Therapeutic democracy: the potential & limits of user-involvement in the NHS

Beginning with a genealogical intersection of psychoanalysis and political theory in psychiatry this study examines some ideological tracts that inform a basis for the application of democracy in clinical mental health practice. In particular it is argued that the Frankfurt tradition has not been fully articulated as an influencing sphere of thought in the Therapeutic Community (TC) movement; the TC method here being a source for the development of democratic clinical practice. Foulkes' contribution to the 'Frankfurt tradition' following Mannheim's vision of 'democratic group analysis' is contrasted with Bion's troublesome engagement with hierarchy and authority. It is argued that Bion's emphasis on pursuing the obstacles to mature functioning in group therapy (basic assumption theory) involved an experiment in therapeutic disorder as much as it was an effort to install co-operative effort towards democracy. In order to generate new data on democracy in action in psychiatric environments three focused inter-connecting studies were undertaken: i) a baseline study gathering comparative data describing democracy in action in 14 UK psychiatric units; ii) an extended pilot study (in a single site) which developed an adapted tool (DemocQ for calibrating staff and patient opinions about democracy & iii) 5 focus groups (in the pilot study site) which was used as a method of triangulating the data from the first two surveys. The results from the descriptive study of 14 sites suggested that the old distinction between TC's in terms of 'hierarchical' or 'democratic' was an over simplification of what was happening in practice. All sites in the study had evidence of various degrees of democracy in clinical practice. A provisional classification system of therapeutic democratic is proposed based on the varying levels of democratic engagement in practice. The results from the DemocQ pointed to a high degree of correlation between staff and patient opinions about democratic climate in the pilot site. The 5 focus groups offered some confirmation of the fair-to-good threshold of democratic climate identified in the pilot DemocQ survey. The focus group interviews threw up an 'unexpected finding' that psychiatric medication withdrawal seemed to be a crucial factor in fostering a sense of agency among the patients. In conclusion a conception of 'therapeutic democracy' is proposed based on a model of 'democratic intimacy'. Divergent clinical modalities are considered in terms of their influence on the facilitation or inhibition of democratically inclined treatment and these divergences are cast in terms of 'therapeutic collectivism' and 'therapeutic individualism'. The evolution of care in community and the decarceration movement is considered in terms of the shift from rural psychiatry to urban psychiatry. It is posited that the move towards primary community care has created the impetus for a re-conceptualisation of the task of psychiatric social integration. The increase in interest in democracy in the NHS emerges simultaneously to i) the necessity of the increased levels of co-operation required by the evolution of community care & ii) as a rhetorical device of a model of citizenship. Some recommendations are made as to how the rhetoric of democracy might be followed through with more rigorous therapeutic intention arising out of an adapted TC model of 'public mental health'