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'.

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