychological literature, as well as lesbian, gay, and bisexual archives and anthologies. We identified 10 examples of young women receiving aversion therapy in England in the 1960s and 1970s. We situate our discussion within the context of post-war British and transnational medical history. As a contribution to a significantly under-researched area, this article adds to a broader transnational history of the psychological treatment of marginalised sexualities and genders. As a consequence, it also contributes to LGBTQIA+ history, the history of medicine, and psychiatric survivor history. We also reflect on the ethical implications of the research for current mental health practice.
... Arguably, activism for a right to conscientious objection might be catalytic in this regard, challenging the mainstream and raising the potential for alternative forms of care. Recognising that radical service users and survivors may be reluctant to enter into alliances with elements of the mental health service workforce, we have also called for grass-roots processes to repair the hurt and harms presently and historically caused by psychiatry (Spandler & McKeown, 2017) and to sincerely apologise for these (Williams et al., 2018). ...
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This paper attempts a critical discussion of the possibilities for mental health nurses to claim a particular right of conscientious objection to their involvement in enforced pharmaceutical interventions. We nest this within a more general critique of perceived shortcomings of psychiatric services, and injustices therein. Our intention is to consider philosophical and practical complexities of making demands for this conscientious objection before arriving at a speculative appraisal of the potential this may hold for broader aspirations for a transformed or alternative mental health care system, more grounded in consent than coercion. We consider a range of ethical and practical dimensions of how to realise this right to conscientious objection. We also rely upon an abolition democracy lens to move beyond individual ethical frameworks to consider a broader politics for framing these arguments.
... Beginning the process with 'healing sessions' where trusted relationships are afforded time to develop may reduce negative impacts and enable the process to deliver more benefits than costs. 17 As tensions come in and out, 'healing sessions' could also be scheduled responsively throughout the process. For researchers and public advisors to work together as equals within a research team, public advisors could be employed as lay researchers. ...
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Background: Patients and public members are increasingly involved across the different stages of the research process. Their involvement is particularly important in the conception and design of applied health research where it enables people with lived experience to influence the aims, content, focus and methods. Objective: To evaluate the process of coproducing a mental health-related research proposal suitable for funding through a national health research funding body. Methods: Reflections from members of the public (n = 3) and academic researchers (n = 3) were collected through semi-structured interviews. Data were thematically analysed. Results: Thematic analysis identified five overarching themes: valuing the lived experience perspective; matching ambitions to the funded research process; 'Us and them': power, relationships and trust; challenges; and benefits of coproduction. Conclusions: Our findings suggest that for successful coproduction of a research funding application, an open and trusting atmosphere, where equal relationships are established and a shared common goal agreed is essential. Although relationships with research professionals were framed by trust and mutual respect for some public advisors, others felt a sense of 'us and them'. With various tensions played out through interpersonal conflict, difficult conversations and disagreements, coproduction was not a positive experience for all stakeholders involved. Among the learning was that when collaboration of this kind is constrained by time or funding, genuine, impactful coproduction can be more challenging than is generally acknowledged.
... However, this is not necessarily a negative; people who have engaged with services (voluntarily or otherwise) may feel a sense of hurt and injustice around their experience, which requires the presence of professionals to hear about this (e.g. Spandler & McKeown, 2017). The opening up discussion and debate between has the potential to promote healing and change going forward. ...
Over the past 30-40 years health policy and literature internationally has emphasised increased user involvement in the shaping of mental health care. However, little has been written to contextualise such involvement experiences within people’s own recovery from mental health crisis and their ‘life story’. This qualitative study interviewed individuals who have accessed mental health services and become involved in working with care providing organisations. Its aim was to contextualise experiences within their life ‘story’ and recovery, exploring identities and roles assumed by the narrators. Ten participants were recruited using a theoretical sampling strategy. The interviews were structured around an oral history/life story approach and the transcription process incorporated performance aspects, as well as spoken content. Drawing on Braun & Clarke’s approach to thematic analysis key emergent themes were clustered to identify overarching themes across all interview narratives. Storytelling devices important to life stories were also explored. The narratives recorded could be broadly split into three phases or ‘acts’; ‘life before mental health crisis’, ‘entering the mental health system’ and ‘enlightenment and changing the script’. The analysis and discussion identified overarching themes of ‘Survival’, ‘Institutional Power and Dominance’, and ‘Asserting Power & Forging a New Identity’, which traversed these acts. The study concluded that to experience recovery from mental health crises, user involvement activity had significant value up to a point. To regain a true sense of autonomy, restoration/formation of identity and challenge services to improve their care, however, a person often needs to step outside of the mental health system. Recommendations about how this might be achieved and areas for future research are discussed.
This chapter argues that change both within and outside of the mental health care system is necessary. Based on the analysis of participant narratives and chart documentation presented in Chapters 4 and 5 respectively, the concluding chapter discusses the necessary change within the mental healthcare system to make it more liveable for 2SLGBTQ people. Drawing on participant narratives from study one about mutual aid and collective care within queer and trans communities, this chapter also explores the ways mad queer and trans people create effective community responses to distress. This chapter explicates the problems with carceral and state-interventionist responses to acute distress and suicidality and describes recent initiatives that offer other ways to respond. The book ends with a call to those invested in social justice for 2SLGBTQ people to interrogate the biomedical model of mental illness beyond the depathologization of gender and sexual dissidence and to further explore the emancipatory promise of queer and trans madness.
Literature and experience suggest that student mental health nurses feel marginalised in core modules. A focus group was held to explore mental health nurse students' experiences of whole cohort core modules in nursing. Students from a university in the North of England attended a one hour focus group followed by dialogical narrative analysis of transcripts. Stories of shared professional identity, marginal status, critical thinking, and practical application of theory were shared by the group. Greater presence of mental health stakeholders earlier in the programme and more applied field specific teaching offer a means to bolster professional identity in mental health nursing students.
Psychiatry has an interesting past, and much debate currently exists on what its future will be. This discussion concerns mostly not a prediction of what is going to happen and how psychiatry will evolve but rather what stakeholders in mental health should do and what path of actions they should follow to shape a particular future on the basis of the unmet needs that we chart today. Everybody asks for more funds in his specific area of expertise, which he/she considers to be at the core of the future developments in psychiatry and mental health. But is this realistic?
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Background: Service user and carer perspectives on safety issues in mental health services are not well known and may be important in preventing and reducing harm. The development of the Yorkshire Contributory Factors Framework-Mental Health (YCFF-MH) provides a broad structure within which to explore these perspectives. Objective: To explore what service users of mental health services and their carers consider to be safety issues. Design, setting and participants: Qualitative interviews with 13 service users and 7 carers in the UK. Participants were asked about their experiences and perceptions of safety within mental health services. Perceived safety issues were identified using framework analysis, guided by the YCFF-MH. Results: Service users and carers identified a broad range of safety issues. These were categorized under 'safety culture' and included psychological concepts of safety and raising concerns; 'social environment' involved threatened violence and sexual abuse; 'individual service user and staff factors' dominated by not being listened to; 'management of staff and staffing levels' resulting in poor continuity of care; and 'service process' typified by difficulty accessing services during a crisis. Several examples of 'active failures' were also described. Discussion and conclusions: Safety issues appear broader than those recorded and reported by health services and inspectorates. Many safety issues have also been identified in other care settings supporting the notion that there are overlaps between service users and carers' perspectives of safety in mental health services and those of users in other settings. Areas for further research are suggested.
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This article explores what has changed in psychiatry the last 30 years. It asks whether the main focus of the psychiatric service user movement has moved away from opposing psychiatric abuse to exposing psychiatric neglect
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This chapter is written by people with quite different experiences of violence in relation to the practice and organisation of psychiatric services. It is our intention to draw upon our own collective experiences, including some relevant research studies to explore the notion of legitimacy with regard to violence and psychiatry. The social relations of care and associated power distribution demand more nuanced understandings than are often applied in practice, and critical reflection on the ways in which legitimacy is established, or appealed to, is similarly required.
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Chronic fatigue syndrome or myalgic encephalomyelitis (CFS/ME) remains a controversial illness category. This paper surveys the state of knowledge and attitudes about this illness and proposes that epistemic concerns about the testimonial credibility of patients can be articulated using Miranda Fricker's concept of epistemic injustice. While there is consensus within mainstream medical guidelines that there is no known cause of CFS/ME, there is continued debate about how best to conceive of CFS/ME, including disagreement about how to interpret clinical studies of treatments. Against this background, robust qualitative and quantitative research from a range of countries has found that many doctors (and medical students) display uncertainty about whether CFS/ME is real, which may result in delays in diagnosis and treatment for patients. Strikingly, qualitative research evinces that patients with CFS/ME often experience suspicion by healthcare professionals, and many patients vocally oppose the effectiveness, and the conceptualisation, of their illness as psychologically treatable. We address the intersection of these issues and healthcare ethics, and claim that this state of affairs can be explained as a case of epistemic injustice (2007). We find evidence that healthcare consultations are fora where patients with CFS/ME may be particularly vulnerable to epistemic injustice. We argue that the (often unintentional) marginalisation of many patients is a professional failure that may lead to further ethical and practical consequences both for progressive research into CFS/ME, and for ethical care and delivery of current treatments among individuals suffering from this debilitating illness.
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Purpose The purpose of this paper is to describe and explain trauma-informed approaches (TIAs) to mental health. It outlines evidence on the link between trauma and mental health, explains the principles of TIAs and their application in mental health and explores the extent to which TIAs are impacting in the UK. Design/methodology/approach The approach is a conceptual account of TIAs including a consideration of why they are important, what they are and how they can become more prevalent in the UK. This is supported by a narrative overview of literature on effectiveness and a scoping of the spread of TIAs in the UK. Findings There is strong and growing evidence of a link between trauma and mental health, as well as evidence that the current mental health system can retraumatise trauma survivors. There is also emerging evidence that trauma-informed systems are effective and can benefit staff and trauma survivors. Whilst TIAs are spreading beyond the USA where they developed, they have made little impact in the UK. The reasons for this are explored and ways of overcoming barriers to implementation discussed. Originality/value This paper – authored by trauma survivors and staff – describes an innovative approach to mental health service provision that, it is argued, could have immense benefits for staff and service users alike.
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The twenty-year anniversary of the establishment of democratic governance in South Africa presents a fitting time to reflect upon the work of the country's Truth and Reconciliation Commission (TRC). This article focusses on the TRC as a key institution in the transition from apartheid to democracy, and commences by outlining the context and remit of the TRC and considering some of its more recent critiques. I conclude that many of these perspectives present an unfair judgement of the Commission based on either a misreading or misunderstanding of its mandate, and to a certain extent, a disregard for the contextual constraints within which it operated. Whilst acknowledging its limitations, I argue that the TRC played an important role in facilitating political transition and maintaining a fragile peace, and that it contributed to creating a more inclusive official historical narrative, as well as a human rights culture. I identify that the Commission's therapeutic ethos and its emphasis on the human capacity for empathy and compassion were particularly significant in cultivating a shared purpose and sense of national community. I conclude by considering the TRC in the context of key contemporary challenges facing South Africa, underscoring the need for ongoing attention to structural injustice.
A challenging reappraisal of the history of antipsychotics, revealing how they were transformed from neurological poisons into magical cures, their benefits exaggerated and their toxic effects minimized or ignored.